On August 15, 2008, Horizon Healthcare Services, Inc., doing business as Horizon Blue Cross Blue Shield of New Jersey ("HBCBSNJ") filed an application with the New Jersey Department of Banking and Insurance ("NJDOBI") to convert from non-profit to for-profit status.

Conversion Process Status Update
The conversion application since that time pursuant to NJSA 17:48E has been under review by the Commissioner of the New Jersey Department of Banking and Insurance and the Attorney General. The potential conversion has stirred debate within the State from current Horizon members, the provider community, Horizon competitors and State constituency groups such as the New Jersey Hospital Association, Medical Society of New Jersey, the Catholic HealthCare Partnership of New Jersey, Qualcare and the Alliance for Advancing Nonprofit Healthcare. The original application submitted was deemed to be incomplete and resulted in a listing of open questions and documents that Horizon was required to submit prior to the application being deemed complete. In response, Horizon at the beginning of March released hundreds of pages of additional information in response to the state Attorney General’s ruling last year that its application was incomplete. Even with the additional documentation submitted, some still feel that important information pertaining to the conversion and the potential impact on the State remain unavailable for public review and are being maintained as confidential by Horizon.

New Jersey regulators again determined that the application by HBCBSNJ to become a for-profit insurance company still failed to provide sufficient information needed for consideration and continues to remain incomplete in a letter issued May 7. The letters detailing the determination can be found at the DOBI link listed below. DOBI’s determination provided the reminder to Horizon that the task at hand is for them to clearly and fully articulate the case for the requested conversion to for-profit status. That argument needs to include how the conversion will benefit policyholders and with enough supporting evidence to clearly substantiate that the conversion would be in the public interest.

Senate Bill 2532
Stemming from the debate which began relatively quickly after the application was submitted last August was the introduction of a bill that would add additional oversight to the conversion of all nonprofit health service organizations. Senate Bill 2532 which is sponsored by Senator Loretta Weinberg (D-Teaneck) would allow for:

• Qualified parties to intervene in conversion applications
• Additional access to documents related to the application
• Required fairness analysis to assess the health impact of the conversion
• Proceeds from the conversion would be required to be placed into a trust
• Required public hearings (4 state-wide) rather than the current required single meeting as per the statute

The Senate Commerce Committee approved S-2532 with amendments on May 14. The bill modifies P.L. 2001, c. 131, which established the conversion process, by:

• Increasing the required public hearing from one to at least four to be held on a regional basis
• Requiring that at least two of the hearings be held after the commissioner receives and makes public all related written reports
• Increasing the notification period of a public hearing from 45 to 75 days prior to the scheduled hearing.
• The "intervenor" clause was amended to grant the public advocate intervenor status.
• Modifies the current fairness analysis to assess the impact of conversion on healthcare subscribers; determine whether adequate costs are addressed; examine the impact on accessible healthcare for underserved and vulnerable individuals; and, determine whether the conversion would meet the needs of all state residents and promote the public interest.

HBCBSNJ did testify against the bill noting that the current statute provided for sufficient public interest protection and also noted opposition for the change from a fairness analysis to a health impact study. The bill now proceeds to the Senate for Second Reading or potential referral to another committee.

New Jersey law provides for a public hearing on the application which occurs once the application is determined to be complete which to date has not occurred. To stay current on the status of the conversion and the information being provided for public consumption, utilize the following links:

Links for Additional Information:

Department of Banking and Insurance Conversion Page
Site provides links to the documents that have been submitted to the State of NJ by Horizon as required by the conversion process and subsequent State responses. It also notes the associated deadlines for filing for each of the documents.

Horizon Blue Cross Blue Shield of NJ Conversion Page
You can sign up by providing your name/e-mail address to get updates from Horizon regarding the conversion process.

Information available at this link also includes: conversion application, Foundation Plan, Non-Privileged Board Materials, Responses to State Questions, Company History, 2007 Annual Report, 2007 Taxes Paid and various other items.

Opinions expressed in articles or features are those of the author(s) and do not necessarily reflect the view of the New Jersey Chapter of the HealthCare Financial Management Association, or the Publications Committee. The HealthCare Financial Management Association and the Publications Committee assume no responsibility for the accuracy or content of any article or feature on the website.

Published 18 June 2009   

Do you know how to read the Explanation of Benefits (EOB) you receive from your insurance company? If you answered yes, consider yourself lucky.

Communications from insurers to their members is a quandary that has been discussed for years. The issues include member confusion and frustration, potential financial obligations, denials, partial payments and, well the list goes on.

I thought a fitting way to open the first installment of the "Marketplace" was to share my New Year's resolution relating to healthcare: help as many people as possible in understanding their insurance benefits, how their claims are paid, how to read the correspondence they receive from insurance companies, and what methods are available for resolving issues. Each year, on average 45% of American adults make one or more New Year's resolutions and only 46% of them maintain those after six months, so I am trying to beat the odds here.

Providers and insurers receive calls on a regular basis from patients confused about what is covered and/or their financial obligations. The overwhelming lack of education among all people who carry insurance really hits home when it affects you personally. Similar to many people in their age group, my parents have multiple medical conditions which they manage. Associated with those conditions are regular monthly, if not weekly, medical bills, prescription renewals, diagnostic testing, etc. The average person (and education really does not play a role here) rarely understands how insurance billing works. Reason being, they are not brought into the process until there is an issue between the insurer and provider or a patient balance remains.

In my opinion the insurance companies and employer human resource departments can do a better job of educating their members/employees regarding benefit plans. In today's economy, we are all strained for resources. Improving the upfront education could resolve the administrative burdens that arise from the lack of understanding. While providing the information on a website is helpful, many in older generations struggle to access this information and may not have someone to help them. There are advocates that can assist them, however there are not enough to service the growing population in this demographic. As an example, my sister and I now serve as my parent's claims clearinghouse; billing, follow-up, reconciliations. We do it all !

We are "lucky" enough to work in an industry that is ever changing and causes confusion as a standard practice. But there is a bright side, as integral parts of the industry we have a better understanding of the avenues available for information and resolution. I encourage you to assist those who cannot interpret their medical statements or benefit plans: you have the knowledge that could change their lives. Do not make the assumption that someone may have the knowledge (including those within your own family) or is comfortable in asking for help. The last thing they need is a collection notice in their mailbox.

As you can tell, I'm rather passionate about Benefits...Future topics include Medicare Advantage, regulatory changes, strategies for success and more...

Opinions expressed in articles or features are those of the author(s) and do not necessarily reflect the view of the New Jersey Chapter of the HealthCare Financial Management Association, or the Publications Committee. The HealthCare Financial Management Association and the Publications Committee assume no responsibility for the accuracy or content of any article or feature on the website.

Published 25 January 2009