ASSEMBLY, No. 1047

STATE OF NEW JERSEY

Introduced Pending Technical Review by Legislative Counsel

PRE-FILED FOR INTRODUCTION IN THE 1996 SESSION

By Assemblyman DORIA

An Act concerning the health care services provided by health maintenance organizations and amending and supplementing P.L.1973, c.337.

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

    1. Section 2 of P.L.1973, c.337 (C.26:2J-2) is amended to read as follows:

    2. As used in P.L.1973, c.337 (C.26:2J-1 et seq.):

    a. "Commissioner" means the [State] Commissioner of Health.

    b. "Basic health care services" means those services, including but not limited to emergency care, inpatient hospital and physician care, [and] outpatient medical services, and services of a licensed chiropractor, as designated by regulations promulgated by the commissioner.

    c. "Health care services" includes basic health care services and any additional services, including services of a licensed chiropractor, as designated by regulations promulgated by the commissioner.

    d. "Enrollee" means an individual who has been enrolled with a health maintenance organization.

    e. "Evidence of coverage" means any booklet, certificate, agreement, or contract issued to an enrollee setting out the services and other benefits to which he is entitled.

    f. "Health maintenance organization" means any person which directly or through contracts with providers furnishes at least basic comprehensive health care services on a prepaid basis to enrollees in a designated geographical area.

    g. "Person" means any natural or artificial person including but not limited to individuals, partnerships, associations, trusts, or corporations.

    h. "Provider" means any physician, chiropractor, hospital, or other person which is licensed or otherwise authorized in this State to furnish health care services.

    i. "Health care facility" means the facility or institution whether public or private, engaged in providing services for health maintenance organizations, diagnosis or treatment of human disease, pain, injury, deformity or physical condition, including, but not limited to, a general hospital, special hospital, mental hospital, public health center, diagnostic center, treatment center, rehabilitation center, extended care facility, skilled nursing home, nursing home, intermediate care facility, tuberculosis hospital, chronic disease hospital, maternity hospital, outpatient clinic, dispensary, home health care agency, boarding home or other home for the sheltered care of adult persons and bio-analytical laboratory or central services facility serving one or more such institutions but excluding institutions that provide healing solely by prayer.

(cf: P.L.1973, c.337, s.2)

    2. (New section) Every health maintenance organization for which a certificate of authority has been issued or continued shall provide that a sufficient number of licensed chiropractors are associated with or available to the health maintenance organization to assure that enrollees may choose to have health care services provided by a licensed chiropractor. Furthermore, the health maintenance organization shall make available to enrollees direct access to chiropractic services without the necessity of any medical referral. For purposes of this provision, one chiropractor for every two-thousand enrollees shall be deemed to be sufficient.

    3. (New section) Whenever a health maintenance organization provides for reimbursement for any health care service which is within the lawful scope of practice of a chiropractor, the enrollee or the chiropractor rendering that service shall be entitled to reimbursement for that service.

    4. (New section) The Commissioner of Health shall revise the rules and regulations promulgated under the "Health Maintenance Organizations Act," P.L.1973, c.337 (C.26:2J-1 et seq.), as are necessary to effectuate the amendments and supplements made thereto by this act, within 180 days of the effective date of this section in accordance with the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.).

    5. This act shall take effect on the 180th day following the date of enactment, except that section 4 shall take effect immediately.

STATEMENT

    This bill amends and supplements the "Health Maintenance Organizations Act," P.L.1973, c.337 (C.26:2J-1 et seq.), to make it clear that chiropractic services shall be included among the health care services which must be provided to enrollees of a health maintenance organization (HMO). The bill further provides that HMO's must make available to enrollees direct access to chiropractic services without the necessity of any medical referral and provide a sufficient number of licensed chiropractors so that they may choose to have health care services provided by a licensed chiropractor. Under the bill's provisions, one chiropractor for every two-thousand enrollees is deemed sufficient. The bill also provides that whenever a health maintenance organization provides for reimbursement for any health care service which is within the lawful scope of practice of a chiropractor, the enrollee or the chiropractor rendering that service shall be entitled to reimbursement for that service. Finally, the bill requires the Commissioner of Health to revise the regulations promulgated with respect to HMO's to reflect these provisions.

Provides that chiropractic services must be provided by HMOs.