| Home > Insurance Division > Mandated Health Benefits Advisory Commission > Frequently Asked Questions |
| Questions and Answers on the Mandated Health
Benefits Advisory Commission Act |
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| 1. |
What does the Act require with respect to mandated health insurance coverage? Answer |
| 2. |
Do New Jersey mandated health benefits only apply to health insurance
coverage issued in New Jersey? Answer |
| 3. |
Which plans must provide mandated health benefits? Answer |
| 4. |
Who serves on the Commission? Answer |
| 5. |
What are the duties of the Commission relative to the review of bills? Answer |
| 6. |
Are all proposed mandated health benefit bills referred to the Commission
for review? Answer |
| 7. |
What information relative to the proposed mandated health benefit is
included in the Commission's review? Answer |
| 8. |
Where can I find information about proposed mandated health benefit bills? Answer |
| 9. |
Can I submit information regarding a proposed mandated health benefit
to the Commission? Answer |
| 10. |
What happens after the Commission issues a report? Answer |
| 11. |
How can I obtain a copy of the Commission's report? Answer |
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1. What does the Act require with respect to mandated health insurance coverage?
The Act requires a review of proposed mandated health benefits by an expert
body to provide the Legislature with adequate and independent documentation
defining the social and financial impact and medical efficacy of the proposed
mandate. |
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2. Do New Jersey mandated health benefits only apply to health insurance
coverage issued in New Jersey?
Yes. Mandated health benefits are defined as a benefit or coverage that is
required by New Jersey law to be provided by any company authorized to transact
health insurance in New Jersey in health policies and contracts issued in
New Jersey, regardless of the state of domicile of the company. Mandated
Health Benefits include coverage for specific health care services, treatments
or practices, or direct reimbursement to specific health care providers.
Mandated benefits do not apply to self-funded plans where the employer is
responsible for the claims but uses an insurer or third party administrator
to process claims. Very large employers typically have self-funded plans. |
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3. Which plans must provide mandated health benefits?
Any benefits plan which pays or provides hospital and medical expense benefits
for covered services, and is delivered or issued for delivery in New Jersey
by or through a carrier must provide a mandated health benefit. Health benefits
plans do not include the following plans, policies or contracts: accident
only, credit, disability, long-term care, coverage arising out of workers'
compensation or similar law, automobile medical payment insurance, personal
injury protection insurance issued pursuant to P. L. 1972, c.70 (C.39:6A-1
et seq.) or hospital confinement indemnity coverage. |
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4. Who serves on the Commission?
The Act provides for a commission of 17 voting members as follows:
| Organization |
Representative |
| Commissioner of Health
or designee |
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| Commissioner of Human Services or designee |
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| Commissioner of Banking and Insurance or
designee |
Michael Fahncke, Assistant Commissioner for Life and Health |
| A representative of a commercial health insurance
company |
Vacant |
| A New Jersey licensed physician who is a
member of the Medical Society of New Jersey |
Mary F. Campagnolo, MD, MBA, Virtua-Lumberton Family Physicians |
| A representative of the New Jersey Business
and Industry Association |
Vacant |
| A representative of a health service corporation |
Sandi Kelly, Director, Actuarial Affairs,
Horizon BCBSNJ, Vice Chair |
| A New Jersey licensed physician |
Vacant |
| A representative of organized labor |
Vacant |
A medical educator from the University of
Medicine and Dentistry of New Jersey whose major field of expertise
is the study and evaluation of the cost of health care and health insurance
|
William E. Halperin, MD, MPH, Dr. P.H., Department
of Preventative Medicine & Community Health, UMDNJ |
| A representative of the New Jersey Association
of Health Plans |
Wardell Sanders, Esq., President, New Jersey Association of Health Plans, Chair |
| A representative of the New Jersey Hospital
Association |
Vacant |
| A representative of the New Jersey State
Nurses Association |
Vacant |
| A representative of the New Jersey Dental
Association |
Vacant |
| A representative of a consumer advocacy organization |
Vacant |
| Two representatives of the general public
who are knowledgeable about health benefit plans |
| Julia A. Oliver, CPA, CFO, The Bridge, Inc. |
| Vacant |
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The Act also provides for 4 nonvoting members:
| Two members of the Senate, not from the same
political party |
| Senator Joseph F. Vitale |
| Vacant |
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| Two members of the Assembly, not from the
same political party |
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5. What are the duties of the Commission relative to the review of bills?
The commission is to review any bill introduced in either House of the
Legislature that would require a carrier to provide a mandated health benefit
within 60 days after the date the review is requested, and provide its comments
and recommendations in writing to the prime sponsor, committee chair and presiding officer of the House in which the bill is pending. |
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6. Are all proposed mandated health benefit bills referred to the Commission
for review?
No. If the presiding officer of the House in which the bill is pending
determines that the bill is an urgent matter, the presiding officer will
notify in writing the Commission and the chair of the standing reference
committee to which the bill is referred, and the House or committee may
consider and vote upon the bill as soon as practicable; or, if the chair
of the standing reference committee to which the bill is referred, in consultation
with the Commissioner of Health, determines that the
bill is of such an urgent matter that it would seriously impair the public
health to wait for the Commission to issue its report, the chair will
notify in writing the presiding officer of the House in which the bill is
pending, and the Commission, of that determination, and the standing reference
committee, with the agreement of the presiding officer of the House, may
consider and vote upon the bill as soon as practicable. |
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7. What information relative to the proposed mandated health benefit is
included in the Commission's review?
The Act limits the Commission's review of a particular mandated health
benefit bill to include the social and financial impact as well as the
medical efficacy of the mandated benefit. The specific factors are listed
below.
Social Impact |
- the extent to which the proposed mandated health benefit and the services
it would provide are needed by, available to and utilized by the population
of New Jersey;
- the extent to which insurance coverage for the proposed mandated health
benefit already exists or, if no coverage exists, the extent to which
the lack of coverage results in inadequate health care or financial hardship
for the affected population of New Jersey;
- the demand for the proposed mandated health benefit from the public
and the source and extent of opposition to mandating the health benefit;
- relevant findings bearing on the social impact of the lack of the proposed
mandated health benefit; and
- such other information with respect to the
social impact as the Commission deems appropriate.
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| Financial Impact |
- the extent to which the proposed mandated health benefit would increase
or decrease the cost for treatment or service;
- the extent to which similar mandated health benefits in other states
have affected charges, costs and payments for services;
- the extent to which the proposed mandated health benefit would increase
the appropriate use of the treatment or service;
- the impact of the proposed mandated health benefit on total costs to
carriers and on administrative costs;
- the impact of the proposed mandated health benefit on total costs to
purchasers and benefit costs;
- the impact of the proposed mandated health benefit on the total cost
of health care within New Jersey; and
- such other information with respect
to the financial impact as the Commission deems appropriate.
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| Medical Efficacy |
- if the proposed health benefit mandates coverage of a particular treatment
or therapy, the recommendation of a clinical study or review article in
a major peer-reviewed professional journal;
- if the proposed health benefit mandates coverage of the services provided
by an additional class of practitioners, the results of at least one professionally
accepted, controlled trial comparing the medical results achieved by the
additional class of practitioners and the practitioners already covered
by benefits;
- the results of other research;
- the impact of the proposed benefit on the general availability of health
benefits coverage in New Jersey; and
- such other information with respect
to the medical efficacy as the Commission deems appropriate.
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| Balancing the Social, Economic and Medical Efficacy |
- the extent to which the need for coverage outweighs the costs of mandating
the health benefit; and
- the extent to which the problem of coverage may
be solved by mandating the availability of the coverage as an option under
a health benefits plan.
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| Analysis of information collected from various sources, such as: |
- a State data collection system;
- the Departments of Health and Banking and Insurance;
- health planning organizations;
- proponents and opponents of the proposed health benefit mandate, who
shall be encouraged to provide appropriate documentation supporting their
positions. The Commission examines such documentation to determine whether:
- the documentation is complete;
- the assumptions upon which the research is based are valid;
- the research cited in the documentation meets professional standards;
- all relevant research respecting the proposed benefit has been cited in
the documentation;
- the conclusions and interpretations in the documentation are consistent
with the data submitted; and
- such other data sources as the Commission deems
appropriate.
In analyzing information from the various sources, the Commission
shall give substantial weight to the documentation provided by the proponents
and opponents of the mandate to the extent that such documentation is made
available to them. |
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8. Where can I find information about proposed mandated health benefit bills?
The New Jersey legislature's
Web site provides a list of all proposed bills by subject. |
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9. Can I submit information regarding a proposed mandated health benefit
to the Commission?
Yes. Submissions of materials and documentation can be made, in writing
to the Commission using this form (HTM) or download
a MS Word document. Your submission should be mailed to:
New Jersey Department of Banking and Insurance
Mandated Health Benefits
Advisory Commission
PO Box 325
Trenton, NJ 08625
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10. What happens after the Commission issues a report?
The Legislature may consider the mandated health benefits bill in its normal
course of business. |
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11. How can I obtain a copy of the Commission's report?
Copies of the Commission's completed analyses are available online. You can receive printed copies by making a request through the Open Public Records Act.
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