Consumer Protection, Transparency, Cost Containment, and Accountability Act

MANDATORY HEALTH PLAN NETWORK PARTICIPATION DISCLOSURES

EFFECTIVE August 29, 2018

This law, also known as the Out of Network law, was signed by Governor Murphy on June 1 and is primarily intended to protect patients from receiving health care services from out of network providers who they do not knowingly select, which will ultimately prevent the receipt of a “surprise” out of network bill. While a great deal of these encounters occur in facilities and are associated with other specialties’ procedures, there are parts of this law that will impact all physicians, including family physicians, whether in or out of network.

While the majority of the NJAFP membership are in network physicians, over the last eight years NJAFP remained engaged on this very challenging issue in Trenton to ensure that the in network and out of network dialogue remained distinct.

Under this law, effective August 29, 2018, all physicians will be required to disclose network status to their patients prior to the provision of services. We are still waiting on guidance to be issued by the state Board of Medical Examiners and other professional licensing boards for the specific requirements of this disclosure prior to the effective date and regulations will also be forthcoming over the next 6 months on the specifics of these disclosures. In the meantime, while this network disclosure process is likely not new to your practices, please make sure that your offices are providing, at a minimum, the following information to your patients in the manner prescribed:

  • Disclose in writing or through a website the plans that you participate and any affiliated facilities prior to non-emergency services AND
  • Disclose verbally OR in writing, at the time of an appointment, the plans that you participate and any affiliated facilities.
  • When primary care/internal medicine are providing an unscheduled in-office procedure, disclosures may be provided at the time of service.

For those family physicians that are non-par with a patient’s health plan, you must provide the following disclosures prior to service:

  • Estimate costs to person for the appointment
  • Provide CPT codes and your anticipated charges, as foreseen
  • Advise person that OON financial responsibility applies, but you are NOT required to tell them what it is.
  • Advise person to consult insurance carrier on costs

If you have any questions, please feel free to contact Claudine Leone at Claudine@njafp.org. This is a very complicated law and much more involved than just these disclosure requirements and the ultimately global implementation by the Department of Banking and Insurance, Department of Health, and the specifics related to disclosures by the NJ Board of Medical Examiners will be key. More to come in the coming week . . .