NATE COMMITTEE SUBSTITUTE FOR

SENATE, Nos. 603 and 171

STATE OF NEW JERSEY

ADOPTED MAY 9, 1996

Sponsored by Senators SINAGRA, McGREEVEY and SCOTT

An Act concerning certain managed care health benefits plans and supplementing P.L.1973, c.337 (C.26:2J-1 et seq.) and P.L.1993, c.162 (C.17B:27A-47 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 care, 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 six months in the case of post-operative follow-up care, for a period not to exceed one year in the case of oncological treatment and psychiatric treatment and through the duration of a pregnancy and up to six weeks after delivery in the case of obstetrical care, in the event that the physician is no longer 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 section 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. a. Notwithstanding the provisions of any law to the contrary, if a covered person is receiving post-operative follow-up care, oncological treatment, psychiatric treatment or obstetrical care by a physician who is employed by or under contract with a selective contracting arrangement entered into by a carrier in accordance with N.J.A.C.11:4-37.1 et seq. at the time the treatment is initiated, the evidence of coverage shall provide that:

      (1) at the option of the covered person, the covered person may continue to be treated by that physician for the duration of the treatment, for a period not to exceed six months in the case of post-operative follow-up care, for a period not to exceed one year in the case of oncological treatment and psychiatric treatment and through the duration of a pregnancy and up to six weeks after delivery in the case of obstetrical care, in the event that the physician is no longer employed by or under contract with the selective contracting arrangement; and

      (2) health care benefits shall be provided by the health benefits plan using a selective contracting arrangement for the treatment of the conditions provided in this subsection to the same extent as such benefits were provided while the physician was employed by or under contract with the selective contracting arrangement. 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 selective contracting arrangement.

      b. The selective contracting arrangement shall also provide for continued coverage of other health care services by a physician who was employed by or under contract with the selective contracting arrangement at the time the treatment was initiated, but is no longer employed by or under contract with the selective contracting arrangement, for up to 120 calendar days in cases where it is medically necessary for the covered person to continue treatment with that physician.

      Health care benefits shall be provided by the health benefits plan using a selective contracting arrangement for medically necessary treatment as provided in this subsection to the same extent as such benefits were provided while the physician was employed by or under contract with the selective contracting arrangement. 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 selective contracting arrangement.

      c. The selective contracting arrangement, health benefits plan or carrier shall not be liable for any inappropriate treatment provided to the covered person by a physician who is no longer under contract with the selective contracting arrangement.

      d. The provisions of this section 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.

      3. This act shall take effect immediately.

Requires certain managed care plans to permit covered person to continue treatment for limited time with a physician no longer employed by or under contract with the plan for certain health conditions.