A5086

An Act concerning plan administration and reimbursement for certain procedures covered under the State Health Benefits Program and the School Employees’ Health Benefits Program, amending and supplementing various parts of the statutory law, and repealing section 55 of P.L.2011, c.78.

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. This act shall be known and may be cited as the “Property Tax Relief Act.”

2. (New Section) a. Notwithstanding any law, rule, or regulation to the contrary, on or after the effective date of P.L. , c. (pending before the Legislature as this bill), any contract purchased or renewed by the State Health Benefits Commission, or its designee, pursuant to section 4 of P.L.1961, c.49 (C.52:14-17.28), shall limit reimbursement for knee replacements, hip replacements, magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, colonoscopies, cataracts, arthroscopy, and diagnostic lab tests performed in an inpatient or outpatient hospital setting to the lesser of the contract price, the billed price, or the reference price as defined under subsection f. of this section.

b. A carrier, hospital, or State-managed care plan shall not collect any money from a covered employee, retiree, dependent thereof, or the State Health Benefits Program in excess of the amount determined in accordance with subsection a. of this section for the listed procedures.

c. (1) The provisions of this section shall not apply when a procedure listed under subsection a. of this section is performed in:

(a) a rural hospital that is certified by the U.S. Centers for Medicare and Medicaid Services as a sole community hospital, as defined in 42 U.S.C. s.1395ww(d)(5)(D)(iii);

(b) a critical access hospital that is certified by the U.S. Centers for Medicare and Medicaid Services, as defined in 42 U.S.C. s.1395x(mm)(1); or

(c) a hospital with a monitor appointed by the New Jersey Department of Health pursuant to subsection c. of section 2 of P.L.2008, c.58 (C.26:2H-5.1a).

(2) The provisions of this section shall not apply when a procedure listed under subsection a. of this section is performed in an emergency.

d. The provisions of this section shall not be construed to require a health benefits plan offered by the State Health Benefits Program to provide reimbursement for claims using a fee-for-service payment method.

e. Not later than two years after the effective date of P.L. , c. (pending before the Legislature as this bill), the Department of the Treasury shall evaluate the list of procedures specified in subsection a. of this section. The evaluation shall assess the amount of money the program has saved on those procedures and recommend changes to the list of procedures for consideration by the Legislature.

f. As used in this section, “reference price” means 165 percent of the amount paid by Medicare for the same or a similar procedure for in-network providers and 150 percent for out-of-network providers.

3. (New section) Notwithstanding the provisions of any other law, rule, or regulation to the contrary, within one year from the effective date of P.L. , c. (pending before the Legislature as this bill), any employer other than the State shall be required to make a determination as to whether to participate in the State Health Benefits Program. Any employer other than the State which elects to participate in the State Health Benefits Program upon the conclusion of that year shall be required to remain enrolled in the program for a period of three consecutive plan years. Any employer other than the State that elects to leave the program upon the conclusion of that year shall be prohibited from reenrolling in the program for three consecutive plan years. Any employer other than the State that is not enrolled in the program and does not elect to participate within that year shall be permitted to join at any time, but shall be required to remain enrolled in the program for three consecutive plan years following new enrollment.

4. Section 3 of P.L.1961, c.49 (C.52:14-17.27) is amended to read as follows:

3. a. There is hereby created a State Health Benefits Commission, consisting of five members: the State Treasurer; the Commissioner of Banking and Insurance; the Chairperson of the Civil Service Commission; a State employees' representative chosen by the Public Employee Committee of the AFL-CIO; and the fifth member of the commission shall be a local employees' representative chosen by the Public Employee Committee of the AFL-CIO.

The treasurer shall be chairman of the commission and the health benefits program authorized by P.L.1961, c.49 shall be administered in the Treasury Department. The Director of the Division of Pensions and Benefits shall be the secretary of the commission. The commission [and committee] shall establish a health benefits program for the employees of the State, the cost of which shall be paid as specified in section 6 of P.L.1961, c.49 (C.52:14-17.30). The commission [, in consultation with the committee,] shall establish rules and regulations as may be deemed reasonable and necessary for the administration of P.L.1961, c.49.

The Attorney General shall be the legal advisor of the commission and committee.

The members of the commission [and committee] shall serve without compensation but shall be reimbursed for any necessary expenditures. The public employee members shall not suffer loss of salary or wages during service on the commission [or committee].

The commission shall publish annually a report showing the fiscal transactions of the program for the preceding year and stating other facts pertaining to the plan. The commission shall submit the report to the Governor and furnish a copy to every employer for use of the participants and the public.

b. [There is established a State Health Benefits Plan Design Committee, composed of 12 members as follows:

six members who shall be appointed by the Governor as representatives of public employers whose employees are enrolled in the program;

three members who shall be appointed by the Public Employee Committee of the AFL-CIO;

one member who shall be appointed by the head of the union, that is not affiliated with the AFL-CIO, that represents the greatest number of police officers in this State;

one member who shall be appointed by the head of the union, that is not affiliated with the AFL-CIO, that represents the greatest number of firefighters in this State; and

one member who shall be appointed by the head of the State Troopers Fraternal Association.

The members of the committee shall serve for a term of three years and until a successor is appointed and qualified. Of the initial appointments by the Governor, three members shall serve for two years and until a successor is appointed and qualified, and two shall serve for one year and until a successor is appointed and qualified. Of the initial appointment by the head of the union representing the greatest number of police officers in the State, the member shall serve for two years and until a successor is appointed and qualified. Of the initial appointment by the head of the union representing the greatest number of firefighters in the State, the member shall serve for one year and until a successor is appointed and qualified.

The members of the committee shall select a chairperson from among the members, who shall serve for a term of one year, with no member serving more than one term as chairperson until all the members of the committee have served a term in a manner alternating among the employer representatives and employee representatives, unless the committee determines otherwise with regard to this process.]

The [committee] commission shall have the responsibility for and authority over the various plans and components of those plans, including for medical benefits, prescription benefits, dental, vision, and any other health care benefits, offered and administered by the program. The [committee] commission shall have the authority to create, modify, or terminate any plan or component, at its sole discretion. [Any reference in law to the State Health Benefits Commission in the context of the creation, modification, or termination of a plan or plan component shall be deemed to apply to the committee.] On or after the effective date of P.L. , c. (pending before the Legislature as this bill), any reference in law to the State Health Benefits Program Plan Design Committee shall be deemed to apply to the commission.

[The members of the committee shall have the same duty and responsibility to the program as do the members of the commission.

If any matter before the committee receives at least seven votes in the affirmative, the commission shall approve and implement the committee's decision.

If any matter before the committee receives six votes in the affirmative and six votes in the negative or the committee otherwise reaches an impasse on a decision, the provisions of section 55 of P.L.2011, c.78 (C.52:14-17.27b) shall be followed.]

(cf: P.L.2011, c.78, s.45)

5. Section 5 of P.L.1961, c.49 (C.52:14-17.29) is amended to read as follows:

5. (A) The contract or contracts purchased by the commission pursuant to subsection b. of section 4 of P.L.1961, c.49 (C.52:14-17.28) shall provide separate coverages or policies as follows:

(1) Basic benefits which shall include:

(a) Hospital benefits, including outpatient;

(b) Surgical benefits;

(d) Obstetrical benefits; and

(e) Services rendered by an extended care facility or by a home health agency and for specified medical care visits by a physician during an eligible period of such services, without regard to whether the patient has been hospitalized, to the extent and subject to the conditions and limitations agreed to by the commission and the carrier or carriers.

Basic benefits shall be substantially equivalent to those available on a group remittance basis to employees of the State and their dependents under the subscription contracts of the New Jersey "Blue Cross" and "Blue Shield" Plans. Such basic benefits shall include benefits for:

(i) Additional days of inpatient medical service;

(ii) Surgery elsewhere than in a hospital;

(iii) X-ray, radioactive isotope therapy and pathology services;

(iv) Physical therapy services;

(v) Radium or radon therapy services;

and the extended basic benefits shall be subject to the same conditions and limitations, applicable to such benefits, as are set forth in "Extended Outpatient Hospital Benefits Rider," Form 1500, 71(9-66), and in "Extended Benefit Rider" (as amended), Form MS 7050J(9-66) issued by the New Jersey "Blue Cross" and "Blue Shield" Plans, respectively, and as the same may be amended or superseded, subject to filing by the Commissioner of Banking and Insurance; and

(2) Major medical expense benefits which shall provide benefit payments for reasonable and necessary eligible medical expenses for hospitalization, surgery, medical treatment and other related services and supplies to the extent they are not covered by basic benefits. The commission may, by regulation, determine what types of services and supplies shall be included as "eligible medical services" under the major medical expense benefits coverage as well as those which shall be excluded from or limited under such coverage. Benefit payments for major medical expense benefits shall be equal to a percentage of the reasonable charges for eligible medical services incurred by a covered employee or an employee's covered dependent, during a calendar year as exceed a deductible for such calendar year of $100.00 subject to the maximums hereinafter provided and to the other terms and conditions authorized by this act. The percentage shall be 80 percent of the first $2,000.00 of charges for eligible medical services incurred subsequent to satisfaction of the deductible and 100 percent thereafter. There shall be a separate deductible for each calendar year for (a) each enrolled employee and (b) all enrolled dependents of such employee. Not more than $1,000,000.00 shall be paid for major medical expense benefits with respect to any one person for the entire period of such person's coverage under the plan, whether continuous or interrupted except that this maximum may be reapplied to a covered person in amounts not to exceed $2,000.00 a year. Maximums of $10,000.00 per calendar year and $20,000.00 for the entire period of the person's coverage under the plan shall apply to eligible expenses incurred because of mental illness or functional nervous disorders, and such may be reapplied to a covered person, except as provided in P.L.1999, c.441 (C.52:14-17.29d et al.). The same provisions shall apply for retired employees and their dependents. Under the conditions agreed upon by the commission and the carriers as set forth in the contract, the deductible for a calendar year may be satisfied in whole or in part by eligible charges incurred during the last three months of the prior calendar year.

Any service determined by regulation of the commission to be an "eligible medical service" under the major medical expense benefits coverage which is performed by a duly licensed practicing psychologist within the lawful scope of psychologist practice shall be recognized for reimbursement under the same conditions as would apply were such service performed by a physician.

(B) The contract or contracts purchased by the commission pursuant to subsection c. of section 4 of P.L.1961, c.49 (C.52:14-17.28) shall include coverage for services and benefits that are at a level that is equal to or exceeds the level of services and benefits set forth in this subsection, provided that such services and benefits shall include only those that are eligible medical services and not those deemed experimental, investigative or otherwise not eligible medical services. The determination of whether services or benefits are eligible medical services shall be made by the commission consistent with the best interests of the State and participating employers, employees, and dependents. The following list of services is not intended to be exclusive or to require that any limits or exclusions be exceeded.

Covered services shall include:

(1) Physician services, including:

(a) Inpatient services, including:

(i) medical care including consultations;

(ii) surgical services and services related thereto; and

(iii) obstetrical services including normal delivery, cesarean section, and abortion.

(b) Outpatient/out-of-hospital services, including:

(i) office visits for covered services and care;

(ii) allergy testing and related diagnostic/therapy services;

(iii) dialysis center care;

(iv) maternity care;

(v) well child care;

(vi) child immunizations/lead screening;

(vii) routine adult physicals including pap, mammography, and prostate examinations; and

(viii) annual routine obstetrical/gynecological exam.

(2) Hospital services, both inpatient and outpatient, including:

(a) room and board;

(b) intensive care and other required levels of care;

(d) therapy and diagnostic services;

(e) surgical services or facilities and treatment related thereto;

(f) nursing care;

(g) necessary supplies, medicines, and equipment for care; and

(h) maternity care and related services.

(3) Other facility and services, including:

(a) approved treatment centers for medical emergency/accidental injury;

(b) approved surgical center;

(d) chemotherapy;

(e) diagnostic x-ray and lab tests;

(f) ambulance;

(g) durable medical equipment;

(h) prosthetic devices;

(i) foot orthotics;

(j) diabetic supplies and education; and

(k) oxygen and oxygen administration.

(4) All services for which coverage is required pursuant to P.L.1961, c.49 (C.52:14-17.25 et seq.), as amended and supplemented. Benefits under the contract or contracts purchased as authorized by the State Health Benefits Program shall include those for mental health services subject to limits and exclusions consistent with the provisions of the New Jersey State Health Benefits Program Act.

(C) The contract or contracts purchased by the commission pursuant to subsection c. of section 4 of P.L.1961, c.49 (C.52:14-17.28) shall include the following provisions regarding reimbursements and payments:

(1) In the successor plan, the co-payment for doctor's office visits shall be $10 per visit with a maximum out-of-pocket of $400 per individual and $1,000 per family for in-network services for each calendar year. The out-of-network deductible shall be $100 per individual and $250 per family for each calendar year, and the participant shall receive reimbursement for out-of-network charges at the rate of 80 percent of reasonable and customary charges, provided that the out-of-pocket maximum shall not exceed $2,000 per individual and $5,000 per family for each calendar year.

(2) In the State managed care plan that is required to be included in a contract entered into pursuant to subsection c. of section 4 of P.L.1961, c.49 (C.52:14-17.28), the co-payment for doctor's office visits shall be $15 per visit. The participant shall receive reimbursement for out-of-network charges at the rate of 70% of reasonable and customary charges. The in-network and out-of-network limits, exclusions, maximums, and deductibles shall be substantially equivalent to those in the NJ PLUS plan in effect on June 30, 2007, with adjustments to that plan pursuant to a binding collective negotiations agreement or pursuant to action by the commission, in its sole discretion, to apply such adjustments to State employees for whom there is no majority representative for collective negotiations purposes.

(3) "Reasonable and customary charges" means charges based upon the 90th percentile of the usual, customary, and reasonable (UCR) fee schedule determined by the Health Insurance Association of America or a similar nationally recognized database of prevailing health care charges.

(D) Benefits under the contract or contracts purchased as authorized by this act may be subject to such limitations, exclusions, or waiting periods as the commission finds to be necessary or desirable to avoid inequity, unnecessary utilization, duplication of services or benefits otherwise available, including coverage afforded under the laws of the United States, such as the federal Medicare program, or for other reasons.

Benefits under the contract or contracts purchased as authorized by this act shall include those for the treatment of alcohol use disorder where such treatment is prescribed by a physician and shall also include treatment while confined in or as an outpatient of a licensed hospital or residential treatment program which meets minimum standards of care equivalent to those prescribed by the Joint Commission on Hospital Accreditation. No benefits shall be provided beyond those stipulated in the contracts held by the State Health Benefits Commission.

(E) The rates charged for any contract purchased under the authority of this act shall reasonably and equitably reflect the cost of the benefits provided based on principles which in the judgment of the commission are actuarially sound. The rates charged shall be determined by the carrier on accepted group rating principles with due regard to the experience, both past and contemplated, under the contract. The commission shall have the right to particularize subgroups for experience purposes and rates. No increase in rates shall be retroactive.

(F) The initial term of any contract purchased by the commission under the authority of this act shall be for such period to which the commission and the carrier may agree, but permission may be made for automatic renewal in the absence of notice of termination by the commission. Subsequent terms for which any contract may be renewed as herein provided shall each be limited to a period not to exceed one year.

(G) A contract purchased by the commission pursuant to subsection b. of section 4 of P.L.1961, c.49 (C.52:14-17.28) shall contain a provision that if basic benefits or major medical expense benefits of an employee or of an eligible dependent under the contract, after having been in effect for at least one month in the case of basic benefits or at least three months in the case of major medical expense benefits, is terminated, other than by voluntary cancellation of enrollment, there shall be a 31-day period following the effective date of termination during which such employee or dependent may exercise the option to convert, without evidence of good health, to converted coverage issued by the carriers on a direct payment basis. Such converted coverage shall include benefits of the type classified as "basic benefits" or "major medical expense benefits" in subsection (A) hereof and shall be equivalent to the benefits which had been provided when the person was covered as an employee. The provision shall further stipulate that the employee or dependent exercising the option to convert shall pay the full periodic charges for the converted coverage which shall be subject to such terms and conditions as are normally prescribed by the carrier for this type of coverage.

(H) The commission may purchase a contract or contracts to provide drug prescription and other health care benefits or authorize the purchase of a contract or contracts to provide drug prescription and other health care benefits as may be required to implement a duly executed collective negotiations agreement or as may be required to implement a determination by a public employer to provide such benefit or benefits to employees not included in collective negotiations units.

(I) The commission shall take action as necessary, in cooperation with the School Employees' Health Benefits Commission established pursuant to section 33 of P.L.2007, c.103 (C.52:14-17.46.3), to effectuate the purposes of the School Employees' Health Benefits Program Act as provided in sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 through C.52:14-17.46.11) and to enable the School Employees' Health Benefits Commission to begin providing coverage to participants pursuant to the School Employees' Health Benefits Program Act as of July 1, 2008.

(J) Beginning January 1, 2012, the State Health Benefits Plan Design Committee shall provide to employees the option to select one of at least three levels of coverage each for family, individual, individual and spouse, and individual and dependent, or equivalent categories, for each plan offered by the program differentiated by out of pocket costs to employees including co-payments and deductibles. Notwithstanding any other provision of law to the contrary, the committee shall have the sole discretion to set the amounts for maximums, co-pays, deductibles, and other such participant costs for all plans in the program. The committee shall also provide for a high deductible health plan that conforms with Internal Revenue Code Section 223.

There shall be appropriated annually for each State fiscal year, through the annual appropriations act, such amounts as shall be necessary as funding by the State as an employer, or as otherwise required, with regard to employees or retirees who have enrolled in a high deductible health plan that conforms with Internal Revenue Code Section 223.

(K) Notwithstanding the provisions of this section, or any other law, rule, or regulation to the contrary, on or after the effective date of P.L. , c. (pending before the Legislature as this bill), the commission, in consultation with the program actuary, shall ensure that the actuarial value of any plan offered to employees and non-Medicare eligible retirees shall not be less than 85 percent.

(cf: P.L.2023, c.177, s.139)

6. (New section) a. Notwithstanding any law, rule, or regulation to the contrary, on or after the effective date of P.L. , c. (pending before the Legislature as this bill), any contract purchased or renewed by the School Employees’ Health Benefits Commission, or its designee, pursuant to section 35 of P.L.2007, c.103 (C.52:14-17.46.5), shall limit reimbursement for knee replacements, hip replacements, magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, colonoscopies, cataracts, arthroscopy, and diagnostic lab tests performed in an inpatient or outpatient hospital setting to the lesser of the contract price, the billed price, or the reference price as defined under subsection f. of this section.

b. A carrier, hospital, or State-managed care plan shall not collect any money from a covered employee, retiree, dependent or the School Employees’ Health Benefits Program in excess of the amount determined in accordance with subsection a. of this section for the listed procedures.

c. (1) The provisions of this section shall not apply when a procedure listed under subsection a. of this section is performed in:

(a) a rural hospital that is certified by the U.S. Centers for Medicare and Medicaid Services as a sole community hospital, as defined in 42 U.S.C. s.1395ww(d)(5)(D)(iii);

(b) a critical access hospital that is certified by the U.S. Centers for Medicare and Medicaid Services, as defined in 42 U.S.C. s.1395x(mm)(1); or

(c) a hospital with a monitor appointed by the New Jersey Department of Health pursuant to subsection c. of section 2 of P.L.2008, c.58 (C.26:2H-5.1a).

(2) The provisions of this section shall not apply when a procedure listed under subsection a. of this section is performed in an emergency.

d. The provisions of this section shall not be construed to require a health benefits plan offered by the School Employees’ Health Benefits Program to provide reimbursement for claims using a fee-for-service payment method.

7. (New section) Notwithstanding the provisions of any other law, rule, or regulation to the contrary, within one year from the effective date of P.L. , c. (pending before the Legislature as this bill), any employer as that term is defined under section 32 of P.L.2007, c.103 (C.52:14-17.46.2) shall be required to make a determination as to whether to participate in the School Employees’ Health Benefits Program. Any employer which elects to participate in the School Employees’ Health Benefits Program upon the conclusion of that year shall be required to remain enrolled in the program for three consecutive plan years. Any employer that elects to leave the program upon the conclusion of that year shall be prohibited from reenrolling in the program for three consecutive plan years. Any employer that is not enrolled in the program and does not elect to participate within that year shall be permitted to join at any time, but shall be required to remain enrolled in the program for three consecutive plan years following new enrollment.

8. Section 33 of P.L.2007, c.103 (C.52:14-17.46.3) is amended to read as follows:

33. a. There is hereby created a School Employees' Health Benefits Commission, consisting of nine members:

(1) the State Treasurer and the Commissioner of the Department of Banking and Insurance serving ex officio;

(2) a member appointed by the Governor who is a New Jersey resident and is qualified by experience, education, or training in the review, administration, or design of health insurance plans for self-insured employers;

(3) a member appointed by the Governor from among three persons nominated by the New Jersey School Boards' Association, which member shall be qualified by experience, education, or training in the review, administration, or design of health insurance plans for self-insured employers;

(4) three members appointed by the Governor from among five persons nominated by the New Jersey Education Association, of whom two shall be qualified by experience, education, or training in the review, administration, or design of health insurance plans for self-insured employers;

(5) a member appointed by the Governor from among three persons nominated by the education section of the New Jersey State AFL-CIO, which member shall be qualified by experience, education, or training in the review, administration, or design of health insurance plans for self-insured employers; and

(6) a member appointed pursuant to subsection b. of this section who shall be the chairperson.

b. The Governor shall appoint the chairperson from among three persons nominated jointly by at least six of the eight members appointed pursuant to subsection a. of this section.

c. If the Governor declines to make an appointment from among the persons nominated for membership, the Governor shall request that a new list of nominees be provided in compliance with subsection a. of this section. If the Governor declines to make an appointment from the new list, the process set forth in this subsection shall be repeated until the Governor makes an appointment from a list of nominees. Except with respect to the appointment of the chairperson, if a new list of nominees is not submitted within 45 days of the Governor's request, the Governor shall make the appointment without the need to select from any list of nominees.

d. The initial terms of the members of the commission shall be as follows:

(1) the member appointed pursuant to paragraph (3) of subsection a. of this section and the two members appointed pursuant to paragraph (4) of subsection a. of this section who are required to be qualified by experience, education, or training shall serve for a term of three years;

(2) the member appointed pursuant to paragraph (2) of subsection a. of this section, the member appointed pursuant to paragraph (4) of subsection a. of this section who is not required to be qualified by experience, education, or training, and the member appointed pursuant to paragraph (5) of subsection a. of this section shall serve for a term of two years; and

(3) the chairperson shall serve for a term of six years.

All subsequent terms shall be for three years, except that the term of the chairperson shall be five years. A member of the commission may be reappointed to succeeding terms without limit in the same manner as the original appointment. A vacancy occurring on the commission shall be filled in the same manner as the original appointment and only for the unexpired term.

e. [There is established a School Employees' Health Benefits Plan Design Committee, composed of six members as follows:

three members who shall be appointed by the Governor as representatives of public employers whose employees are enrolled in the program;

two members who shall be appointed by the New Jersey Education Association; and

one member who shall be appointed by the education section of the New Jersey State AFL-CIO.

The members of the committee shall serve for a term of three years and until a successor is appointed and qualified. Of the initial appointments by the Governor, two members shall serve for two years and until a successor is appointed and qualified, and one shall serve for one year and until a successor is appointed and qualified. Of the initial appointments by the New Jersey Education Association, one member shall serve for one year and until a successor is appointed and qualified.

The [committee] commission shall have the responsibility for and authority over the various plans and components of those plans, including for medical benefits, prescription benefits, dental, vision, and any other health care benefits, offered and administered by the program. The [committee] commission shall have the authority to create, modify, or terminate any plan or component, at its sole discretion. [Any reference in law to the School Employees' Health Benefits Commission in the context of the creation, modification, or termination of a plan or plan component shall be deemed to apply to the committee.] On or after the effective date of P.L. , c. (pending before the Legislature as this bill), any reference in law to the School Employees’ Health Benefits Plan Design Committee shall be deemed to apply to the commission.

[The members of the committee shall have the same duty and responsibility to the program as do the members of the commission.

If any matter before the committee receives at least four votes in the affirmative, the commission shall approve and implement the committee's decision.

If any matter before the committee receives three votes in the affirmative and three votes in the negative or the committee otherwise reaches an impasse on a decision, the provisions of section 55 of P.L.2011, c.78 (C.52:14-17.27b) shall be followed.]

(cf: P.L.2011, c.78, s.46)

9. Section 34 of P.L.2007, c.103 (C.52:14-17.46.4) is amended to read as follows:

34. The School Employees' Health Benefits Program, authorized by sections 31 through 41 of P.L.2007, c.103 (C.52:14-17.46.1 through C.52:14-17.46.11), shall be administered in the Department of the Treasury. Administrative services required by the commission shall be provided through the Division of Pensions and Benefits, and the Director of the Division of Pensions and Benefits shall be the secretary of the commission. The commission [and the committee] shall establish a health benefits program for the school employees of the State, the cost of which shall be paid as specified in this act. The commission shall, by a majority vote of its full authorized membership, establish and change rules and regulations as may be deemed reasonable and necessary for the administration of this act by the commission [and committee]. Until such rules and regulations are established, the rules and regulations of the State Health Benefits Commission shall be deemed to apply to the School Employees' Health Benefits Program.

The Attorney General shall be the legal advisor of the commission [and committee].

The members of the commission [and committee] shall serve without compensation but shall be reimbursed for any necessary expenditure.

The commission shall ensure that audits and reviews are performed as required by section 40 of P.L.2007, c.103 (C.52:14-17.46.10). Actions of the commission related to such audits and reviews shall require a majority vote of the full authorized membership of the commission to be approved.

Except as otherwise specified in this act, actions of the commission shall require the affirmative vote of a majority of the members present at a meeting at which a majority of the full authorized membership is present.

(cf: P.L.2011, c.78, s.36)

10. Section 1 of P.L.2020, c.44 (C.52:14-17.46.13) is amended to read as follows:

1. This section shall apply to the School Employees' Health Benefits Program (SEHBP) and to those employers defined pursuant to section 32 of P.L.2007, c.103 (C.52:14-17.46.2) that participate in the program.

a. (1) Notwithstanding the provisions of any other law, rule, or regulation to the contrary, beginning with the plan year that commences January 1, 2021 and for each plan year thereafter, the School Employees' Health Benefits Program shall offer only three plans that provide medical and prescription drug benefits for employees, and retirees who are not Medicare-eligible, and their dependents if any. All other plans offered prior to January 1, 2021 for employees, and retirees who are not Medicare-eligible, and their dependents if any, shall be terminated.

The three plans shall be the New Jersey Educators Health Plan as developed by the School Employees' Health Benefits Plan Design Committee in accordance with subsection f. of this section which sets forth the plan design of the New Jersey Educators Health Plan; the SEHBP NJ Direct 10 plan as adopted and implemented by the School Employees' Health Benefits Commission for the plan year that began January 1, 2020; and the SEHBP NJ Direct 15 plan as adopted and implemented by the School Employees' Health Benefits Commission for the plan year that began January 1, 2020.

Employers that participate in the School Employees' Health Benefits Program shall retain the ability to enter the program for medical only plans and may separately purchase pharmacy and dental benefits outside of the program without limitation or restriction.

(2) Only the plans set forth in this section shall be offered by the program regardless of any collective negotiations agreement between a participating employer and its employees in effect on the effective date of this act, P.L.2020, c.44, that provides for enrollment in other plans that were offered by the program prior to January 1, 2021.

b. Prior to January 1, 2021, the program, through the Division of Pensions and Benefits in the Department of the Treasury, shall provide for an enrollment period during which all employees who commenced employment prior to the effective date of this act shall be required to select affirmatively one of the three plans specified in subsection a. of this section. If an employee fails to select affirmatively a plan during this enrollment period, the program shall enroll the employee, and the employee's dependents if any, in the New Jersey Educators Health Plan for the plan year beginning January 1, 2021 and ending December 31, 2021.

During the enrollment period, any person who is enrolled in a plan offered by the program and who is paying the full cost of health care benefits coverage shall also be required to select affirmatively one of the three plans specified in subsection a. of this section. If a person fails to select affirmatively a plan during this enrollment period, the program shall enroll the person, and the person's dependents if any, in the New Jersey Educators Health Plan for the plan year beginning January 1, 2021 and ending December 31, 2021. Any such person shall continue to pay the full cost of coverage and shall not be subject to the contribution schedule or any mandatory enrollment period as set forth in this section.

c. (1) Beginning on January 1, 2021, an employee commencing employment on or after the effective date of this act but before January 1, 2028 who does not waive coverage shall be enrolled by the program, with the employee's dependents if any, in the New Jersey Educators Health Plan, or the Garden State Health Plan if selected by the employee. The employee shall remain enrolled in either the New Jersey Educators Health Plan or the Garden State Health Plan selected by the employee at the annual open enrollment for each plan year through the plan year that ends December 31, 2027, provided that the employee during this period may waive coverage as an employee and select and change the type of coverage received under the plan following a qualifying life event, in accordance with the program regulations.

The enrollment required by this paragraph shall not include an employee who commenced employment prior to the effective date of P.L.2020, c.44 and who did not enroll, who waived enrollment, or who was not eligible to enroll prior to that effective date for health care coverage provided by the employer, including, but not limited to, an employee who commenced employment as a part-time employee prior to the effective date of P.L.2020, c.44. If such an employee was required to enroll prior to the effective date of P.L.2021, c.163 in accordance with this paragraph, the employee shall be notified promptly in writing that enrollment is not mandatory and shall be provided promptly with an opportunity to select enrollment in another health care benefits plan. For the plan year beginning January 1, 2028, the employee may select, during any open enrollment period or at such other times or under such conditions as the program may provide, any plan offered by the program.

(2) For the plan year beginning January 1, 2021, the program shall enroll a retiree who is not Medicare-eligible, and the retiree's dependents if any, in the New Jersey Educators Health Plan for health care benefits coverage as a retiree, if the retiree does not waive coverage. The retiree shall remain enrolled in that plan for each plan year through the plan year that ends December 31, 2027 or until the retiree becomes eligible for Medicare, whichever comes first. The retiree who becomes eligible for Medicare shall no longer be eligible for enrollment in the New Jersey Educators Health Plan, except that any dependent of the retiree who is not eligible for Medicare may remain eligible for coverage under the New Jersey Educators Health Plan. For the plan year beginning January 1, 2028, that retiree who is not Medicare-eligible may select, during any open enrollment period or at such other times or under such conditions as the program may provide, any plan offered by the program.

(3) Except as otherwise provided in this subsection or subsection b. of this section, selection of a plan shall be at the sole discretion of the employee or retiree who is not Medicare-eligible.

d. Beginning January 1, 2022 and for each plan year thereafter, the program shall offer a fourth plan to be called the Garden State Health Plan. The plan shall be developed by the School Employees' Health Benefits Plan Design Committee. If the committee does not adopt a design for the Garden State Health Plan by December 31, 2020, the Division of Pensions and Benefits in the Department of the Treasury may develop the Garden State Health Plan. The program shall provide an enrollment period prior to January 1, 2022.

The Garden State Health Plan shall provide medical and prescription drug benefits that are equivalent to the level of medical and prescription drug benefits provided by the New Jersey Educators Health Plan, except that the benefits under the Garden State Health Plan shall be available only from providers located in the State of New Jersey.

Access to a service provider that is located outside of the State shall be available only under such terms, conditions, restrictions, and limitations as the plan design committee or the division, as appropriate, shall provide in the plan governing documents.

e. The plan design of the New Jersey Educators Health Plan, the Garden State Health Plan, the NJ Direct 10 plan, and the NJ Direct 15 plan as those plan designs are specified in subsections a., d., and f. of this section shall remain unchanged until December 31, 2027. No change in the plan design of those plans shall be made before that date unless such a change in plan design is required by federal or State law to governmental health care benefits plans or to both governmental and non-governmental health care benefits plans, except as provided in subparagraph 2 of this subsection.

For the plan year that commences January 1, 2028 and for each plan year thereafter, the plan design of the New Jersey Educators Health Plan, the Garden State Health Plan, the NJ Direct 10 plan, and the NJ Direct 15 plan as those plan designs are specified in subsections a., d., and f. of this section may be modified by the [School Employees' Health Benefits Plan Design Committee] commission pursuant to this subsection.

Modifications to plan design of the plans set forth in this section made by the School Employees' Health Benefits Plan Design Committee or the State Treasurer pursuant to section 7 of this act shall be implemented by the program for the purposes of this section commencing January 1, 2024.

f. The plan design of the New Jersey Educators Health Plan shall be the following:

In Network Benefits

Coverage

Member Coinsurance:10%, Applies Only to Emergency Transportation Care and Durable Medical Equipment

Deductible:N/A

Out-of-Pocket Maximum:$500 Single/ $1,000 Family (covers all in network copayments, coinsurance, and deductible)

Emergency Room Copayment:$125 (To be Waived if Admitted)

PCP Office Visit Copayment:$10

Specialist Office Visit Copayment$15Out-of-Network Benefits

Coverage

Member Coinsurance:30% of the Out-of-Network Fee Schedule

Deductible:$350 / $700

Out-of-Pocket Maximum:$2,000 Single / $5,000 Family Routine Lab:Paid at Out-of-Network Benefit Level

Out-of-Network Fee Schedule:200% of CMS - MedicarePharmacy

Out-of-Pocket Maximum:$1,600 Single / $3,200 Family (Indexed Annually Pursuant to Federal Law)Generic Copayment:$5 Retail 30 Day Supply / $10 Mail 90 Day SupplyBrand Copayment:$10 Retail 30 Day Supply/ $20 Mail 90 Day SupplyMandatory Generic:Member Pays Difference in Cost Between Generic and Brand, Plus Brand CopaymentFormulary: Closed Formulary as contracted with the Pharmacy Benefit Manager and the School Employees' Health Benefits CommissionOther

Chiropractic, Physical Therapy, and Acupuncture:

Subject to the same Out-of-Network Limits as for the State Health Benefits Program as were in effect on June 1, 2020 to take effect as of July 1, 2020, or as soon thereafter as reasonably practicable.

Under a patient centered medical home model, there shall be no office visit copay for primary care for participants who select and commit to a patient centered medical home for primary care in accordance with plan rules and regulations.

g. Any plan offered by the School Employees' Health Benefits Program shall require that chiropractic, physical therapy, and acupuncture benefits shall be subject to the same out-of-network limits as for the State Health Benefits Program that were in effect on June 1, 2020 to take effect as of July 1, 2020 or as soon thereafter as reasonably practicable.

h. Notwithstanding any provision of law, rule, or regulation to the contrary, for any period of time during which the employer does not have to pay a premium or periodic charge for any health care benefits plan or program provided to its employees through the School Employees' Health Benefits Program, an employee enrolled in such plan or program shall not be required to make the employee's contribution toward that premium or periodic charge during that period of time. In the event that a collective negotiations agreement specifically addresses a premium holiday the collective negotiations agreement shall be controlling.

i. Notwithstanding the provisions of this section, or any other law, rule, or regulation to the contrary, on or after the effective date of P.L. , c. (pending before the Legislature as this bill), the commission, in consultation with the program actuary, shall ensure that the actuarial value of any plan offered to employees and non-Medicare eligible retirees shall not be less than 85 percent.

(cf: P.L.2021, c.163, s.2)

11. Section 55 of P.L.2011, c.78 (C.52:14-17.27b) is repealed.

12. This act shall take effect immediately.

STATEMENT

This bill, designated as the “Property Tax Relief Act,” makes various changes to State Health Benefits Program and (SHBP) and School Employees’ Health Benefits Program (SEHBP) administration and reimbursement levels.

Reimbursement Level for Certain Procedures

The bill limits reimbursement for certain medical procedures covered under SHBP and the SEHBP. Under the bill, reimbursement for knee replacements, hip replacements, magnetic resonance imaging (MRI) scans, computed tomography (CT) scans, colonoscopies, cataracts, arthroscopy, and diagnostic lab tests performed in an inpatient or outpatient hospital setting will be limited to the lesser of the contract price, the billed price, or the reference price defined as 165 percent of the amount paid by Medicare for the same or a similar procedure for in-network providers and 150 percent for out-of-network providers.

The bill prohibits a carrier, hospital, or State-managed care plan from collecting any money from a covered employee, retiree, dependent, or either program in excess of this amount for the procedures covered under the bill.

The reimbursement limitations established by the bill will not apply when a procedure listed under the bill is performed in a rural hospital certified by the U.S. Centers for Medicare and Medicaid Services as a sole community hospital; a critical access hospital certified by the U.S. Centers for Medicare and Medicaid Services; or a hospital with a monitor appointed by the New Jersey Department of Health. The limitation also excludes any service or procedure that is performed in an emergency.

The bill will not be interpreted to require a health benefit plan offered by the SHBP or the SEHBP to reimburse claims using a fee-for-service payment method.

The bill requires the Department of the Treasury to evaluate the listed procedures covered under the bill within two years of the effective date. The evaluations will assess the amount of money each program saved on those procedures and recommend changes to the list of procedures for consideration by the Legislature.

Responsibility for Plan Design

This bill eliminates the SHBP Plan Design Committee and the SEHBP Plan Design Committee and transfers the powers and functions of each committee to the respective commission. With the elimination of the SHBP Plan Design Committee and SEHBP Plan Design Committee, the bill ends the use of a super conciliator by the SHBP and the SEHBP to resolve deadlocked matters before the committees, and repeals that statute from the current law.

Plan Value

In addition, this bill requires any plan offered on or after the bill’s effective date by the SHBP or the SEHBP to have an actuarial value of at least 85 percent.

Local and Education Participation in SHBP and SEHBP

The bill also requires that, within one year from the effective date of this bill, any employer other than the State will be required to make a determination as to whether or not to participate in the SHBP, and any employer as defined under current law will be required to make a determination as to whether to participate in the SEHBP. Any employer other than the State which elects to participate in the SHBP and any employer that elects to participate in the SEHBP upon the conclusion of that year will be required to remain enrolled in the program for three consecutive plan years. Any employer that elects to leave either program upon the conclusion of that year will be prohibited from reenrolling for three consecutive plan years. Any employer that is not enrolled in the program and does not elect to participate within that year shall be permitted to join at any time, but shall be required to remain enrolled in the program for three consecutive plan years following new enrollment.