NJ had previously mandated that all out of network plans in the SEH market reimburse out of network claims based on 80th percentile of HIAA. Starting in 2017, NJ is removing that requirement, and allowing the carriers to select the reimbursement schedule of their choosing. This change affects payment for voluntary out of network claims. Emergency out of network claims will still be paid at the in-network levels.

Each of the carriers have selected to move to a % of the CMS schedule - the percentages range from 110% to 150%. See below for each carriers' release. These changes will be effective upon each group's renewal in 2017.

The benefits of this move are greater transparency for the consumer, and potentially more plans with out of network benefits in the coming years. For those who already have out of network benefits, this change will be important to understand because their claims will pay differently (and probably at a lower reimbursement level) than they did previously.

If you have any questions, please contact [email protected].