A1712

An Act concerning medical billing requirements and supplementing Title 45 of the Revised Statutes.

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

1. a. As used in this section:

“Adjudication” means the process by which a carrier reviews a health care claim and provides an explanation of benefits reimbursement to a provider.

"Carrier" means an entity that contracts or offers to contract to provide, deliver, arrange for, pay for, or reimburse any of the costs of health care services under a health benefits plan, including: an insurance company authorized to issue health benefits plans; a health maintenance organization; a health, hospital, or medical service corporation; a multiple employer welfare arrangement; the State Health Benefits Program and the School Employees’ Health Benefits Program; or any other entity providing a health benefits plan. Except as provided under the provisions of this act, “carrier” shall not include any other entity providing or administering a self-funded health benefits plan.

“Episode of care” means the medical care ordered to be provided for a specific medical procedure, condition, or illness.

"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. For the purposes of this act, “health benefits plan” shall not include the following plans, policies or contracts: Medicaid, Medicare, Medicare Advantage, 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.), a dental plan as defined pursuant to section 1 of P.L.2014, c.70 (C.26:2S-26) and hospital confinement indemnity coverage.

“Health care facility” means a health care facility licensed pursuant to P.L.1971, c.136 (C.26:2H-1 et al.).

“Health care professional” means an individual, acting within the scope of the individual’s licensure or certification, who provides professional services in, or under contract with, a health care facility.

“Health care provider” or “provider” means a health care professional or health care facility.

“Health care service” means the preadmission, outpatient, inpatient, and post discharge care provided in or by a health care facility, and such other items or services as are necessary for such care, including but not limited to medical devices, which are provided for the purpose of health maintenance, diagnosis, or treatment of human disease, pain, injury, disability, deformity, or physical condition, including, but not limited to, nursing service, home care nursing, and other paramedical service, ambulance and other medical transport services, dental and vision services, service provided by an intern, resident in training or physician whose compensation is provided through agreement with a health care facility, laboratory service, medical social service, drugs, biologicals, supplies, appliances, equipment, bed and board, including services provided by a health care professional in private practice.

“Plain language” means language that is easily understood by the average patient and that includes uniform definitions of standard insurance and medical terms, to be determined and developed by the Department of Health.

“Self-funded health benefits plan” or “self-funded plan” means a self-insured health benefits plan governed by the provisions of the federal “Employee Retirement Income Security Act of 1974,” 29 U.S.C. s.1001 et seq.

“Sensitive services” means health care services related to sexual assault, pregnancy, family planning, sexually transmitted diseases, domestic violence and substance or alcohol abuse, and any other services that may be determined to be sensitive services by the Department of Health, in consultation with the Department of Banking and Insurance.

b. (1) A health care provider shall, within 30 days after a claim for a health care service is adjudicated by a carrier, provide to the patient or to the patient's survivor or legal guardian, as appropriate, a statement or bill of the charges or expenses for the health care services the patient received from the provider if the patient owes all or a portion of the amount due for the health care service. The statement or bill provided to the patient or to the patient’s survivor or legal guardian shall contain conspicuous language stating that a plain language statement or bill is available upon written request and shall be provided to the patient within 10 days after the written request is received. The plain language statement or bill shall detail the specific nature of the charges or expenses for the health care services that the patient received from the provider.

(2) The plain language statement or bill required by this section shall:

(a) not describe a billed charge using only a medical billing code or a general term such as "miscellaneous charges," "supply charges," or "other charges";

(b) list the specific services received and expenses incurred by date and health care provider;

(d) conspicuously display the telephone number of the health care facility's patient liaison responsible for expediting the resolution of any billing dispute between the patient, or the patient's survivor or legal guardian in accordance with subsection c. of this section; and

(e) provide information on free or reduced cost financial assistance health care programs offered by the provider and available to patients.

Notwithstanding the requirements of this paragraph, a plain language statement or bill shall not contain information about sensitive services unless subsequently requested by the person who is legally authorized to consent to care.

(3) After delivery of the initial statement or bill, any subsequent statement or bill provided to a patient or to the patient's survivor or legal guardian, as appropriate, relating to the same episode of care shall include all the information required by paragraph (2) of this subsection if requested by the patient or the patient’s survivor or legal guardian, with any revisions clearly delineated.

(4) A health care provider shall:

(a) transmit the statement or bill by mail or, upon request, by secure e-mail, via a secure online portal; and

(b) not bill or otherwise charge a patient for preparation of a statement or bill required by this section.

c. Each health care facility shall establish policies and procedures for reviewing and responding to questions from a patient concerning the patient's statement or bill. A response shall be provided no more than 10 business days after the date a question is received.

d. The Division of Consumer Affairs in the Department of Law and Public Safety, in consultation with the Department of Banking and Insurance, shall adopt rules that specify the requirements for health care providers to develop and provide plain language billing statements in accordance with this section. The division shall ensure that the rules are consistent with P.L.2018, c.32 (C.26:2SS-1 et seq.). The rules shall specify, at a minimum, the following:

(1) the contents of the statements, including the patient's rights and payment obligations pursuant to the patient's health benefit plan;

(2) disclosure requirements specific to health care facilities, including the terms used to differentiate in-network and out-of-network services and health care providers; and

(3) requirements to ensure that carriers, health care facilities, and health care providers use language that is consistent with the disclosures required by P.L.2018, c.32 (C.26:2SS-1 et seq.).

e. The Department of Health, in consultation with the Department of Banking and Insurance and the Division of Consumer Affairs in the Department of Law and Public Safety, shall adopt rules that specify the requirements for health care facilities to develop and provide plain-language billing statements in accordance with this section. The Department of Health shall ensure that the rules are consistent with P.L.2018, c.32 (C.26:2SS-1 et seq.). The rules shall specify, at a minimum, the following:

(1) the contents of the statements, including the patient's rights and payment obligations pursuant to the patient's health benefit plan;

(2) disclosure requirements specific to health care facilities, including the terms used to differentiate in-network and out-of-network services and health care providers; and

(3) requirements to ensure that carriers, health care facilities, and health care providers use language that is consistent with the disclosures required by P.L.2018, c.32 (C.26:2SS-1 et seq.).

2. This act shall take effect immediately and shall apply to health care services performed on and after the first day of the 18th month next following promulgation of the implementing regulations.

STATEMENT

This bill establishes certain medical billing requirements concerning the specific nature of charges or expenses for health care services.

The bill requires a health care provider to provide to the patient or to the patient's survivor or legal guardian, as appropriate, a statement or bill detailing the specific nature of the charges or expenses for the health care services the patient received from the provider, if the patient owes all or a portion of the amount due for the received health care service. If the patient owes all or a portion of the amount due for the health care service, then the health care provider must provide the statement or bill within 30 days after a claim for the health care service is adjudicated by a carrier. If a statement or bill is sent to the patient, the statement or bill provided must contain conspicuous language stating that a plain language statement or bill is available upon written request, which will be provided to the patient within 10 days after the written request is received. The description of billed charges in the plain language statement or bill will detail, with certain exceptions, the specific nature of the charges or expenses for the health care services the patient received from the provider, among other requirements.