SENATE, No STATE OF NEW JERSEY. 216th LEGISLATURE INTRODUCED JANUARY 30, 2014

Transcription

1 SENATE, No. 0 STATE OF NEW JERSEY th LEGISLATURE INTRODUCED JANUARY 0, 0 Sponsored by: Senator ANTHONY R. BUCCO District (Morris and Somerset) Senator NELLIE POU District (Bergen and Passaic) Co-Sponsored by: Senators Oroho and Weinberg SYNOPSIS Requires health benefits plans in Medicaid, NJ FamilyCare, SHBP, and SEHBP to offer equal terms for participation of certain health care providers in their provider networks. CURRENT VERSION OF TEXT As introduced. (Sponsorship Updated As Of: //0)

2 AN ACT concerning State-funded health benefits plans and supplementing Titles 0 and of the Revised Statutes. BE IT ENACTED by the Senate and General Assembly of the State of New Jersey:. a. The Legislature finds and declares that: () The State health care sector represents a substantial portion of the total employment and total wages paid in the State of New Jersey; () The State health care sector added,00 new jobs from 0 through 00, while all other State industries, combined, had a net gain of only,00 jobs during that period; () The State of New Jersey must assure that its health care sector has a continued opportunity to grow and contribute to the overall employment opportunities in the State; and () Therefore, to lower the unemployment rate in New Jersey, it is necessary to take concrete measures to ensure that State expenditures to provide health care coverage advance the growth and security of health care sector employment within this State. b. As used in this section: Health care facility means a facility licensed pursuant to P.L., c. (C.:H- et seq.) or P.L., c. (C.:-. et seq.). "Qualified provider" means a provider of a qualifying service rendered to persons receiving benefits under a health benefits plan who are eligible for medical assistance under the Medicaid program established pursuant to P.L., c. (C.0:D- et seq.) or the NJ FamilyCare Program established pursuant to P.L.00, c. (C.0:J- et al.), and which provider satisfies each of the following requirements: () no less than 0 percent of health care services provided to those persons are rendered within a health care facility located within this State; () no less than 0 percent of its employees providing health care services to those persons are residents of this State; () employs no less than 0 residents of this State; () is a participating provider in the Medicaid program established pursuant to P.L., c. (C.0:D- et seq.) and the federal Medicare program established pursuant to Title XVIII of the "Social Security Act," Pub.L.- ( U.S.C. s. et seq.); and () is not a general or special hospital licensed by the Department of Health. "Qualifying service" means a health care service, including an ancillary health care service, rendered by a qualified provider licensed by the Department of Health or the State Board of Medical Examiners.

3 c. () Notwithstanding any other provision of law to the contrary, a health maintenance organization that contracts with the Division of Medical Assistance and Health Services in the Department of Human Services to provide benefits under a health benefits plan to persons who are eligible for medical assistance under the Medicaid program established pursuant to P.L., c. (C.0:D- et seq.) or the NJ FamilyCare Program established pursuant to P.L.00, c. (C.0:J- et al.) shall not exclude a qualified provider from participation in the health care provider network for that plan, provided that the provider: (a) submits an accurate and complete provider enrollment application to the plan; and (b) enters into a participating provider agreement with the plan. () Within 0 days of submission of an accurate and complete provider enrollment application by the qualified provider pursuant to subsection a. of this section, the plan and the provider shall complete negotiations in good faith with the objective of entering into a participating provider agreement granting in-network status to the provider in connection with rendering a qualifying service on terms that are no less favorable to the qualified provider than those of any participating provider agreement between the plan and any other provider. For the purposes of this paragraph, the plan shall not be deemed to be acting in good faith if it fails to agree to a participating provider agreement with a qualified provider on terms that are no less favorable to the qualified provider than those contained in a participating provider agreement that the plan has entered into with any other provider. d. A health benefits plan offered by a health maintenance organization as described in subsection c. of this section shall not: () reimburse a provider for a particular qualifying service but not reimburse a qualified provider for the same service; () assign unfavorable status to a qualified provider relative to any other provider, including, but not limited to: (a) maintaining a substantially lower rate of reimbursement for a similar qualifying service rendered by a qualified provider relative to any another provider; or (b) establishing a substantially different reimbursement procedure for a similar qualifying service rendered by a qualified provider relative to any other provider; or (c) establishing different performance measures or requirements for a qualified provider relative to any other provider, including, but not limited to: (i) inconsistent requirements as to the necessary number and size of physical locations within a geographical area; or (ii) inconsistent reporting guidelines or requirements; () subcontract network management responsibilities to any provider that collects an administrative fee, management fee, or other fee in exchange for network management services; or

4 () administer benefits to a Medicaid or NJ FamilyCare Program recipient utilizing the qualifying service of a qualified provider in a manner which is not the same as, or similar in all material respects to, the manner in which benefits are administered to another recipient utilizing the service of any other provider. e. The health benefits plan offered by the health maintenance organization shall submit reimbursement for a qualifying service at a contracted rate directly to a qualified provider in accordance with the reimbursement schedule for that plan and as required pursuant to law or regulation. f. The Commissioner of Human Services, pursuant to the "Administrative Procedure Act," P.L., c.0 (C.:B- et seq.), shall adopt rules and regulations to effectuate the purposes of this section.. a. The findings and declarations of the Legislature as set forth in subsection a. of section of P.L., c. (C. ) (pending before the Legislature as this bill) are applicable for the purposes of this section. b. As used in this section: Health care facility means a facility licensed pursuant to P.L., c. (C.:H- et seq.) or P.L., c. (C.:-. et seq.). "Qualified provider" means a provider of a qualifying service rendered to persons receiving benefits under a contract purchased by the State Health Benefits Commission that provides hospital or medical expense benefits, and which provider satisfies each of the following requirements: () no less than 0 percent of health care services provided to those persons are rendered within a health care facility located within this State; () no less than 0 percent of its employees providing health care services to those persons are residents of this State; () employs no less than 0 residents of this State; () is a participating provider in the Medicaid program established pursuant to P.L., c. (C.0:D- et seq.) and the federal Medicare program established pursuant to Title XVIII of the "Social Security Act," Pub.L.- ( U.S.C. s. et seq.); and () is not a general or special hospital licensed by the Department of Health. "Qualifying service" means a health care service, including an ancillary health care service, rendered by a qualified provider licensed by the Department of Health or the State Board of Medical Examiners. c. Notwithstanding any other provision of law to the contrary, 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 shall

5 not exclude a qualified provider from participation in the health care provider network for the contracted health benefits plan, provided that the provider: () submits an accurate and complete provider enrollment application to the plan; and () enters into a participating provider agreement with the plan. d. Within 0 days of submission of an accurate and complete provider enrollment application by the qualified provider pursuant to subsection c. of this section, the plan and the provider shall complete negotiations in good faith with the objective of entering into a participating provider agreement granting in-network status to the provider in connection with rendering a qualifying service on terms that are no less favorable to the qualified provider than those of any participating provider agreement between the plan and any other provider. For the purposes of this paragraph, the plan shall not be deemed to be acting in good faith if it fails to agree to a participating provider agreement with a qualified provider on terms that are no less favorable to the qualified provider than those contained in a participating provider agreement that the plan has entered into with any other provider. e. The health benefits plan shall not: () reimburse a provider for a particular qualifying service but not reimburse a qualified provider for the same service; () assign unfavorable status to a qualified provider relative to any other provider, including, but not limited to: (a) maintaining a substantially lower rate of reimbursement for a similar qualifying service rendered by a qualified provider relative to any other provider; or (b) establishing a substantially different reimbursement procedure for a similar qualifying service rendered by a qualified provider relative to any other provider; or (c) establishing different performance measures or requirements for a qualified provider relative to any other provider, including, but not limited to: (i) inconsistent requirements as to the necessary number and size of physical locations within a geographical area; or (ii) inconsistent reporting guidelines or requirements; () subcontract network management responsibilities to any provider that collects an administrative fee, management fee, or other fee in exchange for network management services; or () administer benefits to a covered person utilizing the qualifying service of a qualified provider in a manner which is not the same as, or similar in all material respects to, the manner in which benefits are administered to another covered person utilizing the service of any other provider. f. The health benefits plan shall submit reimbursement for a qualifying service at a contracted rate directly to a qualified

6 provider in accordance with the reimbursement schedule for that plan and as required pursuant to law or regulation. g. The commission, pursuant to the "Administrative Procedure Act," P.L., c.0 (C.:B- et seq.), shall adopt rules and regulations to effectuate the purposes of this section.. a. The findings and declarations of the Legislature as set forth in subsection a. of section of P.L., c. (C. ) (pending before the Legislature as this bill) are applicable for the purposes of this section. b. As used in this section: Health care facility means a facility licensed pursuant to P.L., c. (C.:H- et seq.) or P.L., c. (C.:-. et seq.). "Qualified provider" means a provider of a qualifying service rendered to persons receiving benefits under a contract purchased by the School Employees Health Benefits Commission that provides hospital or medical expense benefits, and which provider satisfies each of the following requirements: () no less than 0 percent of health care services provided to those persons are rendered within a health care facility located within this State; () no less than 0 percent of its employees providing health care services to those persons are residents of this State; () employs no less than 0 residents of this State; () is a participating provider in the Medicaid program established pursuant to P.L., c. (C.0:D- et seq.) and the federal Medicare program established pursuant to Title XVIII of the "Social Security Act," Pub.L.- ( U.S.C. s. et seq.); and () is not a general or special hospital licensed by the Department of Health. "Qualifying service" means a health care service, including an ancillary health care service, rendered by a qualified provider licensed by the Department of Health or the State Board of Medical Examiners. c. Notwithstanding any other provision of law to the contrary, 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 shall not exclude a qualified provider from participation in the health care provider network for the contracted health benefits plan, provided that the provider: () submits an accurate and complete provider enrollment application to the plan; and () enters into a participating provider agreement with the plan. d. Within 0 days of submission of an accurate and complete provider enrollment application by the qualified provider pursuant to subsection c. of this section, the plan and the provider shall

7 complete negotiations in good faith with the objective of entering into a participating provider agreement granting in-network status to the provider in connection with rendering a qualifying service on terms that are no less favorable to the qualified provider than those of any participating provider agreement between the plan and any other provider. For the purposes of this paragraph, the plan shall not be deemed to be acting in good faith if it fails to agree to a participating provider agreement with a qualified provider on terms that are no less favorable to the qualified provider than those contained in a participating provider agreement that the plan has entered into with any other provider. e. The health benefits plan shall not: () reimburse a provider for a particular qualifying service but not reimburse a qualified provider for the same service; () assign unfavorable status to a qualified provider relative to any other provider, including, but not limited to: (a) maintaining a substantially lower rate of reimbursement for a similar qualifying service rendered by a qualified provider relative to any other provider; or (b) establishing a substantially different reimbursement procedure for a similar qualifying service rendered by a qualified provider relative to any other provider; or (c) establishing different performance measures or requirements for a qualified provider relative to any other provider, including, but not limited to: (i) inconsistent requirements as to the necessary number and size of physical locations within a geographical area; or (ii) inconsistent reporting guidelines or requirements; () subcontract network management responsibilities to any provider that collects an administrative fee, management fee, or other fee in exchange for network management services; or () administer benefits to a covered person utilizing the qualifying service of a qualified provider in a manner which is not the same as, or similar in all material respects to, the manner in which benefits are administered to another covered person utilizing the service of any other provider. f. The health benefits plan shall submit reimbursement for a qualifying service at a contracted rate directly to a qualified provider in accordance with the reimbursement schedule for that plan and as required pursuant to law or regulation. g. The commission, pursuant to the "Administrative Procedure Act," P.L., c.0 (C.:B- et seq.), shall adopt rules and regulations to effectuate the purposes of this section.. This act shall take effect on the first day of the seventh month next following the date of enactment, but the Commissioner of Human Services, the State Health Benefits Commission, and the School Employees Health Benefits Commission may take such

8 0 anticipatory administrative action in advance thereof as shall be necessary for the implementation of this act. STATEMENT This bill promotes job growth and job security for health care sector employees in the State by ensuring that a qualified health care provider operating in the State can elect to participate as an innetwork provider, under the same terms and conditions applicable to all other in-network health care providers, with a health benefits plan funded by the State through the Medicaid program, the NJ FamilyCare Program, the State Health Benefits Program, or the School Employees Health Benefits Program.