Bill Text: NJ S4504 | 2026-2027 | Regular Session | Introduced
Bill Title: Requires health insurance carriers to provide opportunity to clinical laboratory and laboratory services provider to participate as preferred or contracting provider in carriers' provider network.
Sponsorship: Partisan Bill (Democrat 1)
Status: (Introduced) 2026-06-22 - Introduced in the Senate, Referred to Senate Commerce Committee [S4504 Detail]
Download: New_Jersey-2026-S4504-Introduced.html
Sponsored by:
Senator VIN GOPAL
District 11 (Monmouth)
SYNOPSIS
Requires health insurance carriers to provide opportunity to clinical laboratory and laboratory services provider to participate as preferred or contracting provider in carriers' provider network.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning provider networks and amending P.L.1993, c.378.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 1 of P.L.1993, c.378 (C.17:48-6j) is amended to read as follows:
1. a. Notwithstanding any other provision of law to the contrary, no group or individual hospital service corporation contract which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State [on or after the effective date of this act,] unless the contract:
(1) Permits the subscriber, at the time of issuance, amendment or renewal, to select benefit coverage allowing the subscriber to choose a pharmacy or pharmacist, clinical laboratory, or laboratory services provider for the provision of prescription drugs or pharmacy services, clinical laboratory services, or laboratory services, provided that:
(a) any pharmacist or pharmacy selected by the subscriber is registered pursuant to R.S.45:14-1 et seq.; and
(b) any clinical laboratory selected by the subscriber is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a);
(2) Provides that no pharmacy or pharmacist, clinical laboratory, or laboratory services provider shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the contract provides for coverage by contracted or preferred providers for pharmaceutical services, clinical laboratory services, or laboratory services, provided:
(a) the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the contract; and
(b) a clinical laboratory is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a), and accepts the terms and conditions of the contract;
(3) Provides that no copayment, fee, or other condition shall be imposed upon a subscriber selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider that is not also equally imposed upon all subscribers selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider;
(4) (a) Provides that no subscriber shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy;
(b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and
(c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days;
(5) Sets forth the auditing procedures to be used by the hospital service corporation and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist, clinical laboratory, or laboratory services provider and the auditor. No audit by a hospital service corporation shall include a review of any document relating to any person or prescription plan other than those reimbursable by the hospital service corporation; and
(6) Provides that the hospital service corporation, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the subscriber for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law[;
(7) The provisions of P.L.1999, c.395 shall apply to all contracts delivered. issued or renewed on or after the effective date of P.L.1999, c.395].
b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any contract.
c. This section shall apply to all hospital service corporation contracts in which the hospital service corporation has reserved the right to change the subscriber charge.
d. A hospital service corporation that offers a managed care plan, or an organized delivery system contracting with the hospital service corporation, shall:
(1) not discriminate against or exclude a willing pharmacy, pharmacist, clinical laboratory, or laboratory services provider on the basis of corporate structure, size, location, or affiliation, provided that the provider meets the hospital service corporation credentialing standards and agrees to the reimbursement schedule and performance criteria applicable to participating providers;
(2) upon request, provide written notice of participation requirements, credentialing criteria, reimbursement terms, and application procedures to a pharmacy, pharmacist, clinical laboratory, or laboratory services provider. A hospital service corporation shall respond to a completed application for participation within 60 days of receipt; and
(3) issue a written notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory services provider is denied participation in a network, stating the specific criteria that were not satisfied and informing the provider of the process for reconsideration.
e. Nothing in this section shall be construed to prohibit a hospital service corporation from establishing quality, safety, utilization, or performance standards for participation in its network, provided that the standards are applied in a uniform and nondiscriminatory manner.
f. As used in this section:
"Laboratory services provider" means any person or entity that performs, directs, supervises, or provides clinical laboratory services.
(cf: P.L.1999, c.395, s.1)
2. Section 2 of P.L.1993, c.378 (C.17:48A-7i) is amended to read as follows:
2. a. Notwithstanding any other provision of law to the contrary, no group or individual medical service corporation contract which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State or approved for issuance in this State [on or after the effective date of this act,] unless the contract:
(1) Permits the subscriber, at the time of issuance, amendment or renewal, to select benefit coverage allowing the subscriber to choose a pharmacy or pharmacist, clinical laboratory, or laboratory services provider for the provision of prescription drugs or pharmacy services, clinical laboratory services, or laboratory services, provided that:
(a) any pharmacist or pharmacy selected by the subscriber is registered pursuant to R.S.45:14-1 et seq.; or
(b) any clinical laboratory selected by the subscriber is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a);
(2) Provides that no pharmacy or pharmacist, clinical laboratory, or laboratory services provider shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the contract provides for coverage by contracted or preferred providers for pharmaceutical services, clinical laboratory services, or laboratory services, provided:
(a) the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the contract; or
(b) a clinical laboratory is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a), and accepts the terms and conditions of the contract;
(3) Provides that no copayment, fee, or other condition shall be imposed upon a subscriber selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider that is not also equally imposed upon all subscribers selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider;
(4) (a) Provides that no subscriber shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy;
(b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and
(c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days;
(5) Sets forth the auditing procedures to be used by the medical service corporation and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist, clinical laboratory, or laboratory services provider and the auditor. No audit by a medical service corporation shall include a review of any document relating to any person or prescription plan other than those reimbursable by the medical service corporation; and
(6) Provides that the medical service corporation, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the subscriber for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law[;
(7) The provisions of P.L.1999, c.395 shall apply to all contracts delivered. issued or renewed on or after the effective date of P.L.1999, c.395].
b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any contract.
c. This section shall apply to all medical service corporation contracts in which the medical service corporation has reserved the right to change the subscriber charge.
d. A medical service corporation that offers a managed care plan, or an organized delivery system contracting with the medical service corporation, shall:
(1) not discriminate against or exclude a willing pharmacy, pharmacist, clinical laboratory, or laboratory services provider on the basis of corporate structure, size, location, or affiliation, provided that the provider meets the medical service corporation's credentialing standards and agrees to the reimbursement schedule and performance criteria applicable to participating providers;
(2) upon request, provide written notice of participation requirements, credentialing criteria, reimbursement terms, and application procedures to a pharmacy, pharmacist, clinical laboratory, or laboratory services provider. A medical service corporation shall respond to a completed application for participation within 60 days of receipt; and
(3) issue a written notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory services provider is denied participation in a network, stating the specific criteria that were not satisfied and informing the provider of the process for reconsideration.
e. Nothing in this section shall be construed to prohibit a medical service corporation from establishing quality, safety, utilization, or performance standards for participation in its network, provided that the standards are applied in a uniform and nondiscriminatory manner.
f. As used in this section:
"Laboratory services provider" means any person or entity that performs, directs, supervises, or provides clinical laboratory services.
(cf: P.L.1999, c.352, s.2)
3. Section 3 of P.L.1993, c.378 (C.17:48E-35.7) is amended to read as follows:
3. a. Notwithstanding any other provisions of law to the contrary, no group or individual health service corporation contract which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State [on or after the effective date of this act,] unless the contract:
(1) Permits the subscriber, at the time of issuance, amendment or renewal, to select benefit coverage allowing the subscriber to choose a pharmacy or pharmacist, clinical laboratory, and laboratory services provider for the provision of prescription drugs or pharmacy services, clinical laboratory services, or laboratory services, provided that:
(a) any pharmacist or pharmacy selected by the subscriber is registered pursuant to R.S.45:14-1 et seq.; or
(b) any clinical laboratory selected by the subscriber is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a);
(2) Provides that no pharmacy or pharmacist, clinical laboratory, or laboratory services provider shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the contract provides for coverage by contracted or preferred providers for pharmaceutical services, clinical laboratory services, or laboratory services, provided:
(a) the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the contract; or
(b) a clinical laboratory is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a), and accepts the terms and conditions of the contract;
(3) Provides that no copayment, fee, or other condition shall be imposed upon a subscriber selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider that is not also equally imposed upon all subscribers selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider;
(4) (a) Provides that no subscriber shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy;
(b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and
(c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days;
(5) Sets forth the auditing procedures to be used by the health service corporation and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist, clinical laboratory, or laboratory services provider and the auditor. No audit by a health service corporation shall include a review of any document relating to any person or prescription plan other than those reimbursable by the health service corporation; and
(6) Provides that the health service corporation, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the subscriber for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law[;
(7) The provisions of P.L.1999, c.395 shall apply to all contracts delivered. issued or renewed on or after the effective date of P.L.1999, c.395].
b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any contract.
c. This section shall apply to all health service corporation contracts in which the health service corporation has reserved the right to change the subscriber charge.
d. A health service corporation that offers a managed care plan, or an organized delivery system contracting with the health service corporation, shall:
(1) not discriminate against or exclude a willing pharmacy, pharmacist, clinical laboratory, or laboratory services provider on the basis of corporate structure, size, location, or affiliation, provided that the provider meets the health service corporation's credentialing standards and agrees to the reimbursement schedule and performance criteria applicable to participating providers;
(2) upon request, provide written notice of participation requirements, credentialing criteria, reimbursement terms, and application procedures to a pharmacy, pharmacist, clinical laboratory, or laboratory services provider. A health service corporation shall respond to a completed application for participation within 60 days of receipt; and
(3) issue a written notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory services provider is denied participation in a network, stating the specific criteria that were not satisfied and informing the provider of the process for reconsideration.
e. Nothing in this section shall be construed to prohibit a health service corporation from establishing quality, safety, utilization, or performance standards for participation in its network, provided that the standards are applied in a uniform and nondiscriminatory manner.
f. As used in this section:
"Laboratory services provider" means any person or entity that performs, directs, supervises, or provides clinical laboratory services.
(cf: P.L.1999, c.395, s.3)
4. Section 4 of P.L.1993, c.378 (C.17B:26-2.1i) is amended to read as follows:
4. a. Notwithstanding any other provision of law to the contrary, no individual health insurance policy which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State [on or after the effective date of this act,] unless the policy:
(1) Permits the insured, at the time of issuance, amendment or renewal, to select benefit coverage allowing the insured to choose a pharmacy or pharmacist, clinical laboratory, and laboratory services provider for the provision of prescription drugs or pharmacy services, clinical laboratory services, or laboratory services, provided that:
(a) any pharmacist or pharmacy selected by the insured is registered pursuant to R.S.45:14-1 et seq.; or
(b) any clinical laboratory selected by the insured is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a);
(2) Provides that no pharmacy or pharmacist, clinical laboratory, or laboratory services provider shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the policy provides for coverage by contracted or preferred providers for pharmaceutical services, clinical laboratory services, or laboratory services, provided:
(a) the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the contract; or
(b) a clinical laboratory is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a), and accepts the terms and conditions of the contract;
(3) Provides that no copayment, fee, or other condition shall be imposed upon an insured selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider that is not also equally imposed upon all insureds selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider;
(4) (a) Provides that no insured shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy;
(b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and
(c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days;
(5) Sets forth the auditing procedures to be used by the insurer and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist, clinical laboratory, or laboratory services provider and the auditor. No audit by an insurer shall include a review of any document relating to any person or prescription plan other than those reimbursable by the insurer; and
(6) Provides that the insurer, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the insured for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law[;
(7) The provisions of P.L.1999, c.395 shall apply to all policies delivered. issued or renewed on or after the effective date of P.L.1999, c.395].
b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any policy.
c. This section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.
d. An insurer that offers a managed care plan, or an organized delivery system contracting with the insurer, shall:
(1) not discriminate against or exclude a willing pharmacy, pharmacist, clinical laboratory, or laboratory services provider on the basis of corporate structure, size, location, or affiliation, provided that the provider meets the insurer's credentialing standards and agrees to the reimbursement schedule and performance criteria applicable to participating providers;
(2) upon request, provide written notice of participation requirements, credentialing criteria, reimbursement terms, and application procedures to a pharmacy, pharmacist, clinical laboratory, or laboratory services provider. An insurer shall respond to a completed application for participation within 60 days of receipt; and
(3) issue a written notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory services provider is denied participation in a network, stating the specific criteria that were not satisfied and informing the provider of the process for reconsideration.
e. Nothing in this section shall be construed to prohibit an insurer from establishing quality, safety, utilization, or performance standards for participation in its network, provided that the standards are applied in a uniform and nondiscriminatory manner.
f. As used in this section:
"Laboratory services provider" means any person or entity that performs, directs, supervises, or provides clinical laboratory services.
(cf: P.L.1999, c.395, s.4)
5. Section 5 of P.L.1993, c.378 (C.17B:27-46.1i) is amended to read as follows:
5. a. Notwithstanding any other provision of law to the contrary, no group health insurance policy which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan, shall be delivered, issued, executed or renewed in this State, or approved for issuance or renewal in this State[, on or after the effective date of this act,] unless the policy:
(1) Permits the insured, at the time of issuance, amendment or renewal, to select benefit coverage allowing the insured to choose a pharmacy or pharmacist, clinical laboratory, and laboratory services provider for the provision of prescription drugs or pharmacy services, clinical laboratory services, or laboratory services, provided that:
(a) any pharmacist or pharmacy selected by the insured is registered pursuant to R.S.45:14-1 et seq.; or
(b) any clinical laboratory selected by the insured is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a);
(2) Provides that no pharmacy or pharmacist, clinical laboratory, or laboratory services provider shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the policy provides for coverage by contracted or preferred providers for pharmaceutical services, clinical laboratory services, or laboratory services, provided:
(a) the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the policy; or
(b) a clinical laboratory is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a), and accepts the terms and conditions of the policy;
(3) Provides that no copayment, fee, or other condition shall be imposed upon an insured selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider that is not also equally imposed upon all insureds selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider;
(4) (a) Provides that no insured shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy;
(b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and
(c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days;
(5) Sets forth the auditing procedures to be used by the insurer and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist, clinical laboratory, or laboratory services provider and the auditor. No audit by an insurer shall include a review of any document relating to any person or prescription plan other than those reimbursable by the insurer; and
(6) Provides that the insurer, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the insured for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or State or federal law[;
(7) The provisions of P.L.1999, c.395 shall apply to all policies delivered. issued or renewed on or after the effective date of P.L.1999, c.395].
b. Nothing in this section shall be construed to operate to add any benefit, to increase the scope of any benefit, or to increase any benefit level under any policy.
c. This section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.
d. An insurer that offers a managed care plan, or an organized delivery system contracting with the insurer, shall:
(1) not discriminate against or exclude a willing pharmacy, pharmacist, clinical laboratory, or laboratory services provider on the basis of corporate structure, size, location, or affiliation, provided that the provider meets the insurer's credentialing standards and agrees to the reimbursement schedule and performance criteria applicable to participating providers;
(2) upon request, provide written notice of participation requirements, credentialing criteria, reimbursement terms, and application procedures to a pharmacy, pharmacist, clinical laboratory, or laboratory services provider. An insurer shall respond to a completed application for participation within 60 days of receipt; and
(3) issue a written notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory services provider is denied participation in a network, stating the specific criteria that were not satisfied and informing the provider of the process for reconsideration.
e. Nothing in this section shall be construed to prohibit an insurer from establishing quality, safety, utilization, or performance standards for participation in its network, provided that the standards are applied in a uniform and nondiscriminatory manner.
f. As used in this section:
"Laboratory services provider" means any person or entity that performs, directs, supervises, or provides clinical laboratory services.
(cf: P.L.1999, c.395, s.5)
6. Section 6 of P.L.1993, c.378 (C.26:2J-4.7) is amended to read as follows:
6. a. Notwithstanding any provision of law to the contrary, a certificate of authority to establish and operate a health maintenance organization in this State shall not be issued or continued [on or after the effective date of this act] for a health maintenance organization which provides pharmacy services, prescription drugs, or a prescription drug plan, unless the coverage for health care services:
(1) Permits the enrollee, at the time of enrollment, to select benefit coverage allowing the enrollee to choose a pharmacy or pharmacist, clinical laboratory, or laboratory services provider for the provision of prescription drugs or pharmacy services, clinical laboratory services, or laboratory services, provided that:
(a) any pharmacist or pharmacy selected by the enrollee is registered pursuant to R.S.45:14-1 et seq.; or
(b) any clinical laboratory selected by the enrollee is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a);
(2) Provides that no pharmacy or pharmacist, clinical laboratory, or laboratory services provider shall be denied the right to participate as a preferred provider or as a contracting provider, under the same terms and conditions currently applicable to all other preferred or contracting providers, if the health maintenance organization provides for coverage by contracted or preferred providers for pharmaceutical services, clinical laboratory services, or laboratory services, provided:
(a) the pharmacy or pharmacist is registered pursuant to R.S.45:14-1 et seq., and accepts the terms and conditions of the health maintenance organization; or
(b) a clinical laboratory is licensed pursuant to the "New Jersey Clinical Laboratory Improvement Act," P.L.1975, c.166 (C.45:9-42.26) or certified pursuant to the federal "Clinical Laboratory Improvement Amendments of 1988," Pub.L.100-578 (42 U.S.C. s.263a), and accepts the terms and conditions of the health maintenance organization;
(3) Provides that no copayment, fee, or other condition shall be imposed upon an enrollee selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider that is not also equally imposed upon all enrollees selecting a participating or contracting pharmacist or pharmacy, clinical laboratory, or laboratory services provider;
(4) (a) Provides that no enrollee shall be required to obtain pharmacy services and prescription drugs from a mail service pharmacy;
(b) Provides for no differential in any copayment applicable to any prescription drug of the same strength, quantity and days' supply, whether obtained from a mail service pharmacy or a non-mail service pharmacy, provided that the non-mail service pharmacy agrees to the same terms, conditions, price and services applicable to the mail service pharmacy; and
(c) Provides that the limit on days' supply is the same whether the prescription drug is obtained from a mail service pharmacy or a non-mail service pharmacy, and that the limit shall not be less than 90 days except for any health care-related programs funded in whole or in part with State funds, including, but not limited to, the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) and the "Children's Health Care Coverage Program" established pursuant to P.L.1997, c.272 (C.30:4I-1 et seq.);
(5) Sets forth the auditing procedures to be used by the health maintenance organization and includes a provision that any audit shall take place at a time mutually agreeable to the pharmacy or pharmacist, clinical laboratory, or laboratory services provider and the auditor, unless authorized by the Division of Medical Assistance and Health Services in the Department of Human Services with regard to any health care-related programs funded in whole or in part with State funds, including, but not limited to, the Medicaid program and "Children's Health Care Coverage Program". No audit by a health maintenance organization shall include a review of any document relating to any person or prescription plan other than those reimbursable by the health maintenance organization, unless authorized by the Division of Medical Assistance and Health Services in the Department of Human Services with regard to any health care-related programs funded in whole or in part with State funds, including, but not limited to, the Medicaid program and "Children's Health Care Coverage Program"; and
(6) Provides that the health maintenance organization, or any agent or intermediary thereof, including a third party administrator, shall not restrict or prohibit, directly or indirectly, a pharmacy from charging the enrollee for services rendered by the pharmacy that are in addition to charges for the drug, for dispensing the drug or for prescription counseling. Services rendered by the pharmacy for which additional charges are imposed shall be subject to the approval of the Board of Pharmacy. A pharmacy shall disclose to the purchaser the charges for the additional services and the purchaser's out-of-pocket cost for those services prior to dispensing the drug. A pharmacy shall not impose any additional charges for patient counseling or for other services required by the Board of Pharmacy or the Division of Medical Assistance and Health Services in the Department of Human Services or State or federal law[;
(7) The provisions of P.L.1999, c.395 shall apply to all health maintenance organization contracts delivered. issued or renewed on or after the effective date of P.L.1999, c.395].
b. Nothing in this section shall be construed to operate to add any coverage for health care services, to increase the scope of any coverage for health care services, or to increase the level of any health care services provided by a health maintenance organization.
c. This section shall apply to health maintenance organization plans in which the right to change the enrollee charge has been reserved.
d. A health maintenance organization that offers a managed care plan, or an organized delivery system contracting with the health maintenance organization, shall:
(1) not discriminate against or exclude a willing pharmacy, pharmacist, clinical laboratory, or laboratory services provider on the basis of corporate structure, size, location, or affiliation, provided that the provider meets the health maintenance organization's credentialing standards and agrees to the reimbursement schedule and performance criteria applicable to participating providers;
(2) upon request, provide written notice of participation requirements, credentialing criteria, reimbursement terms, and application procedures to a pharmacy, pharmacist, clinical laboratory, or laboratory services provider. A health maintenance organization shall respond to a completed application for participation within 60 days of receipt; and
(3) issue a written notice of denial, if a pharmacy, pharmacist, clinical laboratory, or laboratory services provider is denied participation in a network, stating the specific criteria that were not satisfied and informing the provider of the process for reconsideration.
e. Nothing in this section shall be construed to prohibit a health maintenance organization from establishing quality, safety, utilization, or performance standards for participation in its network, provided that the standards are applied in a uniform and nondiscriminatory manner.
f. As used in this section:
"Laboratory services provider" means any person or entity that performs, directs, supervises, or provides clinical laboratory services.
(cf: P.L.1999, c.395, s.6)
7. The Commissioner of Banking and Insurance shall adopt rules and regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.140 (C.52:14B-1 et seq.), as may be necessary to effectuate the provisions of this act.
8. This act shall take
effect on the first day of the seventh month next after the date of enactment
and shall apply to policies and contracts issued or renewed on or after that
date, except that the commissioner may take any anticipatory administrative action
in advance as shall be necessary for the implementation of this act.
STATEMENT
This bill amends current law by requiring a health insurance carrier (a hospital service corporation, medical service corporation, group and individual insurers, and a health maintenance organization) to extend the same opportunity currently allowed pharmacies and pharmacists to participate as a preferred provider or as a contracting provider in a health benefits plan to clinical laboratories and laboratory services providers.
Under the bill, a carrier that offers a managed care plan, or an organized delivery system contracting with a carrier, is to not discriminate against or exclude a willing pharmacy practice site, pharmacist, clinical laboratory, or laboratory services provider on the basis of corporate structure, size, location, or affiliation, provided that the provider meets the carrier's credentialing standards and agrees to the reimbursement schedule and performance criteria applicable to participating providers. A carrier, upon request, is to provide written notice of provider participation requirements, credentialing criteria, reimbursement terms, and application procedures to a pharmacy practice site, pharmacist, clinical laboratory, or laboratory services provider. A carrier is to respond to a completed application for participation within 60 days of receipt. A carrier that denies participation to a provider is to issue a written notice of denial stating the specific criteria that were not satisfied and informing the provider of the process for reconsideration.
Nothing in the bill is to be construed as prohibiting a carrier from establishing quality, safety, utilization, or performance standards for participation in its network, provided that the standards are applied in a uniform and nondiscriminatory manner.
