The New Jersey Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act takes effect today – August 30, 2018 – and requires all licensed health care professionals in the state who bill health benefits plans issued or delivered in New Jersey (NJ Health Plans) to provide certain disclosures to patients enrolled in such plans (Covered Patients).

Most disclosures are required regardless of whether the health care professional is in-network or out-of-network with the Covered Patient’s NJ Health Plan, while others are required only if the health care professional is out-of-network with the Covered Patient’s NJ Health Plan.

Within the next three months, the New Jersey Board of Medical Examiners is expected to publish one or more forms containing the disclosures required by the Act for use by physicians and other health care professionals licensed by the BME. In the interim, licensed health care professionals and their employers – such as New Jersey medical practices and health care facilities – must update their patient disclosure forms to ensure compliance with the Act. Practice and facility websites may also require updating.

The Act does not require disclosures to be made to patients who are not enrolled in a NJ Health Plan. Notably, NJ Health Plans do not include any of the following insurance plans:

• Automobile medical payment insurance
• Dental plans
• Medicare
• Medicare Advantage
• New Jersey Medical Assistance (Medicaid)
• Personal injury protection insurance
• TRICARE supplement coverage
• Workers’ compensation coverage

Disclosures to All Covered Patients

All licensed health care professionals must disclose to their Covered Patients the NJ Health Plans in which the professionals participate, as well as the names of any general acute care hospitals, satellite emergency departments, hospital-based off-site ambulatory care facilities or ambulatory surgery facilities with which the professionals are affiliated.

The disclosures must be given as follows:

• Prior to providing non-emergency services to a Covered Patient, by disclosing the information on the professional’s internet website or in writing; and

• At the time of each appointment with a Covered Patient, by disclosing the information verbally or in writing.

Licensed physicians must also provide each Covered Patient with certain contact information regarding any outside provider scheduled to perform laboratory, anesthesiology, pathology, radiology or assistant surgeon services in connection with care to be provided to the Covered Patient in the physician’s office or otherwise coordinated or referred by the physician. The information must be provided to the Covered Patient at the time of the coordination or referral by the physician, along with (1) instructions on how the Covered Patient may determine the NJ Health Plans in which the outside provider participates and (2) a recommendation that the Covered Patient contact his/her NJ Health Plan for further consultation on the costs associated with such services.

Where a physician will be arranging for the services of another physician in connection with a scheduled admission to a Facility or for scheduled non-emergency services at an outpatient Facility, similar disclosures must be provided by the arranging physician to both the Covered Patient and the Facility at the time that the admission or outpatient services are scheduled.

Disclosures When the Professional is Out-of-Network with the Patient’s NJ Health Plan

If a health care professional does not participate in a Covered Patient’s NJ Health Plan, the professional must provide the Covered Patient with the following disclosures, in terms that the Covered Patient would typically understand:

• Inform the Covered Patient, prior to scheduling a non-emergency procedure or service, that the professional is out-of-network and that the estimated amount the professional will bill the Covered Patient for the service is available upon request.

• Upon receipt of a request from the Covered Patient, disclose to the Covered Patient in writing the estimated amount that the professional will bill the Covered Patient for the service and the CPT codes associated with that service, absent unforeseen medical circumstances that may arise when the service is provided.

• Inform the Covered Patient that he/she will be financially responsible for services provided by an out-of-network professional in excess of the Covered Patient’s co-pay, deductible or coinsurance for the services and those costs allowed by the Covered Patient’s NJ Health Plan.

• Advise the Covered Patient to contact his or her NJ Health Plan for further consultation on the costs for such services.

Except under limited circumstances, the Act requires all disclosures to be made in writing. Therefore, although not expressly required by the Act, health care professionals and their employers should consider requiring Covered Patients to sign an acknowledgement that they have received the required disclosures to document compliance with the Act.

The Act also imposes additional requirements on health care professionals with respect to the billing of “inadvertent out-of-network services” and services provided on an emergency or urgent basis at an in-network or out-of-network Facility. Health care professionals and their employers should seek legal counsel regarding these requirements to the extent that they may be applicable to their practices and facilities.

Nothing in this alert is intended to provide legal advice. All descriptions of disclosures required by the Act are provided solely for the purpose of understanding the required disclosures. The entire text of the Act can be accessed at this link.