A4485

An Act concerning network adequacy and supplementing P.L.1997, c.192 (C.26:2S-1 et al.).

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 shall include the State Health Benefits Program, the School Employees’ Health Benefits Program, the Medicaid program, and a Medicaid managed care organization.

"Commissioner" means the Commissioner of Banking and Insurance and the Commissioner of Health.

"Medicaid" means the Medicaid program established pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.).

“Network” means those physicians who participate as in-network providers within a health benefits plan.

“Office based medical specialist” means physicians practicing in specialty areas recognized by the American Board of Medical Specialties, American Osteopathic Association or the American Podiatric Medical Association that are usually located in office-based practices other than those physicians included in the definition of “primary care physician” pursuant to this section.

“Primary care physician” means a physician who:

(1) has successfully completed a residency program accredited by the Accreditation Council for Graduate Medical Education or approved by the American Osteopathic Association in the specialty of general family medicine, general internal medicine, obstetrics and gynecology or general pediatrics; or

(2) has been evaluated by a carrier’s committee charged with setting standards for and reviewing provider credentialing under the direction of the carrier’s medical director, and who is found by that committee to demonstrate through training, education and experience or expertise in primary care.

2. All networks shall have a sufficient number of physicians to ensure that 100 percent of covered persons reside no more than:

a. a 20 minute drive or 10 miles, whichever is less, from at least three primary care physicians within each type of primary care specialty as defined pursuant to section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill) and within the geographic boundaries of the State; and

b. a 30 minute drive or 15 miles, whichever is less, from at least three office-based medical specialists within each specialty as defined pursuant to section 1 of P.L. , c. (C. ) (pending before the Legislature as this bill) and within the geographic boundaries of the State.

3. a. Pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill), a network shall have a sufficient number of physicians to:

(1) meet the health needs of covered persons;

(2) provide an appropriate choice of physicians sufficient to render services covered by the health benefits plan; and

(3) reasonably ensure that covered persons have timely access, as required pursuant to section 2 of P.L. , c. (C. ) (pending before the Legislature as this bill), to in-network facilities.

b. For purposes of determining whether a sufficient number of physicians are included in the network, the commissioner shall ensure that a carrier providing benefits for emergency services shall ensure that:

(1) requests for emergency care shall be triaged immediately or no later than one hour from the request for emergency care;

(2) requests for urgent care be provided within 24 hours of notification of the carrier;

(3) requests for a routine appointment be scheduled within two weeks; and

(4) requests for a routine physical examination be scheduled within three months.

c. Nothing in P.L. , c. (C. ) (pending before the Legislature as this bill) shall preclude a health benefits plan from offering services via telehealth or telemedicine, but services offered via telehealth or telemedicine shall not be counted toward compliance with network adequacy requirements of P.L. , c. (C. ) (pending before the Legislature as this bill).

d. Nothing in P.L. , c. (C. ) (pending before the Legislature as this bill) shall preclude a health benefits plan from including providers other than physicians, including but not limited to physician assistants, advanced practice nurses and registered nurses, in a network, but inclusion of such non-physician providers shall not be counted toward compliance with network adequacy requirements of P.L. , c. (C. ) (pending before the Legislature as this bill).

4. Upon seeking initial approval of a network and pursuant to P.L. , c. (C. ) (pending before the Legislature as this bill), a carrier shall submit a plain language description of the network to the commissioner with information sufficient to allow the commissioner to determine whether the network is in compliance with the provisions of P.L. , c. (C. ) (pending before the Legislature as this bill). The commissioner shall investigate the information supplied in the description to ensure compliance. Annually thereafter, the carrier shall submit an updated, plain language description of the network to the commissioner and shall certify that the network described therein remains compliant with the provisions of P.L. , c. (C. ) (pending before the Legislature as this bill). The commissioner may investigate the updated description for compliance with the provisions of P.L. , c. (C. ) (pending before the Legislature as this bill).

5. The Commissioner of Banking and Insurance and the Commissioner of Human Services shall establish a system by which covered persons may file formal complaints concerning network adequacy with the Department of Banking and Insurance or the Department of Human Services.

6. A carrier shall display the plain language description of each network available to the public in a conspicuous location on its internet website within 20 days of the submission of the description to the commissioner.

7. An entity providing or administering a self-funded health benefits plan which is subject to the "Employee Retirement Income Security Act of 1974," 29 U.S.C. s.1001 et seq., may elect to meet the requirements of P.L. , c. (C. ) (pending before the Legislature as this bill).

8. A carrier that violates any provision of P.L. , c. (C. ) (pending before the Legislature as this bill) shall be subject to the penalties provided pursuant to section 16 of P.L.1997, c.192 (C.26:2S-16).

9. The commissioner shall annually provide a report to the Legislature, in accordance with section 2 of P.L.1991, c.164 (C.52:14-19.1), containing the descriptions of each network.

10. The Commissioner of Banking and Insurance and the Commissioner of Human Services shall adopt rules and regulations pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.) to effectuate the purposes of this act.

11. This act shall take effect on the first day of the third month next following the date of enactment, except that the Commissioner of Banking and Insurance and the Commissioner of Human Services may take such anticipatory administrative action in advance as shall be necessary for the implementation of this act.

STATEMENT

This bill requires health insurance carriers to provide an adequate network of physicians.

Under the bill, a carrier will ensure that a network have a sufficient number of physicians to ensure that 100 percent of covered persons reside no more than:

(1) a 20 minute drive or 10 miles, whichever is less, from at least three primary care physicians within each type of primary care specialty as defined in the bill and within the geographic boundaries of the State; and

(2) a 30 minute drive or 15 miles, whichever is less, from at least three office-based medical specialists within each specialty as defined in the bill and within the geographic boundaries of the State.

Under the bill, a network will be required to have a sufficient number of physicians to:

(1) meet the health needs of covered persons;

(2) provide an appropriate choice of physicians sufficient to render services covered by the health benefits plan; and

(3) reasonably ensure that covered persons have timely access to in-network facilities.

The bill provides that a carrier will be required to submit a plain language description of the network to the commissioner with information sufficient to allow the commissioner to determine whether the network is in compliance with the provisions of the bill. The commissioner will investigate the information supplied in the description to ensure compliance. Annually thereafter, the carrier will be required to submit an updated, plain language description of the network to the commissioner and must certify that the network described remains compliant with the provisions of the bill.

Additionally, the bill requires the Commissioner of Banking and Insurance and the Commissioner of Human Services to establish a system by which a covered person may file a formal complaint concerning network adequacy with the Department of Banking and Insurance or the Department of Human Services. The bill also requires a carrier to display the plain language description of each network available to the public in a conspicuous location within its internet website within 20 days of the submission of the description to the commissioner.