ASSEMBLY, No. 1997

STATE OF NEW JERSEY

214th LEGISLATURE

 

INTRODUCED FEBRUARY 8, 2010

 


 

Sponsored by:

Assemblyman  HERB CONAWAY, JR.

District 7 (Burlington and Camden)

Assemblywoman  JOAN M. QUIGLEY

District 32 (Bergen and Hudson)

 

 

 

 

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

     As introduced.

  


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.


STATEMENT

 

     This bill, which supplements the “Health Care Quality Act,” is intended to reduce the administrative burden and delay, both for primary care providers who are health maintenance organization (HMO) or other managed care network providers and their patients, which is associated with the process of providing written patient referrals to specialist network providers, while still retaining the gatekeeper role for primary care physicians that is common to HMOs and certain other managed care plans.

     The bill provides as follows:

·   An HMO, which is the primary but not only form of managed care plan requiring primary care provider referrals, must permit an enrollee to receive covered services from a specialist health care provider in its provider network without obtaining a written referral from the enrollee’s primary care provider, provided that the enrollee’s primary care provider of record:

     --  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 is to present to the specialist network provider; or

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

·   A communication that is provided to an enrollee or transmitted to a specialist network provider by the enrollee’s primary care provider pursuant to this bill is to be operative for a period of one year from the date that it is provided or transmitted.

·   The above provisions of the bill 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 an HMO, 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.

·   Nothing in the bill is to be construed to permit an HMO enrollee or other covered person in a managed care plan to access a another network provider directly without initial approval from the person’s primary care physician of record.

·   The bill takes effect on the 180th day after enactment, but authorizes the Commissioner of Banking and Insurance to take anticipatory administrative action in advance as necessary for its implementation.