THE LANDSCAPE
On June 1, 2018, Governor Phil Murphy signed into law the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (the “Act”). The Act’s provisions went into effect on August 30, 2018.
The Act attempts to provide consumer protections related to surprise out-of-network health care charges. It affects health care facilities, health care professionals, and health insurance carriers. The Act defines a health care facility as a general acute care hospital, satellite emergency department, hospital based off-site ambulatory care facility in which surgical cases are performed, or an ambulatory surgery facility. A health care professional is defined as an individual, acting within the scope of his or her licensure or certification, who provides a covered service defined by a patient’s health benefits plan.
The following summary highlights certain of the Act’s requirements for health care facilities and health care professionals. Please note, this is a summary only. More details regarding specific requirements of the Act are embedded in the legislation.
Facilities
Under the Act, a health care facility must make available to the public a list of the facility’s standard charges for items and services provided, and must, prior to scheduling an appointment for non-emergency or elective procedures: (1) disclose to a patient whether the facility is in-network or out-of-network with respect to the patient’s health benefits plan; (2) advise the patient that, if the facility is in-network, the patient will not incur any out-of-pocket costs outside of those typically applicable to an in-network procedure, unless the patient knowingly, voluntarily, and specifically selects an out-of-network provider to provide services; and (3) advise the patient that, if the facility is out-of-network, the patient may have a financial responsibility applicable to health care services provided at an out-of-network facility.
A health care facility must post on its website the health benefits plans in which the facility participates, a statement that physician services are not included in the facility’s charges, and the contact information of the hospital-based physician groups contracted with the facility or employed by the facility. For out-of-network emergency services, a facility may not bill patients more than the in-network deductible, copayment, or coinsurance amount.
Health Care Professionals
Under the Act, a health care professional must disclose the health benefits plans in which the professional participates, as well as the facilities with which the professional is affiliated, prior to performing any non-emergency services. An out-of-network health care professional must: (1) prior to scheduling any non-emergency procedure, inform the patient that the professional is out-of-network and that the estimated amount to be billed for services is available upon request; (2) upon a patient request, disclose to the patient the amount the health care professional will bill absent unforeseen medical circumstances that may arise when the medical service is provided; and (3) advise the patient that the patient will have a financial responsibility for health care services provided by an out-of-network professional in excess of the patient’s copayment, deductible, or coinsurance, and may be responsible for any costs in excess of those allowed by the patient’s health benefits plan.
A health care professional must provide the contact information of any health care providers scheduled to perform anesthesiology, laboratory, pathology, radiology or assistant surgeon services in connection with the care to be provided, and must recommend that the patient contact the patient’s carrier to learn more about any costs associated with these services. For out-of-network emergency services, or inadvertent out-of-network services, a professional may not bill the patient more than the patient’s applicable deductible, copayment, or coinsurance amount.
THE PATH FORWARD
NJSSA Advocacy Committee’s work continues now that the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act has been signed into law. The Committee, in conjunction with the Access to Care Coalition, a large group of physician specialty societies, has taken proactive steps to get in front of the pending regulations which will need to be promulgated by the New Jersey Department of Banking and Insurance, the Board of Medical Examiners and the New Jersey Department of Health to effectuate the Act. We have met with the DOBI Commissioner and the leadership of the Board of Medical Examiners and the Department of Health. We have been providing guidance and direction behind the scenes in advance of the regulations being finalized. Additionally, we have been communicating with the Governor’s Office. NJSSA has been specifically making sure that each of the aforementioned entities understands that the Act impacts hospital-based specialties such as anesthesia differently than other physician specialties in order to ensure that the Act does not disproportionally affect hospital-based specialties.
A meeting with the Governor’s Council and the policy shop to discuss implementation of the Act and some of our concerns are scheduled for early September.
We anticipate it will take roughly 6 to 9 months for the regulatory framework to take shape. To help navigate this uncertain period and to provide insight as to what the future landscape may look like, NJSSA will host an Out-Of-Network Webinar on Thursday, September 27, 2018.
