In the Matter of State and School Employees’ Health Benefits Commissions’ Implementation of I/M/O Philip Yucht

by
The New Jersey State Health Benefits Commission (SHBC) and the School Employees’ Health Benefits Commission (SEHBC) (collectively, the Commissions) administered the New Jersey State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP), respectively. At issue was the method used by the Commissions to correct erroneously tiered reimbursement rates previously applied to members’ out-of-pocket expenses for out-of-network behavioral health services. In a separate matter involving a single plan member, the tiered reimbursement schedule was determined to have violated N.J.S.A. 52:14-17.46.7, which addressed the calculation of reimbursement rates for out-of-network health benefit services. Following that decision, the Commissions permitted members who paid for out-of-pocket behavioral health services and did not receive a proper reimbursement to obtain retroactive reimbursement for charges incurred between May 2009 and March 2014. The challenge before the New Jersey Supreme Court centered on the reasonableness of the Commissions’ notice to members who may have been affected by the application of the erroneous reimbursement rates. The Supreme Court reversed the Appellate Division’s holding and remanded the matter to the Commissions for further proceedings. “Significant questions exist concerning the extent of the notice actually provided, either by the Commissions or through their agents to active employees, former employees, and retirees, a hearing is necessary.” View "In the Matter of State and School Employees' Health Benefits Commissions' Implementation of I/M/O Philip Yucht" on Justia Law