New Jersey Adopts Legislation Requiring Healthcare Providers Disclose Out-of-Network Services

On June 1, NJ Governor Murphy signed into legislation Public Law 2018, C.32 which requires healthcare facilities to make certain disclosures with regard to out of benefit services. All physicians and healthcare providers should be aware of its requirements.

The Act provides that healthcare professionals must make two disclosures to their patients with regard to the health benefit plans with which the healthcare professional participates and is affiliated. The first applies where the healthcare provider is providing non-emergency services. In that case, the disclosure must be in writing or through a website and it must be made again at the time an appointment is made, in writing or verbally.

Furthermore, if a healthcare professional does not participate in the patient’s healthcare plan, the healthcare professional must:

  1. Prior to scheduling non-emergency procedures, inform the patient that the physician is “out-of-network” and that the amount or estimated amount which will be billed is available upon the patient’s request;
  2. Upon request, the healthcare professional must disclose to the patient, in writing, the amount or estimated amount, that the patient will be billed for the procedure as well as the associated current procedural terminology code for the service to be provided;
  3. Inform the patient that he or she will be financially responsible for services provided out-of-network in excess of co-payment deductibles or co-insurance and that he or she may be responsible for the costs in excess of those allowed by the patient’s health benefit plan;
  4. Advise the patient to contact their healthcare plan for consultation regarding costs.

In addition to the foregoing, the healthcare professional is required to provide a patient with the name, practice name, mailing address and telephone number for a healthcare provider providing services in connection with those provided by the physician when that healthcare professional provides the following services: anesthesiology, laboratory, pathology, radiology or assistant surgeon services.

When a healthcare professional is scheduling facility admissions or out-patient facility services, physicians are required to:

  1. Provide the patient and facility with the main practice name, mailing address and telephone number of any other physician whose services are scheduled at the time of pre-admission, testing, registration or admission when non-emergency services are scheduled;
  2. Inform the patient how to determine the health benefit plans which the other physicians participate in;
  3. Recommend that the patient contact his or her health benefit plan for consultation on costs related to those other services.

If the network status of the healthcare professional changes between the time of the disclosure and the provision of the procedure, the healthcare professional must notify the patient.

If a primary care physician or internist performs an unscheduled procedure in his or her office, the required disclosures may be made verbally at the time of service.

If a healthcare professional does not participate in a covered persons health benefit plan, and he or she provides services in an “in-network” healthcare facility when “in-network” services are unavailable in that facility, the healthcare professional may not bill the person in excess of any deductible, co-payment or co-insurance amount.

If the healthcare professional is providing medically necessary services on an emergency or urgent basis, the healthcare professional may not bill a covered person in excess of any deductible, co-payment or co-insurance amount for in-network services pursuant to the covered persons health benefits plan.

Contact Romanowsky Law now for further clarification on this important new legislation. 973 637 0776. [email protected]