Bill Text: NJ A3618 | 2014-2015 | Regular Session | Amended
Bill Title: Requires health insurers, group health plans, SHBP, and SEHBP to share certain health benefits information with Medicaid and other State programs.
Spectrum: Partisan Bill (Democrat 5-0)
Status: (Introduced - Dead) 2014-09-18 - Reported out of Asm. Comm. with Amendments, and Referred to Assembly Appropriations Committee [A3618 Detail]
Download: New_Jersey-2014-A3618-Amended.html
ASSEMBLY, No. 3618
STATE OF NEW JERSEY
216th LEGISLATURE
INTRODUCED SEPTEMBER 15, 2014
Sponsored by:
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington)
Assemblyman DANIEL R. BENSON
District 14 (Mercer and Middlesex)
Assemblyman JOSEPH A. LAGANA
District 38 (Bergen and Passaic)
Co-Sponsored by:
Assemblywoman Tucker
SYNOPSIS
Requires health insurers, group health plans, SHBP, and SEHBP to share certain health benefits information with Medicaid and other State programs.
CURRENT VERSION OF TEXT
As reported by the Assembly Health and Senior Services Committee on September 18, 2014, with amendments.
An Act concerning health benefits coverage information amending various parts of the statutory law and supplementing chapter 14 of Title 52 of the Revised Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 2 of P.L.1995, c.288 (C.17:48-6.16) is amended to read as follows:
2. a. A hospital service corporation shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services, hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, or any other State-funded or administered health care program, that are different from requirements applicable to an agent or assignee of any other subscriber.
b. Notwithstanding any State law to the contrary, a hospital service corporation, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide that hospital service corporation's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against that hospital service corporation's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and hospital service corporation's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the
division, with respect to individuals or their
dependents, who are eligible for, or are provided, medical assistance under a
program administered in whole or in part by the division, or any other
State-funded or administered health care program, as set forth in paragraph (1)
of this subsection, the following information, in a manner to be prescribed by
the division:
(a) the period during which the individuals or dependents were covered by a hospital service corporation, including the effective dates of coverage and the termination of dates of coverage;
(b) the nature of the coverage provided by the hospital service corporation;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth, Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the hospital service corporation for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the hospital service corporation for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if a hospital service corporation fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. All information acquired by the division, and the authority to match information for coordination of benefits provided to the division pursuant to this section, may be extended to the State Health Benefits Program, the School Employees' Health Benefits Program, and any other 1[State funded] State-funded1 or administered health care program not administered by the division, for purposes of coordination of benefits and ensuring efficient and proper use of State resources.
e. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
(cf: P.L.1995, c.288, s.2)
2. Section 4 of P.L.1995, 288 (C.17:48A-7.11) is amended to read as follows:
4. a. A medical service corporation shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services, hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, or any other State-funded or administered health care program, that are different from requirements applicable to an agent or assignee of any other subscriber.
b. Notwithstanding any State law to the contrary, a medical service corporation, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide that medical service corporation's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against that medical service corporation's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and the medical service corporation's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the division, with respect to individuals or their dependents, who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection, the following information, in a manner to be prescribed by the division:
(a) the period during which the individuals or dependents were covered by a medical service corporation, including the effective dates of coverage and the termination of dates of coverage;
(b) the nature of the coverage provided by the medical service corporation;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth, Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the medical service corporation for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the medical service corporation for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if a medical service corporation fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. All information acquired by the division, and the authority to match information for coordination of benefits provided to the division pursuant to this section, may be extended to the State Health Benefits Program, the School Employees' Health Benefits Program, and any other 1[State funded] State-funded1 or administered health care program not administered by the division, for purposes of coordination of benefits and ensuring efficient and proper use of State resources.
e. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
(cf: P.L.1995, c.288, s.4)
3. Section 6 of P.L.1995, c.288 (C.17:48E-32.2) is amended to read as follows:
6. a. A health service corporation shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services, hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, or any other State-funded or administered health care program, that are different from requirements applicable to an agent or assignee of any other subscriber.
b. Notwithstanding any State law to the contrary, a health service corporation, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide that health service corporation's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against that health service corporation's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and the health service corporation's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the division, with respect to individuals or their dependents, who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection, the following information, in a manner to be prescribed by the division:
(a) the period during which the individuals or dependents were covered by a health service corporation, including the effective dates of coverage and the termination of dates of coverage;
(b) the nature of the coverage provided by the health service corporation;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth, Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the health service corporation for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the health service corporation for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if a health service corporation fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. All information acquired by the division, and the authority to match information for coordination of benefits provided to the division pursuant to this section, may be extended to the State Health Benefits Program, the School Employees' Health Benefits Program, and any other 1[State funded] State-funded1 or administered health care program not administered by the division, for purposes of coordination of benefits and ensuring efficient and proper use of State resources.
e. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
(cf: P.L.1995, c.288, s.6)
4. Section 12 of P.L.1995, c.288 (17B:27-30.2) is amended to read as follows:
12. a. An insurer shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services, hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, or any other State-funded or administered health care program, that are different from requirements applicable to an agent or assignee of any other insured.
b. Notwithstanding any State law to the contrary, an insurer, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide that insurer's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against that insurer's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and the insurer's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the division, with respect to individuals or their dependents, who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection, the following information, in a manner to be prescribed by the division:
(a) the period during which the individuals or dependents were covered by an insurer, including the effective dates of coverage and the termination of dates of coverage;
(b) the nature of the coverage provided by the insurer;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth, Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the insurer for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the insurer for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if an insurer fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. All information acquired by the division, and the authority to match information for coordination of benefits provided to the division pursuant to this section, may be extended to the State Health Benefits Program, the School Employees' Health Benefits Program, and any other 1[State funded] State-funded1 or administered health care program not administered by the division, for purposes of coordination of benefits and ensuring efficient and proper use of State resources.
e. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
(cf: P.L.1995, c.288, s.12)
5. Section 16 of P.L.1995, c.288 (C.17B:27-30.4) is amended to read as follows:
16. a. A group health plan as defined in section 607(1) of the "Employee Retirement Income Security Act of 1974," 29 U.S.C.1167(1), hereinafter referred to as "ERISA plan," shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services , hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, 1or any other State-funded or administered health care program,1 that are different from requirements applicable to an agent or assignee of any other covered employee.
b. Notwithstanding any State law to the contrary, an ERISA plan, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide that ERISA plan's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against that ERISA plan's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and the ERISA plan's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the division, with respect to individuals or their dependents, who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection, the following information, in a manner to be prescribed by the division:
(a) the period during which the individuals or dependents were covered by an ERISA plan, including the effective dates of coverage and the termination of dates of coverage;
(b) the nature of the coverage provided by the ERISA plan;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth, Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the ERISA plan for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the ERISA plan for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if an ERISA plan fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. All information acquired by the division, and the authority to match information for coordination of benefits provided to the division pursuant to this section, may be extended to the State Health Benefits Program, the School Employees' Health Benefits Program, and any other 1[State funded] State-funded1 or administered health care program not administered by the division, for purposes of coordination of benefits and ensuring efficient and proper use of State resources.
e. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
(cf: P.L.1995, c.288, s.16)
6. Section 8 of P.L.1995, c.288 (C. 17B:27A-4.2) is amended to read as follows:
8. a. A carrier shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services, hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, or any other State-funded or administered health care program, that are different from requirements applicable to an agent or assignee of any other policy or contract holder.
b. Notwithstanding any State law to the contrary, a carrier, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide that carrier's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against that carrier's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and the carrier's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the division, with respect to individuals or their dependents, who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection, the following information, in a manner to be prescribed by the division:
(a) the period during which the individuals or dependents were covered by a carrier, including the effective dates of coverage and the termination of dates of coverage;
(b) the nature of the coverage provided by the carrier;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth, Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the carrier for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the carrier for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if a carrier fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. All information acquired by the division, and the authority to match information for coordination of benefits provided to the division pursuant to this section, may be extended to the State Health Benefits Program, the School Employees' Health Benefits Program, and any other 1[State funded] State-funded1 or administered health care program not administered by the division, for purposes of coordination of benefits and ensuring efficient and proper use of State resources.
e. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
(cf: P.L.1995, c.288, s.8)
7. Section 10 of P.L.1995, c.288 (C.17B:27A-18.2) is amended to read as follows:
10. a. A carrier shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services, hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, or any other State-funded or administered health care program, that are different from requirements applicable to an agent or assignee of any other covered employee.
b. Notwithstanding any State law to the contrary, a carrier, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide that carrier's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against that carrier's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and the carrier's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the division, with respect to individuals or their dependents, who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection, the following information, in a manner to be prescribed by the division:
(a) the period during which the individuals or dependents were covered by a carrier, including the effective dates of coverage and the termination of dates of coverage;
(b) the nature of the coverage provided by the carrier;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth, Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the carrier for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the carrier for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if a carrier fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. All information acquired by the division, and the authority to match information for coordination of benefits provided to the division pursuant to this section, may be extended to the State Health Benefits Program, the School Employees' Health Benefits Program, and any other 1[State funded] State-funded1 or administered health care program not administered by the division, for purposes of coordination of benefits and ensuring efficient and proper use of State resources.
e. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
(cf: P.L.1995, c.288, s.10)
8. Section 14 of P.L.1995, c.288, s.14 (C.26:2J-10.2) is amended to read as follows:
14. a. A health maintenance organization shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services, hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, or any other State-funded or administered health care program, that are different from requirements applicable to an agent or assignee of any other enrollee.
b. Notwithstanding any State law to the contrary, a health maintenance organization, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide that health maintenance organization's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against that health maintenance organization's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and health maintenance organization's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the division, with respect to individuals or their dependents, who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection, the following information, in a manner to be prescribed by the division:
(a) the period during which the individuals or dependents were covered by a health maintenance organization, including the effective dates of coverage and the termination of dates of coverage;
(b) the nature of the coverage provided by the health maintenance organization;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth, Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the health maintenance organization for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the health maintenance organization for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if a health maintenance organization fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. All information acquired by the division, and the authority to match information for coordination of benefits provided to the division pursuant to this section, may be extended to the State Health Benefits Program, the School Employees' Health Benefits Program, and any other 1[State funded] State-funded1 or administered health care program not administered by the division, for purposes of coordination of benefits and ensuring efficient and proper use of State resources.
e. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
(cf: P.L.1995, c.288, s.14)
9. (New section) a. The State Health Benefits Commission shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services, hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, or any other State-funded or administered health care program, that are different from requirements applicable to an agent or assignee of any other covered person.
b. Notwithstanding any State law to the contrary, the State Health Benefits Commission, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide the State Health Benefits Plan's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against the State Health Benefits Plan's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and the State Health Benefits Plan's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the division, with respect to individuals or their dependents, who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection, the following information, in a manner to be prescribed by the division:
(a) the period during which the individuals or dependents were covered by the State Health Benefits Plan, including the effective dates of coverage and the termination dates of coverage;
(b) the nature of the coverage provided by the State Health Benefits Plan;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the State Health Benefits Plan for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the State Health Benefits Plan for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if the State Health Benefits Plan fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
10. (New section) a. The School Employees' Health Benefits Commission shall not impose requirements on the Division of Medical Assistance and Health Services in the Department of Human Services, hereinafter referred to as the "division," which has been assigned the rights of an individual who is eligible for medical assistance under the State Medicaid program, or any other State-funded or administered health care program, that are different from requirements applicable to an agent or assignee of any other covered person.
b. Notwithstanding any State law to the contrary, the School Employees' Health Benefits Commission, and any insurer, agent, intermediary, or third party administrator thereof, as a condition of doing business in the State, shall, upon the request of the division:
(1) enter into an agreement with the division to electronically provide the School Employees' Health Benefits Plan's files of current and past insured individuals and their dependents to the division and to permit and assist the division in the matching, no less frequently than on a monthly basis, of the eligibility files and adjudicated claims files of the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the Work First New Jersey program, the Work First New Jersey 1[general public assistance] General Public Assistance1 program, and any other 1[State funded] State-funded1 or administered health care program, against the School Employees' Health Benefits Plan's eligibility files of current and past insured individuals and their dependents, including indications of eligibility of coverage derived from the federal "Medicare Prescription Drug, Improvement, and Modernization Act of 2003," Pub.L.108-173, and the School Employees' Health Benefits Plan's adjudicated claims files, for the purpose of coordination of benefits and ensuring efficient and proper use of State funds, utilizing, if necessary, Social Security numbers as common identifiers;
(2) provide to the division, with respect to individuals or their dependents, who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection, the following information, in a manner to be prescribed by the division:
(a) the period during which the individuals or dependents were covered by the School Employees' Health Benefits Plan, including the effective dates of coverage and the termination dates of coverage;
(b) the nature of the coverage provided by the School Employees' Health Benefits Plan;
(c) the name, address, and identifying number of the plan under which coverage was provided; and
(d) the name, date of birth, Social Security number, and address of the covered person;
(3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment from the School Employees' Health Benefits Plan for a health care item or service for which payment has been made;
(4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date that the health care item or service was provided;
(5) not deny a claim submitted by the division solely on the basis of:
(a) the date of submission of the claim;
(b) the type or format of the claim form;
(c) a lack of prior authorization; or
(d) a failure to present proper documentation at the point-of-sale that is the basis of the claim, if:
(i) the claim submitted by the division is made within 10 years of the date on which the item or service was provided; and
(ii) any action by the division to enforce its rights with respect to the claim is commenced within six years of the division's submission of the claim; and
(6) respond to a request for payment after receipt of written proof of loss or claim for payment for health care services provided to individuals and dependents who are covered by the School Employees' Health Benefits Plan for those services and who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as set forth in paragraph (1) of this subsection.
c. In addition to any other sanctions authorized by law, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue any remedy set forth in section 18 of P.L.1979, c.365 (C.30:4D-17.2) if the School Employees' Health Benefits Plan fails to:
(1) comply with any request within 30 days of the date the request is made by the division or by the Medicaid Fraud Division of the Office of the State Comptroller pursuant to paragraphs (1) through (5) of subsection b. of this section;
(2) respond to a request for payment within 90 business days after request for payment is made pursuant to paragraph (6) of subsection b. of this section; or
(3) comply with any other provision of this section.
d. The division or the Medicaid Fraud Division of the Office of the State Comptroller may adopt, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), rules and regulations necessary to effectuate the provisions of this section.
11. This act shall take effect on the first day of the fourth month next following the date of enactment.
