STATE OF NEW JERSEY
216th LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2014 SESSION
Sponsored by:
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington)
SYNOPSIS
Requires certain health benefits plans to include coverage for treatment at ambulatory surgical centers and surgical practices and prohibits riders to the contrary.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel
An Act concerning certain health benefits plans and supplementing various parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. As used in this section:
"Ambulatory surgical center" means an ambulatory care facility that is licensed by the Department of Health and Senior Services to provide surgical and related services to persons who come to the facility to receive services and depart from the facility on the same day.
"Surgical practice" has the same meaning as provided in subsection g. of P.L.1971, c.136 (C.26:2H-12).
b. A hospital service corporation contract offered by a hospital service corporation providing hospital or medical expense benefits shall not be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred for health care treatment or services rendered by surgical practices and ambulatory surgical centers.
c. The benefits provided pursuant to subsection b. of this section shall be provided to the same extent as for any other healthcare treatment or services rendered by any other type of licensed health care facility for which benefits are provided under the contract.
d. Notwithstanding any other law to the contrary, the commissioner shall not in any way, either directly or indirectly, approve any contract, policy, proposal, amendment or rider for coverage that is inconsistent with the provisions of this section.
e. The provisions of this section shall apply to all contracts in which the hospital service corporation has reserved the right to change the premium.
2. a. As used in this section:
"Ambulatory surgical center" means an ambulatory care facility that is licensed by the Department of Health and Senior Services to provide surgical and related services to persons who come to the facility to receive services and depart from the facility on the same day.
"Surgical practice" has the same meaning as provided in subsection g. of P.L.1971, c.136 (C.26:2H-12).
b. A medical service corporation contract offered by a medical service corporation providing hospital or medical expense benefits shall not be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred for health care treatment or services rendered by surgical practices and ambulatory surgical centers.
c. The benefits provided pursuant to subsection b. of this section shall be provided to the same extent as for any other healthcare treatment or services rendered by any other type of licensed health care facility for which benefits are provided under the contract.
d. Notwithstanding any other law to the contrary, the commissioner shall not in any way, either directly or indirectly, approve any contract, policy, proposal, amendment or rider for coverage that is inconsistent with the provisions of this section.
e. The provisions of this section shall apply to all contracts in which the medical service corporation has reserved the right to change the premium.
3. a. As used in this section:
"Ambulatory surgical center" means an ambulatory care facility that is licensed by the Department of Health and Senior Services to provide surgical and related services to persons who come to the facility to receive services and depart from the facility on the same day.
"Surgical practice" has the same meaning as provided in subsection g. of P.L.1971, c.136 (C.26:2H-12).
b. A health service corporation contract offered by a health service corporation providing hospital or medical expense benefits shall not be 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, unless the contract provides benefits to any subscriber or other person covered thereunder for expenses incurred for health care treatment or services rendered by surgical practices and ambulatory surgical centers.
c. The benefits provided pursuant to subsection b. of this section shall be provided to the same extent as for any other healthcare treatment or services rendered by any other type of licensed health care facility for which benefits are provided under the contract.
d. Notwithstanding any other law to the contrary, the commissioner shall not in any way, either directly or indirectly, approve any contract, policy, proposal, amendment or rider for coverage that is inconsistent with the provisions of this section.
e. The provisions of this section shall apply to all contracts in which the health service corporation has reserved the right to change the premium.
4. a. As used in this section:
"Ambulatory surgical center" means an ambulatory care facility that is licensed by the Department of Health and Senior Services to provide surgical and related services to persons who come to the facility to receive services and depart from the facility on the same day.
"Surgical practice" has the same meaning as provided in subsection g. of P.L.1971, c.136 (C.26:2H-12).
b. An individual health insurance policy offered by an insurer providing hospital or medical expense benefits shall not be 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, unless the policy provides benefits to any insured or other person covered thereunder for expenses incurred for health care treatment or services rendered by surgical practices and ambulatory surgical centers.
c. The benefits provided pursuant to subsection b. of this section shall be provided to the same extent as for any other healthcare treatment or services rendered by any other type of licensed health care facility for which benefits are provided under the policy.
d. Notwithstanding any other law to the contrary, the commissioner shall not in any way, either directly or indirectly, approve any policy, proposal, amendment or rider for coverage that is inconsistent with the provisions of this section.
e. The provisions of this section shall apply to all individual health insurance policies in which the insurer has reserved the right to change the premium.
5. a. As used in this section:
"Ambulatory surgical center" means an ambulatory care facility that is licensed by the Department of Health and Senior Services to provide surgical and related services to persons who come to the facility to receive services and depart from the facility on the same day.
"Surgical practice" has the same meaning as provided in subsection g. of P.L.1971, c.136 (C.26:2H-12).
b. A group health insurance policy offered by an insurer providing hospital or medical expense benefits shall not be 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, unless the contract provides benefits to any insured or other person covered thereunder for expenses incurred for health care treatment or services rendered by surgical practices and ambulatory surgical centers.
c. The benefits provided pursuant to subsection b. of this section shall be provided to the same extent as for any other healthcare treatment or services rendered by any other type of licensed health care facility for which benefits are provided under the policy.
d. Notwithstanding any other law to the contrary, the commissioner shall not in any way, either directly or indirectly, approve any policy, proposal, amendment or rider for coverage that is inconsistent with the provisions of this section.
e. The provisions of this section shall apply to all group health insurance policies in which the insurer has reserved the right to change the premium.
6. a. As used in this section:
"Ambulatory surgical center" means an ambulatory care facility that is licensed by the Department of Health and Senior Services to provide surgical and related services to persons who come to the facility to receive services and depart from the facility on the same day.
"Surgical practice" has the same meaning as provided in subsection g. of P.L.1971, c.136 (C.26:2H-12).
b. An individual health benefits plan offered by a carrier providing hospital or medical expense benefits shall not be 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, unless the health benefits plan provides benefits to any covered person or other person covered thereunder for expenses incurred for health care treatment or services rendered by surgical practices and ambulatory surgical centers.
c. The benefits provided pursuant to subsection b. of this section shall be provided to the same extent as for any other healthcare treatment or services rendered by any other type of licensed health care facility for which benefits are provided under the health benefits plan.
d. Notwithstanding any other law to the contrary, the commissioner shall not in any way, either directly or indirectly, approve any health benefits plan, policy, proposal, amendment or rider for coverage that is inconsistent with the provisions of this section.
e. The provisions of this section shall apply to all individual health benefits plans in which the carrier has reserved the right to change the premium.
7. a. As used in this section:
"Ambulatory surgical center" means an ambulatory care facility that is licensed by the Department of Health and Senior Services to provide surgical and related services to persons who come to the facility to receive services and depart from the facility on the same day.
"Surgical practice" has the same meaning as provided in subsection g. of P.L.1971, c.136 (C.26:2H-12).
b. A small employer health benefits plan offered by a carrier providing hospital or medical expense benefits shall not be 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, unless the health benefits plan provides benefits to any covered person or other person covered thereunder for expenses incurred for health care treatment or services rendered by surgical practices and ambulatory surgical centers.
c. The benefits provided pursuant to subsection b. of this section shall be provided to the same extent as for any other healthcare treatment or services rendered by any other type of licensed health care facility for which benefits are provided under the health benefits plan.
d. Notwithstanding any other law to the contrary, the commissioner shall not in any way, either directly or indirectly, approve any health benefits plan, policy, proposal, amendment or rider for coverage that is inconsistent with the provisions of this section.
e. The provisions of this section shall apply to all small employer health benefits plans in which the carrier has reserved the right to change the premium.
8. a. As used in this section:
"Ambulatory surgical center" means an ambulatory care facility that is licensed by the Department of Health and Senior Services to provide surgical and related services to persons who come to the facility to receive services and depart from the facility on the same day.
"Surgical practice" has the same meaning as provided in subsection g. of P.L.1971, c.136 (C.26:2H-12).
b. A health maintenance organization contract providing hospital or medical expense benefits shall not be delivered, issued, executed or revised 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, unless the contract provides benefits to any enrollee or other person covered thereunder for expenses incurred for health care treatment or services rendered by surgical practices and ambulatory surgical centers.
c. The benefits provided pursuant to subsection b. of this section shall be provided to the same extent as for any other healthcare treatment or services rendered by any other type of licensed health care facility for which benefits are provided under the contract.
d. Notwithstanding any other law to the contrary, the commissioner shall not in any way, either directly or indirectly, approve any contract, policy, proposal, amendment or rider for coverage that is inconsistent with the provisions of this section.
e. The provisions of this section shall apply to all health maintenance organization contract in which the health maintenance organization has reserved the right to change the premium.
9. This act shall take effect on the 90th day after enactment.
STATEMENT
This bill requires certain health benefits plans to include coverage for treatment provided at ambulatory surgical centers and surgical practices, and to provide those benefits to the same extent as provided at other health care facilities. The bill also prohibits the Commissioner of Banking and Insurance from approving riders for coverage inconsistent with the requirements set forth in the bill.
As defined in the bill, an ambulatory surgical center means an ambulatory care facility that is licensed by the Department of Health and Senior Services to provide surgical and related services to individuals who come to the facility to receive services and depart from the facility on the same day. The term “surgical practice” means a structure or suite of rooms that is established by a physician, physician professional association surgical practice, or other professional practice solely for the physician’s, association’s or other professional entity’s private medical practice. These facilities usually contain no more than one room that is used primarily to perform surgically-related procedures, and several rooms that are used for post-anesthesia care or recovery area where physicians and their staff can closely monitor and observe patients until they are discharged from the facility.
Currently, services that are provided at ambulatory surgical centers or surgical practices by out-of-network providers could be subject to caps or limitations through riders that may be approved by the Department of Banking and Insurance. The purpose of this bill is to make services performed at these facilities a basic component of health benefits plans and prohibit the department from issuing a rider to cap or limit services performed at these facilities to ensure that there is no discrimination in the way in which insurers, health service corporations and health maintenance organizations provide benefits for procedures performed at these facilities.