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S4498
SENATE, No. 4498
STATE OF NEW JERSEY
222nd LEGISLATURE
�
INTRODUCED JUNE 22, 2026
Sponsored by:
Senator� RAJ MUKHERJI
District 32 (Hudson)
SYNOPSIS
���� Establishes reference-based pricing system for
certain medical services.
CURRENT VERSION OF TEXT
���� As introduced.
��
An Act
concerning reference-based pricing for certain medical
services and supplementing P.L.1997, c.192 (C.26:2S-1 et seq.).
����
Be It
Enacted
by the Senate and General Assembly of
the State of New Jersey:
���� 1.��� As used in this act:
���� �Carrier� means a health,
hospital, and medical service corporation; commercial individual and group
health insurer; or health maintenance organization authorized to issue health
benefits plans in this State.� �Carrier� shall also include the State Health
Benefits Program and School Employees� Health Benefits Program.
���� �Covered person� means a
person on whose behalf a carrier or other entity, who is the sponsor of the
health benefits plan, is obligated to pay benefits pursuant to a health
benefits plan.
���� �Department� means the
Department of Banking and Insurance.
���� �Health benefits plan� means a
benefits plan which pays hospital or medical expense benefits for covered
services, or prescription drug benefits for covered services, and is delivered
or issued for delivery in this State by or through a carrier or any other
sponsor.� For the purposes of this act, �health benefits plan� shall include, to
the maximum extent permitted by federal law, a high-deductible health plan,
except if the plan is used to establish a medical savings account pursuant to
section 220 of the federal Internal Revenue Code of 1986 (26 U.S.C. s.220).�
�Health benefits plan� shall not include the following plans, policies or
contracts: accident only, credit disability, long-term care, Medicare
supplement coverage, TRICARE supplement coverage, coverage for Medicare
services pursuant to a contract with the United States government, the State
Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.),
coverage arising out of a worker's compensation or similar law, coverage under
a policy of private passenger automobile insurance issued pursuant to P.L.1972,
c.70 (C.39:6A-1 et seq.), or hospital confinement indemnity coverage.�
���� �Health care provider� means
an individual or entity which, acting within the scope of its licensure or
certification, provides a covered medical service defined by a health benefits
plan.� �Health care provider� includes, but is not limited to, a physician or
other health care professional licensed pursuant to Title 45 of the Revised
Statutes, and a licensed diagnostic, imaging, and outpatient treatment center; acute
care hospital; ambulatory surgical center; or other health care facility
licensed pursuant to Title 26 of the Revised Statutes.
���� �Medical service� means
medical or surgical care that is provided by a health care provider.� �Medical
service� shall include but not be limited to inpatient hospital care,
outpatient hospital services, imaging services, and ambulatory surgical
procedures.� �Medical service� shall not include medical or surgical care
provided on an emergency basis.
���� �Reference price� means a
pre-determined price used to determine the maximum allowed payment for a
medical service.
���� �Reference-based pricing� or
�reference-based pricing system� means a health insurance cost-containment
model that allows a carrier to pay a claim to a health care provider based on a
reference price for a medical service, rather than on the provider�s billed
charge for the service.
���� �Unit price variation� means the
difference between the Medicare reimbursement rate for a medical service and
the actual negotiated reimbursement rate for that service between a carrier and
health care provider.
���� 2.��� a.� A carrier shall offer
a covered person reference-based pricing for medical services as determined by
the department pursuant to section 3 of this act.� A carrier shall not apply
the provisions of this section in a manner inconsistent with the federal
�Emergency Medical Treatment and Labor Act,� (42 U.S.C. s.1395dd), or P.L.1992,
c.160 (C.26:2H-18.51 et al.).
���� b.��� (1)� A carrier providing
reference-based pricing pursuant to subsection a. of this section shall
disclose to each covered person, at the beginning of coverage for each covered person,
a list, to be updated annually, that contains:
���� (a)�� each medical service
subject to reference-based pricing pursuant to section 3 of this act;
���� (b)�� the reference price for
each medical service; and
���� (c)�� each health care provider
that has a pre-existing agreement with the carrier to accept reference-based
pricing.
���� (2)�� The list disclosed pursuant
to paragraph (1) of this subsection shall also be made available on the
Internet website of the carrier.
���� c.���� Pursuant to subsection
a. of this section, a carrier shall demonstrate to the department, in a form
and manner prescribed by the department, that a covered person has reasonable
access to medical services subject to reference-based pricing, including time
and distance standards and appointment availability standards consistent with
network adequacy requirements established pursuant to State law.
���� 3.��� a.� The department shall
adopt, pursuant to the �Administrative Procedure Act,� P.L.1968, c.410
(C.52:14B-1 et seq.), rules and regulations to establish, pursuant to this act:
���� (1)�� a reference-based
pricing system.� In establishing the reference-based pricing system pursuant to
this paragraph, the department shall:
���� (a)�� limit reference-based
pricing to medical services with the highest unit price variations in the State,
to be determined by the department.� Pursuant to this subparagraph, the
department shall obtain claims information from carriers or the agents of
carriers, otherwise known as payers, to determine the highest unit price
variations among medical services;
���� (b)�� pursuant to subparagraph
(a) of this paragraph, establish a reference price for each medical service determined
by the department to have the highest unit price variations; and
���� (c)�� allow a carrier to apply
for an exemption, in a form and manner to be determined by the department, to
the requirement that reference-based pricing be offered for certain medical
services pursuant to subsection a. of section 2 of this act;
���� (2)�� a program to assist
covered persons in selecting health care providers that accept reference-based
pricing for medical services pursuant to subsection a. of section 2 of this act;
and
���� (3)�� a plan for achieving
continuous quality improvement in the quality of care provided by a health care
provider accepting reference-based pricing.�
���� b.��� The department shall
also adopt, pursuant to the �Administrative Procedure Act,� P.L.1968, c.410
(C.52:14B-1 et seq.), any other rules and regulations as is necessary to
effectuate the provisions of this act.
���� 4.��� This act shall take
effect on January 1, 2028 and shall apply to policies and contracts delivered,
issued, executed, or renewed on or after that date, except that the
Commissioner of Banking and Insurance may take any anticipatory administrative
action in advance as shall be necessary for the implementation of this act.
STATEMENT
���� This bill establishes a
reference-based pricing system for certain medical services.�
���� Under the bill, carriers must offer
a covered person reference-based pricing for certain medical services.� The
medical services to be offered reference-based pricing by the carrier under the
bill will be determined by the department. �A carrier providing reference-based
pricing under the bill must also disclose to each covered person, at the
beginning of coverage for each covered person, a list, to be updated annually,
containing:
���� (1)�� each medical service
subject to reference-based pricing;
���� (2)�� the reference price for
each medical service; and
���� (3)�� each health care provider
that has a pre-existing agreement with the carrier to accept reference-based
pricing.
���� The carrier will also be
required to make the list available on the Internet website of the carrier.
���� The bill additionally requires
that a carrier demonstrate to the department, in a form and manner prescribed
by the department, that a covered person has reasonable access to medical
services subject to reference-based pricing, including time and distance
standards and appointment availability standards consistent with network
adequacy requirements established pursuant to State law.
���� Finally, the bill requires
that DOBI adopt rules and regulations to establish:
���� (1)�� a reference-based
pricing system.� In establishing a reference-based pricing system pursuant to
this paragraph, the department must:
���� (a)�� limit reference-based
pricing to medical services with the highest unit price variations in the
State, to be determined by the department.� To determine the highest unit price
variations among medical services, the department will obtain claims information
from carriers or the agents of carriers, otherwise known as payers, to
determine the highest unit price variations among medical services;
���� (b)�� establish a reference
price for each medical service determined by the department to have the highest
unit price variations; and
���� (c)�� allow carriers to apply
for an exemption, in a form and manner to be determined by the department, to
the requirement that reference-based pricing be offered for certain medical
services;
���� (2)�� a program to assist
covered persons in selecting health care providers that accept reference-based
pricing for medical services; and
���� (3)�� a plan for achieving
continuous quality improvement in the quality of care provided by a health care
provider accepting reference-based pricing.� �