Bill Text: NJ S924 | 2018-2019 | Regular Session | Introduced
Bill Title: Requires continued coverage for primary care physician services for 12 months following termination or withdrawal of physician from provider network.
Spectrum: Partisan Bill (Democrat 1-0)
Status: (Introduced - Dead) 2018-01-16 - Introduced in the Senate, Referred to Senate Commerce Committee [S924 Detail]
Download: New_Jersey-2018-S924-Introduced.html
Sponsored by:
Senator JOSEPH P. CRYAN
District 20 (Union)
SYNOPSIS
Requires continued coverage for primary care physician services for 12 months following termination or withdrawal of physician from provider network.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning managed care plans and amending P.L.1997, c.192 and P.L.1999, c.390.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 5 of P.L.1997, c.192 (C.26:2S-5) is amended to read as follows:
5. a. In addition to the disclosure requirements provided in section 4 of this act, a carrier which offers a managed care plan shall disclose to a subscriber, in writing, in a manner consistent with the "Life and Health Insurance Policy Language Simplification Act," P.L.1979, c.167 (C.17B:17-17 et seq.), the following information at the time of enrollment and annually thereafter:
(1) A current participating provider directory providing information on a covered person's access to primary care physicians and specialists, including the number of available participating physicians, by provider category or specialty and by county. The directory shall include the professional office address of a primary care physician and any hospital affiliation the primary care physician has. The directory shall also provide information about participating hospitals.
In the case of a carrier that owns, wholly or in part, or contracts with a managed behavioral health care organization, the directory shall include a list of participating providers of behavioral health care services with the address of each provider.
The carrier shall promptly notify each covered person prior to the termination or withdrawal from the carrier's provider network of the covered person's primary care physician, and at the same time further notify each such covered person that they may continue to receive treatment or services from that physician pursuant to the terms of the physician's participation in that network for a period of up to 12 months following the date of that notification, as provided by section 1 of P.L. 1999, c. 390 (C. 26:2S-9.1);
(2) General information about the financial incentives between participating physicians under contract with the carrier and other participating health care providers and facilities to which the participating physicians refer their managed care patients;
(3) The percentage of the carrier's managed care plan's network physicians who are board certified;
(4) The carrier's managed care plan's standard for customary waiting times for appointments for urgent and routine care;
(5) The availability through the department, upon request of a member of the general public, of independent consumer satisfaction survey results and an analysis of quality outcomes of health care services of managed care plans in the State;
(6) Information about the Managed Health Care Consumer Assistance Program established pursuant to P.L.2001, c.14 (C.26:2S-19 et al.) as prescribed by regulation of the commissioner, including the toll-free telephone number available to contact the program; and
(7) The carrier's preauthorization and review requirements of the health benefits plan regarding the determination of medical necessity that apply to a covered person who is admitted to an in-network health care facility, and the financial responsibility of the patient for the cost of services provided by an out-of-network admitting or attending health care practitioner.
The carrier shall provide a prospective subscriber with information about the provider network, including hospital affiliations, and other information specified in this subsection, upon request.
b. Upon request of a covered person, a carrier shall promptly inform the person:
(1) whether a particular network physician is board certified; and
(2) whether a particular network physician is currently accepting new patients.
c. The carrier shall file the information required pursuant to this section with the department.
(cf: P.L.2005, c.172, s.3)
2. Section 1 of P.L.1999, c.390 (C.26:2S-9.1) is amended to read as follows:
1. a. Notwithstanding the provisions of any law to the contrary, a carrier which offers a managed care plan shall provide in that plan that if a covered person is receiving post-operative follow-up care, oncological treatment, psychiatric treatment or obstetrical care by a physician who is employed by or under contract with a carrier at the time the treatment is initiated, the covered person may continue to be treated by that physician for the duration of the treatment in the event that the physician is no longer employed by or under contract with the carrier as follows:
(1) for a period not to exceed six months in the case of post-operative follow-up care;
(2) for a period not to exceed one year in the case of oncological treatment and psychiatric treatment; and
(3) through the duration of a pregnancy and up to six weeks after delivery in the case of obstetrical care.
The continuation of treatment by a particular physician as provided for in this subsection shall be at the option of the covered person.
The carrier shall provide that health care benefits or services, as appropriate, shall be provided for the treatment of the conditions provided in this subsection to the same extent as such benefits or services were provided while the physician was employed by or under contract with the carrier. Reimbursement for the health care services shall be pursuant to the same fee schedule used to reimburse for the services when the physician was employed by or under contract with the carrier.
b. A carrier which offers a managed care plan shall also provide in that plan for continued coverage of other health care services by a physician who was employed by or under contract with the carrier at the time the treatment was initiated, but is no longer employed by or under contract with the carrier, for up to 120 calendar days in cases where it is medically necessary for the covered person to continue treatment with that physician, and in the case of a primary care physician, for up to 12 months following the date of notification of the termination or withdrawal of that physician from the carrier's provider network as required pursuant to subsection a. of section 5 of P.L.1997, c.192 (C.26:2S-5).
Health care benefits or services, as applicable, shall be provided by the health benefits plan for medically necessary treatment as provided in this subsection to the same extent as such benefits or services were provided while the physician was employed by or under contract with the carrier. Reimbursement for the health care services shall be pursuant to the same fee schedule used to reimburse for the services when the physician was employed by or under contract with the carrier.
c. During the period of time a covered person is continuing to receive treatment pursuant to subsection a. or b. of this section by a physician who is no longer employed by or under contract with the carrier, the carrier shall provide in its plan for reimbursement for any treatment or services provided or delivered to the covered person in an acute care hospital, regardless of whether the acute care hospital is under contract or agreement with the carrier.
d. The carrier shall not be liable for any inappropriate treatment provided to the covered person by a physician who is no longer employed by or under contract with the carrier.
e. The provisions of this section shall not apply to health care services provided by a physician who is the subject of disciplinary action by the State Board of Medical Examiners.
(cf: P.L.1999, c.390, s.1)
3. This act shall take
effect on the 90th day next following the date of enactment and
shall apply to contracts or policies issued or renewed on or after that date.
STATEMENT
This bill requires managed care plans to continue coverage for primary care physician services for up to 12 months following the date of notification of the termination or withdrawal of the primary care physician from the carrier's provider network. Currently, a carrier is required to promptly notify each covered person prior to the termination or withdrawal from the carrier's provider network of the covered person's primary care physician.
This bill further requires that the covered person shall be entitled to continue to receive treatment or services from that physician pursuant to the terms of the physician's participation in that network for a period of up to 12 months following the date of that notification.
