ASSEMBLY, No. 1868

STATE OF NEW JERSEY

INTRODUCED MAY 2, 1996

By Assemblyman KELLY

An Act concerning health maintenance organizations, amending and supplementing P.L.1973, c.337 and making an appropriation.

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

    1. (New section) a. The Commissioner of Health shall establish and maintain a toll-free telephone number for the purpose of receiving and responding to complaints from enrollees of health maintenance organizations and inquiries regarding departmental procedures to resolve those complaints, as required by section 2 of this act.

    2. (New section) The commissioner shall establish procedures to receive, investigate, respond to and, as appropriate, take action to resolve complaints of enrollees who are dissatisfied with the resolution of their complaint after having completed all stages of a health maintenance organization's internal complaint procedure.

    3. Section 10 of P.L.1973, c.337 (C.26:2J-10) is amended to read as follows:

    10. a. Every health maintenance organization shall annually provide to its enrollees:

    (1) a summary of any material changes since the issuance of the last report;

    (2) a description of the available health care services and information as to where and how to secure them; and

    (3) a clear and understandable description of the health maintenance organization's method for resolving enrollee complaints, the Department of Health's toll-free telephone number and an explanation of the department's procedures to resolve complaints as required by sections 1 and 2, respectively, of P.L. , c. (C. )(now before the Legislature as this bill).

    b. Every health maintenance organization shall make available to

its enrollees the most recent annual statement of financial condition.

(cf: P.L.1973, c.337, §10)

    4. (New section) The Commissioner of Health shall promulgate rules and regulations to effectuate the purposes of this act pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B- 1 et seq.)

    5. There is appropriated from the General Fund to the Department of Health $90,000 for the costs associated with the establishment of a toll-free telephone number as required by section 1 of this act.

    6. This act shall take effect immediately.

STATEMENT

    This bill requires the Commissioner of Health to establish and maintain a toll-free telephone number, or "hot-line," so it can receive and respond to inquiries and complaints regarding health maintenance organizations. It also requires the commissioner to receive, investigate, respond to and, as appropriate, take action to resolve complaints of enrollees who are dissatisfied with the resolution of their complaints pursuant to the HMO's internal complaint procedure. The bill also requires HMO's to provide an enrollee with the toll-free number of the Department of Health and an explanation of the department's program.

Requires DOH to establish toll-free hot-line for HMO complaints; appropriates $90,000.