Bill Text: NJ S2372 | 2010-2011 | Regular Session | Introduced
Bill Title: Clarifies out-of-network payment responsibilities under health benefits plans; requires certain coverage and procedure disclosures to consumers; revises procedures for changes to managed care plan contracts.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2010-11-08 - Introduced in the Senate, Referred to Senate Commerce Committee [S2372 Detail]
Download: New_Jersey-2010-S2372-Introduced.html
Sponsored by:
Senator JOSEPH F. VITALE
District 19 (Middlesex)
SYNOPSIS
Clarifies out-of-network payment responsibilities under health benefits plans; requires certain coverage and procedure disclosures to consumers; revises procedures for changes to managed care plan contracts.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health benefits plans and amending and supplementing various parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. (New section) a. A health care provider delivering health care services under a managed care plan or a self-funded health benefits plan shall make a good faith and timely effort to collect each covered person's liability, including any deductible, copayment, or coinsurance, owed by a covered person to the provider pursuant to the terms of the covered person's health benefits plan. For the purposes of this section, a health care provider shall be deemed to have made a good faith and timely effort to collect the covered person's liability if the health care provider makes three good faith and timely attempts to collect.
b. A health care provider shall retain all records relating to any attempt to collect a covered person's liability pursuant to subsection a. of this section for at least seven years following the date on which the record is made. All such records shall be open to inspection, upon request, by the Department of Banking and Insurance.
c. Notwithstanding subsection a. of this section, a health care provider may waive a covered person's liability to the provider if: (1) the health care provider determines that the covered person has a medical or financial hardship; and (2) such waivers are not granted by the health care provider routinely or excessively. The health care provider shall notify the carrier or the entity providing a self-funded health benefits plan whenever the health care provider waives a covered person's liability pursuant to this subsection.
2. (New section) a. A carrier which offers a managed care plan or an entity which offers a self-funded health benefits plan shall establish and maintain a website to serve as an information clearinghouse for covered persons to obtain information to assist them in their health care needs. The link to the website shall be prominently displayed on the back of each health benefits card issued to a covered person. For the purposes of this section, a "health benefits card" means a card issued to a covered person for the limited purpose of obtaining health care services from a health care provider participating in a network of providers under a managed care plan or a self-funded health benefits plan.
b. The website shall be updated regularly and shall include, but not be limited to, information regarding:
(1) quality rankings for health care
providers, which shall be
provided in a manner to be prescribed by the Department of Banking and
Insurance, in consultation with the State Board of Medical Examiners, the
Division of Consumer Affairs, and the Department of Health and Senior
Services; and
(2) such other information as the Department of Banking and Insurance determines appropriate and necessary to ensure a covered person receives sufficient information necessary to make a well-informed health care decision.
c. The website shall contain links to the information set forth in subsection b. of this section. Each link shall be prominently displayed on the website in at least 14 point font to ensure each link is easily accessible by covered persons and those seeking the information set forth in subsection b. on the website.
3. (New section) a. A health care facility, as defined in section 2 of P.L.1971, c.136 (C.26:2H-2), shall, when scheduling an appointment with a covered person, disclose to that person whether the health care services delivered by the health care facility are in-network or out-of-network with respect to that person's health benefits plan as defined in section 1 of P.L.1999, c.409 (C.17:48H-1) or the covered person's self-funded health benefits plan.
b. The disclosure required pursuant to subsection a. of this section shall include information explaining the financial responsibility of the person concerning any applicable deductibles, copayments, and coinsurance for the receipt of health care services.
c. Any health care facility delivering health care services for any non-emergency or elective procedure shall, prior to delivering the health care services, provide the covered person receiving those services with a description of the procedure and an estimate of the costs for those services in the covered person's primary language.
4. (New section) a. A practitioner, as defined in section 1 of P.L.1989, c.19 (C.45:9-22.4) shall, when scheduling an appointment with a covered person to provide health care services, disclose to that person whether the practitioner is in-network or out-of-network with respect to the covered person's health benefits plan as defined in section 1 of P.L.1999, c.409 (C.17:48H-1) or the covered person's self-funded health benefits plan.
b. The disclosure requirement set forth in subsection a. of this section shall include information explaining the financial responsibility of the covered person concerning any applicable deductibles, copayments, and coinsurance for the receipt of health care services.
c. A practitioner delivering health care services for any non-emergency or elective procedure shall, prior to delivering the health care services, provide the covered person receiving those services with a description of the procedure and an estimate of the costs for those services in the covered person's primary language.
d. The State Board of Medical Examiners may specify the manner in which the description of the procedure and the cost estimate required by subsection c. of this section shall be provided.
e. A practitioner who fails to comply with this section is liable for action by the State Board of Medical Examiners pursuant to R.S. 45:9-1 et seq.
5. (New section) a. A health care provider may file a complaint with the ombudsman, on a form prescribed by the ombudsman, based on a determination pursuant to subsection d. of section 2 of P.L.2001, c.367 (C.26:2S-6.1) to exempt the health care provider from the provisions of subsection c. of section 2 of P.L.2001, c.367 (C.26:2S-6.1).
b. Upon the filing of a complaint, the ombudsman may, in a manner consistent with sections 47 through 61 of P.L.1998, c.21 (C.17:29E-1 et seq.), and within a reasonable time:
(1) Conduct an investigation regarding any alleged violations of any of the provisions of section 1 of P.L. , c. (C. )(pending before the Legislature as this bill);
(2) Compel the health care provider, the carrier, the entity providing a self-funded health benefits plan, or any covered person to produce at a specific time and place, by subpoena, any documents, books, records, papers, objects or other evidence which he believes may relate to the investigation; and
(3) Hold a hearing.
c. The ombudsman shall, within a reasonable time, affirm or reverse the determination pursuant to subsection d. of P.L.2001, c.367 (C.26:2S-6.1), to exempt the health care provider from the provisions of subsection c. of section 2 of P.L.2001, c.367 (C.26:2S-6.1). The decision shall be based on a finding as to whether the health care provider violated any of the provisions of section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill) and whether that violation warranted exemption from the provisions of subsection c. of section 2 of P.L.2001, c.367 (C.26:2S-6.1). The ombudsman shall report his decision and a statement of his findings of fact to the health care provider and the carrier or the entity providing the self-funded health benefits plan, as appropriate.
d. The ombudsman shall calculate the costs of any hearing or investigation and notify the non-prevailing party of those costs. The non-prevailing party shall reimburse the ombudsman for those costs within 30 days of receipt of the notice.
6. Section 2 of P.L.2001, c.367 (C.26:2S-6.1) is amended to read as follows:
2. a. With respect to a carrier which offers a managed care plan that provides for both in-network and out-of-network benefits, in the event that:
(1) a covered person is admitted by an out-of-network health care provider to an in-network health care facility for covered, medically necessary health care services; or
(2) the covered person receives covered, medically necessary health care services from an out-of-network health care provider while the covered person is a patient at an in-network health care facility and was admitted to the health care facility by an in-network provider, the carrier shall reimburse the health care facility for the services provided by the facility at the carrier's full contracted rate without any penalty for the patient's selection of an out-of-network provider, in accordance with the in-network policies and in-network copayment, coinsurance or deductible requirements of the managed care plan.
b. The provisions of subsection a. of this section shall apply only if the covered person complies with the preauthorization or review requirements of the health benefits plan regarding the determination of medical necessity to access in-network inpatient benefits, as set forth in writing pursuant to section 5 of P.L.1997, c.192 (C.26:2S-5).
c. With respect to a carrier which offers a managed care plan or an entity which offers a self-funded health benefits plan that provides for both in-network and out-of-network benefits, in the event that the covered person assigns, through an assignment of benefits, his right to receive reimbursement for medically necessary health care services to an out-of-network health care provider, the carrier or entity shall remit payment for the reimbursement directly to the health care provider in the form of a check payable to the health care provider, or in the alternative, to the health care provider and the covered person as joint payees, with a signature line for each of the payees. Payment shall be made in accordance with the provisions of this section and P.L.1999, c.154 (C.17B:30-23 et al.). Any payment made only to the covered person rather than the health care provider under these circumstances shall be considered unpaid, and unless remitted to the health care provider within the time frames established by P.L.1999, c.154 (C.17B:30-23 et al.), shall be considered overdue and subject to an interest charge as provided in that act.
d. (1) The provisions of subsection c. of this section pertaining to the right of an out-of-network health care provider to receive payment for reimbursement directly from a carrier or an entity which offers a self-funded health benefits plan shall not apply if a carrier or entity determines that a health care provider has violated any of the provisions of section 1 of P.L. , c. (C. )(pending before the Legislature as this bill).
(2) The carrier or entity shall not make such a determination unless the health care provider commits a pattern of violations of any of the provisions of section 1 of P.L. , c. (C. )(pending before the Legislature as this bill) for a period of at least six months. If the carrier or entity makes such a determination, the carrier or entity shall notify the health care provider 30 days in advance of exempting the provider from the provisions of subsection c. of this section. The exemption shall not exceed a period of one year from the date of the notification.
(3) A health care provider exempted from the provisions of subsection c. of this section shall have the right to appeal such a determination to the Office of the Insurance Claims Ombudsman in the Department of Banking and Insurance pursuant to section 5 of P.L. , c. (C. )(pending before the Legislature as this bill).
(4) The carrier or entity shall not make a determination to exempt a health care provider pursuant to this subsection until six months after the effective date of P.L. , c. (C. ) (pending before the Legislature as this bill).
(cf: P.L.2009, c.209, s.1)
7. Section 8 of P.L.1997, c.192 (C.26:2S-8) is amended to read as follows:
8. A carrier which offers a managed care plan shall establish a policy governing removal of health care providers from the provider network which includes the following:
a. The carrier shall inform a participating health care provider of the carrier's removal policy at the time the carrier contracts with the health care provider to participate in the provider network, and at each renewal thereof.
b. If a licensed health care professional's participation will be terminated prior to the date of the termination of the contract, the carrier shall provide the health care professional with 90 days' written notice of the termination and notice of a right to a hearing.
If requested by the health care professional, the carrier shall provide the reasons for the termination in writing, and shall hold a hearing within 30 days of the date of the request. The hearing shall be conducted by a panel appointed by the carrier, which panel shall be comprised of a minimum of three persons, at least one of whom is a clinical peer in the same discipline and the same or similar specialty as the health care professional being reviewed. The panel shall make a decision that: (1) the health care professional shall be terminated, or (2) the health care professional shall be reinstated or provisionally reinstated, subject to conditions set forth by the panel. The panel's determination shall be in writing and shall be made in a timely manner. Participation in this process shall not be deemed to be an abrogation of the health care professional's legal rights.
The notice required and opportunity for a hearing pursuant to this subsection shall not apply in those cases when the contract expires and is not renewed, the termination is for breach of contract, in the opinion of the medical director, the health care professional represents an imminent danger to an individual patient or the public health, safety or welfare, or there is a determination of fraud.
c. If the carrier finds that a health care professional represents an imminent danger to an individual patient or to the public health, safety or welfare, the medical director shall promptly notify the appropriate professional State licensing board. Notification to the State Board of Medical Examiners shall be subject to the provisions of section 5 of P.L.1989, c.300 (C.45:9-19.5).
d. The carrier shall not terminate participation of a health care provider based solely on a determination that the provider referred a covered person to an out-of-network health care provider.
(cf: P.L.1997, c.192, s.8)
8. Section 9 of P.L.1997, c.192 (C.26:2S-9) is amended to read as follows:
9. The contract between a participating health care provider and a carrier which offers a managed care plan:
a. Shall state that the health care provider shall not be penalized or the contract terminated by the carrier because the health care provider acts as an advocate for the patient in seeking appropriate, medically necessary health care services;
b. Shall not provide financial incentives to the health care provider for withholding covered health care services that are medically necessary as determined in accordance with section 6 of this act, except that nothing in this subsection shall be construed to limit the use of capitated payment arrangements between a carrier and a health care provider; [and]
c. Shall protect the ability of a health care provider to communicate openly with a patient about all appropriate diagnostic testing and treatment options; and
d. Shall state that unless a change is agreed upon by both carrier and health care provider, a change may be made in the contract only once in each calendar year and shall be made only if:
(1) the carrier provides the health care provider with written notice of any proposed change at least 30 days prior to the implementation of the change; and
(2) the change conforms to any regulations and standards adopted by the Commissioner of Banking and Insurance.
(cf: P.L.1997, c.192, s.9)
9. This act shall take effect on the 90th day next following enactment.
STATEMENT
This bill makes various changes to the administration of health benefits plans, regarding consumer disclosure, and the responsibilities of plan providers and health care providers. Some of the bill's provisions address only health benefits plans that are insurance plans provided by health insurance carriers. Other provisions affect both health insurance plans and health benefits plans that are self-funded plans under which an employer or a union provide the plan by fully funding the plan.
The bill requires that a health care provider make a good faith and timely effort to collect a covered person's liability, including any deductible, copayment, or coinsurance, owed by a covered person to the provider pursuant to the terms of the covered person's health benefits plan. The bill also provides that a provider shall be deemed to have made a good faith effort to collect the covered person's liability if the health care provider makes three good faith and timely attempts to collect. Under the bill, a health care provider may waive a covered person's liability to the provider if: (1) the health care provider determines that the covered person has a medical or financial hardship; and (2) such waivers are not granted by the health care provider routinely or excessively. The bill requires the health care provider to notify the carrier or the entity providing a self-funded health benefits plan whenever the health care provider waives a covered person's liability. The bill requires health care providers to maintain records relating to any attempts to collect a covered person's liability for at least seven years and to disclose such information to the Department of Banking and Insurance upon request.
The bill allows a carrier or entity providing a self-funded health benefits plan, if the carrier or entity determines that a health care provider has committed a pattern of violations of section 1 of the bill concerning waivers of payment by a covered person, to exempt the provider from the provision law which gives an out-of-network health care provider the right to receive payment for reimbursement directly through an assignment of benefits. Under the bill, the carrier or entity is required to notify the health care provider 30 days in advance of exempting the provider and the exemption is not permitted to exceed a period of one year from the date of the notification. The bill further provides that a determination imposing the exemption may not be made until six months after the effective date of this bill.
The bill also provides that a health care provider has the right to appeal such a determination to the Office of the Insurance Claims Ombudsman in the Department of Banking and Insurance. The bill establishes a procedure for such an appeal and provides the ombudsman with authority, within a reasonable period of time, to conduct an investigation, hold a hearing, and render a binding decision as to upholding or overturning the determination. The bill also requires the non-prevailing party to reimburse the ombudsman for the costs of the investigation and hearing.
The bill also requires health care facilities and health care practitioners delivering health care services for any non-emergency or elective procedure to provide the person receiving those services with a description of the procedure and an estimate of the costs for those services in the person's primary language, prior to delivering the health care services.
This bill requires health care facilities and health care practitioners to disclose to covered persons, when scheduling an appointment with a covered person to provide health care services, whether those services or that practitioner are in-net-work or out-of-network. The bill requires the facility or practitioner to disclose information to the covered person explaining the financial responsibility of the covered person concerning any applicable deductibles, copayments and coinsurance for the receipt of in-network services if the health care provider is in-network, or out-of-network services if the health care provider is out-of-network.
This bill requires health insurance carriers that offer health benefits plans and entities providing self-funded health benefits plans to residents of this State to establish and maintain a website to serve as an information clearinghouse for covered persons to obtain information to assist them in their health care needs. A link to the website must be featured and prominently displayed on the back of each health benefits card issued to covered persons to ensure that they are aware of the website.
Specifically, the bill requires carriers and entities providing self-funded health benefits plans to include on their websites links to information regarding: (1) quality rankings for health care providers, in a manner to be prescribed by the Department of Banking and Insurance, in consultation with the State Board of Medical Examiners, the Division of Consumer Affairs, and the Department of Health and Senior Services; and (2) any other information that the Department of Banking and Insurance determines is appropriate and necessary to ensure that covered persons receive sufficient information needed to make well-informed health care decisions. The bill also prescribes a minimum font size and location for each link featuring the information prescribed.
The bill adds to the current policies governing when a health insurance carrier can remove a health care provider from a provider network, a requirement that the carrier shall not terminate participation of the provider based solely on a determination that the provider referred a covered person to an out-of-network health care provider.
Finally, the bill provides that a contract between a participating health care provider and a health insurance carrier which offers a managed care plan shall state that, unless a change is agreed upon by both the carrier and the health care provider, a change may be made in the contract only once in each calendar year and shall be made only if:
(1) the carrier provides the health care provider with written notice of any proposed change at least 30 days prior to the implementation of the change; and
(2) the change conforms to any regulations and standards adopted by the Commissioner of Banking and Insurance.
