STATE OF NEW JERSEY
218th LEGISLATURE
PRE-FILED FOR INTRODUCTION IN THE 2018 SESSION
Sponsored by:
Assemblyman GARY S. SCHAER
District 36 (Bergen and Passaic)
SYNOPSIS
Limits payments under health benefits plans to in-network amounts in certain circumstances; prohibits out-of-network health providers from charging carriers more than 150 percent of Medicare rate in certain circumstances.
CURRENT VERSION OF TEXT
Introduced Pending Technical Review by Legislative Counsel.
An Act concerning certain health care costs and supplementing Title 26 of the Revised Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. As used in this act:
“Carrier” means an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, and the State Health Benefits Program and School Employees’ Health Benefits Program.
“Covered person” means a person on whose behalf a carrier offering the plan is obligated to pay benefits or provide services pursuant to the health benefits plan.
“Covered service” or “service” means a health care service provided to a covered person under a health benefits plan for which the carrier is obligated to pay benefits or provide health care services.
“Health benefits plan” means a benefits plan which pays or provides hospital and medical expense benefits for covered services, and is delivered or issued for delivery in this State by or through a carrier. “Health benefits plan” includes, but is not limited to, Medicare supplement coverage and risk contracts to the extent not otherwise prohibited by federal law. For the purposes of this act, “health benefits plan” shall not include the following plans, policies, or contracts: accident only, credit, disability, long-term care, TRICARE supplement coverage, coverage arising out of a workers’ compensation or similar law, automobile medical payment insurance, personal injury protection insurance issued pursuant to P.L.1972, c.70 (C.39:6A-1 et seq.) or hospital confinement indemnity coverage.
“Health care facility” means a hospital or other health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.).
“Health care professional” means a person licensed or otherwise authorized to practice in a health care profession pursuant to Title 45 of the Revised Statutes.
2. Notwithstanding any law, rule, or regulation to the contrary:
a. With respect to a covered service at any health care facility on an emergency or urgent basis, the health care facility shall not bill the covered person for the service in an amount in excess of any deductible, copayment, or coinsurance amount applicable to in-network services pursuant to the covered person’s health benefits plan and the covered person’s liability shall be limited to that amount.
b. With respect to a covered service provided at an out-of-network health care facility on an emergency or urgent basis, the health care facility shall not bill the carrier for the service in an amount in excess of 150 percent of the applicable payment rate under the federal Medicare program established pursuant to Pub.L.89-97 (42 U.S.C. s.1395 et seq.) and the carrier’s liability shall be limited to that amount.
c. With respect to a covered service provided by an out-of-network health care professional at any health care facility on an emergency or urgent basis, or provided by an out-of-network health care professional at an in-network health care facility because in-network services are unavailable at that facility, the health care professional shall not bill:
(1) the covered person for the service in an amount in excess of any deductible, copayment, or coinsurance amount applicable to in-network services pursuant to the covered person’s health benefits plan and the covered person’s liability shall be limited to that amount; and
(2) the carrier for the service provided in an amount in excess of 150 percent of the applicable payment rate under the federal Medicare program established pursuant to Pub.L.89-97 (42 U.S.C. s.1395 et seq.) for that service and the carrier’s liability shall be limited to that amount.
d. Subsection c. of this section shall not apply to a covered person who willfully chooses to access an out-of-network health care provider for health care services.
3. a. A health care facility or health care professional that violates any provision of this act shall be liable to a penalty of not more than $1,000 for each violation. Every day upon which a violation occurs shall be considered a separate violation, but a health care facility or a health care professional shall not be liable to a penalty greater than $25,000 for each occurrence. The Commissioner of Banking and Insurance shall collect the penalty in the name of the State in a summary proceeding in accordance with the “Penalty Enforcement Law of 1999,” P.L.1999, c.274 (C.2A:58-10 et seq.).
b. Upon a finding that a health care facility or health care professional has failed to comply with the requirements of this act, including the payment of a penalty as determined under subsection a. of this section, the commissioner may:
(1) in the case of a health care facility, refer the matter to the Commissioner of Health for such action as the Commissioner of Health determines appropriate; or
(2) in the case of a health care professional, refer the matter to the appropriate professional and occupational licensing board within the Division of Consumer Affairs in the Department of Law and Public Safety for such action as the board determines appropriate.
4. The Commissioner of Banking and Insurance, the Commissioner of Health, and any relevant licensing board in the Division of Consumer Affairs in the Department of Law and Public Safety under Title 45 of the Revised Statutes, shall adopt rules and regulations pursuant to the “Administrative Procedure Act,” P.L.1968, c.410 (C.52:14B-1 et seq.) in order to effectuate the purposes of this act.
5. This act shall take effect on the first day of the fourth month next following enactment. The Commissioner of Banking and Insurance, the Department of Health and any relevant licensing board may take such anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.
STATEMENT
This bill codifies certain existing State regulations that protect persons covered under health benefits plans by limiting their payments to health care facilities and health care professionals to in-network amounts in certain situations. Further, the bill limits payments by carriers for out-of-network services to health care facilities and health care professionals to 150 percent of the Medicare payment rate in certain situations.
The bill defines carrier to mean an insurance company, health service corporation, hospital service corporation, medical service corporation, or health maintenance organization authorized to issue health benefits plans in this State, and the State Health Benefits Program and School Employees’ Health Benefits Program.
Specifically, the bill provides that:
§ With respect to a covered service at any health care facility on an emergency or urgent basis, the health care facility shall not bill the covered person for the service in an amount in excess of any deductible, copayment, or coinsurance amount applicable to in-network services pursuant to the covered person’s health benefits plan and the covered person’s liability shall be limited to that amount.
§ With respect to a covered service provided at an out-of-network health care facility on an emergency or urgent basis, the health care facility shall not bill the carrier for the service in an amount in excess of 150 percent of the applicable payment rate under the federal Medicare program established pursuant to Pub.L.89-97 (42 U.S.C. s.1395 et seq.) and the carrier’s liability shall be limited to that amount.
§ With respect to a covered service provided by an out-of-network health care professional at any health care facility on an emergency or urgent basis, or provided by an out-of-network health care professional at an in-network health care facility because in-network services are unavailable at that facility, the health care professional shall not bill:
(1) the covered person for the service in an amount in excess of any deductible, copayment, or coinsurance amount applicable to in-network services pursuant to the covered person’s health benefits plan and the covered person’s liability shall be limited to that amount; and
(2) the carrier for the service in an amount in excess of 150 percent of the applicable payment rate under the federal Medicare program established pursuant to Pub.L.89-97 (42 U.S.C. s.1395 et seq.) for that service and the carrier’s liability shall be limited to that amount.
A health care facility or health care professional that violates any provision of the bill shall be liable to a penalty of not more than $1,000 for each violation. Every day upon which a violation occurs shall be considered a separate violation, but a health care facility or a health care professional shall not be liable to a penalty greater than $25,000 for each occurrence. The Commissioner of Banking and Insurance shall collect the penalty in the name of the State in a summary proceeding in accordance with the “Penalty Enforcement Law of 1999,” P.L.1999, c.274 (C.2A:58-10 et seq.).
Upon a finding that a health care facility or health care professional has failed to comply with the requirements of the bill, including the payment of a penalty under the bill’s provisions, the commissioner may:
(1) in the case of a health care facility, refer the matter to the Commissioner of Health for such action as the Commissioner of Health determines appropriate; or
(2) in the case of a health care professional, refer the matter to the appropriate professional and occupational licensing board within the Division of Consumer Affairs in the Department of Law and Public Safety for such action as the board determines appropriate.