Bill Text: NJ S358 | 2010-2011 | Regular Session | Introduced
Bill Title: Requires managed care plans, SHBP, and SEHBP to provide for reasonable accommodation in accessing providers for persons with physical disabilities. **
Spectrum: Partisan Bill (Democrat 3-0)
Status: (Engrossed - Dead) 2011-12-08 - Reported out of Assembly Comm. with Amendments, 2nd Reading [S358 Detail]
Download: New_Jersey-2010-S358-Introduced.html
STATE OF NEW JERSEY
214th LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2010 SESSION
Sponsored by:
Senator LORETTA WEINBERG
District 37 (Bergen)
Senator JOSEPH F. VITALE
District 19 (Middlesex)
SYNOPSIS
Provides in-network benefits to patient with disability for services provided by out-of-network provider under certain circumstances.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel
An Act concerning health care coverage for persons with physical disabilities 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. With respect to a carrier which offers a managed care plan that provides for both in-network and out-of-network benefits, in the event, as determined by regulation of the Commissioner of Health and Senior Services, that a covered person with a physical disability receives covered, medically necessary health care services from an out-of-network health care provider because there is no in-network provider who is reasonably proximate to the covered person's place of residence, is qualified by area of professional specialty or practice to provide those health care services and has significant experience in treating the particular physical disability, or whose physical accommodations afford reasonably convenient access to a person with the same degree of physical disability as that which the covered person has:
(1) the covered person shall not be required to pay an amount out-of-pocket for the covered services that exceeds the applicable in-network copayment, coinsurance or deductible requirements of the managed care plan;
(2) the carrier shall reimburse the out-of-network health care provider for the covered services at the same rate as that which the carrier would pay to an in-network provider for the same services;
(3) the out-of-network provider shall accept the payment by the carrier as payment in full and shall not be permitted to balance bill the covered person for any amount in excess of the payment made by the carrier plus any required copayment or coinsurance; and
(4) the carrier may establish preauthorization or review requirements, in accordance with regulations adopted by the Commissioner of Health and Senior Services, with which the covered person shall comply as a condition of receiving benefits pursuant to this act.
b. As used in this section:
"Health care provider" means a physician or other health care professional licensed pursuant to Title 45 of the Revised Statutes.
"Physical accommodations" means: the means of entrance to, or exit from, the health care provider's premises, including any parking area that is provided for patients by the health care provider; the physical configuration of the interior of those premises, including any toilet facility available to patients; or the equipment used by the provider to examine or treat patients.
"Reasonably convenient access" means that the health care provider's physical accommodations are designed in such a manner that the covered person is able to enter, transit, utilize and exit those accommodations, by means of the person's own physical efforts or use of a wheelchair or other mobility assistance device or equipment, without assistance from another individual.
"Reasonably proximate" means that the geographic distance from the covered person's place of residence to the professional office in which the health care provider conducts his private practice does not exceed 20 miles.
"Significant experience" means that the health care provider has evaluated and treated a minimum of 24 patients with the particular physical disability each year for at least the last two years.
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 rules and regulations to effectuate the purposes of this act.
3. This act shall take effect on the 180th day after enactment, except that the Commissioner of Health and Senior Services may take such anticipatory administrative action in advance as shall be necessary for the implementation of the act.
STATEMENT
This bill permits a patient with a physical disability who is covered by a managed care plan to receive benefits at the in-network level for health care services provided by an out-of-network health care provider under certain circumstances.
Specifically, the bill applies to a health insurance carrier which offers a managed care plan that provides for both in-network and out-of-network benefits, and a scenario, as determined by regulation of the Commissioner of Health and Senior Services, in which a covered person with a physical disability receives covered, medically necessary health care services from an out-of-network health care provider because there is no in-network provider who is reasonably proximate to the covered person's place of residence, is qualified by area of professional specialty or practice to provide those health care services and has significant experience in treating the particular physical disability, or whose physical accommodations afford reasonably convenient access to a person with the same degree of physical disability as that which the covered person has.
In that instance, the bill provides that:
· the covered person would not be required to pay an amount out-of-pocket for the covered services that exceeds the applicable in-network copayment, coinsurance or deductible requirements of the managed care plan;
· the carrier would be required to reimburse the out-of-network health care provider for the covered services at the same rate as that which the carrier would pay to an in-network provider for the same services;
· the out-of-network provider would be required to accept the payment by the carrier as payment in full and would not be permitted to balance bill the covered person for any amount in excess of the payment made by the carrier plus any required copayment or coinsurance; and
· the carrier may establish preauthorization or review requirements, in accordance with regulations adopted by the Commissioner of Health and Senior Services, with which the covered person must comply as a condition of receiving benefits pursuant to this bill.
The bill takes effect on the 180th day after enactment, but authorizes the Commissioner of Health and Senior Services to take anticipatory administrative action in advance as necessary for its implementation.
