Assembly, No. 4075 state of new jersey 212th legislature



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ASSEMBLY, No. 4075



STATE OF NEW JERSEY

212th LEGISLATURE

INTRODUCED MARCH 8, 2007





Sponsored by:

Assemblyman NEIL M. COHEN

District 20 (Union)

Assemblyman JON M. BRAMNICK

District 21 (Essex, Morris, Somerset and Union)

SYNOPSIS

Establishes fee schedule requirements for certain network-based health or dental benefits coverage regarding reimbursement for out-of-network, non-hospital provider claims.


CURRENT VERSION OF TEXT

As introduced.





An Act concerning certain network-based health or dental benefits coverage, and supplementing chapter 30 of Title 17B of the New Jersey Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. As used in this section:

“Carrier” means an insurance company, health service corporation, hospital service corporation, medical service corporation, health maintenance organization, dental service corporation, dental plan organization, or prepaid prescription service organization authorized to issue any health benefits plan, dental contract or plan, or prescription drug plan in this State.

“Covered person” means a person on whose behalf a carrier or organized delivery system is obligated to pay benefits pursuant to a health benefits plan, dental contract or plan, or prescription drug plan.

“Covered service” means a service provided by a health care provider or organized delivery system to a covered person under a health benefits plan, dental contract or plan, or prescription drug plan, for which the carrier or organized delivery system is obligated to pay benefits.

“Dental contract” means a dental contract issued pursuant to the provisions of the “Dental Service Corporation Act of 1968,” P.L.1968, c.305 (C.17:48C-1 et seq.).

“Dental plan” means a dental plan issued pursuant to the provisions of the “Dental Plan Organization Act,” P.L.1979, c.478 (C.17:48D-1 et seq.).

“Health benefits plan” means “health benefits plan” as defined by section 3 of P.L.2005, c.352 (C.17B:30-50).

“Health care provider” means an individual or entity which, acting within the scope of the individual’s or entity’s licensure or certification, provides a covered service defined by a health benefits plan, dental contract or plan, or prescription drug plan. Health care provider includes, but is not limited to, a physician, dentist, and any other health care professional licensed or certified pursuant to Title 45 of the Revised Statutes, any health care facility licensed pursuant to Title 26 of the Revised Statutes, and a prepaid prescription service organization and any other carrier authorized to provide a prescription service pursuant to P.L.1997, c.380 (C.17:48F-1 et seq.).

“Hospital” means “hospital” as defined by section 3 of P.L.2005, c.352 (C.17B:30-50).

“Network” means one or more health care providers which enter into a selective contracting arrangement with a carrier or organized delivery system.

“Organized delivery system” means “organized delivery system” as defined in section 1 of P.L.1999, c.409 (C.17:48H-1).

“Prescription drug plan” means a prepaid prescription service organization contract provided by a certified organization or other carrier authorized to provide a prepaid prescription service pursuant to P.L.1997, c.380 (C.17:48F-1 et seq.), or any other carrier contract, policy, or plan delivered or issued in this State which provides benefits for pharmacy services, prescription drugs, or for participation in a prescription drug plan.

“Selective contracting arrangement” means an arrangement in which a carrier or organized delivery system participates in selective contracting with one or more participating health care providers, and which arrangement contains reasonable benefit differentials, including, but not limited to, predetermined fee or reimbursement rates for covered services applicable to participating and nonparticipating health care providers.

“Third party administrator” means “third party administrator” as defined by section 1 of P.L.2001, c.267 (C.17B:27B-1).

“Third party billing service” means “third party billing service” as defined by section 1 of P.L.2001, c.267 (C.17B:27B-1).

b. (1) A carrier or organized delivery system which enters into any selective contracting arrangement with a network of health care providers, or a third party administrator or billing service for that carrier or organized delivery system, shall utilize a fee schedule, as set forth in this subsection, for the reimbursement of nonparticipating health care providers, other than nonparticipating general acute care hospitals, providing any covered service to a covered person pursuant to a health benefits plan, dental contract or plan, or prescription drug plan.

(2) The fee schedule utilized by the carrier, organized delivery system, third party administrator, or billing service pursuant to paragraph (1) of this subsection shall comply with applicable fee schedule regulations promulgated by the Commissioner of Banking and Insurance, and:

(a) shall be based upon health care provider billing data collected by the Prevailing Healthcare Charges System, or any other system which collects billing data by the same or substantially similar method; but

(b) shall not be based upon the valuations for health care provider services established under the Resource-Based Relative Value Scale, utilized by the Centers for Medicare and Medicaid Services.
2. This act shall take effect on the first day of the seventh month next following enactment, and shall apply to all health benefits plans, dental contracts or plans, or prescription drug plans that are delivered, issued, executed or renewed, or approved for issuance or renewal in this State, on or after the effective date; but the Commissioner of Banking and Insurance may take any anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act.

STATEMENT


This bill establishes fee schedule requirements for certain network-based health benefits plans, dental contracts or plans, or prescription drug plans regarding reimbursement for out-of-network, non-hospital provider claims.

The bill provides that a carrier or organized delivery system which enters into any selective contracting arrangement with a network of health care providers, or a third party administrator or billing service for that carrier or organized delivery system, shall utilize a fee schedule for the reimbursement of nonparticipating health care providers, other than nonparticipating general acute care hospitals, providing any covered service to a covered person pursuant to a health benefits plan, dental contract or plan, or prescription drug plan.

The fee schedule utilized by the carrier, organized delivery system, third party administrator, or billing service shall comply with applicable fee schedule regulations promulgated by the Commissioner of Banking and Insurance, and:

- shall be based upon health care provider billing data collected by the Prevailing Healthcare Charges System, or any other system which collects billing data in the same or substantially similar method; but



- shall not be based upon the valuations for health care provider services established under the Resource-Based Relative Value Scale, utilized by the Centers for Medicare and Medicaid Services.


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