Sponsored by:
Senator JON M. BRAMNICK
District 21 (Middlesex, Morris, Somerset and Union)
SYNOPSIS
Establishes additional health insurance carrier network adequacy standards with respect to certain physician specialists.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health insurance carrier network adequacy and amending P.L.1997, c.192.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. Section 19 of P.L.1997, c.192 (C.26:2S-18) is amended to read as follows:
19. The commissioner shall enforce the provisions of [this act] P.L.1997, c.192 (C.26:2S-1 et seq.).
[Within six months of the effective date of this act, in consultation with the Commissioner of Banking and Insurance, the] The commissioner shall adopt rules and regulations, pursuant to the "Administrative Procedure Act," P.L.1968, c.410 (C.52:14B-1 et seq.), necessary to carry out the purposes of [this act] P.L.1997, c.192 (C.26:2S-1 et seq.). The regulations shall establish consumer protection and quality standards governing carriers which offer a managed care plan or use a utilization management system that are consistent with the standards governing health maintenance organizations in the State.
The regulations shall include standards for: a quality management program; provider participation in a network; adequacy of the provider network with respect to the scope and type of health care benefits provided by the carrier, the geographic service area covered by the provider network and access to medical specialists, when appropriate; ensuring covered persons have reasonable and timely in-network access to physician specialists, including anesthesiologists, radiologists, pathologists, emergency medicine physicians, and services under their supervision, at in-network hospitals and facilities; utilization management as required in [this act] P.L.1997, c.192 (C.26:2S-1 et seq.); a covered person complaint system; a patient appeals system as required in [this act] P.L.1997, c.192 (C.26:2S-1 et seq.); the establishment of consumer rights of covered persons; carrier disclosure as required in [this act] P.L.1997, c.192 (C.26:2S-1 et seq.); and outcomes and data reporting requirements as required in [this act] P.L.1997, c.192 (C.26:2S-1 et seq.).
(cf: P.L.1997, c.192, s.19)
2. This act shall take effect immediately.
STATEMENT
This bill establishes additional network adequacy standards for health insurance carriers that offer a managed care plan. Current law requires regulations for those carriers to include standards for the adequacy of the provider network with respect to the scope and type of health care benefits provided by the carrier, the geographic service area covered by the provider network, and access to medical specialists. This bill requires the Commissioner of Banking and Insurance to adopt regulations to ensure that covered persons have reasonable and timely access to physician specialists at in-network hospitals and facilities, including anesthesiologists, radiologists, pathologists, emergency medicine physicians, and services under their supervision.