A1380 ACS

Sponsored by:

Assemblyman HERB CONAWAY, JR.

District 7 (Burlington and Camden)

Assemblywoman LINDA R. GREENSTEIN

District 14 (Mercer and Middlesex)

Assemblyman ERIC MUNOZ

District 21 (Essex, Morris, Somerset and Union)

Assemblywoman JOAN M. VOSS

District 38 (Bergen)

Assemblywoman VALERIE VAINIERI HUTTLE

District 37 (Bergen)

Co-Sponsored by:

Assemblywomen Wagner and Evans

SYNOPSIS

Permits person covered by certain managed care plans to receive covered services from network provider without obtaining written referral from primary care provider.

CURRENT VERSION OF TEXT

Substitute as adopted by the Assembly Health and Senior Services Committee.

An Act concerning health maintenance organizations and supplementing P.L.1997, c.192 (C.26:2S-1 et seq.).

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. a. (1) A health maintenance organization shall permit an enrollee to receive covered services from a specialist health care provider in its provider network without obtaining a written or electronic referral from the enrollee’s primary care provider, provided that the enrollee’s primary care provider of record:

(a) provides the enrollee with a New Jersey Prescription Blank or other official form of communication that includes a diagnosis or reason for the referral, which the patient shall present to the specialist network provider, and which shall be operative for a period of one year from the date of issuance by the primary care provider; or

(b) transmits such a communication to the specialist network provider by computer, telephone facsimile machine, or other means.

(2) A communication that is provided to an enrollee or transmitted to a specialist network provider by the enrollee’s primary care provider pursuant to paragraph (1) of this subsection shall be operative for a period of one year from the date that it is provided or transmitted.

b. Nothing in this act shall be construed to permit the enrollee of a health maintenance organization to access a specialist network provider directly without initial approval from the enrollee’s primary care provider of record.

c. The provisions of subsections a. and b. of this section shall also apply with respect to a covered person and the covered person’s primary care provider of record in a managed care plan that is not offered by a health maintenance organization, but which requires a covered person to receive a written or electronic referral from a covered person’s primary care provider in order to receive covered services from a network health care provider.

2. The Commissioner of Banking and Insurance shall adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), to carry out the purposes of this act.

3. This act shall take effect on the 180th day after enactment, except that the Commissioner of Banking and Insurance may take such anticipatory administrative action in advance as shall be necessary for the implementation of the act.