S2913

An Act concerning reimbursement for certain evaluation and management services, and supplementing P.L.1999, c.155 (C.17B:30-26 et seq.).

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

1. This act shall be known as the “Health Care Reimbursement Rate Stabilization Act.”

2. The Legislature finds and declares the need to maintain a stable and functioning health care system for residents of the State of New Jersey, which includes the important role of reasonable and consistent payments by carriers to physicians and other health care providers for services provided to patients. To ensure that the health care system in the State continues to meet the needs of patients, the Legislature deems it necessary to establish a commission, within the Department of Banking and Insurance, to review proposed reductions to payment rates by carriers regulated by the department.

3. As used in this act:

“Carrier” means any entity subject to the insurance laws and regulations of this State, or subject to jurisdiction of the Commissioner of Banking and Insurance, that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services.

“Commission” means the Commission on Insurance Reimbursement.

“Covered person” means a person on whose behalf a carrier offering a health benefits plan is obligated to pay benefits or provide services pursuant to the plan.

“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.

4. There is created, in the Department of Banking and Insurance, a Commission on Insurance Reimbursement. The commission shall consist of seven members, as follows:

a. the Commissioner of Banking and Insurance, ex officio, or a designee; and

b. six members to be appointed by the Governor, as follows:

(1) a member of the State Board of Medical Examiners;

(2) a member appointed upon recommendation of the Medical Society of New Jersey;

(3) a member appointed upon recommendation of the New Jersey Hospital Association;

(4) a member appointed upon recommendation of the New Jersey Association of Health Plans; and

(5) two public members representing two or more patients’ rights or advocacy organizations located in the State, to be appointed upon recommendation of the Senate President. Public members shall have experience with, possess a background in, or demonstrate a specialized knowledge of health care policy.

5. a. Any vacancy in the membership of the commission shall be filled in the same manner as the original appointment was made pursuant to section 3 of this act.

b. Of the two public members first appointed, one shall serve for an initial term of three years and one shall serve for an initial term of two years. Upon the conclusion of the initial terms, each public member shall be appointed for an additional term of three years and until the appointment of a successor.

c. The members of the commission shall be appointed within 30 days following the date of enactment of this act. The commission shall organize upon the appointment of a majority of its authorized membership. The members shall select a chairperson and vice-chairperson from among its membership, and the chair may appoint a secretary, who need not be a member of the commission. The commission shall meet at those times and places within the State as the commission shall determine. The presence of four members of the commission shall constitute a quorum for the transaction of any business, for the performance of any duty, or for the exercise of any power of the commission.

d. The members of the commission shall serve without compensation, but shall be eligible for reimbursement for necessary and reasonable expenses incurred in the performance of official duties within the limits of funds appropriated or otherwise made available to the commission for its purposes.

e. The commission shall be entitled to employ stenographic and clerical assistance from the Department of Banking and Insurance, as it may require to fulfill its purpose.

6. a. It shall be the responsibility of the commission to review and approve or deny applications submitted by carriers approved to issue health benefits plans that seek to reduce the payment rate for any Current Procedural Terminology (“CPT”) code when the CPT code is appended with one or more modifiers.

b. The application shall include, but not be limited to:

(1) a plain language description of the services covered under all CPT codes at issue;

(2) the number of times the CPT codes have been billed in the prior calendar year under the health benefits plan or plans sought to be modified;

(3) the amount of the proposed reduction in payment rate;

(4) a full and complete justification for the reduction in payment rate; and

(5) the number of covered persons anticipated to be affected by the reduction in payment rate.

7. a. Upon receipt of an application submitted pursuant to section 6 of this act, the commission shall consider if the proposed reduction will:

(1) interfere with the ability of covered persons in the State to access necessary medical care;

(2) have an adverse effect on the stability of the State’s health care system; and

(3) adversely affect one or more health care providers licensed pursuant to Title 45 of the Revised Statutes, or one or more facilities licensed pursuant to Title 26 of the Revised Statutes.

b. The commission shall affirmatively solicit and consider information from parties other than the applicant as to the anticipated effect of the proposed reduction. This includes, but is not limited to, health care providers anticipating an impact by the proposed reduction to the payment rate.

8. a. The commission shall provide a written determination, to be considered final, within 60 days of receipt of the application, as to whether the application is approved in whole, approved in part and denied in part, or denied in whole that includes an explanation of the determination.

b. The applicant shall have the opportunity to be heard before the commission issues its final determination. Notice shall be provided by the commission upon receipt of an application.

9. The commission shall report annually to the Governor and to the Legislature, pursuant to section 2 of P.L.1991, c.164 (C.52:14-19.1), the following:

a. a summary of its determinations;

b. a summary of the findings and activities of the commission; and

c. recommendations for proposed changes to the current laws regarding health benefits plans.

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

11. This act shall take effect immediately.

STATEMENT

This bill establishes the “Commission on Insurance Reimbursement.” The commission is to review and approve or deny applications submitted by health insurance carriers approved to issue health benefits plans in New Jersey and which seek to reduce the payment rate for any Current Procedural Terminology (“CPT”) code when the CPT code is appended with one or more modifiers. The application to be submitted is to include, among other items, the amount of the proposed reduction in payment rate and a full and complete justification for the reduction in payment rate.

As part of the review process, the commission is to consider if the proposed reduction will interfere with the ability of residents of the State to access necessary medical care; have an adverse effect on the stability of the State’s health care system; and adversely affect one or more State-licensed health care providers or one or more State-licensed health care facilities. The commission is to affirmatively solicit and consider information from parties other than the applicant, including, but not limited to, health care providers anticipating an impact by the proposed reduction to the payment rate, as to the anticipated effect of the proposed reduction.

A final written determination is to be issued by the commission within 60 days of receipt of an application. Under the bill, the commission may approve in whole, approve in part and deny in part, or deny in whole an application. The applicant is to have the opportunity to be heard before the commission issues its final determination.

The commission is to annually submit a report to the Governor and the Legislature regarding this application process. The report is to include a summary of its determinations and its overall findings and activities; and recommendations for proposed changes to the current laws regarding health benefits plans.