On June 1, Assembly Bill 2039 became law, ushering in bold patient protections and blockbuster realignment of claims-handling processes. Effective Aug. 30, extinction of "surprise" out-of-network claims is its goal. Patient protections now secured, the true "surprise" awaits providers and carriers scrambling to meet disclosure requirements and the uncertain fiscal impact upon plans who must comply. A New Claims Order Protection under the act hinges upon two classifications of medical charges. The first category addresses out-of-network services that are "knowingly, voluntarily and specifically" selected. In these circumstances, aside from brief disclosure obligations of the provider (discussed later), no further protections apply. The second category really shakes things up. Major patient protection provisions are created. Claims practices between providers and payers are significantly modified. Namely, if services are either out-of-network "inadvertently" or are "emergent," the provider is barred from billing the patient in excess of their deductible, copayment or coinsurance obligation. This is the hallmark achievement of the act, sparing patients from so called "surprise medical billing." This shifts the fiscal dispute. Now solely between payer and provider, the act requires plans to provide a "clear and understandable description" of their methodology to determine the allowed amount for out-of-network services. Payment is to follow. Assignment of payment to the provider is automatic under the act. If the provider disagrees with the payment, a novel and fast-tracked process awaits with arbitration at the end. Payment and appeal is abbreviated under the act. Within 20 days of receipt, the claim is to be paid or notice provided stating the charges are considered excessive. A 30-day settlement period follows. If agreement is not reached, the payor nevertheless is to pay their "final offer." If the provider remains unsatisfied and the difference between "final offers" is greater than $1000, the provider holds a 30-day option to initiate binding arbitration through NJDOBI. Arbitration is upon written submissions including each party's "final offer." Oddly, the act freezes the payer's position, with no ability to submit a modified "final offer." Decision is swift (within 30 days) and limited to the two amounts submitted. No discretion exists to fashion a different amount (having been deleted in the final version of the bill). Fees and costs are split, unless the arbitrator finds the payor failed to act in good faith. No mirror provision exists for providers failing to act in good faith. Payment (if any), is to be made within 20 days of decision. Interest rates apply thereafter. Arbitration is barred for those not following pre-authorization or medical necessity review requirements. Similarly, arbitration is unavailable for those who have knowingly and voluntarily selected out-of-network services. "Inadvertent" ... or by Design? Importance hinges upon whether services were "inadvertently" out of network, defined as "[when] for any reason in-network services are unavailable in that facility." The phrasing is significant. Common hospital practice outsources departments, frequently including emergency rooms, radiology, lab services and anesthesiology-such services seldom participating with any carrier. It is precisely this mismatch of participation status that leads to the so-called surprise bills. But rather than tackle root causes, the act goes in a different direction, calling it inadvertent when participating services are "unavailable" "for any reason" (arguably including having outsourced the services in the first place). The result deems all such services as "inadvertent," enjoying the protections of fast track payment and arbitration. The underlying practice is unaddressed and, by virtue of this act, is now protected. All Is Not Roses for Facilities It is not all upside. The act requires facilities to advise patients of their participating status, directing patients to also confirm the participation status of the provider arranging the service(s). Differences in disclosure depend upon the participation status of the facility. A significant twist lies in defining "facility" beyond the traditional concept of a hospital to include broader categories of satellite emergency departments, hospital-based off-site ambulatory care facilities, and free-standing ambulatory surgical centers. The act also requires facility website-based disclosure covering four topics: plans in which the facility participates; notice that physician services are not included in the facility charges; full contact information for all hospital-based groups contracted by the facility (to include anesthesiology, pathology and radiology); and finally, the full contact information of every physician employed at the facility and the plans in which they participate. Disclosure forms will be regulated by the Department of Health. Tougher Disclosure for Providers The burden of disclosure (and modified billing practices) falls even harder upon providers. Either via website or written notice, providers are to list the plans in which they participate. Where the provider does not participate in a plan, the provider is to inform the patient in terms "typically understood" of their non-participating status, and their charges must be available upon request. If requested, the provider is to provide the procedure codes anticipated for the service(s) and their charges. Further, notice is to be given that the patient may be responsible for amounts in excess of the person's deductible, coinsurance and copayment for any out-of-network services and to contact their carrier for further information. Referrals and coordinated treatment bring additional responsibilities. Regardless of setting, the originating provider is to disclose the full contact information of any provider scheduled to provide anesthesiology, laboratory, pathology, radiology or assistant surgery services, advising the patient to determine the plan participation status of referred providers. Disclosure expands when scheduled facility and non-facility services are involved to include the full contact information of any other physician whose services are scheduled at the time of pre-admission testing, registration or admission. Licensing boards are delegated oversight of disclosure forms and sufficiency. Boldly, the act modifies billing practices associated with the waiving of patient responsibilities. A hotly debated practice, the act now forbids providers from waiving any part of a deductible, copayment or coinsurance "as an inducement" to entice patients to utilize their out-of-network services. If a pattern of such waiver is established, the "inducement" is considered satisfied (and a violative practice). Carrier Lift The toughest responsibilities are placed upon carriers. Beyond listing providers who participate with the carrier, the methodology that determines the allowed amount for out-of-network services is to be disclosed. Moreover, carriers are to enable a website to not only calculate reimbursement rates for out-of-network services, but their difference from the usual and customary cost. Now obliged to staff customer service hotlines 16 hours per day, the carrier is responsible to state the allowed amount the plan will reimburse for a particular medical procedure (CPT code) and the portion of the allowed amount for which the patient will be responsible. Carriers are to alter their Explanation of Benefits to clearly state the protections against balance billing for inadvertent and emergent services. NJDOBI is directed to design new medical identification cards consistent with the protections under the act. Tabulations of realized savings under the act are to be filed annually with NJDOBI. Broad brushed, annual independent third-party audits of any "managed care plan" are mandated under the act. While the scope is unclear, apparently audits are to opine upon the adequacy of providers "in accordance with applicable federal or state law." Results will be posted on NJDOBI's website and deficiencies can trigger NJDOBI enforcement. Self-Funded Plans and the Illusion of Opting In Recognizing that not all plans are fully insured with a carrier, the act acknowledges that health benefits can be self-funded. Numerous references are made to self-funded plans' ability to opt in to the act's new world order of claims resolution. Whether plans do so is irrelevant, as the act permits providers to initiate arbitration upon all self-funded plans without qualification. The only difference for a non-opting-in self-funded plan is the decision maker's discretion to fashion an award (the concept of either/or and "final offers" does not apply). Whether arbitration is binding is unclear, the act conflictingly stating both. Further inartful phrasing limits self-funded plans to those regulated under ERISA. This leaves the status unclear for a substantial subset of plans neither fully insured nor self-insured under ERISA-e.g. MEWAs (multiple employer welfare arrangements), association plans and church plans-in addition to government entities permitted to self fund, which includes the NJ State Health Benefit Program, HIFs, counties, municipalities and agencies. Only the Beginning? Patient protection is always the goal. But it did not have to be this way. Or so complicated. Inclusion of the Medicare Allowable Charge upon all billing (a current federal proposal) would have benchmarked the relative value the act clumsily mishandles. The existing statute regarding excessive fees could have been modified to declare charges in excess of "x" times the Medicare Allowable Charge to be de facto excessive and barred. Alternatively, a requirement could have been made that all contracted services to hospitals and all employee physicians of a hospital mirror its participation status. Instead, the act is hastily written, contradicting itself at times, ignoring existing state and federal claims handling and appeal rights. Conflict of laws and federal pre-emption challenges will plague implementation. The data lift of carriers and providers is substantial. The authority in arbitration to exceed stated out-of-network plan limits is unknown, but doubtful. The significance of "plans" not being synonymous with "carriers" is completely missed. Whether estimation of costs will operate as a medical version of a mechanic's pre-estimate is unsettled. Claims negotiation services are constrained due to the new processing deadlines. Because such cost saving mechanisms are curtailed, self-funded plans may be disproportionately affected, particularly those sponsored by municipalities, counties and unions. It did not have to be this way. Or so complicated.

NJ Governor Phil Murphy wants money, if residents don't maintain individual health insurance. Effective January 1, 2019, the governor signed a new law reestablishing the recently repealed "shared responsibly tax". It forces individuals to pay 2.5 percent of a household's income or a per-person charge - whichever is higher. A "hardship exception" for individuals who cannot afford coverage would be decided by one person i.e. the state treasurer Elizabeth Mucio.
At the same time, NJ is one of the worst states for offering individual alternatives to fill the gaps in the out-of-pocket cost for health insurance. NJ also does not allow individuals to secure short term major medical in-between open enrollment periods.
The maximum out-of-pocket cost for health insurance will be raised, based on the inflation-adjusted out-of-pocket limits from $7,350 per individual and $14,700 per family to $7,900 per individual and $15,800 per family in 2019. Meanwhile, according to the Kaiser Family Foundation (KFF), more than a quarter of U.S. adults struggle to pay their medical bills. This includes folks who have insurance, whether independently or through an employer. In fact, medical debt is the No. 1 source of personal bankruptcy filings in the U.S.. In 2014, an estimated 40% of Americans racked up debt resulting from a medical issue. The amount of money owed on average is $13,279 based on a 2007 study. Moreover, according to a recent GoBankingRates survey, 69% of Americans have less than $1,000 in savings, while 34% have no money in the bank whatsoever.
The options are slim to none if you do not have coverage or you lapse your insurance for non-payment of premium. We have been giving individuals with no coverage a way to offset medical expenses based on four services. Access to doc 24/7, broach certified doctors who can prescribe medication, accident plans that pay up to $15,000 per individual based on billed charges, Preferred Provider access to any type of medical expenses allowing you to pay wholesale verses retail rates, life with living benefits of critical, chronic, and Long Term Care protection. Term and Permanent life insurance can advance pay the death benefits for major medical conditions that shorten one's life span.
Everyone should beware of the law when you can enroll and the options available to them. Most people are not aware that each family member can enroll in a different health plan, based on their needs. Some still do not realize that children can be covered for low or no cost through the state children health program. I also find that most people do not know the rules that allow them to qualify for substantial subsidies on individual insurance. They are also unfamiliar with the ways they could take advantage of tax savings for no covered out-of-pocket medical, vision, and dental expenses.
There are numerous other rules and requirements that individual and employers should know as well. Everyone needs to have a trained advisor. Everyone needs to know that a Navigator or the Marketplace representatives are not licensed, cannot discuss insurance plans, and typically just go by what their computer tells them. There is a tremendous amount that you need to be advised on when protecting your family and more changes are coming.
Recent executive orders from the White House will allow for association plans to be marketed. These plans will not offer all the essential services required by the Affordable Care Act. Therefore, you will have to read the contracts to find out what is not included. Buyers beware!

The new law applies to any business entity in NJ that hires employees regardless of its size. The law is broad-based in coverage and will surely hurt employers with high turnover positions. NJ will be following nine other states that are the only ones to implement this benefit. This adds to the already high burden on employers in NJ. The Paid Sick Leave law excludes employers in the construction industry employed by union, per diem healthcare employees, and public employers who must give paid sick leave to their employees. Furthermore, this law supersedes all existing and any future municipal ordinances in the state that deal with paid sick leave. Tax payers will pick up the costs for the municipalities and employers will have to pass on the cost to their customers.
The law allows employees to accrue sick leave time with a cap of 40 hours per benefit year at a rate of 1 hour for every 30 hours worked. Employer can frontload said hours at the beginning of the company's designated benefits year. Although, I do not think there will be many takers. Additionally, employers who have existing PTO, personal days, vacation days, and sick day policies may utilize them to meet the requirements set by the state paid sick leave law. All existing policies have to meet the state law requirements.
Employer can subtract part-time and seasonal workers that work less than 120 days for the company. However, once this waiting period is met, employees can use paid sick time for these reasons:

• The diagnosis, treatment, and recovery from a mental or physical illness (preventive medical care included)
• Caring for a covered family member during the diagnosis, treatment, and recovery from mental or physical illness (preventative medical care included)
• Recovering from domestic or sexual violence (either an employee or an employee's family member)
• The closing of an employee's workplace due to a public health emergency
• The closing of a school of an employee's child due to a public health emergency
• Attending school conferences or meetings to discuss a child's health condition or disability

Employers will face penalties for not following the new law effective October 29 of this year. Plus, there is also an anti-retaliation provision in the law that makes it illegal to retaliate against workers who use their earned time off. An employer who takes retaliatory actions against an employee using their paid sick time could face additional penalties and lawsuits. Employees will be able to sue their employer, if the latter violated the law and can seek damages, as well as, liquidation damages.
Questions remain. For instance, does a NJ employer have to offer the same benefits to out-of-state employees working for the NJ employer? Can they instead avoid the policy with an independent contractor designation? Even temporary help service firms are affected as the paid sick leave will accrue by the total time worked on assignment. Employers are instructed to seek assistance from HR compliance experts to help prepare for the law and ensure compliance when it goes into effect.