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Alliance for Quality Care, Inc. v. New Jersey Department of Banking and Insurance

August 26, 2010

ALLIANCE FOR QUALITY CARE, INC., NEW JERSEY ASSOCIATION OF AMBULATORY SURGERY CENTERS, ORTHOPEDIC SURGEONS OF NEW JERSEY, ROSELAND AMBULATORY SURGERY CENTER, LLC, AND WAYNE SURGICAL CENTER, LLC, APPELLANTS,
v.
NEW JERSEY DEPARTMENT OF BANKING AND INSURANCE, RESPONDENT.



On appeal from the New Jersey Department of Banking and Insurance.

Per curiam.

NOT FOR PUBLICATION WITHOUT THE APPROVAL OF THE APPELLATE DIVISION

Argued April 27, 2010

Before Judges Carchman and Ashrafi.

Appellants are organizations representing ambulatory surgery centers and orthopedic surgeons and two named ambulatory surgery facilities. They appeal from a final decision of the Commissioner of Banking and Insurance (the Commissioner) approving an option for small businesses to reduce costs of their health care coverage by purchasing plans that cap at $2,000 per year per patient benefits for out-of-network ambulatory surgery facilities. We reject the appeal and affirm the final decision of the Commissioner.

Since 1992, statutes enacted as the Small Employer Health Benefits Program (SEHBP) have provided the framework for health care coverage available to employees of businesses in New Jersey with two to fifty employees. See N.J.S.A. 17B:27A-17 to -56. The SEHBP establishes five standard plans for medical benefits, providing certain basic medical coverage and varying in actuarial value by differences in amounts of deductibles and co- payments assigned to the employee or patient. N.J.S.A. 17B:27A-19a. Medical insurance carriers are required to provide at least three of the five basic plans, and those plans must include at a minimum coverage for:

(1) Basic inpatient and outpatient hospital care;

(2) Basic and extended medical-surgical benefits;

(3) Diagnostic tests, including X-rays;

(4) Maternity benefits, including prenatal and postnatal care; and

(5) Preventive medicine, including periodic physical examinations and inoculations. [Ibid.]

The SEHBP does not require that the plans provide coverage for ambulatory surgical facilities, although the basic plans established under SEHBP include such coverage.

Since legislation enacted in 1994, the SEHBP permits health insurance carriers to offer riders to the basic plans revising the level of benefits. N.J.S.A. 17B:27A-19i(1). Proposed riders must be filed for informational purposes with the SEHBP Board, and those riders that decrease rather than increase the level of benefits must first be approved by the Commissioner. Ibid. The statute requires that the Commissioner disapprove any proposed rider "that is unjust, unfair, inequitable, unreasonably discriminatory, misleading, contrary to law or the public policy of this State[,]" or that reduces benefits below the mandatory coverages listed above. Ibid.

In this case, Horizon Blue Cross Blue Shield of New Jersey (Horizon), which is the largest health insurance carrier in this State, submitted a proposed rider to the Commissioner on April 30, 2009, that would provide an option for small business employers to purchase a plan with decreased benefits for out-of-network ambulatory surgery facilities. The rider would cap the coverage for such services at $2,000 per patient per year. The employer would have the ...


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