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05/10/2017

SHBP Appellate Court Oral Arguments Heard 5-9-2017

 

On Tuesday, May 09, 2017, the ANJC’s General Counsel Jeffrey Randolph engaged in oral arguments with a Deputy Attorney General of the New Jersey Attorney General’s Office before the NJ Appellate Court in the ANJC vs. the State Health Benefits Commission et al. case.  This is the case regarding the $35 cap placed on out of network chiropractic benefits through the State Health Benefits Program.   The proceedings took approximately an hour.  Mr. Randolph presented the ANJC’s argument, the Deputy Attorney General offered her arguments and then Mr. Randolph had the opportunity for a rebuttal.  

Mr. Randolph articulated to the court the legal arguments from our briefs outlining the various laws we believe the State’s cap violates. 

  1. J.S.A 52:14-17.29 – This is the law which states that SHBP plan participants be reimbursed at 80 percent of the 90th percentile of the PHCS UCR fee schedule “or a similar nationally recognized database of prevailing healthcare charges.” The $35 cap does not equate to even half of a single adjustment codes reimbursement under these statutorily mandated guidelines.
  2. DOBI Order A09-113 – This is the NJ Department of Banking and Insurance order from 2009 which overturned Horizon’s global fee that had been applied to chiropractic services. The state regulator determined that it was an unfair claims practice for a carrier to not acknowledge, review and determine coverage on each service rendered by a provider.  The cap in question in the SHBP appeal indiscriminately applied one fee to all services rendered by a chiropractor and hence violated this directive.
  3. Section 2706 of PPACA (Obamacare law) – This is the non-discrimination clause of the Patient Protection and Affordable Care Act. As this cap was placed only on certain provider groups our contention is that it discriminates against those groups as no such restriction is placed on all other providers.
  4. Title 17B – This is a New Jersey based non-discrimination law which specifically identifies protections for chiropractic services. Again, as this cap restrictions chiropractic and not all other provider groups, the cap is clearly in violation of this law. 
  5. The Sunshine Act – This is a state law that mandates dealings and decisions of bodies that affect the public and public funds be deliberated in public with adequate notice of such public hearings to be provided. As there is no record of the State Health Benefits Program’s Plan Design Committee having any public discussions specifically regarding this cap prior to the resolution being read and voted on, it appears indisputable that some private discussions must have taken place to arrive at this particular resolution with this particular dollar figure.  As such, this would violate the Sunshine Act.

The panel of three judges asked probing questions on several of these points.  The Deputy Attorney General raised points challenging the applicability of some of these legal precedents as well as the authority granted to the SHBP Plan Design Committee in making changes such as this cap.  Mr. Randolph answered the court’s questions and rebutted the Deputy Attorney General’s points with sound, thoroughly-researched, well-delivered counterpoints.

There is still not a definitive time table for a decision to be rendered.  Nevertheless, the ANJC emerges from these oral arguments feeling confident in the defense of our positions today.  We will advise membership as soon as a decision is announced.