PLEASE DO NOT ALTER THIS FORM - ANY MODIFICATION TO …

Name of Managed Care Organization:

State of New Jersey Department of Banking and Insurance

For the Period Ending:

General Acute Care Hospitals

PLEASE DO NOT ALTER THIS FORM - ANY MODIFICATION TO THIS FORM IS PROHIBITED

General Acute Care Hospitals

Contracted Date Contract

Yes

No

Expires

Hospital Services

ATLANTIC

AtlantiCare Regional Medical Center-City Division AtlantiCare Regional Medical CenterMainland Division

No OB Beds 1

4

3

5

Shore Medical Center

BERGEN

Bergen New Bridge Medical Center Englewood Hospital and Medical Center Hackensack University Medical Center Holy Name Medical Center HackensackUMC At Pascack Valley

No OB Beds RPC, CH

1

3

5

12345

5

The Valley Hospital

1

3

5

BURLINGTON

Virtua Marlton Hospital Virtua Memorial Hospital Virtua Willingboro Hospital

No OB Beds

5

5

No OB Beds

CAMDEN

Cooper Hospital/University Medical Center Jefferson Cherry Hill Hospital Jefferson Stratford Hospital Virtua Our Lady of Lourdes Hospital

RPC, CH No OB Beds No OB Beds RPC

12345

1

3

5

Virtua Voorhees Hospital

RPC

12

CAPE MAY

Cape Regional Medical Center

No OB Beds

CUMBERLAND

Inspira Medical Center Vineland

1

ESSEX

Clara Maass Medical Center Cooperman Barnabas Medical Center CareWell Health Medical Center HackensackUMC Mountainside Hospital Newark Beth Israel Medical Center Saint Michael's Medical Center

5

RPC

123

5

No OB Beds

5

RPC, CH

123

5

No OB Beds

3

5

University Hospital

RPC

12345

Report hospitals with a written executed contract with the Plan. All other arrangements must be reported under comments. 1. NJDHSS licensed Neonatal Intensive Care Unit (NICU) Bassinets 2. NJDHSS licensed Pediatric Intensive Care Unit (PICU) beds 3. NJDHSS designated Cardiac Surgery 4. NJDHSS designated Level l or II Trauma Center 5. NJDHSS designated Primary Angioplasty Site (RPC) - NJDHSS licensed Regional Perinatal Center (CH) - NJDHSS licensed Children's Hospital

rev. 4/26/23

Name of Managed Care Organization:

For the Period Ending:

General Acute Care Hospitals

PLEASE DO NOT ALTER THIS FORM - ANY MODIFICATION TO THIS FORM IS PROHIBITED

General Acute Care Hospitals

GLOUCESTER

Inspira Medical Center Mullica Hill Jefferson Washington Township Hospital

HUDSON

CarePoint Health-Bayonne Medical Center CarePoint Health-Christ Hospital CarePoint Health-Hoboken University Medical Center Hudson Regional Hospital Jersey City Medical Center Palisades Medical Center

HUNTERDON

Hunterdon Medical Center

MERCER

Capital Health Regional Medical Center Capital Health Medical Center - Hopewell RWJ University Hospital at Hamilton

MIDDLESEX

Raritan Bay Medical Center-Old Bridge Raritan Bay Medical Center - Perth Amboy JFK Medical Center RWJ University Hospital at New Brunswick Penn Medicine Princeton Medical Center Saint Peter's University Hospital

MONMOUTH

Bayshore Community Hospital CentraState Medical Center Jersey Shore University Medical Center Monmouth Medical Center Riverview Medical Center

MORRIS

Chilton Medical Center Morristown Medical Center St. Clare's Hospital - Dover St. Clare's Hospital - Denville

OCEAN

Community Medical Center Monmouth Medical Center - Southern Campus Ocean Medical Center - Brick Southern Ocean Medical Center

Contracted

Yes

No

Date Contract Expires

Hospital Services

5 1

5 5

RPC

1

345

No OB Beds RPC No OB Beds No OB Beds

RPC, CH CH, RPC No OB Beds RPC, CH RPC, CH

RPC, CH No OB Beds

No OB Beds

5

34

1

5

5

5

5

12345

5

12

5

12345

12

5

5

5 12345

5

5 5

Report hospitals with a written executed contract with the Plan. All other arrangements must be reported under comments. 1. NJDHSS licensed Neonatal Intensive Care Unit (NICU) Bassinets 2. NJDHSS licensed Pediatric Intensive Care Unit (PICU) beds 3. NJDHSS designated Cardiac Surgery 4. NJDHSS designated Level l or II Trauma Center 5. NJDHSS designated Primary Angioplasty Site (RPC) - NJDHSS licensed Regional Perinatal Center (CH) - NJDHSS licensed Children's Hospital

State of New Jersey Department of Banking and Insurance

Name of Managed Care Organization:

For the Period Ending:

General Acute Care Hospitals

PLEASE DO NOT ALTER THIS FORM - ANY MODIFICATION TO THIS FORM IS PROHIBITED

General Acute Care Hospitals

Contracted

Yes

No

Date Contract Expires

Hospital Services

PASSAIC

St. Joseph's University Medical Center

RPC, CH

12345

St. Joseph's Wayne Medical Center

No OB Beds

St. Mary's General Hospital

3

5

SALEM

Inspira Medical Center Elmer

Salem Medical Center

No OB Beds

SOMERSET

RWJ University Hospital at Somerset

5

SUSSEX

Newton Medical Center

UNION

Overlook Medical Center RWJ University Hospital at Rahway

1

5

No OB Beds

5

Trinitas Regional Medical Center

5

WARREN

Hackettstown Regional Medical Center

No OB Beds

St. Luke's Warren Hospital

No OB Beds

Report hospitals with a written executed contract with the Plan. All other arrangements must be reported under comments. 1. NJDHSS licensed Neonatal Intensive Care Unit (NICU) Bassinets 2. NJDHSS licensed Pediatric Intensive Care Unit (PICU) beds 3. NJDHSS designated Cardiac Surgery 4. NJDHSS designated Level l or II Trauma Center 5. NJDHSS designated Primary Angioplasty Site (RPC) - NJDHSS licensed Regional Perinatal Center (CH) - NJDHSS licensed Children's Hospital

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