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Health Benefit Commission Meeting Minutes
2006



January 11, 2006
MINUTES
1:00 PM
State Health Benefits Commission

The 449th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:10 AM Wednesday, January 11, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Caroline Ehrlich, representing State Treasurer, John E. McCormac
Michael Malloy, representing Acting Commissioner Donald Bryan, Department of Banking and Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Brian Volz, NJEA
Dudley Burdge, Alternate Representative, New Jersey State AFL-CIO

Also Present:

Frederick Beaver, Director, Division of Pensions & Benefits
Florence Sheppard, Deputy Director, Division of Pensions & Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Program
Christine Servis, Chief, State Health Benefits Bureau
Jean Williamson, Acting Secretary, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ representatives
Susanne Culliton, Deputy Attorney General

ISSUES

1. Minutes - Meeting No. 448. Brian Volz made a motion to accept the minutes and Richard Dougherty seconded the motion. Four voted in favor. Michael Malloy abstained.

The following cases due to HIPPA regulations are seen in closed session, with the motions and voting done in open session.

Richard Dougherty made a motion to go into closed session. Dudley Burdge seconded the motion. All voted in favor.

Case # 010601: (Member present) This Division appeal concerns a request for assurance from the State Health Benefits Program (SHBP) that if their adult child should lose her present State Health Benefits Program coverage, she will be eligible for State Health Benefits coverage in the future since she is considered disabled. The adult child was covered as an overage disabled dependent. Since she is employed, has her own SHBP coverage and is not residing at home, the Division terminated her from her parent's coverage. Caroline Ehrlich made a motion to deny the appeal and uphold the termination of coverage. Michael Malloy seconded the motion. All voted in favor.

Case # 010602: This Division appeal concerns a request for retired State Health Benefits Program coverage. Dudley Burdge made a motion to approve the appeal on an exception basis. Brian Volz seconded the motion. Three opposed. The motion fails. Caroline Ehrlich made a motion to deny the appeal. Michael Malloy seconded the motion. Three voted in favor. Two opposed. The motion carries.

Case # 010603: (Member present) This $175 NJ PLUS appeal concerns a denial of continued occupational therapy services for the member's son. Caroline Ehrlich made a motion to deny the appeal. Richard Dougherty seconded the motion. Four voted in favor; Dudley Burdge opposed. The motion carries.

Case # 010604: (Member present) This tabled $30,712.50 Traditional Plan appeal concerns the denial of benefits for expenses for speech therapy. Richard Dougherty made a motion to deny the appeal. Caroline Ehrlich seconded the motion. Four voted in favor; Dudley Burdge opposed. The motion carries.

Case # 010605: The Commission voted to approve a draft of a Final Administrative Determination (FAD) for an appeal concerning the denial of orthodontic treatment, periodic oral exams and x-rays for a dependent child. At its meeting of December 20, 2005 the Commission determined that no issue of material fact exists and therefore, denied the request for an OAL hearing. Caroline Ehrlich made a motion to approve the FAD. Richard Dougherty seconded the motion. Four voted in favor and Dudley Burdge abstained. The motion carries.

There being no further business to transact, a motion to adjourn was made by Caroline Ehrlich and seconded by Brian Volz. All voted in favor. The State Health Benefits Commission meeting was adjourned at 11:34 AM.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission




February 8, 2006

Minutes
10:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:15 AM, Wednesday, February 8, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

Roll Call

Robert Smartt, representing Acting State Treasurer, Bradley I. Abelow
Michael Malloy, representing Acting Commissioner, Donald Bryan, Department of Banking and Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Brian Volz, NJEA
Eric E. Richard, New Jersey State AFL-CIO

Also present:

Frederick Beaver, Director, Division of Pensions & Benefits
Florence Sheppard, Deputy Director, Division of Pensions & Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Program
Christine Servis, Chief, State Health Benefits Bureau
Jean Williamson, Acting Secretary, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ representatives
Aetna representatives
Susanne Culliton, Deputy Attorney General

Issues

1. Minutes Meeting No. 449. - Robert Smartt made a motion to approve the Minutes and Richard Dougherty seconded the motion. All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

Brian Volz made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor.

Case #020601 - This $550 Traditional Plan appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for surgery. Michael Malloy made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #020602 - (Member was represented by Marianne Farber and Dr. Jay Cohen) - This Aetna Plan appeal concerned a request for payment of in-patient mental health care for subscriber's dependent. Robert Smartt made a motion to deny the appeal and Michael Malloy seconded the motion. Three opposed the motion; it did not carry. Eric Richard made a motion to approve payment of the in-patient mental health care claims. Brian Volz seconded the motion. Three voted in favor (Eric Richard, Brian Volz and Richard Dougherty) and two opposed (Robert Smartt and Michael Malloy). The motion carried.

Case #020603 - (Member was present) - This Aetna Dental Expense appeal concerned a denial of benefits for dental implants. Richard Dougherty made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor.

Case #020604 - (Member was present) - This tabled Traditional Plan appeal concerned a denial of benefits for Viagra beyond four Viagra pills per month/twelve pills in a 90-day period for rehabilitative purposes. Richard Dougherty made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor.

There being no further business to transact, a motion to adjourn was made by Richard Dougherty and seconded by Eric Richard. The State Health Benefits Commission meeting was adjourned at 11:45 am.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission



Meeting No. 451
March 8, 2006
Minutes
10:00 AM
State Health Benefits Commission

The 451st meeting of the State Health Benefits Commission of New Jersey was called to order at 10:20 AM, Wednesday, March 8, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

David Ridolfino, representing State Treasurer, Bradley I. Abelow
Michael Malloy, representing Acting Commissioner, Donald Bryan, Department of Banking and Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Eric E. Richard, New Jersey State AFL-CIO

Also present:

Florence Sheppard, Deputy Director, Division of Pensions & Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Program
Christine Servis, Chief, State Health Benefits Bureau
Jean Williamson, Acting Secretary, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ representatives
Oxford Health Plan representative
Susanne Culliton, Deputy Attorney General

ISSUES

1. Minutes - Meeting No. 450. David Ridolfino made a motion to approve the Minutes and Richard Dougherty seconded the motion. All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

David Ridolfino made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor.

Case #030601: This Traditional Plan appeal concerns a denial of benefits for expenses for Viagra beyond four Viagra pills per month/twelve pills in a 90-day period. Richard Dougherty made a motion to deny this appeal. Motion seconded by David Ridolfino. All voted in favor.

Case #030602: This Traditional Plan appeal concerns a denial of benefits for expenses for Viagra beyond four Viagra pills per month/twelve pills in a 90-day period. Richard Dougherty made a motion to deny this appeal. Motion seconded by David Ridolfino. All voted in favor.

Case #030603: (Member was present) - This $982 Oxford appeal concerns a denial of benefits for expenses for an out-of-network provider treating a dependent child. David Ridolfino made a motion for the Commission to go into Executive Session to consult with counsel. Richard Dougherty seconded the motion. All voted in favor. Richard Dougherty made a motion to go back to Closed Session. Motion seconded by Michael Malloy. All voted in favor. Richard Dougherty made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor.

Case #030604: (Member was present) - This NJ PLUS appeal concerns a denial of continued speech therapy services and a denial of pre-authorization for occupational therapy services for a dependent child. David Ridolfino made a motion for the Commission to go into Executive Session to consult with counsel. Richard Dougherty seconded the motion. All voted in favor. Motion made by David Ridolfino to go back into Closed Session. Motioned seconded by Richard Dougherty. All voted in favor. Richard Dougherty made a motion to deny this appeal. Motion seconded by David Ridolfino. Three voted in favor and one opposed. Richard Dougherty made a motion to expedite a Final Administrative Determination. Motion seconded by David Ridolfino . Three voted in favor and one abstained.

Case #030605: The ALJ requested that the Commission reconsider additional information submitted by subscriber regarding a disabled dependent. Additional information was reviewed by Horizon's Medical Director and there were no significant changes. Richard Dougherty made a motion for the Commission to maintain denial of prior decision. Motion seconded by Michael Malloy. All voted in favor.

There being no further business to transact, a motion to adjourn was made by Richard Dougherty and seconded by David Ridolfino. The State Health Benefits Commission meeting was adjourned at 12:45 am.

Respectfully submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 452
March 22, 2006
Minutes 2:30 PM
State Health Benefits Commission

This special meeting of the State Health Benefits Commission of New Jersey was called to order at 3:00 PM, Wednesday, March 22, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Michael Malloy, representing Acting Commissioner, Donald Bryan, Department of Banking and Insurance (Via telephone)
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel (Via telephone)
Eric E. Richard, New Jersey State AFL-CIO (Via telephone)
Brian Volz, NJEA (Via telephone)

Also present:

Florence Sheppard, Deputy Director, Division of Pensions & Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Program
Jean Williamson, Acting Secretary, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ representatives (Via telephone)
Susanne Culliton, Deputy Attorney General
David Dembe, Deputy Attorney General (Via telephone)

ISSUES

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

Case #000001: This appellate case concerning private duty nursing services was remanded to the Commission. An overview of the options available was given by DAG David Dembe. Richard Dougherty made a motion to go into executive session to consult with counsel. Michael Malloy seconded the motion and all voted in favor. Richard Dougherty made a motion to return to closed session. Michael Malloy seconded the motion and all voted in favor. A motion was made by Richard Dougherty to pursue a settlement. Michael Malloy seconded the motion. All voted in favor.

There being no further business to transact, a motion to adjourn was made by Richard Dougherty and seconded by Michael Malloy. The State Health Benefits Commission meeting was adjourned at 3:45 pm.

Respectfully submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 453
April 12, 2006
Minutes 10:00 AM
State Health Benefits Commission

The 453rd meeting of the State Health Benefits Commission of New Jersey was called to order at 10:30 AM, Wednesday, April 12, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Joseph Reilly, representing State Treasurer, Bradley I. Abelow
Gale Simon, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of PersonnelBrian Volz, NJEA
Eric E. Richard, New Jersey State AFL-CIO

Also present:

Frederick Beaver, Director, Division of Pensions and Benefits
Susanne Culliton, Deputy Attorney General
Len Leto, Manager, Policy & Planning, State Health Benefits Program
Christine Servis, Chief, Health Benefits Bureau
Jean Williamson, Policy and Planning, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives
Aetna Representatives

ISSUES

1. Minutes - Meeting No. 451: Richard Dougherty made a motion to approve the Minutes and Brian Volz seconded the motion. Four voted in favor and one abstained.

2. Minutes - Meeting No. 452: Richard Dougherty made a motion to approve the Minutes and Eric Richard seconded the motion. Three vote in favor and two abstained.

3. Aetna Medicare Advantage - Len Leto presented a proposal for a new plan which would be an option for retirees who are eligible for Medicare. Representatives from Aetna were also present. Joseph Reilly made a motion to approve the plan subject to the understanding that the rate would need to be approved. The motion was subsequently withdrawn. Gale Simon requested more time to review the proposal. Eric Richard wanted to wait to hear about the projected cost savings referenced in a memo from AON. In addition, the Commission would like to have a finalized rate for the plan. Richard Dougherty made a motion to review the proposal and Joseph Reilly seconded the motion. All voted in favor.

Joseph Reilly made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

Case #040601: This $9,802.34 Traditional Plan appeal concerns a request for dental services to be considered eligible under the Traditional Plan. Richard Dougherty made a motion to deny this dental appeal. Gale Simon seconded the motion. Three voted in favor and two abstained.

Case #040602: This $5,485 Traditional Plan appeal concerns a denial of benefits for expenses for a routine colonoscopy. Gale Simon made a motion to deny this appeal. Joseph Reilly seconded the motion. All voted in favor.

Case #040603: This $8,785 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery. Richard Dougherty made a motion to deny this appeal. Joseph Reilly seconded the motion. All in favor.

Case #040604: (Member was present) - This $1,400 Traditional Plan appeal concerns a denial of benefits for weight loss classes attended from October 18, 2004 through October 27, 2005. Joseph Reilly made a motion to deny this appeal based on the exclusion in the Traditional Handbook. Richard Dougherty seconded the motion. Four voted in favor and one recuse from the vote.

Case #040605: (Member was represented by an attorney) This $8,755 Traditional Plan appeal concerns a denial for an ineligible mental health provider and the denial of benefits for expenses for mental health care above the mental health lifetime maximum. Gale Simon made a motion to pay up to the lifetime maximum, approximately $7,000. Brian Volz seconded the motion. Four voted in favor and one voted against.

Case #040606: (Member was present) This Traditional Plan appeal concerns a denial of benefits for proposed Vagus Nerve Stimulation (VNS) for the treatment of depression. Joseph Reilly made a motion to deny this appeal because the procedure is considered investigational. Richard Dougherty seconded the motion. All voted in favor.

Case #040607: The Commission agreed to refer case to OAL for decision. Gale Simon made a motion to send to OAL to determine apportionment of covered and noncovered care. Richard Dougherty seconded the motion. All voted in favor.

Case #040608: The Commission approved a Final Administrative Determination concerning (a) continued speech therapy and (b) a pre-authorization for occupational therapy services for a dependent child. Joseph Reilly made a motion to approve the Final Administrative Determination. Richard Dougherty seconded the motion. All voted in favor.

There being no further business to transact, a motion to adjourn was made by Gale Simon, seconded by Joseph Reilly and all voted in favor. The State Health Benefits Commission meeting was adjourned at 12:20 pm.

Respectfully submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 454
May 10, 2006
Minutes 10:00 AM
State Health Benefits Commission

The 454th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:20 AM, Wednesday, May 10, 2006.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Joseph Reilly, representing State Treasurer, Bradley I. Abelow
Gale Simon, representing Commissioner Steven M. Goldman, Department of Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Brian Volz, NJEA
Dudley Burdge, New Jersey State AFL-CIO

Also present:

Frederick Beaver, Director, Division of Pensions & Benefits
Susanne Culliton, Deputy Attorney General
Len Leto, Manager, Policy & Planning, State Health Benefits Program
Christine Servis, Chief, Health Benefits Bureau
David Pointer, State Health Benefits Program
Jean Williamson, Policy & Planning, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives

ISSUES

1. Minutes - Meeting No. 453: Joseph Reilly made a motion to approve the Minutes and Richard Dougherty seconded the motion.  All voted in favor.

Joseph Reilly made a motion to go into Closed Session and Richard Dougherty seconded the motion.   All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

Case #050601: (Member was present)  This $14,098.50 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery.  Because of the unique injury and no recognized reasonable and customary data available, Gale Simon made a motion to treat the actual charges for the following three CPT Codes as reasonable and customary: CPT Codes 27766, 28445 and 28555; and that CPT Code 27766 be treated as primary.  In addition, denial of payment of benefits is upheld for the following three CPT codes: CPT Code 27848-51 in the amount of $4,000, CPT Code 64708-51 in the amount of $4,400 and CPT Code 99283 in the amount of $275.  Joseph Reilly seconded the motion. All voted in favor.

Case #050602: (Member was present) This $591.20 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery. Dudley Burdge made a motion to approve this appeal. Gale Simon seconded the motion.  All voted in favor.

Case #050603: This $1,470 Traditional Plan appeal concerns a denial of benefits for electrolysis treatment, corrective acne treatment and treatment creams and lotions. Richard Dougherty made motion to deny this appeal. Joseph Reilly seconded the motion.  All voted in favor.

Case #050604: This NJ PLUS Plan appeal concerns a denial of benefits for hearing aids. Richard Dougherty made a motion to deny this appeal based on the fact that hearing aids are an excluded benefit as indicated in the NJ PLUS Handbook.  Gail Simon seconded the motion. All voted in favor.

Case #050605: The Commission received a request to forward appeal concerning weight loss classes to the Office of Administrative Law. Joseph Reilly made a motion to reject the request to have the appeal forwarded to the Office of Administrative Law. Richard Dougherty seconded the motion. All voted in favor. A final administrative determination will be drafted for review and approval at the June meeting.

There being no further business to transact, a motion to adjourn was made by Richard Dougherty, seconded by Joseph Reilly and all voted in favor. The State Health Benefits Commission meeting was adjourned at 11:35 pm.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 455
June 14, 2006
REVISED
Minutes 10:00 AM
State Health Benefits Commission

The 455th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:13 AM, Wednesday, June 14, 2006.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Joseph Reilly, representing State Treasurer, Bradley I. Abelow
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Dudley Burdge, New Jersey State AFL-CIO

Also Present:

Frederick Beaver, Director, Division of Pensions & Benefits
Florence Sheppard, Deputy Director, Division of Pensions & Benefits
Susanne Culliton, Deputy Attorney General
Len Leto, Manager, Policy & Planning, State Health Benefits Program
Christine Servis, Chief, Health Benefits Bureau
David Pointer, State Health Benefits Program
Jean Williamson, Policy & Planning, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives

ISSUES

  1. Minutes – Meeting No. 454:  Joseph Reilly made a motion to approve the Minutes and Richard Dougherty seconded the motion. All voted in favor, Michael Malloy abstained.
  2. Local Employers – Entrances and Terminations – Christopher Lowry, Horizon Blue Cross and Blue Shield of NJ gave a presentation on the number of local employers who are entering and terminating. Thirteen local employers joined the SHBP and fifty terminated during 2006. The top reasons for terminations cited are cost savings and flexibility.

Richard Dougherty made a motion to go into Closed Session and Joseph Reilly seconded the motion. All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

Case #060601 (Member was present): This $1,995.56 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for emergency room services. Michael Malloy made a motion to deny this appeal.  Richard Dougherty seconded the motion. All voted in favor.

Case #060602 (Member was present): This Division appeal concerns a request for retroactive health benefit coverage for claims for spouse who did not enroll in Medicare Part B. Joseph Reilly made a motion to go into Executive Session to consult with counsel. Richard Dougherty seconded the motion. All voted in favor. Upon returning the closed session, Joseph Reilly made a motion to table this appeal in order for member to obtain and provide medical documentation of his spouse’s diminished capacity. Member will provide medical documentation to the Social Security Administration for reconsideration of enrollment of his spouse in Medicare Part B. Once a determination is made by the Social Security Administration, the appeal will be brought back before the Commission.  Richard Dougherty seconded the motion. All voted in favor.

Case #06603 (Member was present): This $24,550 Traditional appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for emergency room services.  Joseph Reilly made a motion to deny this appeal recognizing an adjustment of the amount that the Traditional plan will pay for a total of $12,269.00.  Dudley Burge seconded the motion. All voted in favor.

Case #060604 (Member was present): This NJ PLUS appeal is for the denial of benefits for expenses for In-Vitro Fertilization procedures performed for spouse beyond the three attempts limit. Joseph Reilly made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor.

Case #060605: The Commission approved a Final Administrative Determination concerning the denial of payment for weight loss classes. Richard Dougherty made a motion to approve the Final Administrative Determination. Joseph Reilly seconded the motion. All voted in favor.

Case #060606: The Commission agreed to forward this appeal for expenses for an out-of-network provider treating a dependent child. Joseph Reilly made a motion to send the appeal to the OAL for a hearing. Richard Dougherty seconded the motion. All voted in favor.

Case #060607: This is a request for an OAL hearing on an appeal concerning Vagus Nerve Stimulation for the treatment of depression which is considered investigational.  Joseph Reilly made a motion to do a Final Administrative Determination. Richard Dougherty seconded the motion. All voted in favor.

Case #060608: The Deputy Attorney General representing this OAL case requested the Commission authorize a settlement offering in a case involving private duty nursing services. Richard Dougherty made a motion to authorize a settlement offering. Joseph Reilly seconded the motion. All voted in favor.

Case #060609: The Commission approved a settlement proposal from Upper Freehold Regional Board of Education.  Dudley Burge seconded the motion. All voted in favor.

There being no further business to transact, a motion to adjourn was made by Richard Dougherty, seconded by Joseph Reilly and all voted in favor. The State Health Benefits Commission meeting was adjourned at 1:00 pm.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 456
July 12, 2006
AMENDED Minutes 10:00 AM
State Health Benefits Commission

The 456th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:05 AM, Wednesday, July 12, 2006.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Joseph Reilly, representing State Treasurer, Bradley I. Abelow
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Brian Volz, NJEA
Eric Richard, New Jersey State AFL-CIO

Also present:

Frederick Beaver, Director, Division of Pensions & Benefits
Florence Sheppard, Deputy Director, Division of Pensions & Benefits
Susanne Culliton, Deputy Attorney General
Len Leto, Manager, Policy & Planning, State Health Benefits Program
David Pointer, State Health Benefits Program
Jean Williamson, Policy & Planning, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives

ISSUES

1. Minutes – Meeting No. 455:  Michael Malloy made a motion to approve the Minutes and Richard Dougherty seconded the motion. Three voted in favor, Eric Richard and Brian Volz abstained.

The Commission approved the final adoption of NJAC 17:9-6.1 and 17:9-65.3.  Joseph Reilly made a motion to approve the proposed amendment.  Richard Dougherty seconded the motion.  All voted in favor.

Brian Volz made a motion to go into Closed Session and Richard Dougherty seconded the motion.   All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

Case #070601: This $3,025.00 NJ PLUS appeal is for the denial of benefits for expenses for psychological testing services provided to a dependent child.  Joseph Reilly made a motion to table this appeal pending additional information from the provider.  Richard Dougherty seconded the motion.  All voted in favor.

Case #070602: This $2,918.40 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for emergency room services.  Michael Malloy made a motion to deny this appeal.  Joseph Reilly seconded the motion.  All voted in favor.

Case #070603: This $358.58 Traditional Plan appeal concerns a denial of benefits for a Hepatitis B Vaccine administered to a dialysis patient.  Joseph Reilly made a motion to deny this appeal because vaccinations are not covered by the Traditional Plan.  Richard Dougherty seconded the motion.  Four voted in favor.  Michael Malloy voted against.

Case #070604: (Member was present) This $7,030.20 Traditional Plan appeal concerns a denial of benefits for an eight week weight loss program at Duke University Medical Center Diet and Fitness Center.   Eric Richard made a motion to go into executive session.  Joseph Reilly seconded the motion.  All voted in favor.  Richard Dougherty made motion to go back into Closed Session.  Eric Richard seconded the motion.  All voted in favor.  Joseph Reilly made a motion to deny this appeal based on the facts presented in Horizon’s letter of May 11, 2006.  Richard Dougherty seconded the motion.  All voted in favor.

Case #070605: This $3,787.00 Traditional Plan appeal concerns a denial of benefits for expenses for a routine colonoscopy.  Richard Dougherty made a motion to deny this appeal because the Traditional Plan does not cover preventive care/routine screening services.  Joseph Reilly seconded the motion.  All voted in favor.

Case #070606: This $9,000.00 Traditional Plan appeal concerns the denial of benefits for expenses for pre and post operative orthodontic treatment.   Michael Malloy made a motion to deny this appeal.  Joseph Reilly seconded the motion.  All voted in favor.

Case #060707: This $3,715.00 Traditional Plan appeal is for the denial of benefits for expenses for speech therapy.   Michael Malloy made a motion to table this appeal because the member called late in the morning of the meeting indicating she could not be present until 1:00, after the meeting would end.  Brian Volz seconded the motion.  All voted in favor.

Case #060708: The Commission approved a Final Administrative Determination concerning Vagus Nerve Stimulation for the treatment of depression.  Joseph Reilly made a motion to approve the Final Administrative Determination with a change to include additional medical information.  Richard Dougherty seconded the motion.  All voted in favor.

There being no further business to transact, a motion to adjourn was made by Joseph Reilly, seconded by Michael Malloy and all voted in favor.  The State Health Benefits Commission meeting was adjourned at 11:10 am.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 457
August 9, 2006
Minutes 10:00 AM
State Health Benefits Commission

The 457th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:15 AM, Wednesday, August 9, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Robert Smartt, representing State Treasurer, Bradley I. Abelow
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance - AM Session - Appeals
Neil Vance, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance - PM Session - Rate Renewals
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Brian Volz, NJEA
Eric Richard, New Jersey State AFL-CIO

Also Present:

Susanne Culliton, Deputy Attorney General
Len Leto, Manager, Policy & Planning, State Health Benefits Program
David Pointer, State Health Benefits Program
Jean Williamson, Policy & Planning, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives

ISSUES

  1. Minutes - Meeting No. 456:  Michael Malloy made a motion to accept the Minutes with a change to Case#070603 in which he voted no and Richard Dougherty seconded the motion. All voted in favor.
  2. AON Rate Renewal presentation scheduled at 1:00 pm.

Brian Volz made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

Case #080601: This $980 Traditional Plan appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for emergency room services for a dependent child. Michael Malloy made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #080602: This $909 Traditional Plan appeal concerned a denial of benefits for expenses for a routine colonoscopy.  Richard Dougherty made a motion to deny this appeal. Robert Smartt seconded the motion. All voted in favor.

Case #080603 (Member present): This tabled $3,715 Traditional Plan appeal concerns a denial of benefits for speech therapy for a dependent child.  Robert Smartt made a motion to grant this appeal. Brian Volz seconded the motion. Eric Richard voted in favor. Michael Malloy and Richard Dougherty voted no.

Case #080604: This member requested authorization from HealthNet to allow a dependent child to visit an out-of-network provider.  Michael Malloy made a motion to deny this appeal. Eric Richard seconded the motion. All voted in favor

Case #080605: Member requested appeal be referred to OAL for a hearing. Michael Malloy made a motion to forward the case to the OAL. Richard Dougherty seconded the motion. All voted in favor.

Eric Richard made a motion to go into Executive Session. Brian Volz seconded the motion. All voted in favor. Eric Richard made a motion for Susanne Cullition to obtain an AG opinion on whether the alternate designee is privy to the same documents as the designee. Susanne Culliton would check with the DAG office and provide an answer when meeting reconvene at 1:00 pm. Eric Richard made a motion to recess until 1:00 pm. Michael Malloy seconded the motion  All voted in favor.

At 1:00, Brian Volz made a motion to reconvene for the AON Rate Renewal presentation.  Richard Dougherty seconded the motion and all voted in favor.

Eric Richard made a motion to go into Executive Session for response to his question regarding .  Brian Volz seconded the motion.   Susanne Culliton indicated that the Rate Renewal Report is confidential until acted upon by the Commission.

Brian Volz made a motion to go back into Open Public Session.  Richard Dougherty seconded the motion.  All in favor.

AON Representatives Ed Fox and Susan Marsh presented Rate Renewals for 2007 to the Commission.  The following is a summary of the Rate Renewals:

Recommended Plan Year 2007 Rate Renewal for Active
Employees and Retirees of the State Group

  • For Plan Year 2007 for the SHBP medical program (NJ PLUS, Traditional Plan, and Rx), Aon recommends an average premium rate increase of 4.1% for State Active Employees and an average premium rate decrease of 2.6% for  State Retirees, broken down as follows:

    Actives
    Early
    Retirees
    Medicare-Eligible
    Retirees
    NJ PLUS
    7.6%
    -7.4%
    -2.3%
    Traditional Plan
    21.6%
    -0.4%
    -0.3%
    Rx
    -8.1% 
    n/a
    n/a
  • The recommended rate renewal assumes:
    • Increase in office visit copays from $5 to $10 for Retirees in NJ PLUS (State Employee copays are already $10),
    • Implementation of Mandatory Generics and Mandatory Mail-Order Service under the Rx program for all Active Employees and Retirees,
    • Scheduled increases in the Brand Rx copays and the OOP maximum for Retirees, and
    • Duplication of coverage under the SHBP will not be permitted in Plan Year 2007.
  • NJ PLUS capitation charges for MH/SA have exceeded actual claim experience for several years.  For Plan Year 2006, Horizon/Magellan agreed to a risk-share arrangement which shares the savings if actual claims are lower than the capitation, but does not charge the SHBP if claims exceed the capitation.  For Plan Year 2007, the MH/SA capitation is increasing 3.4%.  Horizon/Magellan is only willing to continue the current risk share if the SHBP agrees to share the risk in both directions.  Aon recommends that the SHBP not agree to this, and therefore the risk-share arrangement should be discontinued for Plan Year 2007 and MH/SA claims should be paid on a fee-for-service basis rather than capitation.
  • Traditional Plan enrollment continues to decrease for State Active Employees.  Plans with decreasing enrollment tend to experience higher trend, since they do not have younger, healthier new entrants to offset the impact of an aging population.  The average age of Traditional Plan Active Employee participants is now more than 12 years older than NJ PLUS Active Employee participants.
  • The recommended State Active Employee renewal increases result in Plan Year 2007 Traditional Plan premium rates that are approximately double the Plan Year 2007 NJ PLUS premium rates.  The Traditional Plan continues in an upward assessment spiral.  Since State Employees pay 25% of the premium for the Traditional Plan and 0% of the premium for NJ PLUS, it is expected that Traditional Plan enrollment will continue to decrease in Plan Year 2007, as a result of the recommended 21.6% premium rate increase.
  • Aon recommends that the State Health Benefits Commission consider changes in benefit plan design and contribution formulas for the SHBP.  Consideration should be given to replacing NJ PLUS and the Traditional Plan with a PPO, which would eliminate current differentials in health status between NJ PLUS and the Traditional Plan and move Traditional Plan employees into a plan with better provider discounts and more managed-care protocols.  At the same time, employee contributions should be revised to control the health status selection problems that currently exist among benefit options.
  • The recommended Plan Year 2007 premium rate adjustments for Medicare-Eligible Retirees reflect the anticipated impact of the Medicare Part D Retiree Drug Subsidy ($688 per Medicare-Eligible individual).
Recommended Plan Year 2007 Rate Renewal for Active
Employees and Retirees of the Local Employer Group

  • For Plan Year 2007 for the SHBP Medical Program (NJ PLUS, Traditional Plan, and Rx), Aon recommends a 7.0% average premium rate increase for Active Employees of the Local Employer Group, broken down as follows:
Education
Government
NJ PLUS
  With Rx Plan
4.9%
6.2%
  No Rx Plan
4.9%
6.2%
Traditional Plan
  With Rx Plan
11.7% 
17.1%
  No Rx Plan
11.7% 
17.1%
Prescription Drug Plan
-12.4% 
-12.4% 
  • For Plan Year 2007 for the SHBP Medical Program (NJ PLUS, Traditional Plan, and Rx), Aon recommends a 1.9% average decrease in premium rates for Retirees of the Local Employer Group, broken down as follows:
Education
Government
Early
Medicare
Early
Medicare
NJ PLUS
  -7.9%
-2.8%
-7.9%
-2.8%
Traditional Plan
0.0%
-1.6%
0.0%
  -1.6%
  • The recommended renewal assumes:
    • Increase in office visit copays from $5 to $10 for NJ PLUS (State Employee copays are already $10),
    • Increase Employee Prescription Drug copays to the same level as the State Employees,
    • Implementation of Mandatory Generics and Mandatory Mail-Order Service under the Rx program for all Active Employees and Retirees,
    • Scheduled increases in the Brand Rx copays and the OOP maximum for Retirees, and
    • Duplication of coverage under the SHBP will not be permitted in Plan Year 2007.
  • NJ PLUS capitation charges for MH/SA have exceeded actual claim experience for several years.  For Plan Year 2006, Horizon/Magellan agreed to a risk-share arrangement which shares the savings if actual claims are lower than capitation, but does not charge the SHBP if claims exceed capitation.  For Plan Year 2007, the MH/SA capitation is increasing 3.4%.  Horizon/Magellan is only willing to continue the current risk share if the SHBP agrees to share the risk in both directions.  Aon recommends that the SHBP not agree to this, and therefore the risk-share arrangement should be discontinued for Plan Year 2007 and MH/SA claims should be paid on a fee-for-service basis rather than capitation.
  • Traditional Plan enrollment for Local Employer Active Employees continues to decrease.  Plans with decreasing enrollment tend to experience higher trend, since they do not have younger, healthier new entrants to offset the impact of an aging population.  The average age of Traditional Plan Local Employer Active Employee participants is now about 8 years older than the average age of NJ PLUS Local Employer Active Employee participants.
  • The recommended renewal increases result in Plan Year 2007 Traditional Plan premium rates that are approximately 50% higher than Plan Year 2007 NJ PLUS premium rates for active employees.  The Traditional Plan is in an upward assessment spiral.  Aon recommends that the State Health Benefits Commission consider changes in benefit plan design and contribution formulas.  Consideration should be given to replacing NJ PLUS and the Traditional Plan with a PPO, which would eliminate current differentials in health status between NJ PLUS and the Traditional Plan and move Traditional Plan employees into a plan with better provider discounts and more managed-care protocols.
  • The recommended Plan Year 2007 premium rate adjustments for Medicare-Eligible Retirees reflect the anticipated impact of the Medicare Part D Retiree Drug Subsidy ($688 per Medicare-Eligible individual).
  • Since the projected cumulative surplus target for the Local Employer Group is projected to reach the target level of 2 months of plan costs by the end of Plan Year 2006, there is no margin in the Plan Year 2007 recommended rates and they are projected to result in neither loss nor gain for Plan Year 2007.
Recommended Plan Year 2007 HMO Rate Renewal

  • For Plan Year 2007, Aon recommends an 11.1% average increase in HMO premium rates for Active Employees and Retirees of the State Group and a 4.7% average increase in HMO premium rates for Active Employees and Retirees of the Local Employer Group, broken down as follows:
State
Local Employer
Actives
Early Retirees
Actives
Early Retirees
HMO
       
Aetna 13.6%  13.6%  5.3%  5.3% 
  CIGNA 11.1% 11.1% 4.6% 4.6%
  Oxford 4.6% 4.6% 7.5% 7.5%
  AmeriHealth 10.8% 10.8% 4.6% 0.0%
  Health Net 5.3% 5.3% 3.3% 3.3%
       
Medicare-Eligible Retirees
Medicare-Eligible
Retirees
HMO
   
Aetna
2.6%
  0.0%
CIGNA
  0.0%
  0.0%
Oxford
15.0%
15.0%
AmeriHealth
  0.0%
  0.0%
Health Net
  0.0%
  0.0%
  • As was true for Plan Year 2006, Aon recommends different HMO premium rate increases for the State and Local Employer Groups, due to significant differences in experience.
  • The recommended renewal assumes:
    • Increase in office visit copays from $5 to $10 for the Local Employer Group (State Group copays are already $10),
    • Implementation of Mandatory Generics and Mandatory Mail-Order Service under the Rx program for all Active Employees and Retirees, and
    • Duplication of coverage under the SHBP will not be permitted in Plan Year 2007.
  • The recommended Plan Year 2007 HMO renewal premium rate adjustments for Medicare-Eligible Retirees reflect the anticipated impact of the Medicare Part D Retiree Drug Subsidy ($688 per Medicare-Eligible individual).
  • Since the projected cumulative surplus for the Local Employer Group is projected to reach the target level of 2 months of plan costs by the end of Plan Year 2006, there is no margin in the Plan Year 2007 recommended rates and they are projected to result in neither loss nor gain for Plan Year 2007.
  • MH/SA is capitated under some SHBP HMOs and on a discounted fee-for-service arrangement under others.  Aetna changed from capitation to discounted fee-for-service on 1/1/2006.  CIGNA has proposed moving from capitation to discounted fee-for-service for Plan Year 2007 and Aon recommends that the SHBP make this change.  This eliminates an otherwise required rate increase of 1.7% and should save the SHBP approximately $2 million in Plan Year 2007.
Recommended Plan Year 2007 Dental Plan Rate Renewal

  • For the SHBP Dental Plans, Aon recommends the following premium rate adjustments for both the State and Local Employer Groups for Plan Year 2007:
Actives
Retirees
 
Dental Expense Plans
0.0%
17.0%
 
Dental Plan Organizations (DPOs)
Aetna
2.5%
  n/a
Assurant
0.0%
  n/a
BeneCare
0.0%
  n/a
CIGNA
0.0%
  n/a
Community Dental Associates
0.0%
  n/a
Dental Group of New Jersey
0.0%
  n/a
Flagship
0.0%
  n/a
Group Dental Health Admin.
0.0%
  n/a
Healthplex
0.0%
n/a
Horizon
-5.3%
  n/a
  • The recommended Plan Year 2007 renewal premium rate adjustments assume no changes in benefit plan design or the number of DPOs offered.  However, Aon is recommending that the number of DPOs offered be reduced by at least 3 plans for Plan Year 2008.
  • The recommended DPO renewal assumes that DPO service areas will be expanded into New York and Pennsylvania by DPOs that have networks available in those locations. 
  • The Plan Year 2007 renewal assumes that Dental Expense Plan enrollment will grow by 5.2% in Plan Year 2007 and the DPO enrollment will decrease by 0.5%.
  • The recommended Plan Year 2007 renewal premium rate increase for the Retiree Dental Expense Plan includes a 2% margin, due to the unfavorable experience thus far in Plan Years 2005 and 2006 to date.  The margin is also necessary due to the uncertainty of how utilization will change as the Plan matures beyond the initial 2 years of existence.  Also, 90% of the enrollment will be at the Tier 3 benefit level in Plan Year 2007, compared to 48% in Plan Year 2006.

Eric Richard made a motion to permit public testimony at the rate renewal meeting next week.  He left it up to the Division to decide how many people could testify and for how long.  Brian Volz seconded the motion, and all voted in favor.

There being no further business to transact, a motion to adjourn was made by Robert Smartt, seconded by Richard Dougherty and all voted in favor.  The State Health Benefits Commission meeting was adjourned at 3:40 pm.

Respectfully Submitted,

 

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 458
August 22, 2006
Minutes 10:00 AM
State Health Benefits Commission

The 458th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:05 AM, Tuesday, August 22, 2006.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Joseph Reilly, representing State Treasurer, Bradley I. Abelow
Neil Vance, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance - PM Session - Rate Renewals
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Kevin Kelleher, NJEA
Eric Richard, New Jersey State AFL-CIO

Also Present:

Susanne Culliton, Deputy Attorney General
Carol O’Cleireacain, Deputy State Treasurer
Frederick J. Beaver, Director, Division of Pensions and Benefits
Florence Sheppard, Deputy Director, Division of Pensions and Benefits
Janice Nelson, Assistant Director, Division of Pensions and Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Program
David Pointer, State Health Benefits Program
Jean Williamson, Policy & Planning, State Health Benefits Program

The meeting was an open session to hear comments from the public regarding rate renewals for 2007.  Joseph Reilly gave an opening statement concerning some rules to follow.  Janice Nelson gave an overview of the proposed rule changes, copayments and change to the out-of-pocket maximum for retirees in the Traditional plan and NJ PLUS.  Eric Richard thanked the Administration for providing an opportunity for public comments to be presented.

The following eighteen speakers made comments before the Commission:

Name

Affiliation

Joyce Powell

NJEA

William Dressell

League of Municipalities

Fred Aug

NJREA

Richard Klockner

NJPSA

Joseph Golowski

CWA – State Retiree

Laurie Clark

NJ Pharmacists Association

Regina Benjamin

National Community Pharmacists Association

Pat Stetler

CWA Local 1033

Rae Roeder

President, CWA Local 1033

Lisa Ciccone

Local 195 IFPTE

Carlo Benedetti

Independent Pharmacist

John Holub

NJ Council of Chain Drug Stores

Sam Ferraino

UFCW

Steve Young

AFT

Cathy Chin

NJ Association of Long Term Care Pharmacy Providers

Paul Pologruto

Treasurer, CWA

Bob Pursell

CWA

Tom Tevlin

NJ State Firemen’s Mutual Benevolent Association

Joseph Reilly asked if anyone else wished to make comments. There was no response. Joseph Reilly made a motion to adjourn, seconded by Richard Dougherty and all voted in favor. The State Health Benefits Commission meeting was adjourned at 1:30 pm.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 459
September 5, 2006
Minutes 2:00 PM
State Health Benefits Commission

The 459th meeting of the State Health Benefits Commission of New Jersey was called to order at 2:15 PM, Tuesday, September 5, 2006. The meeting was held at the State House Annex, Committee Room 4, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Joseph Reilly, representing State Treasurer, Bradley I. Abelow
Neil Vance, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Brian Volz, NJEA
Eric Richard, New Jersey State AFL-CIO

Also Present:

Susanne Culliton, Deputy Attorney General
Carol O’Cleireacain, Deputy State Treasurer
Frederick J. Beaver, Director, Division of Pensions and Benefits
Florence Sheppard, Deputy Director, Division of Pensions and Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Program
David Pointer, State Health Benefits Program
Jean Williamson, Policy & Planning, State Health Benefits Program

The special meeting was held in open session to vote on rate renewals.

  • Mandatory Utilization of Mail Order and Generic Drugs
    • Joseph Reilly made a motion that this issue be tabled until January 2007, Richard Dougherty seconded the motion and all voted in favor.
  • Restoration of Uniformity Provisions for Local Employer Participants and Retirees
    • Joseph Reilly made a motion to require the co-payments for office visits and prescription drugs be applied to all plan participants on the same basis as applied to State employees, Richard Dougherty seconded the motion; three voted in favor and two opposed.
  • Neil Vance made a motion to approve publication of a proposed rule change relating to the issue of local employers’ ability to negotiate dependent cost sharing; Richard Dougherty seconded the motion; three voted in favor and two opposed.
  • Joseph Reilly made a motion to approve publication of a proposed rule change to eliminate duplicate coverage.  Richard Dougherty seconded the motion.  Three voted in favor, one opposed and one abstained.
    • Brian Volz asked Deputy Attorney General Susan Culliton to research statutory authority of the proposed rule changes.  DAG Culliton asked that he put such a request in writing and send it to her via the Acting Secretary of the Commission.
  • Eric Richard asked for a brief explanation of the impact of the withdrawal of the generic mandatory and mail order on the rates.  Susan Marsh, Aon Consulting, responded that of the one percent of the total cost, or $34 million, approximately one third, or $11 million corresponds to the mail order component and two thirds, or $23 million, corresponds to the generic component.
  • Joseph Reilly made a motion to adopt the Plan Year 2007 Rate Renewal Recommendations submitted by Aon Consulting.  Eric Richard seconded the motion; all voted in favor.

Joseph Reilly made a motion to adjourn, Richard Dougherty seconded the motion and all voted in favor. The State Health Benefits Commission meeting was adjourned at 2:45 pm.

Respectfully Submitted,

 

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 460
September 13, 2006
Minutes 10:00 AM
State Health Benefits Commission

The 460th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:20 AM, Wednesday, September 13, 2006.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Joseph Reilly, representing State Treasurer, Bradley I. Abelow
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Brian Volz, NJEA
Dudley Burdge, New Jersey State AFL-CIO

Also present:

Frederick Beaver, Director
Florence Sheppard, Deputy Director
Susanne Culliton, Deputy Attorney General
Leonard Leto, Manager, Policy & Planning, State Health Benefits Program
David Pointer, State Health Benefits Program
Jean Williamson, Policy & Planning, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives

ISSUES

  1. Revised Minutes – Meeting No.455, June 14, 2006. Richard Dougherty made a motion to accept the Minutes with changes and Joseph Rielly seconded the motion. Brian Volz and Dudley Burdge abstained.
  1. Meeting No. 457, August 9, 2006. Richard Dougherty made a motion to accept the Minutes and Brian Volz seconded the motion.  Four voted in favor.  Joseph Reilly abstained.
  1. Meeting No.458, August 22, 2006. Richard Dougherty made a motion to accept the Minutes and Joseph Reilly seconded the motion. Three voted in favor and two abstained.
  1. Meeting No 459, September 5, 2006. Richard Dougherty made a motion to accept the Minutes and Brian Volz seconded the motion. Four voted in favor and one abstained.

Joseph Reilly made a motion to go into Closed Session and Richard Dougherty seconded the motion.   All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

Case #090601 (Member was present): This Aetna Dental Expense Plan appeal concerns a denial of benefits for replacement crowns in less than a five year period.  Michael Malloy made a motion to deny this appeal and subsequently withdrew his motion.  Richard Dougherty made a motion to table this case until additional information is provided.  Dudley Burdge seconded the motion.  Three voted in favor.  Joseph Reilly and Brian Volz abstained.

Case #090602: This tabled Division appeal concerns a request for retroactive health benefits coverage for claims for a member who did not enroll in Medicare Part B timely.   Joseph Reilly made a motion to approve this appeal retroactive to May 1, 2006 for member due to proof of diminished capacity from a physician and the Social Security Administration’s retroactive enrollment of member.  Richard Dougherty seconded the motion.  All voted in favor.

Case #090603 (Member present): This $3,715 Traditional Plan appeal concerns a denial of benefits for speech therapy for a dependent child.  Joseph Reilly made a motion to go into Executive Session to consult with counsel in order to reconsider the decision of August 9, 2006.  Brian Volz seconded the motion.  Joseph Reilly made a motion to go back into Closed Session.  Brian Volz seconded the motion.  All voted in favor.  Joseph Reilly made a motion to deny this appeal on the basis that speech therapy is not restorative and is not covered under the SHBP.  Richard Dougherty seconded the motion.  Four voted in favor and one opposed.

Case #090604: Member requested that case concerning a denial of expenses for a Hepatitis B Vaccine be referred to the OAL for a hearing.  Joseph Reilly made a motion to deny this request and to do a Final Administrative Determination.  Richard Dougherty seconded the motion.  All voted in favor.

Case #090605: Member requested that case concerning pre and post operative orthodontic treatment be forwarded to the OAL for a hearing.  Joseph Reilly Dougherty made a motion to deny this request and to do a Final Administrative Determination.  Richard Dougherty seconded the motion.  All voted in favor.

There being no further business to transact, a motion to adjourn was made by Richard Dougherty, seconded by Joseph Reilly and all voted in favor.  The State Health Benefits Commission meeting was adjourned at 12:45 pm.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 461
October 11, 2006
Minutes 10:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:30 AM, Wednesday, October 11, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

Roll Call

Joseph Reilly, representing State Treasurer, Bradley I. Abelow
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Brian Volz, NJEA
Dudley Burdge, New Jersey State AFL-CIO

Also present:

Susanne Culliton, Deputy Attorney General
Len Leto, Manager, Policy & Planning, State Health Benefits Program
David Pointer, State Health Benefits Program
Jean Williamson, Policy & Planning, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives

Issues

  1. Minutes – Meeting No.460, September 13, 2006. Richard Dougherty made a motion to accept the Minutes with changes and Joseph Reilly seconded the motion. All voted in favor.
  1. NJAC 17:9-13. – Provides coverage for dependents between the ages of 23 and 30.  Joseph Reilly made a motion to publish the proposed regulation in the NJ Register for public comment with qualification that coverage will be effective the first coverage period of the month 60 days after the Active or Retired dependent meets all eligibility criteria.  In the event that a subscriber does not submit an enrollment application to the Division within 30 days after the dependent meets all eligibility criteria, the Active or Retired subscriber can only enroll the dependent during the annual October open enrollment period for an effective date the first coverage period in January.  Michael Malloy seconded the motion.  All voted in favor.

Joseph Reilly made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session.

Case #100601(Member present) This $2,975 NJ PLUS appeal concerns a denial of benefits for expenses for physical therapy for child. Joseph Reilly made a motion to permit physical therapy for the child outside of the Botox injections with the caveat that physical therapy unrelated to Botox injections would continue to be subject to review by Horizon Blue Cross and Blue Shield to ensure that such physical therapy is not determined to be an exclusion under the maintenance and supportive care provision of the plan. Michael Malloy seconded the motion. All voted in favor.

Case #100602 – This $3,438.10 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for emergency room services.  Joseph Reilly made a motion to deny this appeal.  Michael Malloy seconded the motion.  All voted in favor.

Case #100603 – Joseph Reilly made a motion to issue a Final Administration Determination for denial of benefits for a Hepatitis B vaccine for spouse.  Richard Dougherty seconded the motion.  All voted in favor.

Case #100604 – Joseph Reilly made a motion to approve the Final Administration Determination for denial of benefits for expenses for pre and post operative orthodontic treatment rendered to daughter.  Richard Dougherty seconded the motion.  All voted in favor.

Case #100605 – Joseph Reilly made a motion for the Commission to accept Administrative Law Judge, Bruce M. Gorman’s decision.  Richard Dougherty seconded the motion.  Joseph Reilly, Michael Malloy and Richard Dougherty voted in favor.  Dudley Burdge abstained and Brian Volz voted against the motion. 

There being no further business to transact, a motion to adjourn was made by Joseph Reilly, seconded by Richard Dougherty and all voted in favor. The State Health Benefits Commission meeting was adjourned at 12:45 pm.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 462
December 13, 2006
Revised Minutes 10:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:05 AM, Wednesday, December 13, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

Roll Call

Susanne Culliton, representing State Treasurer, Bradley I. Abelow
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Brian Volz, NJEA
Dudley Burdge, New Jersey State AFL-CIO

Also present:

Eileen Den Bleyker, Deputy Attorney General
Fred Beaver, Director, Division of Pensions and Benefits
Florence Sheppard, Deputy Director
Len Leto, Manager, Policy & Planning, State Health Benefits Program
David Pointer, State Health Benefits Program
Jean Williamson, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives

Issues

  1. Minutes – Meeting No.461, October 13, 2006. Richard Dougherty made a motion to accept the Minutes with a correction to a typographical error (spelling of Joseph) and Brian Volz seconded the motion. All voted in favor.
  1. Dental Plan Organization Dental Plans – Michael Malloy made a motion to approve CDT-2007 Code Changes and Richard Dougherty seconded the motion. All voted in favor.
  1. Health Insurance Portability and Accountability Act – Susanne Culliton made a motion to go into executive session to consult with counsel. Richard Dougherty seconded the motion. All voted in favor.  Richard Dougherty made a motion to approve filing an exemption from the HIPAA mental health parity requirements for the Traditional Plan and NJ PLUS.  Susanne Culliton seconded the motion.  Three voted in favor.  Brian Volz and Dudley Burge abstained.
  1. 2007 SHBC Meeting Dates – Richard Dougherty made a motion for the Commission to accept the 2007 meeting schedule.  Michael Malloy seconded the motion. All voted in favor.
  1. AON – Susanne Culliton made a motion to accept the AON recommendation to go back to a capitation arrangement (without the risk-share) with Horizon/Magellan for NJ PLUS Mental Health/Substance Abuse claims.  Richard Dougherty seconded the motion. All in voted in favor.

Brian Volz made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor.

The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in closed session.

Case #120601– (Member present) This Traditional Plan appeal concerns a denial of benefits for expenses for the prescription drug, Butorphanol (Stadol). Richard Dougherty made a motion to deny this appeal.  Susanne Culliton seconded the motion.  Four voted in favor. Michael Malloy abstained.

Case #120602 – (Member present) This $8,600 Traditional Plan appeal concerns a denial of benefits for expenses for a surgical procedure performed that was considered investigational. Susanne Culliton made a motion to table this appeal until the February meeting. Brian Volz seconded the motion. All voted in favor.

Case #120603 – This $8,777.20 NJ PLUS appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery. Michael Malloy made a motion to deny this appeal. Susanne Culliton seconded the motion. All voted in favor.

Case #120604 (Member Present) This tabled Aetna Dental Expense Plan appeal concerns a denial of benefits for replacement crowns in less than a five year period. Susanne Culliton made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor.

Case #120605 – Susanne Culliton made a motion to do a Final Administrative Determination (FAD) and deny the appeal be sent to OAL. Richard Dougherty seconded the motion. Four voted in favor. Dudley Burdge voted against. 

There being no further business to transact, a motion to adjourn was made by Richard Dougherty, seconded by Susanne Culliton and all voted in favor. The State Health Benefits Commission meeting was adjourned at 12:50 pm.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission

 

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