Sponsored by:
Assemblyman HERB CONAWAY, JR.
District 7 (Burlington and Camden)
Assemblyman JACK CONNERS
District 7 (Burlington and Camden)
SYNOPSIS
Requires health insurers SHBP, Medicaid, and NJ FamilyCare to provide coverage for ancillary medical services in connection with outpatient diagnostic screening and surgical intervention services.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning health benefits coverage for diagnostic screening and surgical intervention services and supplementing various parts of the statutory law.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. A hospital service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1938, c.368 (C.17:48-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a covered person, when the ancillary service is determined medically necessary by the covered person's treating physician.
The benefits shall be provided to the same extent as for any other condition under the contract.
This section shall apply to those hospital service corporation contracts in which the hospital service corporation has reserved the right to change the premium.
2. A medical service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1940, c.74 (C.17:48A-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a covered person, when the ancillary service is determined medically necessary by the covered person's treating physician.
The benefits shall be provided to the same extent as for any other condition under the contract.
This section shall apply to those medical service corporation contracts in which the medical service corporation has reserved the right to change the premium.
3. A health service corporation contract that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to P.L.1985, c.236 (C.17:48E-1 et seq.), or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a covered person, when the ancillary service is determined medically necessary by the covered person's treating physician.
The benefits shall be provided to the same extent as for any other condition under the contract.
This section shall apply to those health service corporation contracts in which the health service corporation has reserved the right to change the premium.
4. An individual health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:26-1 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a covered person, when the ancillary service is determined medically necessary by the covered person's treating physician.
The benefits shall be provided to the same extent as for any other condition under the policy.
This section shall apply to those policies in which the insurer has reserved the right to change the premium.
5. A group health insurance policy that provides hospital and medical expense benefits and is delivered, issued, executed or renewed in this State pursuant to N.J.S.17B:27-26 et seq., or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide coverage for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a covered person, when the ancillary service is determined medically necessary by the covered person's treating physician.
The benefits shall be provided to the same extent as for any other condition under the policy.
This section shall apply to those policies in which the insurer has reserved the right to change the premium.
6. An individual health benefits plan that is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.161 (C.17B:27A-2 et seq.), on or after the effective date of this act, shall provide coverage for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a covered person, when the ancillary service is determined medically necessary by the covered person's treating physician.
The benefits shall be provided to the same extent as for any other condition under the health benefits plan.
This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
7. A small employer health benefits plan that is delivered, issued, executed or renewed in this State pursuant to P.L.1992, c.162 (C.17B:27A-17 et seq.), on or after the effective date of this act, shall provide coverage for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a covered person, when the ancillary service is determined medically necessary by the covered person's treating physician.
The benefits shall be provided to the same extent as for any other condition under the health benefits plan.
This section shall apply to those health benefits plans in which the carrier has reserved the right to change the premium.
8. A health maintenance organization contract for health care services that is delivered, issued, executed or renewed in this State pursuant to P.L. 1973, c.337 (C.26:2J-1 et seq.) shall not be issued or continued by the Commissioner of Health and Senior Services or approved for issuance or renewal in this State by the Commissioner of Banking and Insurance, on or after the effective date of this act, shall provide health care services for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to an enrollee, when the ancillary service is determined medically necessary by the enrollee's treating physician.
The health care services shall be provided to the same extent as for any other condition under the contract.
This section shall apply to those contracts for health care services under which the right to change the schedule of charges for enrollee coverage is reserved.
9. The State Health Benefits Commission shall ensure that every contract purchased on or after the effective date of this act that provides hospital or medical expense benefits shall provide coverage for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a covered person, when the ancillary service is determined medically necessary by the covered person's treating physician.
10. The Commissioner of Human Services shall ensure that every contract for health care services under the Medicaid program pursuant to P.L.1968, c.413 (C.30:4D-1 et seq.) and the NJ FamilyCare Program pursuant to P.L.2005, c.156 (C.30:4J-8 et seq.), entered into on or after the effective date of this act, and that the fee-for-service Medicaid program on or after the effective date of this act, provides benefits for expenses incurred for any ancillary medical service, including, but not limited to, pathology and anesthesiology services, that is provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a recipient or enrollee, when the ancillary service is determined medically necessary by the treating physician.
11. This act shall take effect on the 60th day after enactment and shall apply to all contracts and policies issued on or after the effective date.
STATEMENT
This bill requires private health insurance carriers (hospital, medical and health service corporations, individual, small employer and larger group commercial insurers, and health maintenance organizations), the State Health Benefits Program, and the Medicaid and NJ FamilyCare programs to provide coverage for ancillary medical services, including, but not limited to, pathology and anesthesiology services, that are provided in connection with the performance of outpatient diagnostic screening and surgical intervention services with respect to a covered person, when the ancillary service is determined medically necessary by the covered person's treating physician.
The bill takes effect on the 60th day after enactment and applies to all contracts and policies issued on or after the effective date.