New Jersey insurers would offer set prices for selected medical care

Insurers would offer set-price payments for selected care, share a list of covered services and participating providers, and show members can reasonably reach that care. The requirements cover members of health plans issued in New Jersey by insurers, health maintenance organizations, and the State and School Employees’ Health Benefits Programs. The state insurance department would select the services, and insurers could apply for exemptions for some services. Emergency care is excluded, and the offer must follow federal and New Jersey emergency-care laws. Covered plans include state and school employee plans, but exclude Medicaid and several other types of coverage. The requirements would apply to covered policies and contracts delivered, issued, executed, or renewed on or after January 1, 2028.

The state insurance department would set reference prices, help members find providers who accept them, and plan for improving care quality. The prices would apply to selected medical and surgical services, excluding emergency care. The department would use claims information to identify services with the largest differences between Medicare rates and insurers’ negotiated rates, then set a price for each selected service. The department would adopt rules to implement the system; the insurance commissioner could take necessary preparatory steps before January 1, 2028.