Horizon Blue Cross Blue Shield of New Jersey (“Horizon”) recently sent letters out to certain specialty pharmacies, ambulatory surgical centers, and other licensed New Jersey healthcare providers and facilities who provide certain Out-of-Network (“OON”) medical benefits to Horizon beneficiaries participating in the New Jersey State Health Benefits Program (“SHBP”) and School Employees’ Health Benefits Program (“SEHBP”). Horizon’s letter demands the targeted provider or facility to sign an attestation stating they will collect copays from members of these programs, and also notes that if either: (i) the provider (or facility representative) fails to sign the attestation; or (ii) the provider or facility fails to collect copays and/or fails to meet the legal exceptions for collecting such copays, then the provider or facility will be reimbursed at the lesser of either 110% of Centers for Medicare & Medicaid Services (“CMS”) rates or the current out-of-network reimbursement rate for elective out-of-network health care services, when those services are rendered to SHBP and SEHBP members, on a prospective basis, and are not subject to the Out-of-Network Consumer Protection, Transparency, Cost Containment and Accountability Act P.L. 2018, C. 32 (N.J.S.A. 26:2SS-1 to-20) (the “Act”).
Some specialty pharmacies provide in-home and in-office infusion services for Horizon members, and these services are billed as a medical benefit, rather than a pharmacy benefit. Many Horizon members prefer to choose an OON provider for these services, because of the superiority of the services over those provided in-network. Horizon’s attempts to limit their members’ right to utilize the pharmacy of their choosing, and their right to choose an OON provider (for which they pay a premium) are inappropriate and legally unsupported. Further, to the extent Horizon has based its actions on the Act, a strong argument can be made that pharmacies are not subject to the Act. Moreover, OON reimbursement is set by statute, and Horizon has not demonstrated that the Legislature has authorized Horizon to modify the applicable statutory minimum. Instead, it appears that Horizon is attempting to coerce providers and facilities to sign a document committing them to certain legal requirements which they may not otherwise be required to abide. As a result, providers who sign these attestations may be subjecting themselves to terms and conditions beyond what is required under the law.
How Frier Levitt Can Help
Before signing these attestations, providers should seek legal advice. Frier Levitt attorneys have years of experience raising these kinds of disputes with Horizon and other providers, and can advise healthcare facilities, pharmacies, and other providers of their respective rights with respect to OON reimbursement and the Act. If Horizon is requesting your pharmacy, healthcare facility or medical practice sign an attestation, and you want to know your relative legal rights prior to doing, contact us to speak to an attorney today.
