Strengthens oversight and enforcement of network adequacy requirements for health insurance carriers; requires health insurance carriers to make network directory available.*

The bill's entire subject matter changed from mental health parity monitoring for minors (amending P.L.2019, c.58) to network adequacy enforcement and surprise billing protections (amending P.L.2018, c.32). The legislative findings now address inadequate provider networks, surprise out-of-network charges, and carrier non-compliance with network adequacy requirements.

Carriers must now undergo an annual audit of their provider network by an independent private auditing firm at the carrier's expense. Audit findings must be submitted to the commissioner or director and made publicly available on the department's website.

Carriers must make their network directory available in a downloadable, machine-readable format and are expressly prohibited from using copyright or any other means to restrict non-commercial use, publication, or dissemination of the directory.

All provisions specific to mental health parity monitoring for minors were removed, including: detailed NQTL definitions, annual carrier reports on mental health services for minors (usage rates, prior authorization data, appeal outcomes), market conduct reviews and secret shopper surveys targeting minors, and the requirement that DOBI post a public compliance report on mental health parity analyses.

A minimum penalty of $5,000 per day is imposed on carriers that fail to meet network adequacy requirements until full compliance is demonstrated. This is in addition to any other penalties available under federal or state law.

The penalty structure was replaced. The introduced version referenced the Health Care Quality Act penalties ($250 to $10,000 per day). The substitute sets specific tiers: up to $1,000 per violation (capped at $25,000 per occurrence) for health care facilities and carriers, and up to $100 per violation (capped at $2,500 per occurrence) for other persons or entities.

The commissioner and director must jointly prepare a guidance document within 90 days establishing the format for annual network adequacy audit submissions, and must submit an annual report by May 31 explaining how they have enforced network adequacy oversight through claims analysis, market conduct reviews, secret shopper surveys, and other means.

A new private cause of action is created allowing any resident who can demonstrate harm from a carrier's failure to meet network adequacy requirements to file suit seeking damages.

The definition of 'carrier' was expanded to explicitly include Medicaid and Medicaid managed care organizations, broadening the bill's reach to publicly funded plans. New definitions were added for 'inadvertent out-of-network services,' 'knowingly, voluntarily, and specifically selected an out-of-network provider,' 'machine-readable,' and 'medical necessity.'

The effective date changed from four months after enactment to immediate effect upon passage.