Bill Text: NJ A3430 | 2012-2013 | Regular Session | Introduced
Bill Title: Prohibits Medicaid managed care organizations from reducing certain provider reimbursement rates without approval from DHS.
Spectrum: Partisan Bill (Democrat 2-0)
Status: (Introduced - Dead) 2012-11-19 - Introduced, Referred to Assembly Health and Senior Services Committee [A3430 Detail]
Download: New_Jersey-2012-A3430-Introduced.html
Sponsored by:
Assemblyman GORDON M. JOHNSON
District 37 (Bergen)
SYNOPSIS
Prohibits Medicaid managed care organizations from reducing certain provider reimbursement rates without approval from DHS.
CURRENT VERSION OF TEXT
As introduced.
An Act concerning Medicaid managed care organizations and supplementing Title 30 of the Revised Statutes.
Be It Enacted by the Senate and General Assembly of the State of New Jersey:
1. a. 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 managed care plan to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.) or P.L.2005, c.156 (C.30:4J-8 et al.) shall not reduce reimbursement rates to any category of participating health care providers in the plan that are subject to the regulatory authority of the Department of Health pursuant to P.L.1971, c.136 (C.26:2H-1 et seq.), or for services provided through a Health Care Service Firm pursuant to P.L.2002, c.126 (C.34:8-45.1 et seq.), without obtaining prior written approval to do so from the Commissioner of Human Services. The approval by the commissioner shall be subject to the requirements of subsection b. of this section.
b. The health maintenance organization shall be required to:
(1) apply on a form and in a manner set forth by the commissioner to obtain approval pursuant to subsection a. of this section;
(2) demonstrate to the satisfaction of the commissioner that the health maintenance organization has taken all appropriate actions to reduce the cost of providing benefits to eligible recipients covered by that plan, including: cost-effective utilization review measures as determined by the commissioner; elimination of unnecessary administrative expenses; enhanced fraud detection and recovery efforts; and any other actions that the commissioner may require as a prior condition of obtaining approval;
(3) demonstrate to the satisfaction of the commissioner that the proposed reduction in provider reimbursement rates will not adversely impact the quality and accessibility of health care services provided to eligible recipients covered by the plan; and
(4) comply with any prospective requirements established by the commissioner at the time, and as a condition, of granting such approval.
c. The Division of Medical Assistance and Health Services shall conduct a public hearing on the proposed reduction in reimbursement rates at least 30 days after receipt of the application by the health maintenance organization pursuant to subsection b. of this section, but before making a decision on whether to approve the proposed reduction.
2. This act shall take effect immediately, and shall apply to any contract that a health maintenance organization has entered into with the Division of Medical Assistance and Health Services in the Department of Human Services to provide benefits under a managed care plan to persons who are eligible for medical assistance under P.L.1968, c.413 (C.30:4D-1 et seq.) or P.L.2005, c.156 (C.30:4J-8 et al.), which is in effect on the effective date of this act or executed thereafter.
STATEMENT
This bill would prohibit a health maintenance organization (HMO) that provides benefits under a managed care plan to persons who are eligible for Medicaid or the NJ FamilyCare Program from reducing reimbursement rates to any category of participating health care facilities, or for services provided through health care service firms without obtaining prior written approval to do so from the Commissioner of Human Services.
In order to reduce reimbursement rates to a category of providers, an HMO would be required to apply on a form and in a manner set forth by the commissioner, demonstrate to the satisfaction of the commissioner that the HMO has taken all appropriate actions to otherwise reduce the cost of providing benefits, demonstrate that the proposed reduction will not adversely impact the quality and accessibility of health care services it provides, and comply with any other requirements established by the commissioner. The bill further requires that a public hearing be held on a proposed rate reduction at least 30 days after receipt of the application by the HMO but before a decision on whether a proposed rate reduction is to be approved.
