S1086

An Act concerning health care coverage for persons with physical disabilities and supplementing P.L.1997, c.192 (C.26:2S-1 et seq.), P.L.1961, c.49 (C.52:14-17.25 et seq.), and P.L.2007, c.103 (C.52:14-17.46.1 et seq.).

Be It Enacted by the Senate and General Assembly of the State of New Jersey:

1. a. A carrier which offers a managed care plan that is subject to the provisions of P.L.1997, c.192 (C.26:2S-1 et seq.) shall establish procedures to ensure that persons with physical disabilities have reasonable access to primary and specialty care providers whose professional offices are accessible to persons with physical disabilities in accordance with the “Americans with Disabilities Act of 1990” standards for accessible design published by the United States Department of Justice pursuant to 28 CFR Part 36. A carrier shall make a good faith effort to ensure reasonable access to such providers within the geographic access standards for network adequacy promulgated by the Department of Banking and Insurance by regulation.

b. The procedures established pursuant to subsection a. of this section shall provide that in the event a covered person with a physical disability is unable to reasonably access an in-network primary or specialty care provider whose professional office is accessible to the covered person, the carrier shall arrange for a provider that is accessible, and if that provider is out-of-network, with the same financial responsibility as the covered person would incur if the provider was in-network. The carrier shall reimburse the accessible out-of-network provider for the covered service at the same rate as that which the carrier would pay to an in-network provider for the same service. The out-of-network provider shall accept the payment by the carrier as payment in full for the covered service and shall not balance bill the covered person for any amount in excess of the payment made by the carrier plus any required copayment or coinsurance.

2. a. The State Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits through a managed care plan, provides procedures to ensure that persons with physical disabilities have reasonable access to primary and specialty care providers whose professional offices are accessible to persons with physical disabilities in accordance with the “Americans with Disabilities Act of 1990” standards for accessible design published by the United States Department of Justice pursuant to 28 CFR Part 36. The commission shall make a good faith effort to ensure reasonable access to such providers in a manner consistent with the geographic access standards for network adequacy applicable to carriers offering managed care plans, as promulgated by the Department of Banking and Insurance by regulation pursuant to the “Health Care Quality Act,” P.L.1997, c.192 (C.26:2S-1 et seq.).

b. The procedures established pursuant to subsection a. of this section shall provide that in the event a covered person with a physical disability is unable to reasonably access an in-network primary or specialty care provider whose professional office is accessible to the covered person, the managed care plan shall arrange for a provider that is accessible, and if that provider is out-of-network, with the same financial responsibility as the covered person would incur if the provider was in-network. The contract purchased by the commission shall provide that the accessible out-of-network provider shall be reimbursed for the covered service at the same rate as that which would be paid to an in-network provider for the same service. The out-of-network provider shall accept the payment pursuant to the contract as payment in full for the covered service and shall not balance bill the covered person for any amount in excess of the payment made pursuant to the contract plus any required copayment or coinsurance.

3. a. The School Employees’ Health Benefits Commission shall ensure that every contract purchased by the commission on or after the effective date of this act that provides hospital or medical expense benefits through a managed care plan, provides procedures to ensure that persons with physical disabilities have reasonable access to primary and specialty care providers whose professional offices are accessible to persons with physical disabilities in accordance with the “Americans with Disabilities Act of 1990” standards for accessible design published by the United States Department of Justice pursuant to 28 CFR Part 36. The commission shall make a good faith effort to ensure reasonable access to such providers in a manner consistent with the geographic access standards for network adequacy applicable to carriers offering managed care plans, as promulgated by the Department of Banking and Insurance by regulation pursuant to the “Health Care Quality Act,” P.L.1997, c.192 (C.26:2S-1 et seq.).

b. The procedures established pursuant to subsection a. of this section shall provide that in the event a covered person with a physical disability is unable to reasonably access an in-network primary or specialty care provider whose professional office is accessible to the covered person, the managed care plan shall arrange for a provider that is accessible, and if that provider is out-of-network, with the same financial responsibility as the covered person would incur if the provider was in-network. The contract purchased by the commission shall provide that the accessible out-of-network provider shall be reimbursed for the covered service at the same rate as that which would be paid to an in-network provider for the same service. The out-of-network provider shall accept the payment pursuant to the contract as payment in full for the covered service and shall not balance bill the covered person for any amount in excess of the payment made pursuant to the contract plus any required copayment or coinsurance.

4. This act shall take effect on the 180th day following enactment and shall apply to any contract or policy issued or renewed on or after that date.

STATEMENT

The purpose of this bill is to ensure that persons with physical disabilities, who have health insurance through a managed care plan, have reasonable access to primary care and specialist providers whose professional offices are accessible in accordance with the federal “Americans with Disabilities Act of 1990” (ADA) standards for accessible design. The provisions of the bill apply to individual, small employer and larger employer health benefits plans, and plans issued by the State Health Benefits Program and the School Employees’ Health Benefits Program.

Specifically, the bill requires a carrier which offers a managed care plan to establish procedures to ensure that persons with physical disabilities have reasonable access to primary and specialty care providers whose professional offices are accessible to persons with physical disabilities in accordance with the ADA standards for accessible design published by the United States Department of Justice pursuant to 28 CFR Part 36. A carrier will be required to make a good faith effort to ensure reasonable access to such providers within the geographic access standards for network adequacy promulgated by the Department of Banking and Insurance by regulation, pursuant to the “Health Care Quality Act,” P.L.1997, c.192 (C.26:2S-1 et seq.).

Under the bill, the procedures must provide that if a covered person with a physical disability is unable to reasonably access an in-network primary or specialty care provider whose professional office is accessible to the covered person, the carrier is required to arrange for a provider that is accessible, and if that provider is out-of-network, with the same financial responsibility as the covered person would incur if the provider was in-network. The carrier will reimburse the accessible out-of-network provider for the covered service at the same rate as that which the carrier would pay to an in-network provider for the same service. The out-of-network provider will be required to accept the payment by the carrier as payment in full for the covered service and will not be permitted to balance bill the covered person for any amount in excess of the payment made by the carrier plus any required copayment or coinsurance.

The bill similarly applies these requirements to managed care plan contracts purchased by the State Health Benefits Commission and the School Employees’ Health Benefits Commission.

The bill takes effect on the 180th day after enactment and applies to any health insurance contract or policy issued or renewed on or after that date.