Bill Text: NJ S1346 | 2016-2017 | Regular Session | Introduced

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Bill Title: Requires managed care plans to deem valid referral for a covered health care service as satisfying requirements for prior notification.

Spectrum: Partisan Bill (Republican 1-0)

Status: (Introduced - Dead) 2016-02-11 - Introduced in the Senate, Referred to Senate Commerce Committee [S1346 Detail]

Download: New_Jersey-2016-S1346-Introduced.html

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SENATE, No. 1346

STATE OF NEW JERSEY

217th LEGISLATURE

 

INTRODUCED FEBRUARY 11, 2016

 

 

Sponsored by:

Senator  ANTHONY R. BUCCO

District 25 (Morris and Somerset)

 

 

 

 

SYNOPSIS

     Requires managed care plans to deem valid referral for a covered health care service as satisfying requirements for prior notification

 

CURRENT VERSION OF TEXT

     As introduced.

  

An Act concerning payment for health care services under 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.  A carrier which issues a managed care plan shall provide in that plan that a referral for a medically necessary covered health care service shall be deemed to satisfy any requirement of the managed care plan for prior notification to, or precertification by, the carrier, and that the carrier shall not deny payment for the covered service, if:  a covered person has obtained a valid referral from the person's primary care physician; that referral is to a health care provider who is in the carrier's provider network or is eligible for reimbursement from the carrier; and the covered person has provided a copy of that referral to the health care provider prior to receiving the service.

     b.    The provisions of this act shall not apply to a carrier providing coverage through the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.), or the NJ FamilyCare Program established pursuant to section 3 of P.L.2005, c.156 (C.30:4J-10).

 

     2.    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 supplements the "Health Care Quality Act," P.L.1997, c.192 (C.26:2S-1 et seq.) concerning referrals for health care services.

     The bill requires that a health insurance carrier (an individual or group commercial insurer, a health, hospital or medical service corporation, or a health maintenance organization) which issues a managed care plan provide in that plan that a referral for a medically necessary covered health care service will be deemed to satisfy any requirement of the plan for prior notification to, or precertification by, the carrier, and that the carrier will not deny payment for the covered service, if:

·    a covered person has obtained a valid referral from the person's primary care physician;

·    the referral is to a health care provider who is in the carrier's provider network or is eligible for reimbursement from the carrier; and

·    the covered person has provided a copy of the referral to the health care provider prior to receiving the service.

     This bill exempts a carrier providing coverage through the Medicaid or NJ FamilyCare program from the provision requiring managed care plans to deem a valid referral for a covered health care service as satisfying prior notification requirements.

     The bill takes effect on the first day of the seventh month following the date of enactment and applies to policies or contracts issued or renewed on or after the effective date.