Bill Text: NJ A3202 | 2014-2015 | Regular Session | Introduced
Bill Title: "Medicare Advantage Disclosure Act," requires health plans to notify subscribers of differences between plan benefits and original Medicare.
Spectrum: Partisan Bill (Democrat 5-0)
Status: (Introduced - Dead) 2014-05-15 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A3202 Detail]
Download: New_Jersey-2014-A3202-Introduced.html
Sponsored by:
Assemblywoman NANCY J. PINKIN
District 18 (Middlesex)
Assemblywoman LINDA STENDER
District 22 (Middlesex, Somerset and Union)
Assemblyman GORDON M. JOHNSON
District 37 (Bergen)
Assemblywoman SHAVONDA E. SUMTER
District 35 (Bergen and Passaic)
SYNOPSIS
"Medicare Advantage Disclosure Act," requires health plans to notify subscribers of differences between plan benefits and original Medicare.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning Medicare Advantage plans and designated as the Medicare Advantage Disclosure Act, and amending P.L.1997, c.192.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 4 of P.L.1997, c.192 (C.26:2S-4) is amended to read as follows:
4. A carrier shall disclose in writing to a subscriber, in a manner consistent with the "Life and Health Insurance Policy Language Simplification Act," P.L.1979, c.167 (C.17B:17-17 et seq.), the terms and conditions of its health benefits plan, and shall promptly provide the subscriber with written notification of any change in the terms and conditions prior to the effective date of the change. The carrier shall provide the required information at the time of enrollment and upon request thereafter.
a. The information required to be disclosed pursuant to this section shall include a description of:
(1) covered services and benefits to which the subscriber or other covered person is entitled;
(2) restrictions or limitations on covered services and benefits, including, but not limited to, physical and occupational therapy services, clinical laboratory tests, hospital and surgical procedures, prescription drugs and biologics, radiological examinations and behavioral health care services;
(3) financial responsibility of the covered person, including copayments and deductibles;
(4) prior authorization and any other review requirements with respect to accessing covered services;
(5) where and in what manner covered services may be obtained;
(6) changes in covered services or benefits, including any addition, reduction or elimination of specific services or benefits;
(7) the covered person's right to appeal and the procedure for initiating an appeal of a utilization management decision made by or on behalf of the carrier with respect to the denial, reduction or termination of a health care benefit or the denial of payment for a health care service;
(8) the procedure to initiate an appeal through the Independent Health Care Appeals Program established pursuant to this act; and
(9) such other information as the commissioner shall require.
b. The carrier shall file the information required pursuant to this section with the department.
c. In the case of a carrier that owns, wholly or in part, or contracts with a managed behavioral health care organization, the information required to be disclosed pursuant to this section shall include the following:
(1) the specific behavioral health care services covered and the specific exclusions that apply to the subscriber or other covered person;
(2) the covered person's responsibilities for obtaining behavioral health care services;
(3) the reimbursement methodology that the carrier and managed behavioral health care organization use to reimburse health care providers for behavioral health care services; and
(4) if the carrier offers a managed care plan that provides for both in-network and out-of-network benefits, the procedure that a covered person must utilize when attempting to obtain behavioral health care services from a health care provider who is not included in the network of providers used by the carrier or managed behavioral health care organization.
d. In the case of a Medicare Advantage plan, in addition to the disclosure required pursuant to 42 CFR 422.111, each element of the carrier's disclosure required pursuant to subsection a. of this section shall include a comparison between the plan and original Medicare. Prior to enrollment, a subscriber shall be required to sign a waiver that indicates the subscriber is aware of these differences and will no longer be eligible for benefits under the original Medicare program.
(cf: P.L.2005, c.172, s.2)
2. This act shall take effect on the first day of the fourth month next following the date of enactment.
STATEMENT
This bill, designated as the "Medicare Advantage Disclosure Act," requires health insurance carriers offering Medicare Advantage plans to disclose a comparison between the terms and conditions of the plan and original Medicare, in order to assist applicants in understanding what benefits under original Medicare they may lose by enrolling in a Medicare Advantage plan.
Current statute requires health plans to disclose in writing the terms and conditions (as specified by statute and regulation) of its health benefits plan to a subscriber, at the time of enrollment and upon request thereafter. The bill would require that, in the case of a Medicare Advantage plan, each element of this disclosure must include a comparison between the plan and original Medicare. Prior to enrollment, a subscriber would be required to sign a waiver that indicates the subscriber is aware of these differences and will no longer be eligible for benefits under the original Medicare program.
