The New Jersey “Out-of-Network Consumer Protection,

Transparency, Cost Containment and Accountability Act”


Question: What is the current status of the New Jersey Out-of-Network bill?

Answer:  New Jersey Assembly Bill No. 1952, the “Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act,” has slowly made its way through the committee process in the New Jersey Assembly. The bill is on its second revision and has just been approved by two committees. The bill must now go before the entire Assembly for a vote. The bill’s Senate counterpart, S1258, is still in its introduced version and has yet to be submitted to any Senate committees for review. A vote in the full Assembly is not expected on A1952 before the Senate holds a committee hearing.

A main thrust of the bill is to cover so-called “surprise” charges to a patient by an out-of-network provider where a health insurer (either a non-ERISA plan or an ERISA plan which “opts in” to the statute) provides out-of-network coverage, under two scenarios: 1) emergent and urgent care treatment; and 2) “inadvertent” out-of-network services (where a patient seeks treatment at an in-network facility for covered services which, for some reason, are not available from that facility on an in-network basis). The bill basically prohibits an out-of-network provider from “balance billing” a patient for covered services, and limits a provider’s ability to bill a patient to an amount no more than the lowest amount of any deductible, co-payment or coinsurance amount for which the patient would have been required to pay had the treatment been rendered by an in-network provider. The provider must then negotiate with the carrier for the balance of the payment. If agreement cannot be reached, the provider and the carrier must go to arbitration, but the bill limits the amount an arbitrator can award. In the present version of the bill, the award must be between 100% and 250% of the Medicare fee schedule for the covered service.

This provision is problematic for physicians, as it places a hard “cap” on the amount that can be reimbursed for out-of-network services. The bill also includes less controversial provisions, such as requiring facilities, providers and insurance companies to disclose their network status and coverage for out-of-network services. Physician groups are lobbying the Legislature to use market-based rates in the arbitration process, rather than some arbitrary percentage of Medicare rates.

At present, it does not appear that the bill is going to move through the Legislature and be submitted to the Governor any time soon. That, however, may change if the Senate President decides to submit the bill for consideration by committee. Updates will be forthcoming if significant developments occur.

Weekly Charting Tip:

If you type your input into your EMR while you are with your patient, do not turn your back to the patient while you are typing. It is both rude and makes the patient feel disconnected from you. See you next week! Larry Kobak, DPM, JD

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