SENATE, No. 171

STATE OF NEW JERSEY

Introduced Pending Technical Review by Legislative Counsel

PRE-FILED FOR INTRODUCTION IN THE 1996 SESSION

By Senators McGREEVEY and SCOTT

An Act concerning health maintenance organizations 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. Notwithstanding the provisions of any law to the contrary, if an enrollee is treated for a life-threatening condition by a physician who is employed by or under contract with a health maintenance organization at the time the treatment for the life-threatening condition is initiated, the evidence of coverage shall provide: (1) that the enrollee may continue to be treated by that physician for the same episode of a life-threatening condition should the physician no longer be employed by or under contract with the health maintenance organization; and (2) that health care services shall be provided by the health maintenance organization for the treatment of that life-threatening condition by that physician to the same extent as such services were provided while the physician was employed by or under contract with the health maintenance organization.

    b. For purposes of this act "treatment for a life-threatening condition" means those health care services that are provided after the onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of medical attention could reasonably be expected by a prudent person, who possesses an average knowledge of health and medicine, to result in:

    (1) placing the patient's health in serious jeopardy;

    (2) serious impairment to bodily functions; or

    (3) serious dysfunction of any bodily organ or part.

    2. The Commissioner of Health, in consultation with the Commissioner of Insurance, shall promulgate rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) as may be necessary to effectuate the purposes of this act.

    3. This act shall take effect immediately

STATEMENT

    This bill permits an enrollee in a health maintenance organization that has begun treatment for a life-threatening condition with a physician who is employed by or under contract with a health maintenance organization at the time the treatment is initiated to continue to be treated by that physician for the life-threatening condition should the physician no longer be employed by or under contract with the health maintenance organization. The bill provides that under such circumstances, health care services shall be provided to the same extent as when the physician was employed by or under contract with the health maintenance organization.

Requires HMOs to permit enrollees to continue to be treated by a physician no longer employed by or under contract with the HMO under certain circumstances.