Effective with plan years beginning on or after January 1, 2019, the New Jersey Department of Banking and Insurance (Department) will permit health carriers to use an individual network (member out-of-pocket) (MOOP) threshold that is no greater than the maximum annual limitation on cost sharing provided under federal law pursuant to 45 C.F.R. § 156.130 and defined annually in the final Notice of Benefit and Payment Parameters rules (NBPP Rules) unless the Commissioner takes action by regulatory order within 40 days of issuance of the final NBPP to freeze the MOOP at the prior policy year’s maximum. The Commissioner reasons that permitting New Jersey’s MOOP to align with the Affordable Care Act’s (ACA) MOOP going forward (unless otherwise ordered by the Commissioner) will hold back increases to up front policyholder cost sharing, i.e., increases to deductibles and co-payments, that often discourage policyholders from seeking essential medical treatment. Hence, these regulatory measures encourage care and are consistent with the ACA’s goals. As most policyholders do not reach the MOOP in any given year, the Department’s approach limits adverse impact on most policyholders and enables New Jersey health insurers to make rational adjustments to satisfy future actuarial value calculator adjustments, while retaining the Commissioner’s authority to limit future increases to the MOOP as circumstances change. The Department anticipates issuing a rule to implement its Bulletin in the near future.  See Bulletin No. 18-09.

The Commissioner also issued Bulletin No. 18-10, extending the transition period for certain health insurance policies consistent with a directive from Director Randy Pate of the Center for Consumer Information Insurance Insight within CMS. The Pate memorandum extends the CMS transitional period to policy years beginning on or after October 1, 2019, provided that all such policies end by December 31, 2019. The transitional period applies with respect to non-grandfathered coverage in the small employer and individual health insurance marketplaces. These authorities enabled health insurance issuers to choose to continue certain coverage that would otherwise have been cancelled, and would affect small businesses seeking to re-enroll in such coverage. This transitional period was first extended for policy years starting between January 1, 2014 and October 1, 2014; was extended a second time on March 5, 2014 for two years – to policy years beginning on or before October 1, 2016 – in the small employer and individual markets. On February 29, 2016 CMS again extended the transitional period for an additional year for policy years beginning on or before October 1, 2017, provided that all policies ended by December 31, 2017, and on February 23, 2018 CMS again extended the transitional policy for an additional year for policy years beginning on October 1, 2018, provided that all policies ended by December 31, 2018. Policies subject to the transitional relief are not considered to be out of compliance with certain provisions of the Public Health Service Act pertaining to:

  • fair health insurance premiums;
  • guaranteed availability of coverage;
  • guaranteed renewability of coverage;
  • the prohibition of pre-existing condition exclusions or other discrimination based on health status with respect to adults, except with respect to group coverage;
  • the prohibition of discrimination against individual participants and beneficiaries based on health status, except with respect to group coverage;
  • non-discrimination in health care;
  • comprehensive health insurance coverage;
  • coverage for individuals participating in approved clinical trials.

It is clear that the Commissioner’s recent Bulletins are intended to maintain consistency between New Jersey’s health insurance laws and federal rules in the regulated marketplaces.

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