Bill Text: NJ A2439 | 2012-2013 | Regular Session | Introduced
Bill Title: Prevents managed care plan from denying coverage for maintenance medications for chronic conditions for covered persons solely because of change in health benefits plan or pharmacy benefits manager.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2012-02-16 - Introduced, Referred to Assembly Financial Institutions and Insurance Committee [A2439 Detail]
Download: New_Jersey-2012-A2439-Introduced.html
Sponsored by:
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington)
SYNOPSIS
Prevents managed care plan from denying coverage for maintenance medications for chronic conditions for covered persons solely because of change in health benefits plan or pharmacy benefits manager.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health care coverage for certain medications and supplementing Titles 17 and 26 of the Revised Statutes and Title 17B of the New Jersey Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. No hospital service corporation that provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a contract that is 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 Banking and Insurance, on or after the effective date of this act, shall deny coverage for a maintenance medication prescribed by a covered person's physician for the covered person's chronic condition because of a change in the covered person's pharmaceutical benefits that results solely from a change in the contract or the pharmacy benefits manager for that contract if:
a. the covered person was taking the medication prior to the date of the change in the contract or the pharmacy benefits manager for that contract; and
b. the new contract, or the contract under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.
2. No medical service corporation that provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a contract that is 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 Banking and Insurance, on or after the effective date of this act, shall deny coverage for a maintenance medication prescribed by a covered person's physician for the covered person's chronic condition because of a change in the covered person's pharmaceutical benefits that results solely from a change in the contract or the pharmacy benefits manager for that contract if:
a. the covered person was taking the medication prior to the date of the change in the contract or the pharmacy benefits manager for that contract; and
b. the new contract, or the contract under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
3. No health service corporation that provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a contract that is 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 Banking and Insurance, on or after the effective date of this act, shall deny coverage for a maintenance medication prescribed by a covered person's physician for the covered person's chronic condition because of a change in the covered person's pharmaceutical benefits that results solely from a change in the contract or the pharmacy benefits manager for that contract if:
a. the covered person was taking the medication prior to the date of the change in the contract or the pharmacy benefits manager for that contract; and
b. the new contract, or the contract under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
This section shall apply to those health service corporation contracts in which the health service corporation has reserved the right to change the premium.
4. No individual health insurer that provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a policy that is 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 Banking and Insurance, on or after the effective date of this act, shall deny coverage for a maintenance medication prescribed by a covered person's physician for the covered person's chronic condition because of a change in the covered person's pharmaceutical benefits that results solely from a change in the policy or the pharmacy benefits manager for that policy if:
a. the covered person was taking the medication prior to the date of the change in the policy or the pharmacy benefits manager for that policy; and
b. the new policy, or the policy under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
This section shall apply to those policies in which the insurer has reserved the right to change the premium.
5. No group health insurer that provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a policy that is 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 Banking and Insurance, on or after the effective date of this act, shall deny coverage for a maintenance medication prescribed by a covered person's physician for the covered person's chronic condition because of a change in the covered person's pharmaceutical benefits that results solely from a change in the policy or the pharmacy benefits manager for that policy if:
a. the covered person was taking the medication prior to the date of the change in the policy or the pharmacy benefits manager for that policy; and
b. the new policy, or the policy under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
This section shall apply to those policies in which the insurer has reserved the right to change the premium.
6. A certificate of authority to establish and operate a health maintenance organization 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 Banking and Insurance, on or after the effective date of this act, shall not be issued or continued on or after the effective date of this act for a health maintenance organization that provides benefits for prescription drugs under a contract if the health maintenance organization denies coverage for any enrollee for a maintenance medication prescribed by the enrollee's physician for the enrollee's chronic condition because of a change in the enrollee's pharmaceutical benefits that results solely from a change in the contract or the pharmacy benefits manager for that contract if:
a. the enrollee was taking the medication prior to the date of the change in the contract or the pharmacy benefits manager for that contract; and
b. the new contract, or the contract under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
This section shall apply to those contracts for health care services by health maintenance organizations under which the right to change the schedule of charges for enrollee coverage is reserved.
7. No carrier that provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under an individual health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall deny coverage for a maintenance medication prescribed by a covered person's physician for the covered person's chronic condition because of a change in the covered person's pharmaceutical benefits that results solely from a change in the plan or the pharmacy benefits manager for that plan if:
a. the covered person was taking the medication prior to the date of the change in the plan or the pharmacy benefits manager for that plan; and
b. the new plan, or the plan under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
8. No carrier that provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a small employer health benefits plan that is delivered, issued, executed, or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall deny coverage for a maintenance medication prescribed by a covered person's physician for the covered person's chronic condition because of a change in the covered person's pharmaceutical benefits that results solely from a change in the plan or the pharmacy benefits manager for that plan if:
a. the covered person was taking the medication prior to the date of the change in the plan or the pharmacy benefits manager for that plan; and
b. the new plan, or the plan under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
9. No prepaid prescription service organization that provides hospital or medical expense benefits for expenses incurred in the purchase of prescription drugs under a contract that is delivered, issued, executed, or renewed in this State on pursuant to P.L.1997, c.380 (C.17:48F-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall deny coverage for a maintenance medication prescribed by the enrollee's physician for the enrollee's chronic condition because of a change in the enrollee's pharmaceutical benefits that results solely from a change in the contract or the pharmacy benefits manager for that contract if:
a. the enrollee was taking the medication prior to the date of the change in the contract or the pharmacy benefits manager for that contract; and
b. the new contract, or the contract under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
This section shall apply to those prepaid prescription plans in which the prepaid prescription service organization has reserved the right to change the premium.
10. This act shall take effect on the first day of the seventh month next following the date of 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 that provides benefits for the purchase of prescription drugs from denying coverage for a maintenance medication prescribed by a covered person's physician for the covered person's chronic condition because of a change in the covered person's pharmaceutical benefits that results solely from a change in the health benefits plan or the pharmacy benefits manager for that plan.
The prohibition applies only if the covered person was taking the medication prior to the date of the change in the covered person's health benefits plan or the pharmacy benefits manager for that plan, and if the covered person's new health benefits plan, or health benefits plan under the new pharmacy benefits manager, as applicable, provides coverage for that class of drugs.
The requirements of this bill would apply to: hospital, medical and health service corporations; individual, small employer, and group health insurers; health maintenance organizations; and prepaid prescription service organizations.
