Bill Text: NJ A2007 | 2010-2011 | Regular Session | Introduced
Bill Title: Prevents managed care plan from denying coverage for certain health care services provided to covered person solely because covered person did not present referral to provider who performed services.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2010-02-08 - Introduced, Referred to Assembly Health and Senior Services Committee [A2007 Detail]
Download: New_Jersey-2010-A2007-Introduced.html
Sponsored by:
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington and Camden)
SYNOPSIS
Prevents managed care plan from denying coverage for certain health care services provided to covered person solely because covered person did not present referral to provider who performed services.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health care services for covered persons in managed care plans and supplementing P.L.1997, c.192 (C.26:2S-1 et seq.).
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. A carrier which offers a managed care plan shall not deny payment for a medically necessary covered health care service for which the carrier requires a referral from a covered person's primary care physician, if:
a. the covered person's primary care physician has referred the covered person to a health care provider who is in the carrier's network or is eligible for reimbursement from the carrier, and has satisfied any requirement of the managed care plan for prior notification to or precertification by the carrier, regardless of whether the covered person provides a copy of that referral to the health care provider who performed the services, except that the health care provider may condition the performance of those services on the provider's confirming authorization for those services from the carrier; and
b. in the case of a covered person who is receiving medically necessary covered health care services for a chronic condition from a health care provider to whom the covered person's primary care physician has referred the covered person and who is in the carrier's network or is eligible for reimbursement from the carrier, and to whom the carrier has authorized payment, the period of time or the number of visits for which the referral was provided has elapsed but the covered person's primary care physician determines that the health care services are still medically necessary, in which case the referral that was provided by the primary care physician shall be deemed to be valid until such time as the covered person's primary care physician determines that the health care services are no longer medically necessary.
2. The Commissioner of Health and Senior Services, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), shall adopt regulations to carry out the provisions of section 1 of this act.
3. This act shall take effect on the 180th day after enactment and shall apply to policies or contracts issued or renewed on or after the effective date.
STATEMENT
This bill would prohibit a health insurance carrier which offers a managed care plan from denying payment for a medically necessary covered health care service for which the carrier requires a referral from a covered person's primary care physician under certain specified circumstances.
These include the following:
--if the covered person's primary care physician has referred the covered person to a health care provider who is in the carrier's network or is eligible for reimbursement from the carrier, and has satisfied any requirement of the managed care plan for prior notification to or precertification by the carrier, regardless of whether the covered person provides a copy of that referral to the health care provider who performed the services, except that the health care provider may condition the performance of those services on the provider's confirming authorization for those services from the carrier; and
--if, in the case of a covered person who is receiving medically necessary covered health care services for a chronic condition from a health care provider to whom the covered person's primary care physician has referred the covered person and who is in the carrier's network or is eligible for reimbursement from the carrier, and to whom the carrier has authorized payment, the period of time or the number of visits for which the referral was provided has elapsed but the covered person's primary care physician determines that the health care services are still medically necessary, in which case the referral that was provided by the primary care physician will be deemed to be valid until such time as the covered person's primary care physician determines that the health care services are no longer medically necessary.
The requirements of this bill would apply to health maintenance organizations and hospital, medical and health service corporations, commercial individual, small employer and group health insurers that offer managed care plans.
The bill takes effect on the 180th day after enactment and applies to policies and contracts issued or renewed on or after the effective date.
