Major out-of-network health care reform bill in the works

Lawmakers will introduce a major health care reform measure Thursday that will attempt to regulate and bring transparency to out-of-network charges.The bill, a draft of which was obtained by NJBIZ, will seek to limit the blow dealt to insured patients receiving urgent or emergency care at an out-of-network facility. It also will limit the fees charged to insurance carriers.

The bill is an attempt to bring order and fairness to what is becoming the most divisive issue in the industry — and will include specific pay structures and arbitration procedures.

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Worked on by several Democrats in the Assembly and Senate, the bill states that facilities would be prohibited from billing the patient for urgent or emergency out-of-network care in excess of any of the deductibles, copayments or coinsurance amounts that they would normally charge for in-network care.

The bill also would restrict health care facilities from billing the out-of-network patient’s insurance carrier in excess of the maximum payment for a given urgent or emergency service. That maximum payment, which would range from 75 percent to 250 percent of the median paid in-network cost for a particular service, would be set by an established health care price index, to be maintained by an organization of the Commissioner of Banking and Insurance’s choosing.

The selected organization would be responsible for gathering and analyzing the health care data needed to form the health care price index, which will also be electronically published and made public.

If reimbursement for out-of-network costs cannot be agreed upon within a 30-day period following the initial billing, both the insurance carrier and the facility have the option of entering into a binding arbitration process.

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The bill also addresses issues of transparency at health care facilities, mandating that providers must now offer patients a written disclosure form at least 30 days prior to a medical procedure that states whether or not the service will be in-network or out-of-network.

The bill states that facilities will also have to provide patients with a straightforward description of the procedure, a “reasonable estimate” of all associated costs and a form of disclosure advising them to further consult with their insurance carriers.

The bill will be introduced Thursday at noon in Trenton at a news conference.

Senate Health, Human Services and Senior Citizens Committee Chair Joseph F. Vitale (D-Woodbridge) will join Assembly Financial Institutions and Insurance Committee Chair Craig Coughlin (D-Woodbridge), Assembly Budget Committee Chair Gary S. Schaer (D-Passaic) and Assemblyman Troy Singleton (D-Mount Laurel) at the event.

Linda Schwimmer, vice president of the New Jersey Health Care Quality Institute, also is scheduled to attend.

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