Governor Phil Murphy on August 30th, 2018 signed a bill that ended the decade-long battle to address the issue of the cost and impact of expensive medical bills for residents in the state.
In a statement, Gov. Murphy said, “Today, we are closing the loophole and reigning in excessive out-of-network costs to prevent residents from receiving that ‘big surprise’ in their mailbox.” “At the same time, we are making health care more affordable by ensuring these costs are not transferred to consumers through increased health premiums.”
The bill that was finally passed this year was sponsored by Assembly Speaker Craig Coughlin and Sen. Joseph Vitale (both D-Woodbridge).
The Assembly 2039 Bill
The Assembly bill 2039, requires hospitals to disclose to patients, which out-of-network providers will be billing them before a patient undergoes procedure or surgery.
With the new law in affect, the Governor said, the state will be able to rein in the “big surprise” bills residents find in their mailboxes after a hospital stay.
Murphy said, “Each year nearly 170,000 New Jersey citizens get medical bills which they didn’t expect. “Bills for services performed, unbeknownst to them, for professionals outside the networks.”
“No one likes to be blindsided. But that’s what’s been happening to residents who did not know they were getting out-of-network medical care until they received a bill in the mail,” Assembly Speaker Craig Coughlin added.
The new bill that turns into a law will allow for a state-regulated, binding arbitration process between patients and out-of-network providers to settle costs of an out-of-network bill.
The state Senate has also amended the bill to prevent insurance providers from using pricing benchmarks for services rendered by out-of-network doctors.
Self-Insured Healthcare Plan
A self-insured plan subject to ERISA that wants to be subject to the act would do so by filing an annual notice with the state and amending its plan documents to reflect that the benefits of the statute apply to the plan’s members.
- If a plan opts-in, its members would not be balance billed for out-of-network charges for emergency care in excess of the deductible, copayment, or coinsurance amount applicable to in-network services, and the plan can take advantage of the act’s binding arbitration provisions.
- The opt-in plan must provide each primary insured with a health insurance identification card indicating that the plan has elected to be subject to the act.
- A self-insured plan subject to ERISA that does not want to opt-in need take any action. If the plan does not opt-in, its members may be balance billed for out-of-network treatment. If the provider and a member do not resolve a payment dispute within 30 days after the member has been sent a bill, the member or provider may initiate binding arbitration to determine payment for the services.
- The arbitrator’s decision will include a final binding amount that the arbitrator determines is reasonable, and a nonbinding recommendation to the self-insured plan of its reasonable contribution for payment. Subject to an exception for financial hardship, the arbitrator’s expenses and fees are divided equally between the provider and the member.
The act takes effect 90 days after enactment which on or near August 30. Self-insured plans covering individuals in New Jersey will need to decide whether to elect to be subject to the act. We are awaiting regulatory guidance as to many details, including the opt-in election and the additional disclosure obligations for covered self-insured plans.
Please feel free to reach out to us at www.medicalbillersandcoders.com and contact if you would like to discuss the pros and cons of opting in or the potential impact of the act on your health plan or operations.