ASSEMBLY, No. 2557

 

STATE OF NEW JERSEY

 

INTRODUCED DECEMBER 9, 1996

 

 

By Assemblyman COHEN

 

 

An Act concerning certain health maintenance organization enrollees 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 certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued by the Commissioner of Health and Senior Services on or after the effective date of this act unless the health maintenance organization offers health care services in conformance with the provisions of subsection b. of this section.

    b. If an enrollee is a resident of a continuing care facility operating under a certificate of authority issued pursuant to P.L.1986, c.103 (C.52:27D-330 et seq.), the enrollee's primary care physician shall refer the enrollee to the facility's Medicare-certified skilled nursing unit, rather than to a nursing facility separate from the continuing care facility, if:

    (1) the primary care physician determines that the referral is in the best interest of the enrollee;

    (2) the facility agrees to be reimbursed at the same contract rate negotiated by the health maintenance organization with similar providers for the same services and supplies; and

    (3) the facility meets all guidelines established by the health maintenance organization relating to quality of care, utilization, referral authorization, risk assumption, use of the health maintenance organization's network, and other criteria applicable to providers under contract for the same services and supplies.

 

    2. This act shall take effect immediately.

 

 

STATEMENT

 

    This bill provides that if an HMO enrollee is a resident of a continuing care facility operating under a certificate of authority issued pursuant to the "Continuing Care Retirement Community Regulation and Financial Disclosure Act," P.L.1986, c.103 (C.52:27D-330 et seq.), the enrollee's primary care physician shall refer the enrollee to the facility's Medicare-certified skilled nursing unit, rather than to a nursing facility separate from the continuing care facility, if:

    (1) the primary care physician determines that the referral is in the best interest of the enrollee;

    (2) the facility agrees to be reimbursed at the same contract rate negotiated by the HMO with similar providers for the same services and supplies; and

    (3) the facility meets all guidelines established by the HMO relating to quality of care, utilization, referral authorization, risk assumption, use of the HMO's network, and other criteria applicable to providers under contract for the same services and supplies.

 

 

                             

 

Requires primary care physician of HMO enrollee residing in continuing care retirement facility to refer enrollee to facility's skilled nursing unit under certain circumstances.