On appeal from the Final Administrative Decision, State Health Benefits Commission.
Before Judges Coburn, S.L. Reisner and Graves.
The opinion of the court was delivered by: S.L. Reisner, J.A.D.
NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION
Plaintiffs, Deborah Green and Steven Green, appeal a final determination of the State Health Benefits Commission (SHBC) that Mrs. Green's home health aide services are not covered under the Greens' State-provided health benefits plan. We reverse and remand this matter to the SHBC for an administrative hearing.
Steven and Deborah Green (plaintiffs) are members of the State Health Benefits Program (SHBP) through Steven's employer, the Administrative Office of the Courts.*fn1 Plaintiffs are covered under the SHBP Traditional Plan, which is an indemnity plan covering hospital confinements, medical, surgical and diagnostic services. The Commission, through the open public bidding process, has contracted with Horizon Blue Cross/Blue Shield of New Jersey... to provide claims administration services. The Plan must be administered consistent with the contract, including the plan benefit design described in the plan document....
In the fall of 1976, Mrs. Green was diagnosed with multiple sclerosis. As a result of exacerbations of the symptoms of the disease, she required several hospitalizations. Her condition deteriorated over time, and by 1994, she was suffering from depression, physical incapacitation, and was virtually unable to function. In February of 1994, Mr. Green contacted Staffbuilders, a home health care agency, for assistance in getting Mrs. Green to the office of her neurologist, Dr. Michael Margolin. Staffbuilders dispatched Lucille Rizzo, a home health aide, who immediately developed a rapport with Mrs. Green. However, Mrs. Green's symptoms worsened, and Dr. Margolin recommended that she be hospitalized. Mrs. Green was admitted to the hospital for seven days and then released to a rehabilitation center. The Green's Plan paid for both the hospitalization and rehabilitation care.
Upon Mrs. Green's return home from the rehabilitation center, Ms. Rizzo began providing home health care eight hours a day. Additionally, Mrs. Green received skilled nursing care three times a day, for seven days a week. Her condition improved considerably, because the health aide assisted with physical therapy and catheterization as well as more routine care.
Plaintiffs filed a claim with Prudential, then the administrator of the SHBP, for reimbursement for the services provided by Ms. Rizzo and the skilled nurses. The claim was supported by a home health care plan created for the Greens by a social worker, Lori Lazaroff, and Mrs. Green's physician, Dr. Shoemaker.*fn2 Prudential determined that the home health aide did not qualify as an eligible provider under the Plan, but was considered eligible for coverage on an exception basis through June 16, 1995. The May 16, 1995 letter granting the exception also indicated that the Greens could apply for continued coverage under the exception if needed. The Greens did apply, and the Plan paid for the home health care for five years. Since the home health care services have been provided, Mrs. Green has not required any hospitalizations and has been able to live at home despite the debilitating effects of multiple sclerosis.
In September 1999, plaintiffs were informed by Horizon Blue Cross Blue Shield of New Jersey (Horizon), the new claims administrator for the SHBP, that the home health care services would no longer be eligible for benefits under the SHBP Traditional Plan because the services were categorized as"custodial." The letter suggested that Mrs. Green might be better served in a nursing home, the costs of which are not covered by the SHBP. Horizon agreed to pay benefits through October 1999, and the Greens received payments through February 2000.
Through their attorney, plaintiffs attempted to convince Horizon to resume coverage of the home health aide. On February 7, 2001, Dr. Margolin wrote a letter stating that Mrs. Green has thrived in her home environment, asserting that there is no need for institutionalization. On March 31, 2001, the Green's social worker, Lori Lazaroff, issued an evaluation and assessment detailing the beneficial effect that the services of a home health aide have had on Mrs. Green's health and well-being. Specifically, Ms. Lazaroff explained that home health care has enabled Mrs. Green to avoid recurrent hospitalizations. On July 31, 2001, Ms. Lazaroff issued a report recommending that Mrs. Green"stay in her own home and be allowed to function in the community with the assistance of her Home Health Aide."
On November 1, 2002, plaintiffs appealed the denial of benefits and included the evaluations of Dr. Margolin and Lori Lazaroff to support their appeal. On March 12, 2003, Horizon denied the appeal. The denial letter referred to an evaluation performed by Virtua Homecare of West Jersey, which Horizon construed as concluding that"the home health aide is considered custodial/maintenance as there is no skilled need."
On May 29, 2003, plaintiffs filed an appeal with the SHBC and requested an administrative hearing. On June 11, 2003, the SHBC issued an initial administrative decision denying the Greens an administrative hearing and denying their appeal. On July 16, 2003, plaintiffs appealed the initial decision. On December 10, 2003, the SHBC denied the appeal by a Final Administrative Determination, based upon the ...