Sponsored by:
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington and Camden)
Co-Sponsored by:
Assemblywoman Casagrande
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 initiated by employer or carrier.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health care coverage for certain medications, supplementing P.L.1997, c.192 (C.26:2S-1 et seq.) and revising parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. A carrier which offers a managed care plan that provides benefits or health care services, as applicable, for the purchase of prescription drugs shall not 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 person's pharmaceutical benefits that results solely from a change in the covered person's employer-provided health benefits plan or the pharmacy benefits manager for that plan, either of which is initiated by the employer or the carrier, if:
a. 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
b. 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.
2. Notwithstanding the provisions of chapter 27 of Title 17B of the New Jersey Statutes to the contrary, no policy shall be delivered, issued, executed or renewed on or after the effective date of P.L. , c. (C. )(pending before the Legislature as this bill) unless the policy meets the requirements of section 1 of P.L. , c. (C. )(pending before the Legislature as this bill) and the regulations adopted thereto. The provisions of this section shall apply to all policies in which the insurer has reserved the right to change the premium.
3. Notwithstanding the provisions of P.L.1992, c.162 (C.17B:27A-17 et seq.) to the contrary, no policy or contract shall be delivered, issued, executed or renewed on or after the effective date of P.L. , c. (C. )(pending before the Legislature as this bill) unless the policy or contract meets the requirements of section 1 of P.L. , c. (C. )(pending before the Legislature as this bill) and the regulations adopted thereto. The provisions of this section shall apply to all policies or contracts in which the carrier has reserved the right to change the premium.
4. Notwithstanding the provisions of P.L.1938, c.366 (C.17:48-1 et seq.) to the contrary, no contract shall be delivered, issued, executed or renewed on or after the effective date of P.L. , c. (C. )(pending before the Legislature as this bill) unless the contract meets the requirements of section 1 of P.L. , c. (C. )(pending before the Legislature as this bill) and the regulations adopted thereto. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.
5. Notwithstanding the provisions of P.L.1940, c.74 (C.17:48A-1 et seq.) to the contrary, no contract shall be delivered, issued, executed or renewed on or after the effective date of P.L. , c. (C. )(pending before the Legislature as this bill) unless the contract meets the requirements of section 1 of P.L. , c. (C. )(pending before the Legislature as this bill) and the regulations adopted thereto. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
6. Notwithstanding the provisions of P.L.1985, c.236 (C.17:48E-1 et seq.) to the contrary, no contract shall be delivered, issued, executed or renewed on or after the effective date of P.L. , c. (C. )(pending before the Legislature as this bill) unless the contract meets the requirements of section 1 of P.L. , c. (C. )(pending before the Legislature as this bill) and the regulations adopted thereto. The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.
7. Notwithstanding the provisions of P.L.1973, c.337 (C.26:2J-1 et seq.) 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 P.L., c. (C. ) (pending before the Legislature as this bill) unless the health maintenance organization meets the requirements of section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill) and the regulations adopted thereto. The provisions of 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.
8. A prepaid prescription service organization that provides benefits for expenses incurred in the purchase of prescription drugs under a contract shall provide coverage under every such contract delivered, issued, executed or renewed in this State 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, for expenses incurred in the purchase of a maintenance medication prescribed by a covered person's physician for the covered person's chronic condition when there has been a change in the person's pharmaceutical benefits that results solely from a change in the covered person's employer-provided health benefits plan or the pharmacy benefits manager for that plan, either of which is initiated by the employer or the prepaid prescription service organization, if:
a. 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
b. 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 provisions of this section shall apply to those prepaid prescription plans in which the prepaid prescription service organization has reserved the right to change the premium.
9. 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 regulations to carry out the provisions of section 1 of this act.
10. This act shall take effect on the 180th day after 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 which offers a managed care plan that provides benefits or health care services, as applicable, 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 person's pharmaceutical benefits that results solely from a change in the covered person's employer-provided health benefits plan or the pharmacy benefits manager for that plan, either of which is initiated by the employer or the carrier, 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
· 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, small employer and group health insurers, health maintenance organizations and prepaid prescription service organizations.
The bill takes effect on the 180th day after enactment and applies to policies and contracts issued or renewed on or after the effective date.