Bill Text: NJ A1833 | 2012-2013 | Regular Session | Introduced
Bill Title: Deletes prior authorization requirements by certain insurers for accessing certain health care services.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2012-01-10 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A1833 Detail]
Download: New_Jersey-2012-A1833-Introduced.html
STATE OF NEW JERSEY
215th LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2012 SESSION
Sponsored by:
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington)
SYNOPSIS
Deletes prior authorization requirements by certain insurers for accessing certain health care services.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel
An Act concerning prior authorization requirements by certain carriers for accessing certain health care services and amending P.L.1997, c.192.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 6 of P.L.1997, c.192 (C.26:2S-6) is amended to read as follows:
6. a. A carrier which offers a managed care plan or uses a utilization management system in any of its health benefits plans shall designate a licensed physician to serve as medical director. The medical director, or his designee, shall be designated to serve as the medical director for medical services provided to covered persons in the State and shall be licensed to practice medicine in New Jersey.
The medical director shall be responsible for treatment policies, protocols, quality assurance activities and utilization management decisions of the carrier. The treatment policies, protocols, quality assurance program and utilization management decisions of the carrier shall be based on generally accepted standards of health care practice. The quality assurance and utilization management programs shall be in accordance with standards adopted by regulation of the department pursuant to this act.
b. The medical director shall ensure that:
(1) Any utilization management decision to deny, reduce or terminate a health care benefit or to deny payment for a health care service, because that service is not medically necessary, shall be made by a physician. In the case of a health care service prescribed or provided by a dentist, the decision shall be made by a dentist;
(2) A utilization management decision shall not retrospectively deny coverage for health care services provided to a covered person when prior approval has been obtained from the carrier for those services, unless the approval was based upon fraudulent information submitted by the covered person or the participating provider;
(3) In the case of a managed care plan, a procedure is implemented whereby participating physicians and dentists have an opportunity to review and comment on all medical and surgical and dental protocols, respectively, of the carrier;
(4) The utilization management program is available on a 24-hour basis to respond to authorization requests for emergency and urgent services and is available, at a minimum, during normal working hours for inquiries and authorization requests for nonurgent health care services; [and]
(5) In the case of a managed
care plan, a covered person is
permitted to: choose or change a primary care physician from among
participating providers in the provider network, and, when appropriate, choose
a specialist from among participating network providers following an authorized
referral, if required by the carrier, and subject to the ability of the
specialist to accept new patients; and
(6) Prior authorization is not required by the carrier in order for a covered person to access prescription drugs and biologics, or surgical services that address a single organ or organ system, and, in the case of radiological examinations, is required only in order for a covered person to access those services for which the carrier does not routinely approve coverage, as documented by an audited report of such prior authorization determinations for the previous plan year submitted to the Department of Banking and Insurance; except that nothing in this paragraph shall be construed to permit the covered person to access a specialist network provider directly without initial approval from the covered person's primary care provider of record.
(cf: P.L.1997, c.192, s.6)
2. This act shall take effect on the first day of the fourth month next following the date of enactment and shall apply to all contracts and policies issued or renewed on or after the effective date.
STATEMENT
This bill amends the "Health Care Quality Act," P.L.1997, c.192 (C.26:2S-1 et seq.), to prohibit certain health insurance carriers from requiring prior authorization for accessing certain health care services.
The bill requires the medical director of a carrier which offers a managed care plan or uses a utilization management system in any of its health benefits plans to ensure that prior authorization is not required by the carrier in order for a covered person to access prescription drugs and biologics, or surgical services that address a single organ or organ system, and, in the case of radiological examinations, is required only in order for a covered person to access those services for which the carrier does not routinely approve coverage, as documented by an audited report of such prior authorization determinations for the previous plan year submitted to the Department of Banking and Insurance; except that this bill is not to be construed to permit the covered person to access a specialist network provider directly without initial approval from the covered person's primary care provider of record.
The bill takes effect on the first day of the fourth month following enactment and applies to all contracts and policies issued or renewed on or after the effective date.
