ASSEMBLY, No. 2086

STATE OF NEW JERSEY

INTRODUCED JUNE 3, 1996

By Assemblymen DORIA and DiGAETANO

An Act concerning managed care entities.

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

    1. For purposes of this act:

    "Carrier" means an insurer, hospital service corporation, medical service corporation, health service corporation, or health maintenance organization authorized to issue health benefits plans in this State.

    "Covered person" means a person with coverage under a managed care plan.

    "Enrollee" means an individual who is enrolled under a managed care plan.

    "Health care provider" means a health care professional licensed pursuant to Title 45 of the Revised Statutes or a health care facility as defined in section 2 of P.L.1971, c.136 (C.26:2H-2).

    "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 health care 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.

    2. a. A managed care entity shall offer each enrollee, at the time of enrollment and during a one-month period in each subsequent year, the option provided pursuant to subsection b. of this section. The managed care entity shall provide written notice of this option to each enrollee upon enrollment and annually thereafter, and shall include in that notice a detailed explanation of the financial costs to be incurred by a covered person who selects that option.

    b. A managed care entity shall offer an option which allows an enrollee and other covered persons to use a health care provider which is not a member of the managed care entity's network of providers, but the covered person may be required to pay a coinsurance charge which shall not exceed 20% of the managed care entity's usual and customary payment for the benefit provided.

    3. This act shall take effect shall take effect on the 180th day after enactment.

STATEMENT

    This bill requires managed care entities, including health maintenance organizations, to provide enrollees with an option that permits the enrollee and other covered persons to use a health care provider which is not in the managed care entity's network of providers, but the enrollee may be required to pay a coinsurance charge for covered benefits which cannot exceed 20% of the managed care entity's usual and customary payment for the benefit.