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  • NJ A1823
  • Requires health insurers, group health plans, SHBP, and SEHBP to share certain health benefits information with Medicaid and other State programs.
Introduced
(1/27/2016)
In Committee
(1/27/2016)
Crossed OverPassedSignedDead/Failed/Vetoed
2016-2017 Regular Session
This bill requires commercial individual and group health insurers, health maintenance organizations, health insurers issuing plans through the New Jersey Individual Health Coverage Program and the New Jersey Small Employer Health Benefits Program, the State Health Benefits Program, and the School Employees' Health Benefits Program (the "health plans"), to share health benefits eligibility and claims files and to engage in certain information-sharing practices designed to coordinate benefits with Medicaid and other State programs. The purpose of the bill is to achieve greater compliance with the requirement under federal law that Medicaid be the payer of last resort in situations in which Medicaid members are eligible for other health benefits coverage. The bill also expands the benefits of file-sharing and information-sharing practices to other State-funded and administered health care programs. The bill requires that, upon the request of the Division of Medical Assistance and Health Services in the Department of Human Services (the "division"), and as a condition of doing business in the State, the health plans shall: (1) enter into an agreement with the division to electronically share eligibility and adjudicated claims files of covered individuals and their dependents, to permit coordination of benefits with the Medicaid program, the NJ FamilyCare Program, the New Jersey Hospital Care Payment Assistance Program, the AIDS Drug Distribution Program, the Pharmaceutical Assistance to the Aged and Disabled program, the Senior Gold Prescription Discount Program, the State Health Benefits Program, the School Employees' Health Benefits Program, the Work First New Jersey program, the Work First New Jersey General Public Assistance program, and any other State-funded or administered health care program; (2) provide to the division, with respect to individuals or dependents who are eligible for, or are provided, medical assistance under a program administered in whole or in part by the division and any other State-funded or administered health care program, as listed in paragraph (1) above, certain information relating to the extent of the coverage provided; (3) accept the division's right of recovery and the assignment to the State of any right of an individual or other entity to payment for a health care item or service for which payment has been made; (4) respond to an inquiry by the division regarding a claim for payment for any health care item or service that is submitted within 10 years of the date of the provision of a health care item or service; (5) not deny a claim submitted by the division solely on the basis of certain administrative reasons, such as a lack of prior authorization or timeliness; and (6) respond to a request for payment within 90 business days after receipt of written proof of loss or claim for payment for health care services provided to covered individuals and dependents who have received medical assistance under a program administered in whole or in part by the division, or any other State-funded or administered health care program, as listed in paragraph (1) above. The bill provides that health plans have 30 days to respond to a request made pursuant to paragraphs (1) through (5) above. The bill also provides that, in addition to any other sanctions authorized by law, if a health plan fails to comply with any of the bill's provisions, the division or the Medicaid Fraud Division of the Office of the State Comptroller may pursue certain civil remedies provided in existing Medicaid statutes.
Health and Senior Services
Assembly Health and Senior Services Hearing (19:00 6/12/2017 )  (on 6/12/2017)
 
 

Date Chamber Action Description
6/12/2017 Assembly Health and Senior Services Hearing (19:00 6/12/2017 )
1/27/2016 A Introduced, Referred to Assembly Health and Senior Services Committee
Date Motion Yea Nay Other
None specified