On June 1, 2018, New Jersey Gov. Murphy passed the Out-of-Network Consumer Protection, Transparency, Cost
Containment and Accountability Act (the “OON Act”). In general, the OON Act applies to emergency services and other
care provided by out-of-network physicians in in-network settings (i.e. hospital-based physicians). It takes effect on
September 1, 2018.
The Act provides reforms to several aspects of the state’s health care system involving disclosures of out-of-network
(OON) charges, arbitration for billing disputes, and provider network adequacy audits. The bill applies to fully-insured plans
and does not apply to self-insured plans unless they choose to opt-in.
The Act requires that a covered patient be responsible only for “in-network” amounts when receiving care at an in-network
facility, but may be receiving care from an OON provider. The Act prohibits out-of-network health care providers from
directly or indirectly waiving or paying all or part of the deductible, copayment, or coinsurance owed by a covered person
pursuant to the terms of the covered person’s health benefits plan as an inducement for the covered person to seek health
care services from that provider.
Health care professionals and health care facilities are required to provide disclosures of out of network status and obtain
specific, knowing and voluntary consent from patients who wish to receive out of network services at the out of network
cost. The health care providers and insurance carriers will look to negotiate or go to arbitration for a disputed fee amount.
However, the providers cannot seek payment from the patient for payment of out of network balances unless the patient
has given a specific consent to do so.
Employers should connect with their carriers for specific direction and questions on this new law.
Cosmo Insurance Agency is an independent insurance agency serving surrounding communities in New Jersey. Cosmo keeps its promise to assure an efficient and creative approach to the services we offer. Each of our clients experience a personalized and long-term relationship with us. Our New Jersey based team of health brokers guides our clients in helping them choose the most cost-effective options. By incorporating the latest in technology-based tools and laws on healthcare, employee benefits, life insurance and finance, we keep our clients up-to-date with the plans that encompass all of their needs, whether it is individual or group insurance.
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