Hemophilia Association of New Jersey

Services >> Legislative Update

LAWS IN EFFECT

2000 Standards of Hemophilia Homecare: P. L. 2000, Chapter 121

At a minimum the standards shall require:

  • A carrier must provide homecare service companies that:
    1. Provide services pursuant to a prescription from an attending physician and not make any substitutions of blood products without the physician's prior approval.
    2. Provide all brands of clotting factor product, with all assay ranges and needed ancillary supplies.
    3. Have ability to deliver blood products, medications, and nursing services within three hours during an emergent situation. (PLEASE NOTE: this is complete nursing services including actual home or site visits, not just phone contact or Q&A) and maintain 24 hour on call service.
    4. Demonstrate knowledge of and experience with bleeding disorders with a minimum of 10 patients within 12 months.
    5. Demonstrate appropriate record keeping and documentation.
    6. Provide for proper removal and disposal of hazardous waste material.
    7. Provide covered person with written policy regarding discontinuation of Services related to loss of coverage.
    8. Provide covered persons with information on costs of medications and services, if requested, that are not covered by individual's health plan.
  • A carrier shall provide payment for services to the clinical lab at a hospital with a state recognized hemophilia care center if the covered person's attending physician determines that use of the hospital's clinical lab is necessary because:
    1. Test results are medically necessary immediately or sooner than the normal return time for carrier's participating lab.
    2. Accurate test results need to be determined by closely supervised procedures in venipuncture and lab techniques in controlled environment that cannot be adequately achieved by carrier's participating lab.

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1992 Healthcare Reform Act:

  • Provides coverage for everyone; no one can be denied for a pre-existing condition.
  • Pre-existing exclusion clause time period (up to 1 year is allowed) can be waived if proof of uninterrupted coverage for that time period is shown.
  • Coverage must be found 30 days after termination for individual plans; coverage must be found 60 days after termination for group plans.

1997 HMO Regulations:

  • It is mandated in subchapter 6 (Provider Services), section 3 (Tertiary and Specialized Services), Number 6 . . . "that the HMO must have a policy assuring access to specialty outpatient centers for hemophilia (pediatric and adult) and to prescribed treatment regimens . . . "
  • Under "provider network" it also states . . . "at discretion of HMO, exceptions may be made for appropriate medical specialists to be designated as primary care providers for specified individuals or patient groups who, due to health status or chronic conditions, would benefit from medical care management by such a medical specialist . . . "

2001 Healthcare Accountability Act P. L. 2001, Chapter 187

Persons covered under a health or dental benefits plan can sue their carrier or an organized delivery system for loss that occurs (economic or non-economic) as a result of a denial or delay in approving or providing medically necessary covered services.


SOME OF THE NEW LEGISLATION RECENTLY INTRODUCED:

S-1557 � Sponsor: Senator Joseph F. Vitale

A health care reform proposal which expands the New Jersey FamilyCare Program to more low income parents, mandates that all children 18 and under in the state have health care coverage either through public programs or private coverage, and proposes various reform measures to the individual and small employer insurance markets.
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A-1579 � Sponsor: Assemblyman Neil M. Cohen

Another Health Insurance Reform Act with many of the same points and, thus, concerns as Senator Vitale's bill.

Both "reforms" represent a change in community rating (S-1557 by age only; A-1579 by age, gender and geography) and types of policies offered with addition of riders for more extensive coverage which will also cost more money.

S-1557 introduces a life-time cap on major medical expenses in the small group market up to $1,000,000.

A-1579 introduces the idea of eligible employees who work 20 hours or more, thus permitting insurance for part-time employees.

Both of these bills may offer significant problems for our community, resulting in less coverage for more money. In addition, FamilyCare policies are basically HMO Medicaid policies. HMO Medicaids are not as comprehensive as "fee for service" Medicaid. It can mean countless hours of trying to convince a "casemanager" what company may provide more service for the same cost and thus be much more cost effective.

The "Healthcare Reform Bills" may wreak havoc on our community. They try to lower cost by excluding services. These cost-saving strategies may cost the state much more in the long run. There needs to be a mutual balance between enticing the small group employers and the young, mostly healthy, uninsured with basic policies and still maintain comprehensive health insurance for the chronically ill that desperately need to be covered without wearing them down with an astronomical price tag for coverage.

Both bills need to be monitored. Action may be needed on the part of the hemophilia community.

A-1578 � Sponsor: Assemblyman Neil M. Cohen

A bill to regulate PBMs (Pharmaceutical Benefits Managers). The only concern is that it excludes insurance companies that have their own in-house pharmacy. The other concern was rectified when HANJ requested language that prevented insurance companies from switching prescriptions to another drug on the formulary. Members could stay with the original product if they were willing to pay the difference. The added language forbids switching of prescriptions for any clotting factor product. It states . . ."A PBM shall not initiate a substitution for a prescribed drug in situations in which the prescribed drug is a clotting factor used in the treatment of hemophilia or related bleeding disorders."

Under Consumer Protections:

New Jersey has ---

Comprehensive Consumer Rights Laws: they define and protect the rights of health care consumers enrolled in managed care.

Any Willing Provider: Managed care organizations must contract with any provider that is willing to meet the terms of the contract (excludes self-insured plans).

Continuity of Care: Direct access to OB/GYN: specialist as primary care provider (hemophilia is listed specifically in HMO regulations).


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