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Health Benefit Commission Meeting Minutes 2007

The State Health Benefits Commission held a SPECIAL MEETING at 10:00 a.m. on Monday, November 19, 2007, at Thomas Edison State College, Prudence Hall, 101 West State Street, Trenton, NJ  08608. (Final Evaluation Committee Report and Exhibits)

A SPECIAL MEETING of the New Jersey State Health Benefits Commission was held on JULY 26, 2007 at 1:00 P.M., Division of Pensions and Benefits, First Floor Board Room, 50 West State Street, Trenton, New Jersey 08625-0295.

GASB 43 Report - State of New Jersey Postemployment Benefits Other Than Pension,
Actuarial Valuation - July 1, 2006
(PDF)


   
*Both the February 14, 2007 State Health Benefits Commission Meeting and the March 14, 2007 State Health Benefits Commission Meeting were cancelled; the March 6, 2007 meeting was scheduled to replace the cancelled meetings.

To view 2006 Health Benefit Commission Meeting Minutes (and prior years), click here.


Meeting No. 463
January 10, 2007
Minutes 10:00 AM
State Health Benefits Commission

The 463rd meeting of the State Health Benefits Commission of New Jersey was called to order at 10:10 AM, Wednesday, January 10, 2007. 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
Eric Richard, New Jersey State AFL-CIO

ALSO PRESENT

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

ISSUES

  1. Minutes – Meeting No.462, December 13, 2006. Brian Volz made a motion to accept the Minutes with a correction to a typographical error (Case #120604) should say “in closed session”. Richard Dougherty seconded the motion. Four voted in favor. Eric Richard abstained.
  2. Resolutions A (Go into Closed Session) and B (Go into Executive Session) - (Resolutions A and B are below ).  Susanne Culliton made a motion to go into executive session to discuss the Resolutions. Richard Dougherty seconded the motion. All voted in favor. The Commission returned from Executive Session and Richard Dougherty made a motion to adopt Resolutions A and B as standard resolutions. Michael Malloy seconded the motion. All voted in favor.

Susanne Culliton made a motion to go into Closed Session under Resolution A and Michael Malloy 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 #010701: This $250 Traditional Plan appeal concerns a denial of benefits for expenses for a comprehensive breast thermogram performed on June 27, 2006. Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #010702 - (Member Present): This NJ PLUS appeal concerns a denial of benefits for continued occupational therapy and physical therapies. Susanne Culliton made a motion to table this appeal until they receive the Appellate Decision on other similar cases. Richard Dougherty seconded the motion.  All voted in favor.

Case #010703: This Traditional Plan appeal concerns a denial of benefits for expenses for a work-related injury. Richard Dougherty made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor.

Case #010704: This $4,807.80 Traditional Plan appeal concerns a denial of benefits for expenses for services provided by a Registered Nurse First Assistant (RNFA) on January 17, 2006. Richard Dougherty made a motion to deny this appeal.  Michael Malloy seconded the motion. All voted in favor.

Case #010705: This NJ PLUS appeal is for the denial of benefits for expenses for speech therapy.  Michael Malloy made a motion to deny this appeal. Susanne Culliton seconded the motion. All voted in favor.

Case #010706: This Atlantic Southern (Benecare) 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. Richard Dougherty seconded the motion.  All voted in favor.

Case #010707: This Traditional Plan appeal concerns a denial of benefits for expenses for Viagra/Cialis beyond four Viagra/Cialis pills per month /twelve pills in a 90-day period. Susanne Culliton made a motion to deny this appeal.  Richard Dougherty seconded the motion. All voted in favor.

Case #010708: Richard Dougherty made a motion to approve the Final Administrative Determination (FAD). Michael Malloy seconded the motion. Four voted in favor. Susanne Culliton abstained.

The Commission returned to open session. There being no further business to transact, a motion to adjourn was made by Susanne Culliton, seconded by Richard Dougherty and all voted in favor. The State Health Benefits Commission meeting was adjourned at 12:55 pm.

Respectfully Submitted,

 

Jean M. Williamson
Acting Secretary
State Health Benefits Commission

****************************************************

RESOLUTION A

RESOLUTION TO GO INTO CLOSED SESSION
TO CONSIDER MEMBERS’ HEALTH BENEFITS APPEAL

In accordance with the provisions of the Open Public Meetings Act, N.J.S.A. 10:4-13, be it resolved that the State Health Benefits Commission go into closed session for purposes of discussing matters pertaining to benefits provided under the State Health Benefits Program which involves material involving personal medical and health records, data, reports and recommendations relating to specific individuals, pursuant to N.J.S.A. 10:4-12(3), and includes Protected Health Information maintained as confidential under the federal Health Insurance Portability and Accountability Act (HIPAA).

The actions taken during closed session are anticipated to become available to the public at the conclusion of the meeting and are posted on the Division of Pensions and Benefits’ website within a reasonable time; except all personal information pertaining to an individual shall be redacted or all identifying information unless the member waives his privacy interest and consents in writing to disclosure in accord with HIPAA.

RESOLUTION B

RESOLUTION TO GO INTO EXECUTIVE SESSION
TO REQUEST/RECEIVE ATTORNEY-CLIENT ADVICE FROM THE DEPUTY ATTORNEY GENERAL

“In accordance with the provisions of the Open Public Meetings Act, N.J.S.A. 10:4-13, be it resolved that the State Health Benefits Commission go into closed (executive) session to discuss matters falling within the attorney client privilege, and/or matter in which litigation is pending or anticipated, pursuant to N.J.S.A. 10:4-12(7).

The minutes of such meeting shall remain confidential until after such time as the Board determines that the need of confidentiality no longer exists and the matters discussed can be disclosed and the Board waives the attorney-client privilege.”


Meeting No. 464
March 6, 2007
Minutes 10:00 AM
State Health Benefits Commission

The 464th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:10 AM, Tuesday, March 6, 2007.  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
Gale Simon, 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

Eileen Den Bleyker, Deputy Attorney General
Florence Sheppard, Deputy Director, Division of Pensions and Benefits
David Pointer, Chief, Operations, State Health Benefits Program
Jean Williamson, Acting Secretary
Horizon Blue Cross Blue Shield of NJ Representatives

ISSUES

  1. Minutes – Meeting No.463, January 10, 2007.  Susanne Culliton made a motion to accept the Minutes.  Richard Dougherty seconded the motion.  All voted in favor.
  2. Richard Dougherty made a motion to approve the Amerihealth Network Access Fee.  Susanne Culliton seconded the motion.  All voted in favor.

Gale Simon made a motion to go into Closed Session under Resolution A 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 #030701: This $16,087.50 NJ PLUS appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery.  Susanne Culliton made a motion to deny this appeal.  Richard Dougherty seconded the motion.  All voted in favor.

Case #030702: This Division appeal concerns a request for a partial refund of one month’s premium due to his mother’s death while enrolled as a retiree in the State Health Benefits Program (SHBP) retired group.  Susanne Culliton made a motion to deny this appeal.  Richard Dougherty seconded the motion.  All voted in favor.

Case #030703: This $4,300 Traditional Plan appeal concerns a denial of benefits for expenses for dental services deemed ineligible for reimbursement. Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion.  All voted in favor.

Case #030704 - (Member Present): This tabled $8,600 appeal concerns a denial of benefits for expenses for a surgical procedure performed that was deemed investigationalSusanne Culliton made a motion to go into executive session under Resolution B to seek advise from counsel.  Eric Richard seconded the motion and all voted in favor.  Upon returning from executive session, Richard Dougherty made a motion to deny this appeal.  Susanne Culliton seconded the motion.  All voted in favor.

Case #030705: The Commission had denied this appeal for expenses for the payment of claims for injuries determined to be work related at the January 10, 2007 meeting.  Member has requested that the appeal be forwarded to OAL for a hearing.  Susanne Culliton made a motion to issue a Final Administrative Determination (FAD).  Richard Dougherty seconded the motion.  All voted in favor.

Case #030706: The Commission denied this appeal for a pre-authorization of speech therapy at the January 10, 2007 Meeting.  Member has requested that the appeal be forwarded to OAL for a hearing.  Richard Dougherty made a motion to issue a Final Administration Determination (FAD). Gale Simon seconded the motion.  All voted in favor.

Case #030707: Richard Dougherty made a motion to reject a settlement regarding denial of benefits for expenses for a neonatologist.  The settlement was for $481, half of the disputed claim amount.  Susanne Culliton seconded the motion.  Four voted in favor and Gale Simon abstained.

Case #030708: Susanne Culliton made a motion to accept the OAL decision concerning private duty nursing.  Eric Richard seconded the motion.  All voted in favor.

Case #030709: Susanne Culliton made a motion to accept the Appellate Decision.  Richard Dougherty seconded the motion.  All voted in favor.

Case #0307010: Eileen Den Bleyker was recused from this case. Jeff Ignatowitz joined the meeting as the DAG for this case.  Susanne Culliton made a motion to accept the Appellate Decision.  Richard Dougherty seconded the motion.  All voted in favor.

Case #0307011: Susanne Culliton made a motion to accept the Appellate Decision.  Richard Dougherty seconded the motion.  All voted in favor.

Susanne Culliton made a motion to return to open session.  It was seconded by Brian Volz and all voted in favor.

  Susanne distributed Financial Disclosure forms to the Commission members.  A couple of the members asked Eileen Den Bleyker if they needed to complete the forms since they had already done so in a different capacity.  Ms. Den Bleyker will be giving the Commission written advice.

There being no further business to transact, a motion to adjourn was made by Susanne Culliton, seconded by Richard Dougherty and all voted in favor.  The State Health Benefits Commission meeting was adjourned at 11:30 am.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 465
April 11, 2007
Minutes 10:00 AM — Revised
State Health Benefits Commission

The 465th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:07 AM, Wednesday, April 11, 2007. 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

*Michelline Davis, representing State Treasurer, Bradley I. Abelow
*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
Eric Richard, New Jersey State AFL-CIO
*Ms. Davis chaired the first portion of the meeting concerning a request to release a Request for Proposal (RFP); Ms. Culliton chaired the remainder of the meeting.

ALSO PRESENT:

Eileen Den Bleyker, Deputy Attorney General
Jeff Ignatowitz, Deputy Attorney General
Florence Sheppard, Deputy Director, Division of Pensions and Benefits
David Pointer, Chief, Operations, State Health Benefits Program
Jean Williamson, Acting Secretary
Horizon Blue Cross Blue Shield of NJ Representatives
Cigna Representatives
Aetna Representatives
Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

ISSUES

  1. Michellene Davis made a motion under Resolution B to go into Executive Session, to discuss a request to allow the release of Request for Proposals (RFP). Richard Dougherty seconded and all voted in favor. DAG Den Bleyker clarified that the executive session motion was also to discuss contract negotiations which is also permitted under the same section N.J.S.A. 10:4-12(7). The Commission returned from Executive Session to Open Session and Michael Malloy made a motion to allow a release of the RFP for a new Participating Provider Organization (PPO) and Health Maintenance Organization (HMO) Contract(s). Richard Dougherty seconded the motion. Three voted in favor. Eric Richard and Brian Voltz abstained.
  2. Minutes – Meeting No.464, March 6, 2007. Richard Dougherty made a motion to accept the Minutes. Susanne Culliton seconded the motion. Four voted in favor and Michael Malloy abstained.

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

Case #040701: The Division appeal concerns a request to retroactively add a child to coverage at the time of birth.  Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #040702: (Member Present) This Division appeal concerns a request to allow widow of a State Health Benefits Program (SHBP) active ABP employee to continue SHBP coverage as a surviving spouse following the employee’s death. Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion. Four voted in favor. Brian Voltz abstained.

Case #040703: This $4,225.85 Traditional Plan appeal concerns a denial of benefits for expenses for unpaid claims for intravenous infusion therapy for the member.  Susanne Culliton made a motion to deny this appeal. Michael Malloy seconded the motion.  All voted in favor.

Case #040704: This $4,666.73 Traditional Plan appeal concerns a denial of benefits for expenses above reasonable and customary allowance for surgery and anesthesia services.Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #040705 (Member Present): This Aetna appeal concerns a request for reimbursement for Somatropin Injections (Growth Hormone therapy) for member’s son. Richard Dougherty made a motion deny this appeal. Susanne Culliton seconded the motion. All voted in favor. 

Case #040706 (CIGNA Representatives Present): This CIGNA appeal concerns a denial of benefits for a proposed surgical procedure, an abdominoplasty. Susanne Culliton made a motion to table this request since additional information was needed for CIGNA to make a determination. Richard Dougherty seconded the motion. All voted in favor.

Case #040707: This Traditional Plan appeal concerns a request to continue coverage for his overage disabled dependent.  Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #040708: The OAL case was withdrawn following additional review by Oxford.

Case #040709: A settlement offer was reviewed by the Commission on an OAL case. Susanne Culliton made a motion to accept the settlement, Eric Richard seconded it and all voted in favor.

Case #040710: Susanne Culliton made a motion to approve the draft letter of Final Administrative Determination.  Michael Malloy seconded the motion. All voted in favor.

Case #040711: Susanne Culliton made a motion to approve the draft letter of Final Administrative Determination. Michael Malloy seconded the motion. All voted in favor.

Case #040712: The Commission voted to deny this appeal for expenses for the prescription medication Cialis/Viagra at the January 10, 2007 Meeting. Member requested that the appeal be forwarded to OAL for a hearing. Susanne Culliton made a motion to issue a Final Administration Determination (FAD). Michael Malloy seconded the motion. All voted in favor.

There being no further business to transact, a motion was made to return to open session by Susanne Culliton, seconded by Richard Dougherty. All voted in favor. Then there was a motion to adjourn which was made by Susanne Culliton, seconded by Brian Volz and all voted in favor. The State Health Benefits Commission meeting was adjourned at 11:50.

Respectfully Submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 466
May 9 , 2007
Minutes 10:00 AM
State Health Benefits Commission

The 466th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:02 AM, Wednesday, May 9, 2007. 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
Eric Richard, New Jersey State AFL-CIO

ALSO PRESENT

Eileen Den Bleyker, Deputy Attorney General
Frederick Beaver, Director, Division of Pensions and Benefits
Len Leto, Manager, Policy & Planning, State Health Benefits Unit
David Pointer, Chief, Operations, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives

Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

ISSUES

  1.  Minutes - Meeting No.465, April 11, 2007. Correction was made to the minutes on page 2, Issues as follows,
    1. Michellene Davis made a motion under Resolution B to go into Executive Session, to discuss allowing the release of Request for Proposals (RFP). Richard Dougherty seconded and all voted in favor. DAG Den Bleyker clarified that the executive session motion was also to discuss contract negotiations which is also permitted under same section N.J.S.A. 10:4-12(7). Richard Dougherty made a motion to accept the Minutes.  Brian Volz 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 #050901: This Horizon Dental appeal concerns unpaid claims of a non-participating dentist. Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #050902: This Division appeal concerns an effective date of termination from the State Health Benefits Program (SHBP). Susanne Culliton made a motion to postpone case until June 13, 2007 Commission Meeting where as it will be heard. Richard Dougherty seconded the motion. All voted in favor.

Case #050903: This Traditional Plan appeal concerns denial of benefits for Optifest. Susanne Culliton made a motion to postpone case until June 13, 2007 Commission Meeting. Brian Volz seconded the motion. All voted in favor.

Case #050904: Reconsideration of Final Administrative Decision. Susanne Culliton made a motion to forward appeal to OAL. Richard Dougherty seconded the motion. All voted in favor.

Case #050905: Settlement Proposal was reviewed by the Commission. Michael Malloy made a motion to modify proposal to include a condition that no future payments would be made, Susanne Culliton seconded it and all voted in favor.

Case #050906: Final Administrative Determination - Susanne Culliton made a motion to accept FAD. Richard Dougherty seconded the motion. All voted in favor.

Case #050907: Amount above the R&C for Surgery. Susanne Culliton motion to forward appeal to OAL. Brian Volz seconded the motion. All voted in favor.

Case #050908: Denial of benefits for expenses for Surgery deemed investigational. Susanne Culliton motion to forward appeal to OAL.  Michael Malloy seconded the motion.  All voted in favor.

Case #050909: Denial of Benefits for expenses determined to be dental in nature. 
Susanne Culliton motion to issue Final Administrative Decision. Richard Dougherty seconded the motion.  All voted in favor.

There being no further business to transact, a motion was made to return to open session by Susanne Culliton, seconded by Richard Dougherty. All voted in favor.

Then there was a motion to adjourn which was made by Richard Dougherty, seconded by Susanne Culliton and all voted in favor. The State Health Benefits Commission meeting was adjourned at 11:10.

Respectfully Submitted,

Mary Ann Ryan
Acting Secretary
State Health Benefits Commission


Meeting No. 467
June 13, 2007
Minutes 10:30 AM
State Health Benefits Commission

The 467th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:35 AM, Wednesday, June 13, 2007. 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 Schlindwein Den Bleyker , Deputy Attorney General
Lewis A. Scheindlin, Assistant Attorney General
Frederick J. Beaver, Director, Division of Pensions and Benefits
Florence J. Sheppard, Deputy Director, Division of Pensions and Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Unit
David Pointer, Chief, Operations, State Health Benefits Program
Jean Williamson, Acting Secretary
Horizon Blue Cross Blue Shield of NJ Representatives
Aetna Representatives

Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

ISSUES

  1.  Minutes - Meeting No. 466, May 9, 2007. Richard Dougherty made a motion to accept the Minutes.  Susanne Culliton seconded the motion.  Four voted in favor and Dudley Burdge abstained.
  2. Co-Payment Changes:  Susanne Culliton made a motion under Resolution B to go into Executive Session, to discuss Co-Payment Changes. Brian Volz seconded the motion. All voted in favor.  Susanne Culliton made a motion to go back into Open Session. Richard Dougherty seconded the motion. All voted in favor. Dudley Burdge made a motion to approve the Recommendations with the following changes:  (1) Correct the typographical error in the next to the last paragraph concerning Mail Order to read $40 brand name with a generic equivalent available and (2) change the last paragraph to read: Members who are medically unable to take a generic equivalent will be permitted to pay at the second tier level. Michael Malloy seconded the motion. Three voted in favor.  Richard Dougherty and Susanne Culliton opposed.

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

Susanne Culliton made a motion to go into closed session (Resolution A).  Richard Dougherty seconded the motion.  All voted in favor.

Case #061301: This Aetna dental appeal concerns the denial of payment for a second set of X-rays which were taken within a 36 month interval. Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #061302 (Member Present): This Aetna medical appeal concerns denial of reimbursement for in-patient treatment beyond 35 days per benefit year for an eating disorder. Dr. Friedlander, a Medical Director with Aetna, gave a detailed presentation explaining the definition of biologically-based mental illness (BBMI) and explained that an eating disorder is not considered to be eligible under the BBMI law. Furthermore, he explained how the statement in the law “including, but not limited to, schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, paranoia and other psychotic disorders, obsessive-compulsive disorder, panic disorder and pervasive developmental disorder or autism” is interpreted as including surrounding diagnosis related to the specific disease areas listed in the law. An example is atypical mood disorder.   Brian Volz made a motion under Resolution B to go into Executive Session. Susanne Colliton seconded the motion. All voted in favor. Brian Volz made a motion to return to closed session. Richard Dougherty seconded the motion.  All voted in favor. Michael Malloy made a motion to deny this appeal.  Susanne Culliton seconded the motion.  All voted in favor.

Case #061303: Workers Compensation Settlement - Susanne Culliton made a motion to table this case pending additional information from Horizon. Richard Dougherty seconded the motion. All voted in favor.
 
Case #061304 (Member was present but left before case was heard): This Horizon NJ PLUS appeal concerns the denial of pre-authorization for occupational therapy visits for feeding therapy. Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #061305 (Local Employer representative present): This Division appeal concerns an effective date of termination from the State Health Benefits Program (SHBP) for a Local Employer. Michael Malloy recused himself from this case because the representative of the location was a former employee of the DOBI. Brian Volz made a motion to go into open session.  Dudley Burdge seconded the motion. All voted in favor. The Local Employer submitted a resolution for termination from the SHBP on January 9, 2007 and requested a termination date of January 1, 2007. The Local Employer Representative indicated that telephone calls and an e-mail were made to the Division of Pensions and Benefits, however, nothing was sent in writing to the Division prior to January 9, 2007. Therefore, the Division terminated the Local Employer effective March 1, 2007 in accordance with NJAC 17:9-1.5.  Dudley Burdge made a motion to deny this appeal. Susanne Culliton seconded the motion.  All voted in favor.
 
Richard Dougherty made a motion to go into Closed Session. Brian Volz seconded the motion. All voted in favor. 

Case #061306 (Member present): This Traditional Plan appeal concerns the denial of benefits for a liquid weight loss product, Optifast. Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #061307 (Horizon BCBSNJ Representatives present): This NJ PLUS appeal concerns payment of claims for Applied Behavioral Analysis/Verbal Behavior (ABA/VB) therapy. Eileen Schlindwein Den Bleyker recused herself from the case. Lewis Scheindlin, Deputy Attorney General, gave a summary to the Commission of his memorandum to Frederick Beaver. Wendy Rutan, Horizon, BCBSNJ indicated that the provider, Childs Play Center, did not respond to their inquiries for additional information. The Commission requested that Horizon BCBSNJ make another attempt to obtain additional information from the provider of services including but not limited to a treatment plan and determination of how many hours of therapy are rendered by Kerrie Pawlikoski. In addition Horizon, BCBSNJ will request the Provider rendering services and their credentials.   

Case #061308: Reconsideration of a decision concerning an appeal deemed to be work related.  Susanne Culliton made a motion to reaffirm the Commission’s former denial and to forward the appeal to OAL. Richard Dougherty seconded the motion. All voted in favor.

Case #061309: Final Administrative Determination – Susanne Culliton made a motion to accept the FAD draft concerning denial of dental services under the Traditional Plan.  Richard Dougherty seconded the motion. All voted in favor.
 
Case #061310: A settlement offer was reviewed by the Commission on an OAL case which involved a work-related injury. Michael Malloy made a motion to accept the settlement, Susanne Culliton seconded the motion. All voted in favor.

Case #061311: Retired Group Benefits for a Surviving Spouse. Susanne Culliton made a motion to draft a Final Administrative Decision. Michael Malloy seconded the motion.  Four voted in favor; Dudley Burdge abstained.

Case #061312: Denial of Coverage for an Overage Dependent. Susanne Culliton made a motion to forward the appeal to the Office of Administrative Law. Michael Malloy seconded the motion. All voted in favor.

Susanne Culliton made a motion to go into Executive Session. Richard Dougherty seconded the motion and all voted in favor. 

There being no further business to transact, a motion was made to return to open session by Susanne Culliton, seconded by Brian Volz. All voted in favor. Subsequently, there was a motion to adjourn which was made by Susanne Culliton, seconded by Brian Volz. All voted in favor. The State Health Benefits Commission meeting was adjourned at 2:20 PM.

Respectfully submitted,

 

Jean M. Williamson
Acting Secretary


Meeting No. 468
July 11, 2007
Minutes 10:30 AM
State Health Benefits Commission

The 468th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:06 AM, Wednesday, July 11, 2007.  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

Florence J. Sheppard, 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
Kevin Kelleher, NJEA
Eric Richard, New Jersey State AFL-CIO

 ALSO PRESENT:

Eileen Den Bleyker , Deputy Attorney General
Frederick J. Beaver, Director, Division of Pensions and Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Unit
David Pointer, Chief, Operations, State Health Benefits Program
Jean Williamson, Acting Secretary
Horizon Blue Cross Blue Shield of NJ Representatives
Magellan Behavioral Health Representatives

Resolutions A (Closed Session) and B (Executive Session) - were read in their entirety.

ISSUES

  1.  Minutes - Meeting No. 467, June 13, 2007.  Richard Dougherty made a motion to adjourn the minutes to August 8, 2007, the next Commission Meeting. Michael Malloy seconded the motion.  All voted in favor.
  2. Performance Guarantees:  Richard Dougherty made a motion to approve the Performance Guarantees. Michael Malloy 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.

Florence Sheppard made a motion to go into closed session (Resolution A). Richard Dougherty seconded the motion. All voted in favor.

Case #070701: This Horizon-Traditional Plan appeal concerns the denial of benefits for expenses above the reasonable and customary allowance for epidural injections under fluoroscopic guidance. Horizon explained that several issues led to the overpayment of claims, including that the incorrect number of units reported on the HCFA 1500 claim form was greater than the number of times the reported procedure was performed. The provider is being investigated by Horizon. Richard Dougherty made a motion to deny this appeal.  Florence Sheppard seconded the motion. All voted in favor.

Case #070702 (Member present): Horizon-NJ PLUS-Out-of-Network level of reimbursement - Eric Richard made a motion under Resolution B to go into Executive Session. Michael Malloy seconded the motion.  All voted in favor.  Florence Sheppard made a motion to return to closed session.  Richard Dougherty seconded the motion. All voted in favor. Kevin Kelleher made a motion to use the 2006 HIAA rates for the surgery on an exception basis.  This was due to the unique circumstances for this particular case. It is not the intent of the Commission to set a precedent or to discount the use of a formula in cases where a HIAA rate is unavailable. Eric Richard seconded the motion. All voted in favor.

Case #070703 (Member Present): This Horizon-NJ PLUS-Magellan Behavioral Health appeal concerns denial of residential substance abuse treatment rendered by a non-participating facility. The Member presented additional information from a physician which contradicts a document previously submitted concerning ASAM admission requirements.  Richard Dougherty made a motion under Resolution B to go into Executive Session.  Kevin Kelleher seconded the motion. All voted in favor. Richard Dougherty made a motion under Resolution A to return to closed session. Kevin Kelleher seconded the motion. All voted in favor.  Eric Richard made a motion to table this case pending Horizon/Magellan’s request from the Caron Foundation for additional information that will clarify the discrepancy. Richard Dougherty seconded the motion. All voted in favor.

Case #070704: Workers Comp Settlement – The Commission was asked to consider a settlement of $15,000.00. Florence Sheppard made a motion under Resolution B to go into Executive Session. Richard Dougherty seconded the motion. All voted in favor. Florence Sheppard made a motion to return to closed session. Richard Dougherty seconded the motion.  All voted in favor. Michael Malloy made a motion for Horizon to collect the lien.  Florence Sheppard seconded the motion. All voted in favor

Case #070705: Final Administrative Determination Draft - Richard Dougherty made a motion to accept the FAD.  Florence Sheppard seconded the motion. All voted in favor.

There being no further business to transact, a motion was made to return to open session by Florence Sheppard, seconded by Richard Dougherty. All voted in favor. Subsequently, there was a motion to adjourn which was made by Florence Sheppard, seconded by Richard Dougherty. All voted in favor. The State Health Benefits Commission meeting was adjourned at 11:59 AM.

Respectfully submitted,

Jean M. Williamson
Acting Secretary


Meeting No. 469
July 26, 2007
Minutes 1:00 PM
Special State Health Benefits Commission

A special meeting of the State Health Benefits Commission of New Jersey was called to order at 1:15 PM, Thursday, July 26, 2007.  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
Neil Vance, representing Commissioner, Steven M. Goldman, Department of
Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Kevin Kelleher, NJEA
Eric Richard, New Jersey State AFL-CIO

ALSO PRESENT: 

Eileen Den Bleyker , Deputy Attorney General
Frederick J. Beaver, Director, Division of Pensions and Benefits
Florence J. Sheppard, Deputy Director, Division of Pensions and Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Unit
David Pointer, Chief, Operations, State Health Benefits Program
Jean Williamson, Acting Secretary

ISSUES

The Commission met in open public session.  John Megariotis, Deputy Director for Finance, introduced AON Representatives Michael Morfe and Kristine Klepper. Mr. Morfe gave a GASB Valuation Presentation: Other Post Employment Benefits (OPEBs). The complete report is available on the Division of Pensions and Benefits’ website:  http://www.state.nj.us/treasury/pensions/shbp.htm.

Following the presentation, Susanne Culliton requested that a 15 minute break be taken.  The meeting reconvened at 2:15.

Ms. Culliton introduced AON Representatives Edward Fox, Susan Marsh, and James Christ. Susan Marsh presented the rate renewals to the Commission for the medical plans for the first quarter of 2008.  The following is a summary of the rate renewals:

Recommended 1st Quarter Plan Year 2008 Rate
Renewal for State Active Employees and Retirees

  • For the 1st Quarter of Plan Year 2008 for the SHBP NJ PLUS, Traditional Plan, and prescription drug plans, Aon recommends continuation of the Plan Year 2007 premium rates.
  • This recommended renewal assumes:
    • Scheduled increases in the Rx copays and the out-of-pocket (OOP) maximum for Retirees;
    • A change in the contribution scenario, effective July 2007, when approximately 85% of State Active employees began paying 1.5% of salary to participate in the SHBP, regardless of benefit plan choice or family status;
    • State Active enrollment will decrease 3% as a result of the change in contribution scenario, and
    • A new benefit landscape will take place for the SHBP, effective 4/1/08, as a result of the current PPO/HMO RFP.
  • The recommended renewal should generate 1st Quarter Plan Year 2008 premiums which are $6.5 million greater than projected costs.
  • Factors contributing to this favorable rate action include:
    • Favorable SHBP experience over the past several years, with Plan Year 2006 actual costs 8% lower than premiums and Plan Year 2007 costs projected to be 5% lower than premiums.
    • Benchmark trends for the medical plans and Rx have decreased 1% and 2% per year, respectively, over the last four years.

    • Since the Plan Year 2008 renewal is for the 1st quarter only, less than a full year’s trend is used to project costs from the Plan Year 2007 to the 1st Quarter of Plan Year 2008.
    • Effective January 2007, Retiree copays for NJ PLUS and HMO office visits increased from $5 to $10, which is projected to reduce medical costs 2.5%.
    • Effective July 2007, NJ PLUS and HMO office visit and ER copays for most State employees are increasing, and a third tier drug copay was added, which are projected to reduce medical costs 2% and Rx costs 4%.
    • Vendor administrative fees are reducing an average of 4% from Plan Year 2007 levels.
    • Negotiations with Horizon have reduced network access fees $12 million annually for the State and Local Employer Groups combined.
  • 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 on claim costs. The average age of the Traditional Plan Active Employee participants is now more than 13 years older than NJ PLUS Active Employee participants.  This is a significant factor in the Plan Year 2007 (and thus 1st Quarter Plan Year 2008) Traditional Plan rates being twice the NJ PLUS rates.
  • The recommended 1st Quarter Plan Year 2008 premium rates for Medicare-Eligible Retirees reflect the anticipated impact of the Medicare Part D Retiree Drug Subsidy ($673 per Medicare-Eligible member in Plan Year 2008), which amounts to $22 million for the State Group annually.
  • Should there be a delay in the RFP process and the anticipated 4/1/08 effective date is not realized for the new benefit plan landscape; the recommended rate continuation should cover Plan Year projected costs through June 30, 2008.

Recommended 1st Quarter Plan Year 2008 Rate
Renewal for Active Employees and Retirees
Of the Local Employer Group

  • For the 1st Quarter of Plan Year 2008 for the SHBP NJ PLUS, Traditional Plan, and prescription drug plans, Aon recommends continuation of the Plan Year 2007 rates for Active Employees and Retirees of the Local Employer Group.
  • Continuation of Plan Year 2007 rates is projected to result in a $1 million loss for the 1st Quarter of Plan Year 2008. However, since the Local Employer Group is projected to have a $584 million surplus (approximately 3.5 months of claims) as of 12/31/2007, the impact of the projected loss is minimal.
  • The recommended continuation of Plan Year 2007 rates assumes:
    • Scheduled increases in the Rx copays and out-of-pocket (OOP) maximum for Retirees, and
    • A new benefit landscape for the SHBP, effective 4/1/08, as a result of the current PPO/HMO RFP.
  • Factors contributing to this favorable rate action include:
    • Favorable experience over the past several years, with Plan Year 2006 actual costs 9% lower than premiums and Plan Year 2007 costs projected to be 6% lower than premiums.
    • Benchmark medical and Rx trends have decreased 1% and 2% per year, respectively, over the last four years.
    • Since the Plan Year 2008 renewal is for the 1st Quarter only, less than a full year’s trend is used to project costs from the Plan Year 2007 to the 1st Quarter of Plan Year 2008.
    • Effective January 2007, Employee and Retiree copays for NJ PLUS and HMO office visits increased from $5 to $10, which is projected to reduce medical costs 2.5%.
    • Effective January 2007, copays for the Employee prescription drug plan increased, which is projected to reduce prescription drug costs 14%.
    • Retiree Rx copays and OOP maximums increase according to a formula.  This will not apply to Local Education Retirees in Plan Year 2008, but it will apply to Local Government Retirees and will help reduce projected Plan Year 2008 Rx costs.
    • Vendor administrative fees are reducing an average of 4% from Plan Year 2007 levels.
    • Negotiations with Horizon have reduced network access fees $12 million annually for the State and Local Employer Groups combined.
  • Traditional Plan enrollment for the 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 on claims costs.  The average age of Traditional Plan Local Employer Active Employee participants is now about 7 years older than the average age of NJ PLUS Local Employer Active Employee participants.
  • The recommended rate continuation results in 1st Quarter Plan Year 2008 Traditional Plan premium rates that are approximately 50% higher than 1st Quarter Plan Year 2008 NJ PLUS premium rates for active employees.  The Traditional Plan remains in an upward assessment spiral.
  • The recommended rate continuation for Medicare-Eligible Retirees reflects the anticipated impact of the Medicare Part D Retiree Drug Subsidy ($668 per Medicare eligible member in Plan Year 2008), which amounts to $62 million for the Local Employer Group annually.
  • Since the projected cumulative surplus for the Local Employer Group is projected to reach 3.5 months of claim costs by the end of 2007, there is no margin in the 1st Quarter Plan Year 2008 recommended rates.
  • Should there be a delay in the RFP process and the anticipated 4/1/08 effective date is not realized for the new benefit landscape, the recommended rate continuation is projected to produce a loss of $2.5 million (for all benefit plans combined) each month beyond the 1st Quarter of Plan Year 2008. However, the projected surplus is adequate to cover projected losses if it proves necessary to delay the implementation of the new benefit landscape for several months.

 Recommended 1st Quarter Plan Year 2008
HMO Rate Renewal

  • For the 1st Quarter of Plan Year 2008, Aon recommends:
    • A continuation of the Plan Year 2007 HMO premium rates for Active Employees and Retirees of the Local Employer  Group, and
    • A 5.4% average increase in HMO premium rates for Active Employees and Retirees of the State Group, broken down as follows:
    State Group
    HMO 
    Active
    Early
    Retirees 
    Medicare-Eligible
    Retirees 
    Aetna
    6.0%
    6.0%
    6.0%
    CIGNA
    6.0%
    6.0%
    6.0%
    Oxford
    6.0%
    6.0%
    6.0%
    AmeriHealth
    0.0%
    0.0%
    0.0%
    HealthNet 
    0.0%
    0.0%
    0.0%
  • As was true in Plan Year 2007, Aon recommends different HMO premium rate increases for the State and Local Employer Groups, due to significant differences in experience.
  • This recommended renewal assumes:
    • A change in the contribution scenario, effective July 2007, when approximately 85% of State Active Employees began paying 1.5% of salary to participate in the SHBP, regardless of benefit plan choice or family status;
    • State Active enrollment will decrease 3% as a result of the change in contribution scenario, and
    • A new benefit landscape will take place for the SHBP, effective 4/1/08, as a result of the current PPO/HMO RFP.
  • Legislation enacted in April 2007 affords Local Employers more flexibility in determining employee contributions.  However, there is no way of determining at this point when or in what manner a particular Local Employer will modify its contribution scenario.  However, we are assuming that this change, in combination with the recommended continuation of rates for the 1st Quarter of Plan Year 2008, will have a favorable impact on Local Government Employer enrollment in the SHBP.
  • Factors contributing to the favorable rate action include:
    • Since the Plan Year 2008 renewal is for the 1st Quarter only, less than a full year’s trend is used to project costs from Plan Year 2007 to the 1st Quarter of Plan Year 2008.
    • Effective January 2007, Local Employer copays for HMO office visits increased from $5 to $10, which is projected to reduce costs 2.5%.
    • Effective July 2007, HMO office visit and ER copays are increasing for most State employees, which is projected to reduce costs 2.0%.
    • Vendor administrative fees are reducing an average of 4% from Plan Year 2007 levels.
    • Aetna and Oxford have agreed to increase the percent of Rx rebates paid to the SHBP to 100%, with a concurrent increase in their administrative fees.  All SHBP HMOs will be paying the SHBP 100% of rebates as of the 1st Quarter of Plan Year 2008.
  • The recommended 1st Quarter Plan Year 2008 HMO renewal premiums for Medicare-Eligible Retirees reflect the anticipated impact of the Medicare Part D Retiree Drug Subsidy ($669 per Medicare-Eligible member in Plan Year 2008), which amounts to an annual total of $84 million for the SHBP, $9 million of which is attributable to the SHBP HMOs.
  • Should there be a delay in the RFP process and the anticipated 4/1/08 effective date is not realized for the new benefit plan landscape, the recommended First Quarter Plan Year 2008 rates should be adequate to cover projected costs through June 30, 2008 for the State Group.  For the Local Employer groups, the recommended rate continuation is projected to produce a loss of $2.5 million (for all benefit plans combined) each month beyond the 1st Quarter of Plan Year 2008.  However, the projected surplus is adequate to cover these projected losses.

There being no further business to transact, a motion was made to adjourn by Richard Dougherty and seconded by Susanne Culliton.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 3:15 PM.

Respectfully submitted,

Jean M. Williamson
Acting Secretary


Meeting No. 470
August 8, 2007
REVISED Minutes 10:00 AM
State Health Benefits Commission

The 470th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:10 AM, Wednesday, August 8, 2007.  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
Kevin Kelleher, NJEA
Eric Richard, New Jersey State AFL-CIO

ALSO PRESENT: 

Dawn Harris, Deputy Attorney General
Florence J Sheppard, Deputy Director, Pensions & Benefits
Leonard Leto, Manager, Policy & Planning, State Health Benefits Unit
Jean Williamson, Acting Secretary
David Pointer, Chief, Operations, State Health Benefits Program
Aon Representatives
Horizon Blue Cross Blue Shield of NJ Representatives
Aetna Representatives

Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

  1.  Minutes - Meeting No. 467, June 13, 2007.  Susanne Culliton made a motion to accept the minutes for the regular meeting including the Executive Session minutes. Richard Dougherty seconded the motion.  Three voted in favor and Eric Richard and Kevin Kelleher abstained.
  2. Minutes - Meeting No. 468, July 11, 2007.  Michael Malloy made a motion to accept the minutes for the regular meeting including the Executive Session minutes.  Richard Dougherty seconded the motion.  Four voted in favor and Susanne Culliton abstained.
  3. Minutes - Special Meeting No. 469, July 26, 2007.  Richard Dougherty made a motion to accept the minutes for the regular meeting including the Executive Session minutes.  Susanne Culliton seconded the motion.  Four voted in favor and Michael Malloy abstained.

ISSUES:

  1. 2008 Rate Renewals:  Susanne Culliton made a motion to approve the recommendations for the 2008 Rate Renewals.  Richard Dougherty seconded the motion.  Eric Richard expressed concern over the increase in copayments and out-of-pocket maximum for retirees on a fixed income.  Kevin Kelleher agreed with Mr. Richard.  Three voted in favor and Eric Richard and Kevin Kelleher abstained.
  2. 2008 Dental Rate Renewals: The following is a summary of the 2008 Dental Rate Renewal Presentation which was given by Ed Fox and Susan Marsh, Aon Consulting. 
Recommended Plan Year 2008
Dental Plan Rate Renewal

  • For the SHBP Dental Plans (Employee and Retiree Dental Expense Plans and Employee DPOs), Aon recommends the following premium rate adjustments for both the State and Local Employer Groups for Plan Year 2008:
      Actives  Retirees
    Dental Expense Plans 0.0%  0.0% 
    Dental Plan Organizations 0.0%     n/a
  • For Employees, this favorable rate action reflects a continuation of favorable SHBP Dental Expense Plan trends which have averaged 4% lower than industry norms since Plan Year 2002.
  • For Retirees, the favorable rate action reflects lower retiree utilization as the group matures from a new dental offering in Plan Year 2005 where 20% of the population did not have prior dental coverage, to a more mature dental offering where only 4% of the Plan Year 2008 retirees are projected to have no prior dental coverage.
  • The recommended Plan Year 2008 renewal premiums assume no change in benefit plan design.  However, Aon is recommending that the number of DPOs offered by the SHBP be reduced from the current 10 to 6 for Plan Year 2008, with the following DPOs being terminated:
    • Assurant
    • Dental Group of New Jersey
    • Flagship
    • Group Dental Health Administrators

This recommendation to reduce the number of DPOs and terminate the specific plans identified above is based on an assessment process, outlined in the renewal report that takes the following into consideration:

    • Enrollment growth over the past two Plan Years;
    • DPO Size;
    • Value Ratio;
    • Network Size, which evaluated access (being defined as having at least 1 open (i.e., accepting new patients) general dentist per thousand DPO employees and 1 of each major specialty open providers in a county);
    • Disruption, which evaluated the number of DPO members that would be disrupted (being defined as a member having to select a new provider, since his/her provider is not available in any of the remaining DPO networks) due to termination of a particular DPO, and
    • DPO Cost.

Disruption is a key consideration in determining which DPOs should be terminated.  The suggested DPO consolidation will result in approximately 1,574 SHBP members (out of approximately 90,000 total DPO members) having to select a new DPO and DPO provider – or, alternatively, transferring to the Dental Expense Plan.

The decrease in the number of DPOs is projected to save the SHBP an average of $1.5 million per year over the next three years. 

  • The Plan Year 2008 renewal assumes that 3% of Active Employee DPO enrollment will migrate to the Dental Expense Plan.  At the same time, Retiree Dental Expense Plan enrollment is expected to increase 13% during Plan Year 2008.
  • Aon is projecting a total accumulated surplus for the Retiree pay all Dental Expense Plan at the end of Plan Year 2008 of $4.8 million.  This is equivalent to 1.7 months of claims, which is close to the target margin of 2 months of claims.  Therefore, there is no margin included in the Plan Year 2008 Retiree Dental Expense Plan premiums.

Susanne Culliton made a motion to approve the recommendations for the 2008 Dental Rate Renewals. Eric Richard seconded the motion.  All voted in favor.

  1. Update Performance Guarantees Standard Report:  Len Leto gave an update on the performance standards which included corrections to a table that had been distributed at the previous meeting.
  2. NJAC 17:9-5.3 Proposed Amendment-Local Employer Payment of Dependent Charges - Susanne Culliton made a motion to accept the modification to the regulation and promulgate it.  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.

Susanne Culliton made a motion to go into closed session (Resolution A).  Kevin Kelleher seconded the motion.  All voted in favor.

Case #080701(Member Present) This NJ PLUS appeal concerned the denial of a preauthorization for a BAHA (Bone Anchored Hearing Aid).  The Horizon Medical Director explained that whether a device uses a bone or air it is considered a hearing aid.  Hearing aids are a plan exclusion.  Richard Dougherty made a motion to deny this appeal.  Susanne Culliton seconded the motion.  All voted in favor.

Case #080702 - This Traditional Plan concerned denial of a Hepatitis B Vaccine.  The vaccine was denied because preventive vaccines are not a covered benefit.  Susanne Culliton made a motion to deny this appeal.  Richard Dougherty seconded the motion.  Four voted in favor and Michael Malloy voted against.

Case #080703 - This Aetna Dental Expense Plan concerned the denial of Dental Implants and other Dental Services not covered by plan.  Dental implants are an excluded benefit under the plan.  Richard Dougherty made a motion to deny this appeal.  Susanne Culliton seconded the motion. All voted in favor.

Case #080704 - This Employee Prescription Drug Program appeal concerned the denial of a preauthorization for the Growth Hormone, Humatrope.  The member did not meet the established medical necessity criteria for this drug.  Susanne Culliton made a motion to deny this appeal.  Richard Dougherty seconded the motion.  All voted in favor.

Case #080705 - (Member Present) Traditional Plan- Denial of Retro-Active coverage for speech therapy for son diagnosed with Autism.  Susanne Culliton made a motion under Resolution B to go into Executive Session.  Richard Dougherty seconded the motion.  All voted in favor. Susanne Culliton made a motion to return to closed session.  Richard Dougherty seconded the motion.  All voted in favor.  Susanne Culliton motioned to deny this appeal.  The motion to deny was based on (1) a Department of Banking and Insurance regulation issued in May 2005 that did not apply retroactively to the contracts that were already in force; (2) the fact that an appeal was not filed at the time the claims were denied and therefore it is too late to appeal those claims; and (3) the Commission’s decision to apply the appellate decision prospectively effective 1/17/07.  Michael Malloy seconded the motion.  All voted in favor.

Case #080706 - NJ Plus - This appeal concerns the denial of pre-authorization for occupational therapy visits for feeding therapy.  Susanne Culliton made a motion to forward the appeal to the Office of Administrative Law (OAL).  Richard Dougherty seconded the motion.  All voted in favor.

Case #080707 - This OAL appeal concerning private duty nursing was remanded to the Commission to consider exceptions that were submitted late.  Susanne Culliton made a motion to table the decision to obtain transcript of the OAL hearing and permit both parties to submit additional information.  Richard Dougherty seconded the motion.  All voted in favor

There being no further business to transact, a motion was made to return to open session by Susanne Culliton, seconded by Richard Dougherty.  All voted in favor.  Subsequently, there was a motion to adjourn which was made by Susanne Culliton, seconded by Richard Dougherty.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 12:02 PM.

Respectfully submitted,

Jean M. Williamson
Acting Secretary


Meeting No. 471
September 12, 2007
Minutes 10:00 AM
State Health Benefits Commission

The 471st meeting of the State Health Benefits Commission of New Jersey was called to order at 10:07 AM, Wednesday, September 12, 2007.  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
Kevin Kelleher, NJEA
Eric Richard, New Jersey State AFL-CIO

ALSO PRESENT: 

Eileen Den Bleyker, Deputy Attorney General
Jean Williamson, Acting Secretary
David Pointer, Chief, Operations, State Health Benefits Program
Leonard Leto, Manager, Policy & Planning, State Health Benefits Unit
Horizon Blue Cross Blue Shield of NJ Representatives
Magellan Representatives

Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

  1.  Minutes - Meeting No. 470, August 8, 2007.  Richard Dougherty made a motion to accept the minutes for the regular and executive meetings after two changes were noted on the regular meeting as follows:  1.) Case 080702 Michael Malloy voted no on this appeal.  2.) Case 080705 Department of Banking and Insurance regulation issues did not apply retroactively to contracts that were already in force.  Eric Richard seconded the motion.  All voted in favor.

ISSUES

1. Oxford Administrative Fee Update was provided to the Commission for their information.

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

Richard Dougherty made a motion to go into closed session (Resolution A); Susanne Culliton seconded the motion.  All voted in favor.

Case #090701 - This Horizon Traditional appeal concerned the denial of an amount above the reasonable and customary allowance for two separate surgeries.  Susanne Culliton made a motion to deny this appeal.  Michael Malloy seconded the motion.  All voted in favor.

Case #090702 - (Parents of the member present) This NJ PLUS-Magellan Mental Health Service appeal concerned denial of a residential substance abuse treatment.  Susanne Culliton made a motion to go into Executive Session under Resolution B; Richard Dougherty seconded the motion and all voted in favor.  Susanne Culliton made a motion to recess and go back into closed session (Resolution A).  Kevin Kelleher seconded the motion.  All voted in favor.  The parents of the member provided a HIPAA release form and the recess was postponed until after hearing the rest of this appeal. 

Michael Malloy made a motion to deny the appeal on the basis that no evidence was available that the patient met the criteria for obtaining residential treatment.  He also motioned to pay the equivalent of three sessions of intensive outpatient treatment.  Eric Richard seconded the motion.  All voted in favor.
 
Case #090703 - This Horizon-NJ PLUS appeal concerned the denial of Occupational Therapy for a dependent child.  Susanne Culliton made a motion to go into Executive Session (Resolution B).  Kevin Kelleher seconded the motion.  All voted in favor.   Susanne Culliton made a motion to go back into closed session (Resolution A).  Richard Dougherty seconded the motion.  All voted in favor.  Susanne Culliton made a motion to deny this appeal.  Michael Malloy seconded the motion. All voted in favor.

Case #090704 - (Member Present; member’s attorney had to leave before this case was heard.) This Horizon-NJ PLUS appeal concerned the denial of benefits for an auto related injury. Susanne Culliton made a motion to deny this appeal with the stipulation that if documentation is submitted to prove that PIP benefits were not available, the appeal could be brought back to the Commission.  Richard Dougherty seconded the motion.  Four voted in favor and Michael Malloy abstained. Copy attorney of board letter sent to member.

 Case #090705 - (Attorney was present on behalf of member) This Traditional Plan- appeal concerned a denial under the Employee Prescription Drug Plan for Growth Hormone Therapy for a dependent child.  Michael Malloy made a motion to deny to this appeal.  Susanne Culliton seconded the motion.  Michael Malloy withdrew his motion to deny.  Eric Richard motioned to approve the appeal.  Kevin Kelleher seconded the motion.  Two vote in favor and three voted against.  Richard Dougherty made a motion to deny.  Three voted in favor. Two voted against.

Case #090706 - (Member present)  This tabled appeal concerns a denial of benefits for expenses for residential substance abuse treatment by a non-participating facility.  At issue was a discrepancy concerning whether or not the member met the ASAM II criteria for inpatient residential substance abuse treatment.  Kevin Kelleher made a motion to go into Executive Session under Resolution B; the motion was seconded by Susanne Culliton and all voted in favor.  Susanne Culliton made a motion to return to Closed Session under Resolution A; Michael Malloy seconded the motion and all voted in favor.  Eric Richard made a motion to approve the appeal; Kevin Kelleher seconded the motion.  Two voted in favor and three voted against; therefore, the motion did not carry.  Michael Malloy made a motion to deny payment of the residential treatment but to pay at the intensive out-patient level of benefits.  Susanne Culliton seconded the motion and it carried with three in favor and two members, Eric Richard and Kevin Kelleher, abstaining.  It came to light that intensive outpatient benefits were paid for following the member’s in-patient stay.  Kevin Kelleher made a motion to go into Executive Session under Resolution B.  Eric Richard seconded the motion and all voted in favor.  Susanne Culliton made a motion to return to Closed Session under Resolution A.  Richard Dougherty seconded the motion and all voted in favor.  The medical director from Magellan was asked about intensive out-patient treatment.  He indicated that it is very common for people to attend it for several months.  The Commission approved the equivalent of expenses which would have been incurred for intensive outpatient treatment three times per week for four weeks.

Case #090707 - The Commission was asked to reconsider forwarding this Horizon Traditional Plan appeal to the Office of Administrative Law for a hearing.  The appeal concerned the denial of speech therapy for a dependent child.  Previously, the Commission voted for a Final Administrative Determination.  Susanne Culliton made a motion to transmit the appeal to the OAL contingent whether this case was remanded from the Appellate Court back to the Commission.  Michael Malloy seconded the motion.  Three voted in and two, Eric Richard and Kevin Kelleher, abstained.

Case #090708 - Washington Township requested that their appeal concerning the effective date of termination from the State Health Benefits Program (SHBP) be forwarded to the Office of Administrative Law.  Susanne Culliton made a motion to do a Final Administrative Determination.  Richard Dougherty seconded the motion.  Four voted in favor.  Michael Malloy abstained. 

Case #090709 - This OAL Decision for reconsideration was remanded to the Commission to consider exceptions.  Susanne Culliton made a motion to reaffirm the Commission’s decision to accept the Administrative Law Judge’s decision and to issue a Final Administrative Determination.  Richard Dougherty seconded the motion.  Three voted in favor and two, Eric Richard and Kevin Kelleher, abstained.

There being no further business to transact, a motion was made to return to open session by Susanne Culliton, seconded by Richard Dougherty.  All voted in favor.  Subsequently, there was a motion to adjourn which was made by Susanne Culliton, seconded by Richard Dougherty.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 3:22 PM.

Respectfully submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


Meeting No. 472
October 10, 2007
Minutes 10:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:08 AM, Wednesday, October 10, 2007.  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 Acting State Treasurer, Michellene Davis
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of
Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Kevin Kelleher, NJEA
Dudley Burdge, New Jersey State AFL-CIO

ALSO PRESENT: 

Eileen Den Bleyker, Deputy Attorney General
Florence J. Sheppard, Deputy Director
Len Leto, Manager Policy & Planning, State Health Benefits Unit
Jean Williamson, Acting Secretary
David Pointer, Chief, Operations, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives
Magellan Representatives

Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

  1.  Minutes – Meeting No. 471, September 12, 2007.  Susanne Culliton made a motion to accept the minutes.  Richard Dougherty seconded the motion.  Four voted in favor and Dudley Burdge abstained.

ISSUES

  1. COBRA Vision Rates for CY2008 were given to the Commission for review and approval.  Michael Malloy made a motion to approve the rates.  Susanne Culliton seconded the motion.  All voted in favor.
  2. Proposed Amendment to NJAC 17:9-6.10, Retiree Prescription Drug Plan – David Pointer gave an overview of the changes to the regulation.  Susanne Culliton made a motion to publish the proposed regulation for a 60 day comment period.  Richard Dougherty seconded the motion.  Three voted in favor and two, Kevin Kelleher and Dudley Burdge voted against.

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

Susanne Culliton made a motion to go into closed session (Resolution A) Dudley Burdge seconded the motion.  All voted in favor.

Case #100701 - This Horizon-Traditional Plan appeal concerned a denial of benefits for nutritional counseling by a registered dietician.  A registered dietician is not an eligible provider.  Richard Dougherty made a motion to deny this appeal.  Susanne Culliton seconded the motion.  All voted in favor.

Case #100702 - (Member present.) This NJ PLUS/Magellan appeal concerned a request for reimbursement for in-patient residential eating disorder treatment for a dependent child.  Kevin Kelleher made a motion to go into executive session (Resolution B).  Richard Dougherty seconded the motion.  All voted in favor. Michael Malloy made a motion to go back into closed session (Resolution A).  Richard Dougherty seconded the motion.  All voted in favor.  Since there was no evidence that the patient met the criteria for in-patient residential treatment, Kevin Kelleher motioned that Magellan pay at the appropriate level of care which would have been permitted -- fourteen days partial hospitalization and twelve sessions of intensive outpatient treatments.  Michael Malloy seconded the motion.  All voted in favor.
 
Case #100703 - This Division appeal concerned the denial of a request by a retiree to change medical plans in less than a 12 month period.  Susanne Culliton made a motion to deny to this appeal.  Richard Dougherty seconded the motion.  All voted in favor.

Case #100704 - This Horizon Traditional Plan appeal concerned the denial of nutritional counseling for a dependent child.  Nutritional counseling is limited to the diagnosis of diabetes under the Plan.  Richard Dougherty made a motion to deny this appeal.  Susanne Culliton seconded the motion.  All voted in favor.

Case #100705 - (Member present) This Horizon Traditional Plan appeal concerns the denial of Viagra beyond the four tablets per month/12 tablets in a 90 day period.  Request was made to reconsider dosage limit when used as a post-operative treatment plan for prostate cancer.  Per Horizon’s medical director large studies have yet to be conducted to date to reconsider changing the policy at this time.  Michael Malloy made a motion to deny to this appeal.  Susanne Culliton seconded the motion.  All voted in favor.

Case #100706 - This Horizon Employee Prescription Drug Plan appeal concerned the denial of Growth Hormone Therapy for a dependent child.  Susanne Culliton motioned to approve this request to be forwarded to the Office of Administrative Law (OAL) for a hearing.  Kelleher seconded the motion.  All voted in favor.

Case #100707 - OAL Decision:  Exceptions to case concerning private duty nursing.  Susanne Culliton made a motion to approve the draft of the Final Administrative Decision with technical changes to be made by Eileen Den Bleyker.  Richard Dougherty seconded the motion.  All voted in favor.

Case #100708 - FAD postponed to next Commission meeting.

There was a brief discussion concerning the RFP.  A very general update and timeline was provided.  The Commission members were advised that oral presentations had taken place and that best and final offer letters were expected to be sent out in two to three weeks.  A report from the Evaluation Committee would then go to Fred Beaver.  It is likely a Special Commission meeting will be convened in November.

There being no further business to transact, a motion was made to return to open session and adjourn by Susanne Culliton.  It was seconded by Richard Dougherty.  All voted in favor. 

Respectfully submitted,

Jean M. Williamson
Acting Secretary


Meeting No. 473
November 14, 2007
Minutes 10:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:17 AM, Wednesday, November 14, 2007.  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 (for opening and first appeal), representing Acting State Treasurer, Michellene Davis
David Pointer (for the remainder of the meeting), representing Acting State Treasurer, Michellene Davis
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of
Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Kevin Kelleher, NJEA
Dudley Burdge, New Jersey State AFL-CIO

ALSO PRESENT: 

Eileen Den Bleyker, Deputy Attorney General
Len Leto, Manager Policy & Planning, State Health Benefits Unit
Jean Williamson, Acting Secretary
Horizon Blue Cross Blue Shield of NJ Representatives
Aetna Representatives

Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

  1.  Minutes – Meeting No. 472, October 10, 2007.  Richard Dougherty made a motion to accept the minutes. Susanne Culliton seconded the motion.  All voted in favor.

ISSUES

  1. 2008 SHBC Meeting Dates - Richard Dougherty made a motion to approve the meeting dates.  Michael Malloy 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.

Richard Dougherty made a motion to go into closed session (Resolution A) Susanne Culliton seconded the motion.  All voted in favor.

Case #110701 - This Aetna Dental Expense Plan appeal concerned the denial of replacement crown in less than a five-year period.  The Plan prohibits replacement crowns within a five-year period.  Susanne Culliton made a motion to deny this appeal.  Richard Dougherty seconded the motion.  All voted in favor.

Case #110702 - (Member’s attorney present.)  Michael Malloy recused himself from the case.  This Horizon Traditional Plan appeal concerned denial of benefits for expenses for claims for a Percutaneous Laser Disc Decompression (PLDD) procedure performed.  During the meeting, the medical director for Horizon, Blue Cross and Blue Shield of NJ indicated that the procedure is considered investigational due to insufficient large scale long term studies for PLDD.  In addition, a copy of report by an Independent Medical Examiner (IME) was distributed at the meeting.  The IME concluded that “PLDD is regarded as investigational because there are no randomized controlled studies in the peer reviewed medical literature showing long term safety and effectiveness of this procedure.  Based on the peer reviewed medical literature, there is little likelihood that this patient would have long term relief from PLDD or that such outcome would be better than that from conventional treatments”.  Richard Dougherty made a motion to deny this appeal.  David Pointer seconded the motion.  Three voted in favor.  Dudley Burdge abstained.
 
Case #110703 - (Member’s attorney present.) This Horizon-Traditional Plan concerned denial of benefits for expense above the reasonable and customary allowance for surgery.  During the meeting, representatives from Horizon, Blue Cross and Blue Shield of NJ indicated that since a non-participating healthcare professional the member is responsible for the difference between the physician’s charges and the reimbursed amount in accordance with the provisions of the Traditional Plan.  Kevin Kelleher made a motion to deny to this appeal.  Richard Dougherty seconded the motion.  All voted in favor.

Case #110704 - (Member was present) Horizon – NJ PLUS appeal concerned the denial of benefits for expenses for auto related physical therapy services.  During the meeting, the representatives for Horizon, Blue Cross and Blue Shield of NJ (Horizon) indicated that bills were not submitted through the local Blue Cross and Blue Shield (Delaware) since February 15, 2006 and that they were trying to work with the provider to submit the bills.  Kevin Kelleher made a motion to go into Executive Session under Resolution B.  Michael Malloy seconded the motion.  All voted in favor Michael Malloy made a motion to back into closed session.  David Pointer seconded the motion.  All voted in favor.  Kevin Kelleher made a motion to deny this appeal based on the documentation provided.  The Commission members stipulated that if the member can provide documented proof of improvement, it can be submitted and the claims will be reconsidered.  Richard Dougherty seconded the motion.  All voted in favor.

Case #110705 - Horizon-Traditional Plan appeal concerned the denial of benefits for expenses for virtual colonoscopy deemed investigational.  The medical director for Horizon stated that a virtual colonoscopy is not a covered benefit and is considered investigational.  The only exceptions under the Plan are anatomical and functional reasons which were not met in this case.  Michael Malloy made a motion to deny to this appeal.  David Pointer seconded the motion.  All voted in favor.

Case #110706 - The member requested that the Commission’s previous denial of an appeal for expenses for dental implants and other services not covered by the plan be forwarded to the Office of Administrative Law (OAL) for a hearing.  David Pointer made a motion to deny forwarding the appeal to the OAL and to issue a Final Administration Determination (FAD).  Richard Dougherty seconded the motion.  All voted in favor.

Case #110707 - David Pointer made a motion to approve the draft letter of Final Administrative Determination.  Richard Dougherty seconded the motion.  Four voted in favor and Michael Malloy abstained.

There being no further business to transact, a motion was made to return to open session by David Pointer, seconded by Richard Dougherty.  All voted in favor.  Subsequently, there was a motion to adjourn which was made by David Pointer, seconded by Richard Dougherty.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 12:02 PM.

Respectfully submitted,

Jean M. Williamson
Acting Secretary


Meeting No. 474
November 19, 2007
Minutes 10:00 AM
State Health Benefits Commission

A Special meeting of the State Health Benefits Commission of New Jersey was called to order at 10:20 AM, Monday, November 19, 2007. The meeting was held at Thomas Edison State College, 101 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

David Ridolfino, representing Acting State Treasurer, Michellene Davis
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of
Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Kevin Kelleher, NJEA
Dudley Burdge, New Jersey State AFL-CIO

ALSO PRESENT: 

Josh Lichtblau, Deputy Attorney General
Frederick J. Beaver, Director
Florence J. Sheppard, Deputy Director
Susanne Culliton, Assistant Director
Mary Ann Ryan, Acting Secretary

RFP Evaluation Team Members:

Janice Nelson, Assistant Director
Len Leto, Manager HB Policy & Planning
David Pointer, Chief, Operations, State Health Benefits Program
Nancy Ronaghan, Financial Supervisor
Jean Williamson, Administrative Analyst

Resolution C was read in its entirety.

The only issue on the agenda was the award of the contracts for a Preferred Provider Organization (PPO) and Health Maintenance Organizations (HMO).

A motion was made by David Ridolfino to go into Executive Session under Resolution C.  Richard Dougherty seconded the motion.  All voted in favor.

Kevin Kelleher made a motion to take a ten minute break. David Ridolfino seconded the motion.  All voted in favor.

A motion was made by Kevin Kelleher to go back into Executive Session under Resolution C.  David Ridolfino seconded the motion.  All voted in favor.

A motion was made by David Ridolfino to go into open session.  Richard Dougherty seconded the motion.  All voted in favor.

David Ridolfino made a motion to accept the recommendations to award the contracts for the PPO to Horizon (PPO) and the HMO contracts to Aetna and CIGNA.  Richard Dougherty seconded the motion. 4 voted in favor 1 opposed.

There being no further business, a motion to adjourn was made by David Ridolfino and it was seconded by Richard Dougherty.  All voted in favor. The State Health Benefits Commission meeting was adjourned at 12:56 PM.

Respectfully submitted,

Mary Ann Ryan
Acting Secretary
State Health Benefits Commission


Meeting No. 475
December 19, 2007
Minutes 10:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:09 AM, Wednesday, December 19, 2007. 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 Acting State Treasurer, Michellene Davis
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of
Banking & Insurance
Richard Dougherty, representing Commissioner Rolando Torres, Jr., Department of Personnel
Kevin Kelleher, NJEA
Dudley Burdge, New Jersey State AFL-CIO

ALSO PRESENT: 

Eileen Den Bleyker, Deputy Attorney General
Florence J. Sheppard, Deputy Director
Len Leto, Manager Policy & Planning, State Health Benefits Unit
Jean Williamson, Acting Secretary
David Pointer, Chief, Operations, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives

Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

  1.  Minutes – Meeting No. 473, November 14, 2007.  Richard Dougherty made a motion to accept the minutes. Michael Malloy seconded the motion.  All voted in favor.

ISSUES

  1. Health Insurance Portability and Accountability Act – For Approval
    There was a discussion concerning mental health parity. Kevin Kelleher advised the Commission that the dollar caps are not mentioned in the Education section of Chapter 103. Dudley Burdge made a motion to apply for waiver for the Traditional Plan and not NJ PLUS through April 2008. Kevin Kelleher seconded the motion. Two voted in favor and 3 opposed. The motion did not carry. Richard Dougherty made a motion to apply for an exemption. Susanne Culliton seconded the motion. Three voted in favor and 2 opposed.
  1. Surcharge Rates – Boards of Education
    Richard Dougherty made a motion to accept the 2.5% rate for 2008 and 2009.    Kevin Kelleher 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.

Susanne Culliton made a motion to go into closed session under Resolution A.  Richard Dougherty seconded the motion.  All voted in favor.

Case #120701 - This Horizon-Employee Prescription Drug Program appeal concerned the denial of benefits for expenses for Growth Hormone Therapy for a dependent child. The Horizon’s medical director indicated that the child does not meet the criteria established under Horizon’s Uniform Medical Policy for this drug. Susanne Culliton made a motion to deny this appeal.  Richard Dougherty seconded the motion. All voted in favor.

Case #120702 - This Horizon-Traditional Plan concerned denial of benefits for expenses above the reasonable and customary allowance for surgery for subscriber’s spouse.  Claims were paid in accordance with the reasonable and customary provisions of the plan as described on page 17 of the Traditional Plan Member Handbook (January 2005). Susanne Culliton made a motion to deny this appeal.  Dudley Burdge seconded the motion.  All voted in favor.
 
Case #120703 - This Division appeal concerned denial of enrollment in the Aetna Dental Retiree Plan because the subscribed failed to enrol in the plan upon retirement in accordance with N.J.A.C. 17:9-12.1(c)4.  Kevin Kelleher made a motion to deny to this appeal.  Susanne Culliton seconded the motion.  All voted in favor.

Case #120704 - Susanne Culliton made a motion to approve the draft letter of a Final Administrative Determination.  Richard Dougherty seconded the motion.  All voted in favor.

Case #120705 - The member requested that the Commission’s previous denial of an appeal for expenses for Hormone Growth Therapy be forwarded to the Office of Administrative Law (OAL) for a hearing.  Susanne Culliton motioned to approve this request for a hearing at the Office of Administrative Law (OAL).  Richard Dougherty seconded the motion.  All voted in favor.

Case #120706 - OAL Initial Decision. Michael Malloy made a motion to approve adopt the OAL Initial Decision.  Richard Dougherty seconded the motion.  Four voted in favor and Susanne Culliton abstained.

There being no further appeals, a motion was made to return to open session by Susanne Culliton, seconded by Richard Dougherty.  All voted in favor.

Kevin Kelleher motioned to have a history of surcharge rates prepared for the next Commission meeting, January 9, 2008.  Dudley Burdge seconded the motion.  All voted in favor.

Subsequently, there was a motion to adjourn which was made by Susanne Culliton, seconded by Richard Dougherty.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 10:57 AM.

Respectfully submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission


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