ASSEMBLY, No. 2988

STATE OF NEW JERSEY

217th LEGISLATURE

INTRODUCED FEBRUARY 16, 2016

 


 

Sponsored by:

Assemblyman† GARY S. SCHAER

District 36 (Bergen and Passaic)

Assemblywoman† L. GRACE SPENCER

District 29 (Essex)

Assemblyman† THOMAS P. GIBLIN

District 34 (Essex and Passaic)

 

 

 

 

SYNOPSIS

†††† "Healthcare Disclosure and Transparency Act."

CURRENT VERSION OF TEXT

†††† As introduced.

††


An Act concerning health benefits plans, amending P.L.1997, c.192 and supplementing Title 26 of the Revised Statues.

 

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

 

†††† 1.††† (New section) †Sections 1 through 5 of this act shall be known and may be cited as the "Health Care Disclosure and Transparency Act."

 

†††† 2.††† (New section) †As used in sections 3 through 5 of 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.

†††† ďCovered personĒ means a person on whose behalf a carrier or entity providing a self-funded health benefits plan is obligated to pay benefits or provide services pursuant to the health benefits plan.

†††† "Health benefits plan" means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is: (1) delivered or issued for delivery in this State by or through a carrier; or (2) offered in this State by an entity providing a self-funded health benefits plan.† 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, 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.), and 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.).

†††† ďPhysicianĒ means a physician licensed by the State Board of Medical Examiners to practice medicine and surgery pursuant to chapter 9 of Title 45 of the Revised Statutes.

 

†††† 3.††† (New section) a. A carrier which offers a health benefits plan or an entity which offers a self-funded health benefits plan shall disclose in writing to a covered person, at the time of enrollment in the plan and upon request thereafter, the reimbursement methodology that the carrier or entity uses to determine amounts of reimbursement for out-of-network health care services; and

†††† b.††† A carrier which offers a health benefits 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 ďhealth benefits cardĒ means a card issued to a covered person for the limited purpose of obtaining health care services under a health benefits plan. The website shall be updated regularly and shall include, but not be limited to:

†††† (1)†† links to quality rankings that are produced, audited, and publicly reported by State and federal agencies for physicians, which rankings 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;

†††† (2)†† for each health benefits plan offered in this State:

†††† (a)†† a clear and understandable description of the planís out-of-network health care benefits, including a covered personís financial responsibility for those benefits;

†††† (b)†† the reimbursement methodology of the carrier or entity, and based on the reimbursement methodology, the amount that the plan generally reimburses for each procedure or treatment for which coverage is provided as an out-of- network health care service; and

†††† (3)†† such other information as the Department of Banking and Insurance determines appropriate and necessary to ensure† that 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.

†††† d.††† The provisions of this section shall not apply to a health maintenance organization with respect to its contract with Medicaid.

†††† e.†††† A carrier that fails to comply with this section is liable to a penalty of not more than $1,000 for each violation. The penalty shall be collected by the Commissioner of Banking and Insurance in a summary proceeding in accordance with the ďPenalty Enforcement Law of 1999,Ē P.L.1999, c.274 (C.2A:58-10 et seq.).).

 

†††† 4.††† (New section) a. Prior to scheduling an appointment with a covered person for a non-emergency or elective procedure, and at least three days prior to the procedure, a health care facility shall provide a written disclosure form to the covered person on which the health care facility shall make the following disclosures, as applicable to each covered personís health benefits plan, in clear and understandable terms and in a language the covered person understands:

†††† (1)†† whether the health care facility is in-network or out-of-network with respect to the covered personís health benefits plan;

†††† (2)†† if the health care facility is in-network with respect to the personís health benefits plan, and the health care facility will ensure that the covered person will only receive health care services from health care providers that are in-network with respect to the covered personís health benefits plan, the health care facility shall disclose that:

†††† (a)†† all of the health care services received at the facility will be provided on an in-network basis; and

†††† (b)†† the covered person will have a financial responsibility applicable to an in-network procedure and not in excess of the covered personís copayment, deductible, or coinsurance as provided for in the covered personís health benefits plan.

†††† (3)†† if the health care facility is in-network, but a covered person may receive health care services in that facility from health care providers that are out-of-network with respect to the covered personís health benefits plan, the health care facility shall:

†††† (a)†† disclose that the health care services associated with the facility will be provided on an in-network basis, but other health care services, including services of certain physicians, may be provided on an out-of-network basis;

†††† (b)†† disclose that the covered person may have a financial responsibility applicable to certain out-of-network health care services, in excess of the covered personís copayment, deductible, or coinsurance as provided for in the covered personís health benefits plan, and that the covered person should contact his health insurance carrier for further consultation on those costs; and

†††† (c)†† provide the covered person with a list of the three health care facilities located closest to the health care facility that are in-network with respect to that personís health benefits plan.

†††† (4)†† if the health care facility is out-of-network with respect to the covered personís health benefits plan, the health care facility shall:

†††† (a)†† disclose that certain health care services will be provided on an out-of-network basis, including those health care services associated with the health care facility;

†††† (b)†† disclose that the covered person will have a financial responsibility applicable to health care services provided at an out-of-network facility, in excess of the covered personís copayment, deductible, or coinsurance as provided for in the covered personís health benefits plan, and that the covered person should contact his health insurance carrier for further consultation on those costs; and

†††† (c)†† provide the covered person with a list of the three health care facilities located closest to the health care facility that are in-network with respect to that personís health benefits plan.

†††† b.††† A health care facility shall, prior to the performance of the procedure, ensure that the covered person signs and returns the disclosure form to the health care facility.

†††† c.†††† The Department of Health may specify in further detail the content and design of the disclosure form and the manner in which the form shall be provided.

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

 

†††† 5.††† (New section) a. A physician shall, when scheduling an appointment with a covered person to provide health care services, disclose to that person whether the physician is in-network or out-of-network with respect to the personís health benefits plan.

†††† b.††† The disclosure required pursuant to subsection a. of this section shall inform the covered person that the covered person may have a financial responsibility, including any applicable deductibles, copayments, and coinsurance, for the receipt of health care services under the terms of the covered personís health benefits plan.

†††† c.†††† A physician delivering out-of-network health care services for any non-emergency or elective procedure shall, prior to delivering the health care services and in terms the covered person typically understands, provide the covered person receiving those services with a clear and understandable: (1) description of the procedure; (2) estimate of the costs for those services to be charged by that physician; and (3) notice to the covered person to contact the covered personís health insurance carrier for further consultation on the costs of the procedure.

†††† 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 physician 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.

 

†††† 6.††† 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] pursuant to the provisions of [section 5 of P.L.1989, c.300 (C.45:9-19.5)] the ďHealth Care Professional Responsibility and Reporting Enhancement Act,Ē P.L.2005, c.83 (C.45:1-33 et seq.).

†††† d.††† The carrier shall not terminate participation of a health care provider based on a determination that the provider referred a covered person to an out-of-network health care provider, except that this restriction shall not apply to a health maintenance organization with respect to a Medicaid contract.

(cf: P.L.1997, c.192, s.8)

 

7.† This act shall take effect on the 90th day next following enactment.

 

 

STATEMENT

 

†††† This bill is designated the "Healthcare Disclosure and Transparency Act" and requires providers of health benefits plans to:

†††† (1)†† disclose in writing to a covered person, at the time of enrollment in the plan and upon request thereafter, the reimbursement methodology that the carrier or entity uses to determine amounts of reimbursement for out-of-network services; and

†††† (2)†† 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 the websites to have:

†††† (1)†† links to quality rankings that are produced, audited, and publicly reported by State and federal agencies for physicians, which rankings 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;

†††† (2)†† for each health benefits plan offered in this State, a clear and understandable description of the planís out-of-network health care benefits, including a covered personís financial responsibility for those benefits and, based on the reimbursement methodology of the carrier or entity, the amount that the plan generally reimburses for each procedure or treatment for which coverage is provided as an out-of-network health care service; and

†††† (3)†† 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 requires a health care facility, at least three days prior to an elective procedure, to provide a written disclosure form to the covered person on which the health care facility shall make certain disclosures regarding whether the health care facility and physicians providing services at the facility are in-network or out-of-network with respect to the covered personís health benefits plan and information concerning the financial responsibility of the covered person with regard to services received at the facility. The health care facility must, prior to the performance of the procedure, ensure that the covered person signs and returns the disclosure form to the health care facility.

†††† The bill also requires a physician, when scheduling an appointment with a covered person, to disclose whether the health care services are in-network or out-of-network with respect to that personís health benefits plan and that there may be a financial responsibility of the covered person, including applicable deductibles, copayments and coinsurance.† The bill also requires the physician, if providing out-of-network services, to provide to the covered person, in a clear and understandable manner and in the terms the covered person typically understands, the following:

†††† (1)†† a description of the procedure;

†††† (2)†† an estimate of the costs charged by the physician for those services; and

†††† (3)†† a notice to contact their insurance carrier for further consultation on the costs of the procedure.

†††† The bill also amends the ďHealth Care Quality ActĒ by adding to the current policies governing when a health insurance carrier can remove a health care provider from a provider network.† The bill provides that the carrier shall not terminate participation of the provider based on a determination that the provider referred a covered person to an out-of-network health care provider.