Sponsored by:
Assemblyman JOHN F. MCKEON
District 27 (Essex and Morris)
Assemblywoman VERLINA REYNOLDS-JACKSON
District 15 (Hunterdon and Mercer)
SYNOPSIS
Imposes certain rate filing requirements concerning certain health benefits plans available on State-based exchange.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning the review of rates anid rate changes for certain health benefits plans and supplementing Title 17B of the New Jersey Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. As used in P.L. , c. (C. ) (pending before the Legislature as this bill):
Carrier means any entity subject to the insurance laws and regulations of this State.
Commissioner means the Commissioner of Banking and Insurance.
Cost sharing reduction variant means the version of a silver plan that provides coverage offering 94% actuarial value, 87% actuarial value, 73% actuarial value, or 70% actuarial value, plus or minus de minimis variations, as defined in 45 C.F.R. s.156.400.
Department means the Department of Banking and Insurance.
"Individual health benefits plan" means an individual health insurance policy pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.).
"Small employer health benefits plan" means a small employer health benefits plan issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.).
Qualified health plan" means the same as that term is defined in section 1301(a) of the federal Patient Protection and Affordable Care Act, Pub.L.111-148 (42 U.S.C. s.18021).
2. a. The provisions of P.L. , c. (C. ) (pending before the Legislature as this bill) shall apply only to rates for the following health benefits plans:
(1) individual health benefits plans issued pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.); and
(2) small employer health benefits plans issued pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.).
b. The requirements established pursuant to P.L. , c. (C. ) (pending before the Legislature as this bill) shall be in addition to any other provision of law concerning health benefits plan rates.
3. The commissioner shall ensure that the process under which the commissioner reviews health benefits plan rates and rate changes complies with P.L. , c. (C. ) (pending before the Legislature as this bill) and other applicable State and federal law, including sections 1201(4), 1003, and 1312 of the federal Patient Protection and Affordable Care Act, Pub.L.111-148 (42 U.S.C. s.300gg, 42 U.S.C. 300gg-94, and 42 U.S.C. s.18032(c)) and those sections' implementing regulations, including rules establishing geographic rating areas.
4. a. The commissioner shall adopt, pursuant to the Administrative Procedure Act, P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations concerning additional requirements related to individual health benefits plans, including qualified health plans, to address the following factors:
(1) whether the carrier issuing the health benefits plan has complied with all requirements for pooling risk, as provided in 45 C.F.R. s.156.80(d), and participating in risk adjustment programs in effect under State or federal law;
(2) the covered benefits or health benefits plan design or, for a rate change, any changes to the benefits or design; and
(3) any other factor listed in 45 C.F.R. s.154.301(a)(4), as appropriate.
b. In making a determination pursuant to this section concerning a proposed rate for a qualified health plan, the commissioner shall consider, in addition to the factors under subsection a. of this section:
(1) the purchasing power of consumers who are eligible for a premium subsidy under the Patient Protection and Affordable Care Act, Pub.L.111-148;
(2) if the plan is in the silver level, as described by section 1302 of the federal Patient Protection and Affordable Care Act, Pub.L.111-148 (42 U.S.C. s.18022), whether the rate is appropriate for the plan in relation to the rates charged for qualified health plans offering coverage at other metal levels, taking into account any funding or lack of funding for cost sharing reductions, the covered benefits for each level of coverage, and expected service utilization by the carriers entire individual market risk pool, if enrolled in each metal level of coverage; and
(3) whether the carrier issuing the health benefits plan utilized the induced demand factors developed by the Centers for Medicare and Medicaid Services for the risk adjustment program established under section 1343 of the federal Patient Protection and Affordable Care Act, Pub.L.111-148 (42 U.S.C. s.18063) for the level of coverage offered by the plan, unless the department determines that the use of other factors would be more accurate in estimating the impact of cost sharing on expected utilization by the carriers entire individual market risk pool.
c. The commissioner may consider:
(1) if the commissioner determines it appropriate for the purposes of comparison, medical claims trends reported by carriers in this State or in a region of the United States or the United States as a whole; and
(2) inflation indexes.
5. In any rate filing issued by a carrier offering a health benefits plan through the State-based exchange established pursuant to P.L.2019, c.141 (C.17B:27A-57 et seq.), the carrier shall base the price of any plan in the silver level, as described by section 1302 of the federal Patient Protection and Affordable Care Act, Pub.L.111-148 (42 U.S.C. s.18022), on a distribution of silver-tier enrollment among cost sharing reduction variants that:
a. for rates charged in 2024, assumes that the plans enrollees will be distributed among cost sharing reduction variants in proportion to the total Statewide distribution of silver-tier enrollees among those variants in 2022, as estimated by the commissioner; and
b. for rates charged after 2024, assumes that the plans enrollees will enroll in plans with an average actuarial value of 90 percent.
6. Notwithstanding the provisions of any other section of P.L. , c. (C. ) (pending before the Legislature as this bill), and except as provided in section 7 of P.L. , c. (C. ) (pending before the Legislature as this bill), a carrier may:
a. offer different plan designs by rating area to individuals and small employers;
b. provide network access beyond the geographic rating area; and
c. offer plan designs with deductibles, coinsurance, and other cost sharing mechanisms necessary to comply with federal actuarial values for plans issued pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.) or P.L.1992, c.162 (C.17B:27A-17 et seq.).
7. Notwithstanding the provisions of any other section of P.L. , c. (C. ) (pending before the Legislature as this bill), when a carrier makes an individual o