SENATE, No. 289

STATE OF NEW JERSEY

217th LEGISLATURE

 

PRE-FILED FOR INTRODUCTION IN THE 2016 SESSION

 


 

Sponsored by:

Senator  JOSEPH F. VITALE

District 19 (Middlesex)

Senator  RAYMOND J. LESNIAK

District 20 (Union)

 

 

 

 

SYNOPSIS

     Requires disclosures of out-of-network services performed by health care providers under certain circumstances.

 

CURRENT VERSION OF TEXT

     Introduced Pending Technical Review by Legislative Counsel.

  


An Act concerning certain health care costs and supplementing Title 26 of the Revised Statutes.

 

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

 

1.      As used in this act:

     “Carrier” means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State.

     “Covered person” means a person on whose behalf a carrier offering the plan is obligated to pay benefits or provide services pursuant to the health benefits plan.

     “Covered service” means a health care service provided to a covered person under a health benefits plan for which the carrier is obligated to pay benefits or provide services, except for services related to the treatment of an emergency medical condition.

     “Health benefits plan” means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier.  Health benefits plan includes, but is not limited to, Medicare supplement coverage and risk contracts to the extent not otherwise prohibited by federal law.  For the purposes of this act, health benefits plan shall not include the following plans, policies, or contracts: accident only, credit, disability, long-term care, CHAMPUS supplement coverage, TRICARE supplement coverage, coverage arising out of a workers’ compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.) or hospital confinement indemnity coverage.

     “Health care facility” means a hospital or other health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.).

     “Health care professional” means a person licensed or otherwise authorized to practice in a health care profession pursuant to Title 45 or Title 52 of the Revised Statutes.

 

     2.    a.  A health care facility that is in-network as to a covered person’s health benefits plan, in situations in which a health care professional who is not in-network will provide a covered service to the covered person during the hospitalization or treatment at the health care facility, shall, prior to the provision of the covered service:

     (1)   provide a written disclosure form to the covered person that:

     (a)   states the name of any health care professional who is out-of-network as to the covered person’s health benefits plan and from whom the covered person will receive the covered service at the health care facility; and

     (b)   contains a description of the covered service to be provided by the out-of-network health care professional; and

     (2)   obtain a written consent form, signed by the covered person or the covered person’s representative, which expressly allows the out-of-network health care professional to provide the covered service.

     b.    The disclosure and consent forms required to be provided pursuant to this section shall be made available to the covered person in English and in the covered person’s first language.

     c.     A health care facility that fails to comply with this section shall be liable for action by the Department of Health pursuant to section 13 of P.L.1971, c.136 (C.26:2H-13).

     d.    The Commissioner of Health shall adopt, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the purposes of this section, including the manner in which the disclosure and consent forms required by subsections a. and b. of this section shall be provided. 

 

     3.    a.  A health care professional who is in-network as to a covered person’s health benefits plan, in situations in which a health care professional who is not in-network will assist or cooperate with the health care professional in providing a covered service to the covered person, shall, prior to the provision of the covered service:

     (1)   provide a written disclosure form to the covered person that:

     (a)   states the name of any health care professional who is out-of-network as to the covered person’s health benefits plan and from whom the covered person will receive the covered service; and

     (b)   contains a description of the covered service to be provided by the out-of-network health care professional; and

     (2)   obtain a written consent form, signed by the covered person or the covered person’s representative, which expressly allows the out-of-network health care professional to provide the covered service.

     b.    The disclosure and consent forms required to be provided pursuant to this section shall be made available to the covered person in English and in the covered person’s first language.

     c.     A health care professional who fails to comply with this section shall be liable for action by the licensing board that governs the licensing of that health care profession.

     d.    The Director of the Division of Consumer Affairs, in consultation with appropriate licensing boards, shall pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), adopt rules and regulations necessary to effectuate the purposes of this section, including the manner in which the disclosure and consent forms required by subsections a. and b. of this section shall be provided. 

     4.    This act shall take effect on the 90th day next following enactment but the Commissioner of Health and the Director of the Division of Consumer Affairs may take such anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.

 

 

STATEMENT

 

     This bill requires health care facilities and health care professionals that are in-network as to a covered person’s health benefits plan to make certain disclosures to health care consumers about out-of-network covered services, prior to the provision of the services.

     The bill provides that a health care facility and a health care professional that is in-network, in situations in which a healthcare professional who is not in-network will provide a non-emergency covered service, shall, prior to providing the covered service:

     (1)   provide a written disclosure form to the covered person that states the name of any health care professional who is out-of-network as to the covered person’s health benefits plan and who will provide a covered service, and that contains a description of the covered service to be provided by the out-of-network health care professional; and

     (2)   obtain a written consent form, signed by the covered person or the covered person’s representative, which expressly allows the out-of-network health care professional to provide the covered service.

     The disclosure and consent forms shall be made available to the covered person in English and in the covered person’s first language.

     A health care facility that fails to comply with the bill’s provisions is liable for action by the Department of Health. A health care professional who fails to comply with the bill’s provisions is liable for action by the licensing board that governs the licensing of that health care profession.

     Finally, the bill provides that the Commissioner of Health and the Director of the Division of Consumer Affairs shall, as to health care facilities and health care professionals, respectively, adopt rules and regulations necessary to effectuate the purposes of the bill, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.).