August 30, 2018

 

 

Written by Michael Foster, Esq. - 

On September 1, 2018, the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act (the “Act”), will go into effect in New Jersey.   The Act provides for consumer protections related to surprise out-of-network healthcare charges, and affects health care facilities and health care professionals, and health insurance carriers. A health care facility is  defined in the Act as a general acute care hospital, satellite emergency department,  hospital  based  off site  ambulatory  care  facility  in  which  ambulatory  surgical  cases  are  performed,  or an  ambulatory  surgery  facility.  A health care  provider  is an individual, acting within the scope of his licensure or  certification, who provides a covered service defined by the health benefits plan.

If you practice in NJ you likely need to update your patient forms and employee training forms, specifically to incorporate the Act requirements into training and practice.  Call or email us for assistance.  We charge $850 for the Out of Network Forms that comply with the Act - www.healthcarepracticecompliance.com.  
 
Specifics of the Act - 

Facilities
Under the Act, health care facilities 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 appoint for  non-emergency or elective procedures: (1) disclose to patients whether the facility is in-network or out-of-network in respect to the patient’s health benefits plan; (2) advise patients 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) inform patients that, if the facility is out-of-network, the patient will have a financial responsibility applicable to health care services provided at an out-of-network facility.

Facilities must also post on their 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, facilities may not bill patients more than the in-network deductible, copayment, or coinsurance amount.

Health Care Professionals
Under the Act, health care professionals must disclose the health benefits plans in which the professionals participate, as well as the facilities with which they are affiliated, prior to performing any non-emergency services. Out-of-network health care professionals must: (1) prior to scheduling any non-emergency procedure, inform patients that they are out-of-network and that the estimated amount to be billed for services is available upon request; (2) disclose to patients the amount the health care professional will bill absent unforeseen medical circumstances that may arise when the medical service is provided; and (3) advise patients that they will have financial responsibility for health care services provided by an out-of-network professional in excess of their copayment, deductible, or coinsurance, and that they may be responsible for any costs in excess of those allowed by their health benefits plan.

Health care professionals must also provide the contact information of any health care providers scheduled to perform anesthesiology, lab, pathology, radiology or assistant surgeon services in connection with the care to be provided, and to recommend that the patient contact their carrier to learn more about any costs associated with these services. For out-of-network emergency services, or inadvertent out-of-network services, professionals may not bill patients more than the in-network deductible, copayment, or coinsurance amount.



The Act is available online at http://www.njleg.state.nj.us/bills/BillView.asp?BillNumber=A2039