Health Maintenance Organization of New Jersey, Inc. v. Whitman

72 F.3d 1123, 1995 WL 759552
CourtCourt of Appeals for the Third Circuit
DecidedDecember 26, 1995
Docket94-5698
StatusUnknown
Cited by1 cases

This text of 72 F.3d 1123 (Health Maintenance Organization of New Jersey, Inc. v. Whitman) is published on Counsel Stack Legal Research, covering Court of Appeals for the Third Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Health Maintenance Organization of New Jersey, Inc. v. Whitman, 72 F.3d 1123, 1995 WL 759552 (3d Cir. 1995).

Opinion

OPINION OF THE COURT

LEWIS, Circuit Judge.

This appeal requires us to address the delicate balance between federal and state authority established under the Supremacy Clause of the United States Constitution. The Health Maintenance Organization of New Jersey (“HMO/NJ”) appeals from the district court’s grant of summary judgment to defendants Christine Todd Whitman, the Governor of New Jersey, Elizabeth Randall, the Commissioner of the New Jersey Department of Insurance, and Charles Wowkanech, the Chairman of the New Jersey Individual Health Coverage Program (collectively, “the State”). The sole issue we address in this appeal is whether the Federal Employee Health Benefits Act, 5 U.S.C. §§ 8901 et seq. (“FEHBA”) preempts certain provisions of the New Jersey Health Insurance Reform Act, N.J.S.A. §§ 17B:27A-2 to -16.4 (the “Reform Act”). HMO/NJ argues that the premium assessments under the Reform Act are preempted by FEHBA because they will increase the cost of individual health care benefits to federal employees, benefits which are payable from the Federal Employee Health Benefits Fund. We agree. For the reasons set forth below, we hold that section 8909(f) of FEHBA preempts premium assessments under the Reform Act when applied to insurance plans governed by FEH-BA, and will reverse the district court’s order on the issue of FEHBA preemption.

I.

A.

In response to this nation’s growing health care crisis, New Jersey enacted the Reform Act to ensure that all its citizens would receive the benefits of individual health care coverage. (Individual health care coverage is coverage offered by an insurance company or health maintenance organization directly to *1125 an individual and his or her family. By increasing the availability of individual health care coverage, the State intends to reduce the number of uninsured self-employed or unemployed residents, who often do not have the option of purchasing employer-based or group health coverage).

Under the Reform Act, a non-compensated, nine-member Board of Directors “shall establish the policy and contract forms and benefit levels to be made available” under an Individual Health Coverage Program. NJ.Stat.Ann. § 17B:27A-7. In 1993, the Board of Directors devised a program whereby state residents would be offered five standardized individual health plans. 1 The program requires New Jersey health insurance companies and health maintenance organizations (collectively referred to in the Reform Act as “carriers”) to offer state residents the five standardized policies as a condition of continuing to issue any type of health benefit plans in the state. See NJ.Stat.Ann. §§ 17B:27A-4, 17B:27A-l(a)(3)(c). Carriers were required to start offering the five plans on August 1,1993.

The central component of the Reform Act is the requirement that all carriers in the state pay an “assessment” that is used to defray financial losses incurred by those companies that provide a disproportionate share of the “higher-risk” individual health insurance coverage in the state. In group health plans, the cost of insuring higher-risk people, individuals who require expensive medical treatment, is spread among the entire insured population. In contrast, when people are individually insured, these costs must be borne by either the individual or the insurance company. As a result, insurance sold on an individual basis may be prohibitively expensive for the consumer and unprofitable for the insurance company. Through the assessment, the Reform Act attempts to spread the cost of insuring higher-risk individuals among New Jersey’s entire insurance industry in order to reduce the cost to the individual while increasing the profitability of insuring those individuals.

New Jersey carriers are required to “pay or play” with respect to the individual health insurance market. For each carrier, the Board establishes a target goal of individual policies, or more specifically “non-group” policies, that the carrier must issue in a calendar year if it wishes to obtain an exemption from the assessment. In general, a carrier’s target number of non-group policies for the exemption is calculated based on the carrier’s proportion of the overall state-wide health coverage market. See NJ.Stat.Ann. § 17B:27A-12(d)(3).

The State pools the money collected pursuant to the annual assessment and uses it to reimburse carriers who suffer losses in the individual insurance market during the calendar year. The assessment is calculated as the proportion of the carrier’s “net earned premium” for the calendar year preceding the assessment in relation to the net earned premium of all carriers for the calendar year preceding the assessment. NJ.Stat.Ann. § 17B:27A-12(a)(2). The Reform Act uses a carrier’s net earned premium as a proxy for the carrier’s market share. A simplified example would be if a carrier earned 15% of all health insurance premiums in New Jersey, then it would be assessed 15% of the total losses incurred by carriers issuing individual policies. The “net earned premium” is all premiums earned in New Jersey by a earner on any of its health benefit plans, including “the aggregate premiums earned on the carrier’s insured group and individual business and health maintenance organization business!.]” NJ.Stat.Ann. § 17B:27A-2. Nota *1126 bly, premiums from self-insured plans administered by a carrier are not included in the assessment calculation. In addition, carriers are assessed their proportion of the administrative expenses incurred by the Individual Health Coverage Program. § 17B.T7A-11(a).

B.

FEHBA provides health benefits for federal employees, their families, and federal retirees. See 5 U.S.C. § 8901 et seq. The program is administered by the Office of Personnel Management (“OPM”), which is authorized to negotiate contracts with qualified carriers for the provision of health benefits to federal employees and other enrollees. Premiums for enrollment in a health plan are set annually and determined in OPM’s contract negotiations with each participating carrier.

The costs of enrolling in a health plan are paid by contributions from the enrollee and the federal government. The government’s share is equal to 60% of the average premium charged by major participating health plans and may not exceed 75% of the total charge for enrollment. 5 U.S.C. § 8906. The balance of the enrollment charge is paid by the enrollee and withheld from the enroll-ee’s salary or retirement annuity. These contributions are then paid into a specifically-designated account in the United States Treasury: the Employee Health Benefits Fund (the “Fund”). 5 U.S.C. § 8909. Payments and reimbursements to participating insurance carriers are then made from the Fund.

As part of the Omnibus Budget Reconciliation Act of 1990, Pub.L. 101-508, Congress amended FEHBA by adding subsection 8909(f) which provides that:

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72 F.3d 1123, 1995 WL 759552, Counsel Stack Legal Research, https://law.counselstack.com/opinion/health-maintenance-organization-of-new-jersey-inc-v-whitman-ca3-1995.