July 24, 2013 Vol. 22 No. 926

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Applies to: All markets

Delivering better, cost-effective care

2012 results show positive outcomes in our patient-centered practices

Innovative new models of care are beginning to transform the delivery of health care benefitting patients and lowering costs, according to results from one of Horizon Blue Cross Blue Shield of New Jersey’s patient-centered programs. The 2012 Patient-Centered Medical Home Program (Program) results show that patient-centered physician practices are improving the coordination of care and reducing unnecessary complications for their patients.

“Our positive 2012 results demonstrate that health insurers and physicians can work together to transform how care is delivered to benefit patients and lower costs,” said Jim Albano, Vice President, Network Management and Horizon Healthcare Innovations, Horizon BCBSNJ.

Horizon BCBSNJ compared how health care was delivered to 70,000 members in patient-centered practices to the health care delivered to members in other primary care practices. The results showed impressive improvements in care and reduced costs to those members in the Program, including:

Providing better care

• 5 percent higher rate in improved diabetes control (HbA1c).

• 3 percent higher rate in breast cancer screenings.

• 11 percent higher rate in pneumonia vaccinations.

Utilization and cost measures

• 23 percent lower rate in hospital inpatient admissions.

• 12 percent lower rate in Emergency Room (ER) visits.

• 9 percent lower cost of care for diabetic patients.

“Under this collaborative medical home program, patient care coordinators have helped to create personalized care plans for patients at high risk of complications from their illnesses, which is working to produce improved quality outcomes,” said Dr. Roger Thompson of Integrated Medicine Alliance in Monmouth County. “This initiative has helped us deliver proactive outreach programs to discover obstacles to proper care, fill gaps in care and to engage patients and encourage participation in making their own health care decisions.”

Participating physicians in the Program focus on actively improving care coordination among a patient’s treating physician as well as promoting preventive and wellness care. Horizon BCBSNJ members in the Program receive:

• Quality, personalized and team-based care led by a physician.

• Coordinated care, from start to finish.

• Follow-up primary care immediately after an ER visit or hospital discharge.

• Improved access to care when needed most.

• Enhanced communications with their care team.

• Wellness and preventive care based on national guidelines.

• Extra support and resources – including health education.

“The momentum from our early successes makes it possible to expand our program so that an additional 80,000 Horizon BCBSNJ members can experience the benefits of improved care coordination,” added Albano. “We’re committed to the transformation of care in New Jersey and to having most of our members in patient-centered practices within a few years.”

Horizon BCBSNJ has a number of patient-centered programs, including Accountable Care Organizations, Patient-Centered Medical Homes and programs focused on Episodes of Care (i.e. joint replacement). More than 320,000 members and 1,400 doctors are participating in Horizon BCBSNJ’s patient-centered programs that are working to improve patient care while controlling costs.

If you have questions, please contact your Horizon BCBSNJ account executive or account manager.

Vol. 22 No. 924- Horizon Blue Cross Blue Shield of New Jersey and Hunterdon Healthcare

 Applies to: All markets

 Horizon Blue Cross Blue Shield of New Jersey and Hunterdon Healthcare launch Patient- Centered ACO

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Improving care for more than 18,000 patients

 Horizon Blue Cross Blue Shield of New Jersey and Hunterdon Healthcare Partners have launched a Patient-Centered Accountable Care Organization (ACO) that will benefit more than 18,000 Horizon BCBSNJ members in Hunterdon, Somerset and Mercer counties. Nineteen Hunterdon Healthcare Partners doctors’ offices will be part of the Patient-Centered ACO.

 Since July 2012, Hunterdon Healthcare Partners – and its 19 participating locations – have participated in one of Horizon BCBSNJ’s patient-centered programs, specifically the Patient-Centered Medical Home Program (Program). This new expansion of the Program to a Patient-Centered ACO will focus on increasing accountability for participating practices in delivering more comprehensive, integrated care to Horizon BCBSNJ members. In addition to better coordination of care, all patient treatments will be tied to evidence-based standards for prevention and wellness. Participating practices will take on increased accountability for improving quality outcomes for Horizon BCBSNJ members, while reducing the total cost of their care.

 “Over the past year, Horizon BCBSNJ has successfully collaborated with Hunterdon Healthcare to improve quality outcomes and reduce unnecessary emergency room visits,” said Jim Albano, Vice President of Network Management and Horizon Healthcare Innovations at Horizon BCBSNJ. “Expanding this relationship as a Patient-Centered ACO adds more accountability to improve health outcomes, and maintains a team-based, coordinated approach to care.”

 “Collaborating with Horizon BCBSNJ will help Hunterdon Healthcare deliver better care at a better price. We think patients will see direct benefit from this approach,” explained Jeffrey Weinstein, Executive Director for Hunterdon Healthcare Partners. Weinstein added, “This not only supports our mission to deliver better access to primary care and specialist physicians, but will allow us to better provide integrated care to improve the health of our community

 The following family practices affiliated with Hunterdon Healthcare Partners will participate in this Patient-Centered ACO:

Annandale Family Practice – 56 Payne Road, Suite 21, Lebanon

Branchburg Family Health Center – 2143 South Branch Road, Somerville

Cornerstone Family Practice – 9100 Wescott Drive, Suite 103, Flemington

Dein Shapiro, MD – 3461 Route 22 East, Branchburg, NJ 08876

Delaware Valley Family Health Center – 200 Frenchtown Road, Milford

Highlands Family Health Center – 61 Frontage Road, Hampton

Hopewell Family Practice – 84 East Broad Street, Hopewell

Hopewell Family Practice – 84 Route 31 North, Pennington

Hunterdon Family Practice and Obstetrics – 1100 Wescott Drive, Suite 101, Flemington

Morningstar Family Health Center, Inc. – 54 Old Highway 22, Clinton

Phillips Barber Family Health Center – 72 Alexander Avenue, Lambertville

Raritan Family Health Care – 901 US Highway 202 and Quick Avenue, Upper Level, Raritan

Raritan Family Health Care – 2345 Lamington Road, Suite 104, Bedminster

Riverfield Family Health Center – 1738 Route 31 North, Suite 203, Clinton

Riverfield Family Health Center – 140 Boulevard, Washington

The Doctor Is In – 59 Old Highway 22, Clinton

The Doctor Is In – 149M Highway 31, Flemington

The Doctor Is In – 1205 US Highway 22, Phillipsburg

Your Doctors Care – 71 Route 206 South, Hillsborough

Under this Program, Horizon BCBSNJ provides participating practices with funding to support Population Care Coordinators (PCCs) on site at all practice locations. PCCs are nurses who coordinate treatment and engage patients to take more control of their own health.

About Hunterdon Healthcare Partners

Hunterdon HealthCare Partners was created by physicians and the Hunterdon Healthcare System, the parent organization of the Hunterdon Medical Center. The partnership’s goal is to provide the residents of Hunterdon County and the surrounding areas better access to integrated care delivered through their network of primary care and specialist physicians.

If you have questions, please contact your Horizon BCBSNJ account executive or account manager.

Horizon Broker News – Special issue Health Care Reform & You

June 2013

 What’s Inside

 A message from Michael J. Considine, Director, Commercial and Public Sector Sales

 How will the Affordable Care Act (ACA) affect the small group market?

 How will the ACA affect premiums?

 The new benefits and new costs of the ACA

 Changes impacting your clients’ plan options

 The public exchanges

 What your clients need to know about the Employer Reporting Requirements

Click here to view this Special issue of Broker News dedicated to health care reform

 New Health Insurance Exchange (Marketplace) Notices

The Exchange Notice provides employees with certain information related to the new Exchanges (also called Marketplaces) which are expected to begin operating next year. Following a delay in the original effective date, employers are required to provide this written notice to each current employee not later than October 1, 2013, and to each new employee at the time of hiring beginning October 1, 2013. For 2014, a notice will be considered provided “at the time of hiring” if it is provided within 14 days of an employee’s start date.

Employers must provide the notice to each employee (automatically and free of charge) regardless of plan enrollment status (if applicable) or of part-time or full-time status. Two separate notices are available from the DOL–one model notice for employers who offer a health plan to some or all employees, and another model notice for employers who do not offer a health plan. The notice may be provided by first-class mail, or, alternatively, it may be provided electronically if certain requirements are met. Employers do not need to provide a separate notice to dependents or other individuals who are or may become eligible for coverage under the plan but who are not employees.

Additional details regarding the Exchange Notice are explained in Technical Release 2013-02. According to the DOL, this temporary guidance will remain in effect until the issuance of regulations or other guidance. Future regulations or other guidance will provide adequate time for employers to comply with any additional or modified requirements.

Updated Model COBRA Election Notice Includes Information Regarding Health Insurance Exchanges (Marketplaces)

A revised Model COBRA Election Notice is now available for group health plans to inform eligible employees and dependents of the right to continuation of coverage under federal law and how to make an election when a qualifying event occurs. The updated model notice includes additional information for qualified beneficiaries who may want to consider and compare health coverage alternatives to COBRA that will be available through the Exchanges (also known as Marketplaces), which are expected to begin operating in 2014. The revised notice also describes the availability of premium tax credits for purchasing coverage through the Exchange.

Federal COBRA generally applies to group health plans sponsored by employers with 20 or employees (including both full- and part-time employees) on more than 50% of their typical business days in the previous calendar year. In general, an individual who was covered by a group health plan on the day before a qualifying event (such as termination of employment) may be able to elect COBRA continuation coverage upon a loss of coverage due to the qualifying event. Upon the occurrence of a qualifying event, the plan administrator is required to provide these individuals (called “qualified beneficiaries”) with an election notice, generally within 14 days after the administrator receives notice of the qualifying event

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What is a Small Employer?

New Jersey brokers: Keep in mind these guidelines for new business quotes

A Small Employer

The Small Employer Health (SEH) Program Act states that there are three measures a company must meet in order to be considered a small employer.

The company must:
• Employ an average of at least two but no more than 50 eligible employees* on business days during the preceding calendar year;
• Employ at least two eligible employees on the first day of the plan year; and
• Have a majority of the eligible employees working at a location in New Jersey

Not a Small Employer

Associations, Employer Associations, Purchasing Groups, Alliances, MEWAs and Affinity groups are not eligible to be a small employer.

These types of groups include:

Employer Associations
Purchasing Groups
Affinity Groups
Franchises
Trade Associations
Cooperatives
Alliances
Coalitions
MEWAs
VEBAs
Professional Associations
Financial Institutions
Alumni

In addition, groups can’t be banded together to be written as one, especially separate companies that have different tax ID numbers, even if they have a common purpose or common ownership.
For example, ABC Group of X County, DEF Group of Y County, and GHI of Z County cannot be banded together and written as one group. They can, however, be written as separate groups as long as they meet the guidelines of a small employer.
Remember, in New Jersey, small group coverage is mandated by the State of New Jersey.

*Eligible Employees
For purposes of the SEH Program, an eligible employee is a bona fide employee who works for an employer 25 or more hours per week every week. Eligible employees may include the owner(s) (partners and proprietors) of a business if the owner is a bona fide employee of the business. Independent contractors may also be covered. However, the independent contractor must meet the SEH Program Act’s definition of an eligible employee, and they must meet all of the requirements for being an independent contractor under state, federal, tax, and employment laws.
Eligible employees do not include employees who are covered as members under a union’s collectively bargained welfare arrangement. But if the employee’s union has not collectively-bargained for health coverage, or the employee has decided not to participate in the collectively-bargained health coverage even though eligible, and he or she also works 25 or more hours per week on a regular basis, then you must include the union employee in the count of eligible employees.
Eligible employees do not include employees hired on a temporary or substitute basis, or seasonal employees, regardless of the number of hours worked. Carriers have underwriting guidelines that define whether employees are temporary, seasonal or otherwise bona fide employees.
When a company is affiliated with one or more other companies, all of the companies in the affiliation are treated as one company, and all eligible employees of all affiliated companies – including employees of out-of-state affiliates – are considered in determining small employer status for purposes of the SEH Program. If, when combined, the number of eligible employees of affiliated companies is more than 50, none of the affiliated companies is eligible for small group coverage.
Affiliated Companies
Whether companies are affiliated for purposes of the SEH Program depends upon whether the companies are considered a single employer pursuant to paragraphs (b), (c), (m) or (o) of section 414 of the Internal Revenue Code of 1986 (26 U.S.C. § 414(b), (c), (m) or (o)). An employer will need to obtain a statement from a tax accountant or tax attorney as to whether multiple companies are considered affiliated for federal tax purposes.**

**http://www.state.nj.us/dobi/division_insurance/ihcseh/sehguide/whatis.html