ASSEMBLY, No. 539

 

STATE OF NEW JERSEY

 

Introduced Pending Technical Review by Legislative Counsel

 

PRE-FILED FOR INTRODUCTION IN THE 1996 SESSION

 

 

By Assemblywoman CRECCO

 

 

An Act concerning primary and preventive obstetrical and gynecological care provided by health maintenance organizations and supplementing P.L.1973, c.337 (C.26:2J-1 et seq.).

 

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

 

    1. a. A health maintenance organization shall not limit a female enrollee's direct access to primary and preventive obstetrical and gynecological services provided by a qualified provider of these services of her choice who has a contract with the health maintenance organization to less than two examinations annually for these services or to any care related to a pregnancy. In addition, a health maintenance organization shall not limit direct access to primary and preventive obstetrical and gynecological services required as a result of the two examinations or as a result of an acute gynecological condition, except that the qualified provider shall discuss the services and treatment plan for the female enrollee with the enrollee's primary care practitioner in accordance with the requirements established by the health maintenance organization.

    b. A health maintenance organization shall notify each of its female enrollees of the provisions of this act in writing no later than the 30th day after the effective date of this act.

 

    2. This act shall take effect on the 180th day after the date of enactment.

 

 

STATEMENT

 

    This bill prohibits a health maintenance organization (HMO) from limiting a female enrollee's direct access to primary and preventive obstetrical and gynecological services provided by a qualified provider of these services of her choice who has a contract with the HMO to less than two examinations annually for these services or to any care related to a pregnancy. In addition, an HMO is prohibited from limiting direct access to primary and preventive obstetrical and gynecological services required as a result of the two examinations or as a result of an acute gynecological condition, except that the qualified provider is required to discuss the services and treatment plan for the female enrollee with the enrollee's primary care practitioner in accordance with the requirements established by the HMO.

    The bill further requires that an HMO notify each of its female enrollees of its provisions in writing within 30 days after the effective date of the bill.

    This bill is intended to ensure that a female HMO enrollee is able to receive the following primary and preventive services directly from an obstetrician/gynecologist (without a referral by a "gatekeeper"): all maternity care, two visits annually for examinations, follow-up services resulting from the two examinations, and acute gynecological care.

    The bill is based on a recently enacted New York State law which conforms to the recommendations of the American College of Obstetricians and Gynecologists (ACOG). The ACOG recommendations reflect the fact that for most women, obstetrician/gynecologists serve as the primary care physician, and that these providers therefore serve a significant role in the provision of primary health care services to women. These services include periodic health screening, evaluation and counseling about health and lifestyle risk behaviors, and immunizations.

    The bill takes effect on the 180th day after the date of enactment.

 

 

 

Prohibits HMO from limiting a female enrollee's direct access to an obstetrician/gynecologist.