SENATE, No. 859
STATE OF NEW JERSEY
INTRODUCED FEBRUARY 26, 1996
By Senator BUBBA
An Act concerning coordination of health care benefits and reimbursement to health care providers.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), a group or individual hospital service corporation contract providing benefits for health care services requiring the coordination of benefits shall provide that a health care provider shall be reimbursed for the full amount billed for health care services if the total of the reimbursement rates under each applicable contract, policy or enrollee agreement equals or exceeds the amount billed by the health care provider. If no contract, policy or enrollee agreement is primary and the total of the combined applicable reimbursement rates exceeds the amount billed by the health care provider, the health care provider shall be reimbursed in full in proportion to the reimbursement rate established under each applicable contract, policy or enrollee agreement.
b. No contract subject to the provisions of this section shall prohibit a person from purchasing more than one contract, policy or enrollee agreement providing benefits for health care services.
c. For purposes of this section "health care provider" means a provider of health care services; and "health care service" means a service or product sold by a health care provider and includes, but is not limited to, hospital, medical, surgical, dental, vision and pharmaceutical services or products.
d. The provisions of this section shall apply to every group or individual hospital service corporation contract delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.366 (C.17:48-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act and to all contracts in which the hospital service corporation has reserved the right to change the premium.
2. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), a group or individual medical service corporation contract providing benefits for health care requiring the coordination of benefits shall provide that the health care provider shall be reimbursed for the full amount billed for health care services if the total of the reimbursement rates under each applicable contract, policy or enrollee agreement equals or exceeds the amount billed by the health care provider. If no contract, policy or enrollee agreement is primary and the total of the combined applicable reimbursement rates exceeds the amount billed by the health care provider, the health care provider shall be reimbursed in full in proportion to the reimbursement rate established under each applicable contract, policy or enrollee agreement.
b. No contract subject to the provisions of this section shall prohibit a person from purchasing more than one contract, policy or enrollee agreement providing benefits for health care services.
c. For purposes of this section "health care provider" means a provider of health care services; and "health care service" means a service or product sold by a health care provider and includes, but is not limited to, hospital, medical, surgical, dental, vision and pharmaceutical services or products.
d. The provisions of this section shall apply to every group or individual medical service corporation contract delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act and to all contracts in which the medical service corporation has reserved the right to change the premium.
3. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), a group or individual health service corporation contract providing benefits for health care services requiring the coordination of benefits shall provide that the provider of health care services shall be reimbursed for the full amount billed for health care services if the total of the reimbursement rates under each applicable contract, policy or enrollee agreement equals or exceeds the amount billed by the provider. If no contract, policy or enrollee agreement is primary and the total of the combined applicable reimbursement rates exceeds the amount billed by the provider, the provider shall be reimbursed in full in proportion to the reimbursement rate established under each applicable contract, policy or enrollee agreement.
b. No contract subject to the provisions of this section shall prohibit a person from purchasing more than one contract, policy or enrollee agreement providing benefits for health care services.
c. The provisions of this section shall apply to every group or individual health service corporation contract delivered, issued, executed or renewed in this State pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act and to all contracts in which the insurer has reserved the right to change the premium.
4. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), an individual health insurance policy providing benefits for health care services requiring the coordination of benefits shall provide that the health care provider shall be reimbursed for the full amount billed for health care services if the total of the reimbursement rates under each applicable contract, policy or enrollee agreement equals or exceeds the amount billed by the health care provider. If no contract, policy or enrollee agreement is primary and the total of the combined applicable reimbursement rates exceeds the amount billed by the health care provider, the health care provider shall be reimbursed in full in proportion to the reimbursement rate established under each applicable contract, policy or enrollee agreement.
b. No policy subject to the provisions of this section shall prohibit a person from purchasing more than one contract, policy or enrollee agreement providing benefits for health care services.
c. For purposes of this section "health care provider" means a provider of health care services; and "health care service" means a service or product sold by a health care provider and includes, but is not limited to, hospital, medical, surgical, dental, vision and pharmaceutical services or products.
d. The provisions of this section shall apply to every policy delivered, issued, executed or renewed in this State pursuant to Chapter 26 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act and to all policies in which the insurer has reserved the right to change the premium.
5. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), a group health insurance policy providing benefits for health care services requiring the coordination of benefits shall provide that the health care provider shall be reimbursed for the full amount billed for health care services if the total of the reimbursement rates under each applicable contract, policy or enrollee agreement equals or exceeds the amount billed by the health care provider. If no contract, policy or enrollee agreement is primary and the total of the combined applicable reimbursement rates exceeds the amount billed by the health care provider, the health care provider shall be reimbursed in full in proportion to the reimbursement rate established under each applicable contract, policy or enrollee agreement.
b. No policy subject to the provisions of this section shall prohibit a person from purchasing more than one contract, policy or enrollee agreement providing benefits for health care services.
c. For purposes of this section "health care provider" means a provider of health care services; and "health care service" means a service or product sold by a health care provider and includes, but is not limited to, hospital, medical, surgical, dental, vision and pharmaceutical services or products.
d. The provisions of this section shall apply to every policy delivered, issued, executed or renewed in this State pursuant to Chapter 27 of Title 17B of the New Jersey Statutes or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act and to all policies in which the insurer has reserved the right to change the premium.
6. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), an enrollee agreement providing benefits for health care services requiring the coordination of benefits shall provide that the provider shall be reimbursed for the full amount billed for health care services if the total of the reimbursement rates under each applicable contract, policy or enrollee agreement equals or exceeds the amount billed by the provider. If no contract, policy or enrollee agreement is primary and the total of the combined applicable reimbursement rates exceeds the amount billed by the provider, the provider shall be reimbursed in full in proportion to the reimbursement rate established under each applicable contract, policy or enrollee agreement.
b. No enrollee agreement subject to the provisions of this section shall prohibit a person from purchasing more than one contract, policy or enrollee agreement providing benefits for health care services.
c. The provisions of this section shall apply to every enrollee agreement delivered, issued, executed or renewed in this State pursuant to P.L.1973, c.337 (C.26:2J-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Health on or after the effective date of this act and to all enrollee agreements in which the health maintenance organization has reserved the right to change the premium.
7. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), a group or individual dental service corporation contract providing dental expense benefits requiring the coordination of benefits shall provide that the health care provider shall be reimbursed for the full amount billed for health care services if the total of the reimbursement rates under each applicable contract, policy or enrollee agreement equals or exceeds the amount billed by the health care provider. If no contract, policy or enrollee agreement is primary and the total of the combined applicable reimbursement rates exceeds the amount billed by the health care provider, the health care provider shall be reimbursed in full in proportion to the reimbursement rate established under each applicable contract, policy or enrollee agreement.
b. No contract subject to the provisions of this section shall prohibit a person from purchasing more than one contract, policy or enrollee agreement providing benefits for health care services.
c. For purposes of this section "health care provider" means a provider of health care services; and "health care service" means a service or product sold by a health care provider and includes, but is not limited to, hospital, medical, surgical, dental, vision and pharmaceutical services or products.
d. The provisions of this section shall apply to every group or individual contract delivered, issued, executed or renewed in this State pursuant to P.L.1968, c.305 (C.17:48C-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act and to all contracts in which the dental service corporation has reserved the right to change the premium.
8. a. Except as otherwise provided in P.L.1992, c.161 (C.17B:27A-2 et seq.) and P.L.1992, c.162 (C.17B:27A-17 et seq.), a group or individual dental plan organization contract providing dental expense benefits requiring the coordination of benefits shall provide that the health care provider shall be reimbursed for the full amount billed for health care services if the total of the reimbursement rates under each applicable contract, policy or enrollee agreement equals or exceeds the amount billed by the health care provider. If no contract, policy or enrollee agreement is primary and the total of the combined applicable reimbursement rates exceeds the amount billed by the health care provider, the health care provider shall be reimbursed in full in proportion to the reimbursement rate established under each applicable contract, policy or enrollee agreement.
b. No contract subject to the provisions of this section shall prohibit a person from purchasing more than one contract, policy or enrollee agreement providing benefits for health care services.
c. For purposes of this section "health care provider" means a provider of health care services; and "health care service" means a service or product sold by a health care provider and includes, but is not limited to, hospital, medical, surgical, dental, vision and pharmaceutical services or products.
d. The provisions of this section shall apply to every group or individual contract delivered, issued, executed or renewed in this State pursuant to P.L.1979, c.478 (C.17:48D-1 et seq.) or approved for issuance or renewal in this State by the Commissioner of Insurance on or after the effective date of this act and to all contracts in which the dental plan organization has reserved the right to change the premium.
9. This act shall take effect immediately.
STATEMENT
This bill provides that hospital service, medical service and health service corporation contracts, individual and group commercial health insurance policies, dental service corporation and dental plan organization contracts, and health maintenance organization enrollee agreements providing benefits for health care services which require the coordination of benefits shall provide for full reimbursement to a health care provider for services, if the total of the reimbursement rates under each applicable contract, policy or enrollee agreement equals or exceeds the amount billed by the health care provider. The bill also provides that in the event that no contract, policy or enrollee agreement is considered primary, and the total of the combined applicable reimbursement rates exceeds the amount billed by the health care provider, the health care provider shall be reimbursed in full in proportion to the reimbursement rate established under each applicable contract, policy or enrollee agreement.
The bill also clarifies that a person may purchase more than one contract, policy or enrollee agreement providing benefits for health care services in certain circumstances.
Provides for full reimbursement to health care providers under insurance contracts subject to coordination of benefits.