Spring Edition 2019 - Vol. 15 No. 2
Optum has agreed to lease its network to Zelis (formerly Stratose). Zelis is a “health care savings company” which is also sometimes known as a silent PPO company. What this means is that if you are in-network with Optum but out of network with a number of companies Zelis works with, then you will be paid at the Optum contracted rates rather than the out of network rate for the carrier under contract with Zelis.
Recording of webinar presented on Monday Feb. 25, 2019.
President Trump signed the federal Protecting Young Victims from Sexual Abuse and Safe Sport Authorization Act of 2017 (“Safe Sport Act”) into law in February 2018. Though initially it was thought that this act primarily applies to National Governing Bodies (“NGB”s) such as U.S. Gymnastics, Paralympic Organizations and their member organizations, it also directly or indirectly applies to almost all amateur youth sports organizations all the way down to local Babe Ruth baseball organizations.
Review of the latest updates regarding Aetna, NIA and the SHBP/SEHBP Medicare Advantage Plans.
Winter Edition - Vol. 15 No. 1
As you know, approximately 175,000 retired state workers and school employees have been moved to Aetna Medicare Advantage plans that will be effective Jan. 1, 2019. Aetna had sent letters to providers with a breakdown of the claim and contact information for these plans. In case you missed or did not receive the letter, the information is below.
As previously reported, Aetna will be implementing a new pre-authorization program being managed by National Imaging Associates (NIA) beginning January 1st. The process will be required for in-network providers on fully funded policies only. For claims submitted on or after January 1st pre-authorization will be required in order for payment to be issued.
On Oct. 2, 2018, we advised that many members had received denials from Aetna for lack of pre-authorization of care. We immediately approached Aetna regarding this as the new pre-authorization program is not set to begin here in New Jersey until Jan. 1, 2019
As previously reported, Aetna’s contract with Triad/eviCore is expiring on Dec. 31, 2018. A vendor called National Imaging Associates (NIA) will be managing a new pre-authorization program immediately following the Triad contract expiration, starting Jan. 1, 2019.
We want to remind you about the chiropractic benefits that are available as part of your Aetna Medicare Advantage PPO plan with Extended Service Area (ESA). We’re matching your current benefits. This is a custom benefit for members of the State Health Benefits Program (SHBP) and School Employees’ Health Benefits Program (SEHBP).
As a follow up to our earlier email regarding the revisions to Aetna’s SHBP/SEHBP Medicare Advantage plans please be advised that the Summary of Benefits and Coverage documents for these plans have been updated and re-posted to the NJ Division of Pension and Benefits website.
Late Friday we were notified by Aetna of revised plan designs for the SHBP/SEHBP Medicare Advantage plans for 2019.
The ANJC webinar on the major changes to the State Health and School Employee Health Benefits Program recorded on Tuesday, October 30 is now available.
We have previously reported that all Medicare eligible retirees under the SEHBP (teachers) who are enrolled in traditional Medicare with either the NJ Direct 10 or NJ Direct 15 plans will be automatically enrolled into new Aetna Medicare Advantage plans. It has come to our attention that additionally, any retired SHBP (police, fireman, etc.) employees who had been enrolled in the Horizon Medicare Advantage NJ Direct 10 or 15 will also be moved to new Aetna Medicare Advantage plans.
Additional details have become available regarding changes to the School Employee Health Benefits Program (SEHBP). First, the changes previously described were approved by the School Employee Health Benefits Commission and are hence, official. Both the new plan option and the retiree changes will be effective as of January 1, 2019.
Fall Edition - Vol. 14 No. 4
Many members have received a letter from Aetna regarding a new pre-authorization process coming January 1, 2019. Aetna’s contract with Triad/eviCore is expiring on December 31, 2018. A vendor called National Imaging Associates (NIA) will be managing this new pre-authorization program immediately following the Triad contract expiration. The process will apply to all physical medicine procedure codes regardless of what type of provider performs them whether it be a DC, PT or MD. The pre-authorization program will be applied to in-network providers on fully funded plans only.
Yesterday, following an agreement between Gov. Murphy and the New Jersey Education Association, the School Employee Health Benefits Program’s (SEHBP) Plan Design Committee passed several resolutions enacting reforms to reduce costs under the plan. The SEHBP covers all employees of K-12 schools and community colleges that opt into the state program.
As previously reported, the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act requires a disclosure form to be signed by patients beginning August 29, 2018. We have updated our interim sample form (to be replaced by official form once released by the Board of Chiropractic Examiners) to include sections for both in and out of network providers/patients.
The Government Accountability Office (GAO) released a report on July 31 which was, in essence, following up on several directives issued to the Centers for Medicare & Medicaid Services (CMS) in the 2015 MACRA law (Medicare Access and CHIP Reauthorization Act).
Originally taking effect on June 1, 2018, United amended their policy on manipulative therapy (including chiropractic and osteopathic manipulation) to consider the treatment “unproven and/or not medically necessary for treating . . . headaches.” Immediately, the ANJC reached out to United/Optum to contest the policy. The ANJC also signed on to a letter from the ACA to United contesting the policy change along with 40 other chiropractic associations.
As you are aware, on June 1, 2018, Governor Murphy signed into law the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act. The main components of the bill were designed to protect patients from unexpected out-of-network bills for providers operating at in-network hospitals or other healthcare facilities. There are however several new disclosure requirements that apply to all out-of-network providers, including chiropractic physicians.
Summer Edition - Vol. 14 No. 3
Spring Edition - Vol. 14 No. 2
One of the most frequent requests from our members has been for health insurance options available through their membership in the ANJC. The ANJC is proud to announce that we have entered into an agreement with Medova Healthcare to offer our members exclusive access to their line of Lifestyle Health Plans.
The ANJC today received the Appellate Division's decision in the State Health Benefit Plan $35 cap on out-of-network chiropractic reimbursement appeal.
While no legislation to repeal or amend Obamacare has become law, we do have a bill passed by the U.S. House of Representatives and a draft of a bill from the U.S. Senate. Here we examine some of the major themes from the most recent offerings of the two chambers of Congress.
CMS has released an updated Advanced Beneficiary Notice of Non-coverage (ABN) form (Form CMS-R-131). There are no substantive changes to the form or its usage. However, the updated form has added language informing beneficiaries of their rights to CMS nondiscrimination practices and how to request the ABN in an alternative format if needed. The new form also includes the updated expiration date of the form which is 03/2020.
As previously advised, as of April 17th 2017 the New Jersey Department of Banking and Insurance (DOBI) mandates a uniform appeal process using specific forms for pre- and post-service appeals created and provided by the NJ DOBI. Shortly after implementation, it came to our attention that nearly all carriers made changes to their Decision Point Review (DPR) plans following this change. Certain changes found are clearly detrimental to medical providers treating PIP patients and most importantly, to the patients themselves.
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.
As previously advised, the NJDOBI is instituting a uniform appeals process for PIP claims. This new uniform appeal process will be in effect as of April 17, 2017. Jeffrey Randolph Esq., General Counsel to the ANJC, has created a webinar explaining the changes and new process.
On Oct. 17, 2016, the New Jersey Department of Banking and Insurance (DOBI) published in the N.J. Register amendments to the PIP regulations implementing a new, mandatory appeal process for PIP claims to take effect April 17th.
The 2017 Medicare fee schedule has been released.
There are significant changes coming to the Medicare system of reimbursement beginning in 2017. This comes in the form of what is called the Quality Payment Program.
For the sixth consecutive year, ANJC is making available six $1,000 scholarships, including the second annual “Sigmund Miller Spirit of Chiropractic Award,” for chiropractic students who reside and have a home-base in NJ, and plan to return to NJ to practice.
Since our last update on the State Health Benefits Plan we have obtained the resolutions passed by the SHBP Plan Design Committee at their 8/29/16 meeting via OPRA request. Three of the seven resolutions have possible bearing on ANJC members.
There are changes to the ICD-10 diagnosis codes going into effect October 1st, 2016. CMS will be requiring codes to be submitted to the greatest available specificity beginning on October 1st. Also, there have been a number of codes added and deleted from the ICD-10 code set.