Overview, Answers and Text from New Jersey parity bill
Morgan Sheets
Description
Collection
Title:
Overview, Answers and Text from New Jersey parity bill
Creator:
Morgan Sheets
Date:
1/18/2008
Text:
There have been a number of questions on the New Jersey parity bill. We wanted to help clear some of them up. An overview and the bill text are also included below.
Sincerely,
Morgan
Morgan Sheets
National Advocacy Director
Amputee Coalition of America
Direct ph. (202) 742-1880
ACA Headquarters: (888) AMP-KNOW
In regards to some of the questions:
I am a member of the California Orthotic and Prosthetic Association and we also have passed a parity bill recently. It sounds like we have similar language. The issue that we are waiting to see is if insurances will apply creative language in their benefit offerings to skirt the ruling. As I recall there was talk that an Insurance Company could carve out O&P coverage. If they offered the coverage then they would have to cover the service at the same rate as Medicare. The other issue I believe was an Insurance Company could create a high enough deductible that would prevent the ruling to kick in in that colander year because the deductible was not met.
The California bill differs from the other 7 that have passed. It is a mandated offer, meaning that it says if you offer coverage, then you must offer it in such a way. The other bills simply say that you must offer coverage.
Don't quote me on this but I believe these were issues. Parity is a great thing as long as the coverage does not change. Example; Ins. A now has to cover O and P at medicare allowable. Now, we all know that insurance companies are the only one's making any money and will do anything to ensure this remains a fact.
The bill does state, reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule. This will be an increase in some cases and a decrease in others.
Even though it may be mandated that they issue coverage for O and P, they can certainly put a limit per year or lifetime for this coverage. Patients must be made aware of this fact and not get hooked on saving money on premiums without reading the fine print.
This is not true. The bill says, The benefits shall be provided to the same extent as for any other medical condition under the contract. So the limits are the same as for any other coverage including heart attack, stroke, etc. That effectively prevents cost prohibitive caps of $2,000 or $5,000 or the once per lifetime restriction.
An insurance CO. can simply put limits to say, a thousand dollars a year for prosthetic coverage. They will then pay the thousand dollars at MC allowable's and leave the rest to the amputee.
Again, with the requirement of to the same extent as for any other medical condition under the contract, $1000 limits could not be put on prosthetic care unless they were put on all other benefits in the plan. This is the truest meaning of parity.
Dave: I don't' believe the bill has been signed by the governor yet, and don't forget that as a state initiative it has no impact on all employer plans where the employer is self-insured. These self-insured plans are covered by Federal ERISA law and can't be trumped by state mandates.
Overview of the Bill
The bill was signed on Wednesday, January 16th. As for ERISA, this will be impacted by the federal parity bill which is being worked on by the ACA and allies right now. The goal is to introduce in the next couple of months.
The New Jersey legislature passed the parity bill passed at 8:45 pm on Monday, January 7th. The Senate version was approved (S502). This includes coverage for both prosthetic and orthotic care. It covers health insurers and the State Health Benefits Program (SHBP). An overview and the bill text are included below.
The bill requires reimbursement for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.
It covers:
1) Every hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
2) Every medical service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
3) Every health service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
4) Every individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
5) Every group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
6) Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey, and
7) Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey.
Additionally, the bill states that a certificate of authority to establish and operate a health maintenance organization in New Jersey shall not be issued or continued by the Commissioner of Health and Senior Services unless the health maintenance organization provides health care services for orthotic or prosthetic appliances.
This act shall take effect on the 90th day after enactment. The bill was signed on Wednesday, January 16th.
It is safe to say that this is the most comprehensive bill that has been passed thus far.
The passage of this bill is incredibly exciting not only for the state campaign efforts, but also for the federal legislation. Rep. Rob Andrews (D- NJ) is the Chairman of the Subcommittee on Health, Employment, Labor, and Pensions (HELP). This is a committee that the parity bill is likely to go through. We have been working to confirm him as one of the lead sponsors of the federal bill. I think this will help us secure his support.
Congratulations and thank you to all of our members and activists in New Jersey. A special thanks goes out to Nancy Pinkin of MBI GluckShaw, Richard Bray, the Prosthetic and Orthotic Society of New Jersey, Dennis O'Donnell, and Amps in Action support group.
Senate Bill 502:
1) <URL Redacted>
2) Type in S502
_____________________________________________________________________________________
________________________________
From: Orthotics and Prosthetics List on behalf of <Email Address Redacted>
Sent: Mon 1/14/2008 11:42 AM
To: <Email Address Redacted>
Subject: [OANDP-L] Responses to N.J. Parity post
They below are the responses to my original post regarding N. J. and O & P
parity. From the reply's I got, it looks like there may still be room for
insurance companies to carve out O & P coverage and set limits. I thought the
idea of Parity was to not allow these activities. I guess we will soon find
out.
David Falk, LPO
I am a member of the California Orthotic and Prosthetic Association and
we also have passed a parity bill recently. It sounds like we have
similar language. The issue that we are waiting to see is if insurances
will apply creative language in their benefit offerings to skirt the
ruling. As I recall there was talk that an Insurance Company could carve
out O&P coverage. If they offered the coverage then they would have to
cover the service at the same rate as Medicare. The other issue I
believe was an Insurance Company could create a high enough deductible
that would prevent the ruling to kick in in that colander year because
the deductible was not met.
Don't quote me on this but I believe these were issues.
Parity is a great thing as long as the coverage does not change. Example;
Ins. A now has to cover O and P at medicare allowable. Now, we all know that
insurance companies are the only one's making any money and will do anything to
ensure this remains a fact.
Even though it may be mandated that they issue coverage for O and P, they
can certainly put a limit per year or lifetime for this coverage. Patients must
be made aware of this fact and not get hooked on saving money on premiums
without reading the fine print.
An insurance CO. can simply put limits to say, a thousand dollars a year for
prosthetic coverage. They will then pay the thousand dollars at MC
allowable's and leave the rest to the amputee. Their argument will then be Well, we
did not deny treatment, we are just not paying over the max amount. And also
be careful, if you have a contract that states you have to accept what they
pay, you may not have any recourse when trying to bill the patient.
Just food for thought. Pass along if you wish.
Dave: I don't' believe the bill has been signed by the governor yet,
and don't forget that as a state initiative it has no impact on all
employer plans where the employer is self-insured. These self-insured
plans are covered by Federal ERISA law and can't be trumped by state
mandates.
Having said that, it is still a nice, positive step in the right
direction. FYI, the Amputee Coalition of American played a very big
role in getting this bill done, and done right. If you have a chance to
send the ACA a thank you note, or if you need help on a parity
initiative in your own state, I would start with them.
Does this mean that the current Horizon or Aetna or United contracts at
30-40% below Medicare are going to be paid at Medicare rates?????I agree
with David that it sounds to good to be true.
**************Start the year off right. Easy ways to stay in shape.
<URL Redacted>
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Sincerely,
Morgan
Morgan Sheets
National Advocacy Director
Amputee Coalition of America
Direct ph. (202) 742-1880
ACA Headquarters: (888) AMP-KNOW
In regards to some of the questions:
I am a member of the California Orthotic and Prosthetic Association and we also have passed a parity bill recently. It sounds like we have similar language. The issue that we are waiting to see is if insurances will apply creative language in their benefit offerings to skirt the ruling. As I recall there was talk that an Insurance Company could carve out O&P coverage. If they offered the coverage then they would have to cover the service at the same rate as Medicare. The other issue I believe was an Insurance Company could create a high enough deductible that would prevent the ruling to kick in in that colander year because the deductible was not met.
The California bill differs from the other 7 that have passed. It is a mandated offer, meaning that it says if you offer coverage, then you must offer it in such a way. The other bills simply say that you must offer coverage.
Don't quote me on this but I believe these were issues. Parity is a great thing as long as the coverage does not change. Example; Ins. A now has to cover O and P at medicare allowable. Now, we all know that insurance companies are the only one's making any money and will do anything to ensure this remains a fact.
The bill does state, reimburse for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule. This will be an increase in some cases and a decrease in others.
Even though it may be mandated that they issue coverage for O and P, they can certainly put a limit per year or lifetime for this coverage. Patients must be made aware of this fact and not get hooked on saving money on premiums without reading the fine print.
This is not true. The bill says, The benefits shall be provided to the same extent as for any other medical condition under the contract. So the limits are the same as for any other coverage including heart attack, stroke, etc. That effectively prevents cost prohibitive caps of $2,000 or $5,000 or the once per lifetime restriction.
An insurance CO. can simply put limits to say, a thousand dollars a year for prosthetic coverage. They will then pay the thousand dollars at MC allowable's and leave the rest to the amputee.
Again, with the requirement of to the same extent as for any other medical condition under the contract, $1000 limits could not be put on prosthetic care unless they were put on all other benefits in the plan. This is the truest meaning of parity.
Dave: I don't' believe the bill has been signed by the governor yet, and don't forget that as a state initiative it has no impact on all employer plans where the employer is self-insured. These self-insured plans are covered by Federal ERISA law and can't be trumped by state mandates.
Overview of the Bill
The bill was signed on Wednesday, January 16th. As for ERISA, this will be impacted by the federal parity bill which is being worked on by the ACA and allies right now. The goal is to introduce in the next couple of months.
The New Jersey legislature passed the parity bill passed at 8:45 pm on Monday, January 7th. The Senate version was approved (S502). This includes coverage for both prosthetic and orthotic care. It covers health insurers and the State Health Benefits Program (SHBP). An overview and the bill text are included below.
The bill requires reimbursement for orthotic and prosthetic appliances at the same rate as reimbursement for such appliances under the federal Medicare reimbursement schedule.
It covers:
1) Every hospital service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
2) Every medical service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
3) Every health service corporation contract that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
4) Every individual health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
5) Every group health insurance policy that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey,
6) Every individual health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey, and
7) Every small employer health benefits plan that provides hospital or medical expense benefits and is delivered, issued, executed or renewed in New Jersey.
Additionally, the bill states that a certificate of authority to establish and operate a health maintenance organization in New Jersey shall not be issued or continued by the Commissioner of Health and Senior Services unless the health maintenance organization provides health care services for orthotic or prosthetic appliances.
This act shall take effect on the 90th day after enactment. The bill was signed on Wednesday, January 16th.
It is safe to say that this is the most comprehensive bill that has been passed thus far.
The passage of this bill is incredibly exciting not only for the state campaign efforts, but also for the federal legislation. Rep. Rob Andrews (D- NJ) is the Chairman of the Subcommittee on Health, Employment, Labor, and Pensions (HELP). This is a committee that the parity bill is likely to go through. We have been working to confirm him as one of the lead sponsors of the federal bill. I think this will help us secure his support.
Congratulations and thank you to all of our members and activists in New Jersey. A special thanks goes out to Nancy Pinkin of MBI GluckShaw, Richard Bray, the Prosthetic and Orthotic Society of New Jersey, Dennis O'Donnell, and Amps in Action support group.
Senate Bill 502:
1) <URL Redacted>
2) Type in S502
_____________________________________________________________________________________
________________________________
From: Orthotics and Prosthetics List on behalf of <Email Address Redacted>
Sent: Mon 1/14/2008 11:42 AM
To: <Email Address Redacted>
Subject: [OANDP-L] Responses to N.J. Parity post
They below are the responses to my original post regarding N. J. and O & P
parity. From the reply's I got, it looks like there may still be room for
insurance companies to carve out O & P coverage and set limits. I thought the
idea of Parity was to not allow these activities. I guess we will soon find
out.
David Falk, LPO
I am a member of the California Orthotic and Prosthetic Association and
we also have passed a parity bill recently. It sounds like we have
similar language. The issue that we are waiting to see is if insurances
will apply creative language in their benefit offerings to skirt the
ruling. As I recall there was talk that an Insurance Company could carve
out O&P coverage. If they offered the coverage then they would have to
cover the service at the same rate as Medicare. The other issue I
believe was an Insurance Company could create a high enough deductible
that would prevent the ruling to kick in in that colander year because
the deductible was not met.
Don't quote me on this but I believe these were issues.
Parity is a great thing as long as the coverage does not change. Example;
Ins. A now has to cover O and P at medicare allowable. Now, we all know that
insurance companies are the only one's making any money and will do anything to
ensure this remains a fact.
Even though it may be mandated that they issue coverage for O and P, they
can certainly put a limit per year or lifetime for this coverage. Patients must
be made aware of this fact and not get hooked on saving money on premiums
without reading the fine print.
An insurance CO. can simply put limits to say, a thousand dollars a year for
prosthetic coverage. They will then pay the thousand dollars at MC
allowable's and leave the rest to the amputee. Their argument will then be Well, we
did not deny treatment, we are just not paying over the max amount. And also
be careful, if you have a contract that states you have to accept what they
pay, you may not have any recourse when trying to bill the patient.
Just food for thought. Pass along if you wish.
Dave: I don't' believe the bill has been signed by the governor yet,
and don't forget that as a state initiative it has no impact on all
employer plans where the employer is self-insured. These self-insured
plans are covered by Federal ERISA law and can't be trumped by state
mandates.
Having said that, it is still a nice, positive step in the right
direction. FYI, the Amputee Coalition of American played a very big
role in getting this bill done, and done right. If you have a chance to
send the ACA a thank you note, or if you need help on a parity
initiative in your own state, I would start with them.
Does this mean that the current Horizon or Aetna or United contracts at
30-40% below Medicare are going to be paid at Medicare rates?????I agree
with David that it sounds to good to be true.
**************Start the year off right. Easy ways to stay in shape.
<URL Redacted>
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
Morgan Sheets, “Overview, Answers and Text from New Jersey parity bill,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/228940.
