ASSEMBLY, No. 1412

STATE OF NEW JERSEY

INTRODUCED JANUARY 29, 1996

By Assemblyman DORIA

An Act concerning managed care health benefits plans and supplementing Title 26 of the Revised Statutes.

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

    1. This act shall be known and may be cited as the "Patient Right-to-Know Act."

    2. 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.

    "Commissioner" means the Commissioner of Health.

    "Covered person" means a person on whose behalf a managed care entity is obligated to pay benefits pursuant to the managed care plan.

    “Covered service” means a health care service provided to a covered person under a managed care plan for which the managed care entity is required to pay benefits.

    "Department" means the Department of Health.

    "Health benefits plan" means a policy, contract or other agreement delivered or issued for delivery in this State by a carrier.

    "Health care professional" means a health care professional licensed pursuant to Title 45 of the Revised Statutes.

    "Health care provider" means a health care facility as defined in section 2 of P.L.1971, c.136 (C.26:2H-2) or a health care professional or other provider recognized under State law.

    "Health care service" means a service that is provided by a health care provider, including admitting a patient to a health care facility, and that is involved in or incident to the furnishing to a person of preventive, diagnostic, therapeutic, or rehabilitative care for the purpose of ensuring the restoration, protection, maintenance, and support of physical, mental, or emotional health.

    "Managed care entity" means a carrier that operates a managed care plan.

    "Managed care plan" means a health benefits plan that integrates the financing and delivery of appropriate health care services to covered persons by arrangements with participating providers, who are selected to participate on the basis of explicit standards, to furnish a comprehensive set of health care services and financial incentives for covered persons to use the participating providers and procedures provided for in the plan. Managed care includes, but is not limited to, a health maintenance organization or any other similar health benefits delivery system, whether issued by or through a carrier.

    "Participating provider" means a health care provider that has entered into an agreement with a managed care entity to provide health care services to a covered person.

    3. a. A covered person shall be entitled to review upon request a copy of the contract between a participating provider and a managed care entity which governs the provision of covered services to the covered person, and to receive a copy of the contract upon request at a reasonable cost to be determined by the commissioner.

    b. A participating provider shall post in a conspicuous public place a notice which advises covered persons of the provisions of subsection a. of this section.

    4. The commissioner, pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.), and in consultation with the Commissioner of Insurance, shall adopt rules and regulations to effectuate the purposes of this act.

    5. This act shall take effect immediately.

STATEMENT

    This bill requires health care providers participating in managed care health benefits plans to make available to their patients who are covered by such plans, upon their request, a copy of the contract between the provider and the managed care entity which governs the provision of health care services to that patient.

Designated the “Patient Right-to-Know Act.”