SENATE, No. 603

STATE OF NEW JERSEY

INTRODUCED JANUARY 29, 1996

By Senator SINAGRA

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 receiving post-operative follow-up, oncological treatment, psychiatric treatment or obstetrical care by a physician who is employed by or under contract with a health maintenance organization at the time the treatment is initiated, the evidence of coverage shall provide that:

    (1) at the option of the enrollee, the enrollee may continue to be treated by that physician for the duration of the treatment, for a period not to exceed one year, in the case of post-operative follow-up, oncological treatment and psychiatric treatment, and, in the case of obstetrical care, through the duration of a pregnancy, including childbirth, in the event that the physician no longer is employed by or under contract with the health maintenance organization; and

    (2) health care services shall be provided by the health maintenance organization for the treatment of the conditions provided in this section to the same extent as such services were provided while the physician was employed by or under contract with the health maintenance organization. Reimbursement for the health care services shall be pursuant to the same fee schedule used to reimburse for the services when the physician was employed by or under contract with the health maintenance organization.

    b. The health maintenance organization shall not be liable for any inappropriate treatment provided to the enrollee by a physician who is no longer under contract with the health maintenance organization.

    c. The provisions of this act shall not apply to health care services provided by a physician who is the subject of disciplinary action by the State Board of Medical Examiners.

    2. This act shall take effect immediately.

STATEMENT

    This bill permits an enrollee in a health maintenance organization who is receiving post-operative follow-up care, oncological treatment, psychiatric treatment or obstetrical care from a physician who is employed by or under contract with a health maintenance organization when the treatment or care is initiated, to continue to be treated by that physician for the duration of the treatment, for a period not to exceed one year or in the case of a pregnancy, through the duration of the pregnancy, including childbirth, should the physician no longer be employed by or under contract with the health maintenance organization. The 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.

    The bill also provides that:

♦   reimbursement for the health care serv ices shall be pursuant to the same fee schedule used to reimburse for the services when the physician was employed by or under contract with the health maintenance organization;

♦   the health maintenance organization shall not be liable for any inappropriate treatment provided to the enrollee by a physician who is no longer under contract with the health maintenance organization; and

♦   the provisions of the bill shall not apply to health care services provided by a physician who is the subject of a disciplinary action by the State Board of Medical Examiners.

Requires HMOs to permit enrollees to continue treatment for limited time with a physician no longer employed by or under contract with the HMO for certain health conditions.