26:2SS-4 Disclosures by health care facility.

814 words·~4 min read·/nj/26-72

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

4. a. Prior to scheduling an appointment with a covered person for a non-emergency or elective procedure and in terms the covered person typically understands, a health care facility shall:

(1)disclose to the covered person whether the health care facility is in-network or out-of-network with respect to the covered person's health benefits plan;

(2)advise the covered person to check with the physician arranging the facility services to determine whether or not that physician is in-network or out-of-network with respect to the covered person's health benefits plan and provide information about how to determine the health plans participated in by any physician who is reasonably anticipated to provide services to the covered person;

(3)advise the covered person that at a health care facility that is in-network with respect to the person's health benefits plan:

(a)the covered person will have a financial responsibility applicable to an in-network procedure and not in excess of the covered person's copayment, deductible, or coinsurance as provided in the covered person's health benefits plan;

(b)unless the covered person, at the time of the disclosure required pursuant to this subsection, has knowingly, voluntarily, and specifically selected an out-of-network provider to provide services, the covered person will not incur any out-of-pocket costs in excess of the charges applicable to an in-network procedure;

(c)any bills, charges or attempts to collect by the facility, or any health care professional involved in the procedure, in excess of the covered person's copayment, deductible, or coinsurance as provided in the covered person's health benefits plan in violation of subparagraph

(b)of this paragraph should be reported to the covered person's carrier and the relevant regulatory entity; and

(d)that if the covered person's coverage is provided through an entity providing or administering a self-funded health benefits plan that does not elect to be subject to the provisions of section 9 of this act, that:

(i)certain health care services may be provided on an out-of-network basis, including those services associated with the health care facility;

(ii)the covered person may have a financial responsibility applicable to health care services provided by an out-of-network provider, in excess of the covered person's copayment, deductible, or coinsurance, and the covered person may be responsible for any costs in excess of those allowed by the person's self-funded health benefits plan; and

(iii)the covered person should contact the covered person's self-funded health benefits plan sponsor for further consultation on those costs; and

(4)advise the covered person that at a health care facility that is out-of-network with respect to the covered person's health benefits plan:

(a)certain health care services may be provided on an out-of-network basis, including those health care services associated with the health care facility;

(b)the covered person may have a financial responsibility applicable to health care services provided at an out-of-network facility, in excess of the covered person's copayment, deductible, or coinsurance, and the covered person may be responsible for any costs in excess of those allowed by their health benefits plan; and

(c)that the covered person should contact the covered person's carrier for further consultation on those costs.

b. In a form that is consistent with federal guidelines, a health care facility shall make available to the public a list of the facility's standard charges for items and services provided by the facility.

c. A health care facility shall post on the facility's website:

(1)the health benefits plans in which the facility is a participating provider;

(2)a statement that:

(a)physician services provided in the facility are not included in the facility's charges;

(b)physicians who provide services in the facility may or may not participate with the same health benefits plans as the facility;

(c)the covered person should check with the physician arranging for the facility services to determine the health benefits plans in which the physician participates; and

(d)the covered person should contact their carrier for further consultation on those costs;

(3)as applicable, the name, mailing address, and telephone number of the hospital-based physician groups that the facility has contracted with to provide services including, but not limited to, anesthesiology, pathology, and radiology; and

(4)as applicable, the name, mailing address, and telephone number of physicians employed by the facility and whose services may be provided at the facility, and the health benefits plans in which they participate.

d. If, between the time the notice required pursuant to subsection a. of this section is provided to the covered person and the time the procedure takes place, the network status of the facility changes as it relates to the covered person's health benefits plan, the facility shall notify the covered person promptly.

e. The Department of Health shall specify in further detail the content and design of the disclosure form and the manner in which the form shall be provided.

L.2018, c.32, s.4.