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Pensions and Benefits
HEALTH BENEFITS COMMISSION MEETING MINUTES 2008


To view 2007 Health Benefit Commission Meeting Minutes (and prior years), click here.


Meeting No. 476
January 9, 2008
Minutes 10:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:10 AM, Wednesday, January 9, 2008.  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, David Rousseau
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
Aon Representatives

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

  1. Minutes – Meeting No. 474, November 19, 2007.  Richard Dougherty made a motion to accept the minutes. Michael Malloy seconded the motion.  Four voted in favor and Susanne Culliton abstained.
  2. Minutes – Meeting No. 475, December 19, 2007.  Susanne Culliton made a motion to accept the minutes. Richard Dougherty seconded the motion.  All voted in favor.

ISSUES

  1. Rates for New Plans – For approval
    Aon briefly reviewed new rates. Susan Marsh of Aon gave review of the rate recommendations (see Summary of rate recommendations below). Susan Marsh also answered questions posed by e-mail prior to the meeting by Kevin Kelleher and Dudley Burdge.

    Kevin Kelleher asked Aon if the charts on page 23 through 28 of the Local Employer Group 2008 Rate Renewal - 4/1/08 Rate Recommendation Report could be split into Local Education Government and Local Government.  Aon said yes and would provide them by e-mail by the week of January 14, 2008.

    Richard Dougherty made a motion to accept the new rates.  Susanne Culliton seconded the motion. All voted in favor. 

Rate Recommendation for Active Employees and Retirees
Of the State Group

For the Period April 1, 2008 through December 31, 2008


  • For the period April 1, 2008 through December 31, 2008, Aon is recommending premium rate changes that – in the aggregate – represent an overall increase of 3% for State Active Employees and an overall decrease of 11% for State Retirees:

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  • Aggregate differences in the rate changes between Actives and Retirees reflect the impact of:
  • State Retirees having 38% of their claims in the Traditional Plan (where the largest savings will be achieved in the transition to the new PPO plans), while State Actives have only 10% of their claims in the Traditional Plan;
  • Retiree trends being lower than Active Employee trends, and
  • The anticipated impact of the Medicare Part D Retiree Drug subsidy.
  • State Police and select Correction and Judiciary unions have not yet settled their contracts, so Employees/Retirees in these unions who are enrolled in NJ PLUS or the Traditional Plan will continue in the current NJ PLUS and Traditional Plan; Employees/Retirees in this group currently enrolled in one of the three terminated HMOs will have to enroll in either Aetna, CIGNA, NJ PLUS or, if eligible, the Traditional Plan effective April 1, 2008.  The following rate changes will apply to these Employees/Retirees:

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  • Factors contributing to the overall favorable rate actions include:
    • Favorable experience for Plan Year 2006 and favorable experience projected for Plan Year 2007, as well as the 1st Quarter of Plan Year 2008.
    • Benchmark medical and Rx trends have decreased 1% and 2% per year, respectively, over the last four years.
    • July 2007 increases in NJ PLUS and HMO copays for State Active Employees, as well as an increase in emergency room copays and the addition of a third tier copay for the Prescription Drug program.
    • January 2007 increases in State Retiree copays for NJ PLUS and HMOs, as well as formula increases in the Retiree Rx copays and out-of-pocket maximum.
    • The new benefit landscape that will be effective April 1, 2008, with the new PPO plans replacing NJ PLUS and the Traditional Plan for 85% of State Employees, as well as a reduction in the number of HMOs from 5 to 2, resulting in lower overall SHBP costs due to improved provider discounts, greater rebates, reduced vendor administrative fees, and an overall increase in managed care.
  • The premium levels for April 1, 2008 through December 31, 2008 are projected to match projected costs for that period, so no loss or gain is projected for this period.

Rate Recommendation for Active Employees and Retirees
Of the Local Employer Group

For the Period April 1, 2008 through December 31, 2008


  • For the period April 1, 2008 through December 31, 2008, Aon is recommending premium rate changes that – in the aggregate – represent an overall decrease of 10% for the Local Education Group and 5% for the Local Government Group, for Active Employees and Retirees of both groups:

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  • These premium levels were set so that NJ Direct15 premium rates for employees with a prescription drug card are at the same level as the 1st Quarter Plan Year 2008 NJ PLUS premiums.
  • These premium levels were set with the goal of minimizing Local Employer terminations during the transition to the new SHBP benefit options.
  • These premium levels are projected to produce an aggregate loss of $90 million between April 1, 2008 and December 31, 2008.  Fortunately, the Local Employer surplus has sufficient funds to cover this loss and still maintain an adequate level of approximately 3.2 months of claims at the end of Plan Year 2008, considering the new benefit landscape as of April 1, 2008.
  • Factors contributing to this favorable financial picture for the Local Employer Group include:
    • Favorable experience over the past several years. 
    • Benchmark medical and Rx trends have decreased 1% and 2%, respectively, over the past four years.
    • Effective January 2007, Employee and Retiree copays for NJ PLUS and HMO office visits increased from $5 to $10.
    • Effective January 2007, copays for the Employee Prescription Drug Plan increased.
    • Retiree Rx copays and OOP maximums increase according to a formula set by regulation and was the case in Plan Year 2008 for Local Government Retirees. Chapter 103, PL 2007 froze the Retiree Rx copays and OOP maximums at the Plan Year 2007 levels for retirees of Education Employers.
    • The new benefit landscape, with the new PPO plans replacing NJ PLUS and the Traditional Plan, as well as a reduction in the number of HMOs from 5 to 2, will result in reduced claim costs as a result of improved provider discounts, greater rebates, reduced vendor administrative fees, and an overall increase in managed care.   
  • The recommended rate levels for Medicare-Eligible Retirees reflect the anticipated impact of the Medicare Part D Retiree Drug subsidy.
  1. SHBP Surcharge Rate History – Requested

      Copies of the SHBP Surcharge Rate History that was requested the previous
     Commission meeting was distributed to Commission members.

There being no further business to transact, a motion was madeto adjourn by Susanne Culliton, seconded by Richard Dougherty.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 11:08 AM.

                                                                  Respectfully submitted,

                                                                  Jean M. Williamson
                                                                  Acting Secretary


Meeting No. 477
February 13, 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 10:10 AM, Wednesday, February 13, 2008.  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, R. David Rousseau
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
Mary Ann Ryan, Acting Secretary
David Pointer, Chief, Operations, State Health Benefits Program
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. 476, January 9, 2008.  Richard Dougherty made a motion to accept the minutes. Susanne Culliton seconded the motion.  All voted in favor.
  2. Issues Horizon Update Concerning Stolen Laptop Computer – Douglas E Falduto, Director of Corporate Investigation and Security in Horizon’s Legal Affairs Division and Cheryl Eagan of Horizon Blue Cross and Blue Shield of NJ (Horizon BCBSNJ) gave the Commission members an overview and update of the incident involving the stolen laptop computer. The employee’s laptop computer was stolen on January 5, 2008.  The incident was reported on January 7, 2008 because the employee thought it may have been left in their office over the weekend.  The employee believed that the information was deleted but was not a hundred percent positive. Horizon has taken precautions to protect the members of the State Health Benefits Program (SHBP) and advised them of the stolen laptop computer and the remedies that Horizon BCBSNJ has taken.     

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.  Michael Malloy seconded the motion.  All voted in favor.

Case #020801 – (Member present) - This Horizon (BCBSNJ) NJ PLUS appeal concerned a denial for a preauthorization for the reimbursement of growth hormone therapy for the member’s son.  The member has prescription drug coverage through a separate prescription drug plan provided by the member’s employer Lacy Township Board of Education.  The SHBP NJ PLUS Member Handbook (2005), page 20, states the following:  “If you are eligible for prescription drug coverage through a separate drug plan provided by your employer, your SHBP medical plan will not include prescription drug coverage and any prescription drug copayments from other group plans will not be reimbursed through the Traditional Plan, NJ PLUS or any SHBP HMO.”  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 go back into closed session under Resolution A.  Richard Dougherty seconded the motion and all voted in favor.  Susanne Culliton made a motion to advise Lacey Township Board of Education that their prescription drug plan must include the drug to be in compliance with the SHBP.  Lacey Township Board of Education should expedite the inclusion of this growth hormone in their prescription drug plan.  If Lacey Township Board of Education does not comply with this request they may be required to rejoin  into the SHBP Prescription Drug Plan.  A letter to the employer will be copied to the member.  Richard Dougherty seconded the motion.  All voted in favor.

Case #020802(Member present) - This Aetna Dental Expense Plan appeal concerned the denial of benefits for expenses of more than one panoramic x-ray taken within a thirty-six month period.  Susanne Culliton made a motion to deny this appeal.  Richard Dougherty seconded the motion.  Four voted in favor and one abstained.

Case #020803 – This Horizon (BCBSNJ) NJ PLUS appeal concerned denial of out-of-network routine immunizations.  A letter to member should clarify that travel is not deemed a medical necessity.  Kevin Kelleher made a motion to deny to this appeal.  Susanne Culliton seconded the motion.  All voted in favor. 

Case #020804(Member present) - This Horizon (BCBSNJ) NJ PLUS appeal concerned denial of benefits for unpaid medical expenses for a Magnetic Resonance Imaging (MRI) that was deemed work related.  Kevin Kelleher made a motion to go into executive session under Resolution B.  Michael Malloy seconded the motion and all voted in favor.  Susanne Culliton made a motion to go back into closed session under Resolution A.  Richard Dougherty seconded the motion and all voted in favor.  Susanne Culliton made a motion to deny this appeal and for the member to appeal the denial of reopening the Workers’ Compensation claim.  Michael Malloy seconded the motion.  All voted in favor.

Case #020805(Member Present) – This Horizon (BCBSNJ) NJ PLUS denial of benefits concerned payment for surgery that was deemed to be work-related.  Kevin Kelleher made a motion to go into executive session under Resolution B.  Dudley Burdge seconded the motion and all voted in favor.  Susanne Culliton made a motion to go back into closed session under Resolution A.  Richard Dougherty seconded the motion and all voted in favor.  Susanne Culliton made a motion to request that Horizon (BCBSNJ) review the case to see if surgery was a medical necessity and to pay the claims if that is the finding.  Richard Dougherty seconded the motion.  All voted in favor.

Case #020806 – The member requested that the Commission’s previous denial of an appeal under the Horizon (BCBSNJ) Traditional Plan for a Percutaneous Laser Disc Decompression (PLDD) deemed investigational in nature, be forwarded to the Office of Administrative Law (OAL) for a hearing.  Dudley Burdge motioned to approve this request for a hearing at the Office of Administrative Law (OAL).  Richard Dougherty seconded the motion.  Four voted in favor and one abstained.

Case #020807 – The member requested that the Commission’s previous denial of an appeal under the Horizon (BCBSNJ) Traditional Plan concerning a denial of payment amount above the reasonable and customary allowance for surgery, be forwarded to the Office of Administrative Law (OAL) for a hearing.  Susanne Culliton made a motion to issue a Final Administrative Decision (FAD). Richard Dougherty seconded the motion.  Four voted in favor and one abstained.

Case # 020808 – The ACS Recovery Services Settlement Proposal under the Horizon (BCBSNJ) Traditional Plan was for $1,666.66.  Dudley Burdge made a motion to accept settlement proposal.  Kevin Kelleher seconded the motion. Four voted in favor and one against.

Case # 020809 – The ACS Recovery Services Settlement Proposal under the Horizon (BCBSNJ) Traditional Plan is for $10,000.  Susanne Culliton made a motion to table the settlement proposal for additional information.  Richard Dougherty seconded the motion.  All voted in favor.

There being no further appeals, a motion was made to return to open session by Richard Dougherty; seconded by Dudley Burdge.  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 1:44 PM.

                                                                  Respectfully submitted,

                                                                  Mary Ann Ryan
                                                                  Acting Secretary
                                                                  State Health Benefits Commission


Meeting No. 478
March 12, 2008
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, March 12, 2008.  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, R. David Rousseau
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: 

Dawn Harris, 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 (Horizon BCBSNJ) Representatives

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

Minutes – Meeting No. 477, February 13, 2008. A correction to the minutes for case 020808 was made to show that Michael Malloy voted against the motion. Michael Malloy made a motion to accept the minutes with the correction. Dudley Burdge seconded the motion. All voted in favor.

Issues

1.  N.J.A.C. 17:9-13 (Chapter 375 Dependents) - For Approval

Richard Dougherty made a motion to approve the regulation.  Kevin Kelleher seconded the motion. Approved (Commissioner Culliton abstained).

2.   NJ Direct Included Under Mental Health Parity Exemption - FYI

A letter needs to be filed with CMS to update the Mental Health Parity Exemption to include NJ DIRECT.

3.  Open Enrollment

Dave Pointer gave a brief update on the status of Open Enrollment. 

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.  Dudley Burdge seconded the motion.  All voted in favor.

Case #030801 – This Horizon BCBSNJ - Traditional Plan appeal concerned continuation of coverage for a disabled dependent.  The medical necessity to continue enrolment as a disabled dependent was not established.  Michael Malloy made a motion to deny this appeal.  Susanne Culliton seconded the motion.  All voted in favor.

Case #030802 – This Horizon BCBSNJ - Traditional Plan appeal concerned the denial of benefits for expenses for surgery which was deemed cosmetic in nature.  The member sought a precertification of the procedure but chose to have the surgery before a determination was made.  Susanne Culliton made a motion to table this appeal to allow Horizon BCBSNJ to review the prescription drug history of the member and have the medical director review it.  Richard Dougherty seconded the motion.  All voted in favor.

Case #030803 Final Administrative Decision concerns a Horizon BCBSNJ – Traditional Plan appeal for the denial of payment for expenses above the reasonable and customary allowance for surgery.  Susanne Culliton motioned to approve the draft of the Final Administrative Decision.  Richard Dougherty seconded the motion.  Approved (Commissioner Malloy 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.

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 11:14 AM.

Respectfully submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission

 

 

 


Meeting No. 479
April 9, 2008
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, April 9, 2008. 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, R. David Rousseau
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
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 (Horizon BCBSNJ) Representatives
Aetna Representatives

Resolutions A (Closed Session) and B (Executive Session) - were read in their entirety. Susanne Culliton made a statement indicating that a court reporter was present to record the meeting.

  1. Minutes – Meeting No. 478, March 12, 2008.  Richard Dougherty made a motion to accept the minutes. Susanne Culliton seconded the motion.  Approved (Commissioner Richard abstained).
  2. Issues

Dental Implants Memo: The NJEA Commission representative requested that the Division review the current dental policy that excludes coverage for Dental Implants with the possibility that such coverage could be added to the State Health Benefits Program’s (SHBP) dental plans.  Leonard Leto, Manager, Policy and Planning responded to the request in a memo to the Commission. The policy was reviewed and it was found that very few plans offer the benefit since generally the maximum benefit designs in the market place would not sustain the coverage of even one tooth before the maximum would be hit. While the addition of this procedure would provide SHBP members with a valuable benefit, it would also have a significant impact on the dental program cost.

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 #040801 – This Aetna Dental Plan Organization appeal concerned a denial of benefits for dental implants and other proposed services.  Susanne Culliton made a motion to deny this appeal since dental implants are excluded under the plan.  Richard Dougherty seconded the motion.  All voted in favor.

Case #040802(Member Present) This Horizon BCBSNJ - Traditional Plan appeal concerned the denial of benefits for a surgical procedure deemed investigational.  Susanne Culliton made a motion to go into Executive Session. Kevin Kelleher seconded the motion.  All voted in favor.  Upon returning to closed session, Susanne Culliton made a motion to approve this appeal due to the unique circumstances for this particular case.  The expenses will be paid at the reasonable and customary amount.  Michael Malloy seconded the motion.  All voted in favor.

Case #040803 – This Aetna Dental Expense Plan Organization appeal concerned a denial of benefits for dental implants as an alternate benefit.  Richard Dougherty made a motion to deny this appeal since dental implants are excluded under the plan.  Kevin Kelleher seconded the motion.  All voted in favor.

Case #040804 – The Division Appeal concerned denial of payments for retroactive reimbursement for Medicare Part B premiums for more than one year for the member and spouse.  Richard Dougherty made a motion to deny this appeal. Michael Malloy seconded the motion.  All voted in favor.

Case #040805 – This Horizon BCBSNJ - NJ PLUS appeal concerned denial of pre-authorization of surgery deemed cosmetic in nature.  Michael Malloy made a motion to deny this appeal since the medical necessity and appropriateness criteria for the requested services had not been met. Susanne Culliton seconded the motion.  All voted in favor.

Case #040806(Member Present) This Horizon BCBSNJ - NJ PLUS appeal concerned the denial of benefits for an auto related injury. The Commission denied this appeal at the September 2007 meeting with the stipulation that if documentation was submitted to prove that PIP benefits were not available, the appeal could be brought back to the Commission. Susanne Culliton made a motion to authorize payment for medical claims and to work with Horizon BSBCNJ to obtain full reimbursement of those medical claims that are payable under the plan and are asserted as a lien against the member’s settlement with the auto insurance carrier.  Richard Dougherty seconded the motion. All voted in favor.

Case #040807 – The member requested that the Commission’s previous denial of an appeal for benefits for the expenses above the reasonable and customary allowance for surgery be forwarded to the Office of Administrative Law (OAL) for a hearing.  Michael Malloy motioned to approve this request to forward the case to the Office of Administrative Law (OAL).  Kevin Kelleher seconded the motion. All voted in favor.

There being no further appeals, a motion was made to return to open session by Richard Dougherty, seconded by Kevin Kelleher. All voted in favor.  Subsequently, there was a motion to adjourn which was made by Kevin Kelleher, seconded by Susanne Culliton. All voted in favor. The State Health Benefits Commission meeting was adjourned at 11:52 AM.

Respectfully submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission

 

 

 


Meeting No. 480
May 14, 2008
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, Tuesday, May 14, 2008. 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, R. David Rousseau
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 Sheppard, Deputy Director, Division of Pensions and Benefits
Len 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 (Horizon BCBSNJ) Representatives

Resolutions A (Closed Session) and B (Executive Session) - were read in their entirety. A court reporter was present to record the meeting.

  1. Minutes – Meeting No.479, April 9, 2008.  Susanne Culliton made a motion to go into Executive session under Resolution B. Michael Malloy seconded the motion and all voted in favor. Upon return to the Public session, Richard Dougherty made a motion to accept the Minutes and to add a sentence to the Executive Session minutes.  Kevin Kelleher seconded the motion.  Approved (Commissioner Dudley Burdge abstained).
  1. Issues

    N.J.A.C. 17:9-5.3, Local Employer Payment of Charges
    :  Susanne Culliton made a motion to go into Executive Session under Resolution B for legal interpretation of the regulation and Richard Dougherty seconded the motion.  Approved (Commissioner Kelleher abstained and Commissioner Burdge against). Upon return to the Public session, Michael Malloy made a motion to adopt the regulation and Richard Dougherty seconded the motion.  Approved (Commissioner Kelleher abstained and Commissioner Burdge 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 under Resolution A.  Richard Dougherty seconded the motion.  All voted in favor.

Case #050801 This $69,126.56 Traditional Plan appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for separate surgeries on November 3, 2006 , May 29, 2007 and May 30, 2007.  Susanne Culliton made a motion to deny this appeal. Kevin Kelleher seconded the motion. All voted in favor.

Case #050802 (Member present) This $19,500 Traditional Plan appeal concerned a denial of benefits for surgery for a panniculectomy and flank lipectomy.  Michael Malloy made a motion to approve the panniculectomy as an exception but subsequently withdrew the motion.  He then made a motion to approve both the panniculectomy and flank lipectomy due to the unique circumstances for this particular case.  The claims will be paid in accordance with the contract.  Kevin Kelleher seconded the motion.  All voted in favor.

Case #050803 This NJ PLUS appeal concerns a denial of an authorization for a proposed Bilateral MRI of the Breast.  Michael Malloy made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor.

Case #050804 – This Horizon appeal concerned a denial of benefits for expenses for Growth Hormone Therapy for two dependent children who did not meet the medical criteria stated in Horizon Blue Cross Blue Shield of New Jersey’s medical policy. Michael Malloy made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor. 

Case #050805 – (Member present) This $5,047.79 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for two separate unrelated surgeries for the member’s daughter. The issue of coordination of benefits should be pursued by the member with the other insurance carrier. Dudley Burdge made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor.

Case #050806 – Susanne Culliton made a motion to table this settlement proposal pending additional information. Eileen Den Bleyker will contact Francesca Sollima, Associate Counsel for ACS Recovery Services. Richard Dougherty seconded the motion. All voted in favor.

Dudley Burdge made a motion to return to Public session. Richard Dougherty seconded the motion and all voted in favor. 

Jean Williamson announced that the July 9, 2008 State Health Benefits Commission meeting will be cancelled. 

Dudley Burdge expressed concern about security of the health risk assessments. David Pointer stated that the Division of Pensions and Benefits will request information from the health carriers concerning security. Dudley Burdge made a motion to request the information and Kevin Kelleher seconded the motion. All voted in favor.

Kevin Kelleher requested a listing of the new Local Employers. David Pointer indicated that it would be available quarterly.

There was some discussion about coordination of benefits. Wendy Rutan stated “When Horizon is secondary, they will pay the lesser of the amount that will take the claim to charge or our normal liability.”

There being no further business to transact, a motion to adjourn was made by Dudley Burdge and seconded by Kevin Kelleher. All voted in favor. The State Health Benefits Commission meeting was adjourned at 12:45 am.

Respectfully submitted,

Jean M. Williamson, CEBS
Acting Secretary
State Health Benefits Commission


 

 

 


Meeting No. 481
June 11, 2008
Minutes 10:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:12 AM, Wednesday, June 11, 2008. 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, R. David Rousseau
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Richard Dougherty, representing Acting Commissioner Hope Cooper, Department of Personnel
Kevin Kelleher, NJEA

ALSO PRESENT:

Eileen Den Bleyker, Deputy Attorney General
Leonard 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
Aetna Representatives

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

  1. Minutes – Meeting No. 480, May 14, 2008.  Richard Dougherty made a motion to accept the minutes. Susanne Culliton seconded the motion.  All voted in favor.
  1. Issues

    1. Performance Guarantees – FYI

For calendar year 2007, Horizon failed to meet only the Traditional Plan Payment Incidence Accuracy standard, which amounts to a penalty of $563,348.

Aetna HMO failed to meet the Measured Data Standard for the DOBI HMO report card, which amounts to a penalty of $937,930.

Aetna was present to field/address any related questions or concerns regarding their 2007 HEDIS performance. Aetna representatives stated that Aetna is committed to continuous quality improvement and is devoting resources to both promote the delivery of the appropriate preventive and chronic care services and improve their reporting plan performance.

Commissioner Malloy asked that Aetna representatives provide the commission with an explanation of why they were below the performance standard required as stated in the contract. It was added that this is the second year in a row that Aetna has fallen below the performance standards.

Aetna representatives explained that there are three general factors contributing to their sub par performance:  1) data capture; 2) suboptimal record collection; and 3) data collection methodology (hybrid vs. administrative data only methodology. Hybrid data collection includes the capture of data via claims, as well as on-site chart review. Administrative data collection is limited to claims related data, and does not include any on-site file review in providers’ offices. HEDIS reporting involves very long lead-times; the service reflected in 2008 HEDIS was delivered in 2007 and we completed our data collection for 2008 on May 16, 2008. Several enhancements have been added to the data capture system for Aetna. 

Commissioner Dougherty asked if they were confident that the current system will show improvement.  Aetna representatives stated that they are confident that their 2008 HEDIS results will show improvement over their 2007 results. However, several enhancements to their data collection for the behavioral health measures were not fully implemented for 2008, thus 2008 HEDIS results may not show as much improvement as the 2009 HEDIS results, when the results will reflect these enhancements. 

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 #060801(Member Present) This NJ PLUS appeal concerned a denial of benefits for expenses for ABA therapy provided by Childs Play, Inc.  Susanne Culliton made a motion to go into Executive Session under Resolution B. Kevin Kelleher seconded the motion. All voted in favor. Upon returning to closed session, Richard Dougherty made a motion to deny this appeal for two reasons: 1) Reimbursement under the plan is only available for services provided by an eligible provider and 2)  ABA therapy is considered investigational. He also moved that Horizon BCBSNJ continue to review data on ABA therapy, such as the NIH study, and to advise the Commission of any policy changes. Kevin Kelleher seconded the motion. All voted in favor. Susanne Culliton made a motion to expedite this appeal to the Office of Administrative Law (OAL). Richard Dougherty seconded motion. All voted in favor.

Case #060802(Member Present with Attorney) This Division appeal concerned the denial of health benefits coverage under the retired group of the State Health Benefits Program based on a PERS Board Determination. The member does not meet the definition of “retired employee” under the provisions of N.J.A.C.17:9-6.1(b)(2). Kevin Kelleher made a motion to go into Executive Session under Resolution B.  Richard Dougherty seconded the motion. All voted in favor.  Upon returning to closed session, Susanne Culliton made a motion to deny the appeal based on factual finding from the PERS Board that member was an employee of Mt. Laurel. Motion was subsequently withdrawn. Kevin Kelleher made a motion to continue paying for post-retirement health benefits coverage during the member’s appeal. This motion was also withdrawn. Susanne Culliton made a motion to deny this request; motion was withdrawn. Susanne Culliton made a motion to go into Executive Session. Kevin Kelleher seconded the motion. All voted in favor. Upon returning to closed session, Michael Malloy made a motion to deny the appeal and to permit the member to remain enrolled in the SHBP at his own expense for forty-five days ending August 1, 2008. Richard Dougherty seconded the motion. All voted in favor.

Case #060803 (Member Present) This Horizon BCBSNJ Traditional Plan appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for surgery for member’s spouse.  The eligible amount considered for the procedure represents the HIAA reasonable and customary charge.  Susanne Culliton made a motion to deny this appeal. Richard Dougherty seconded the motion.  All voted in favor.

Case #060804(Member’s Mother Present) This tabled Traditional Plan appeal concerned denial of benefits for expenses for a surgical procedure deemed cosmetic in nature. Horizon BCBSNJ conducted a review of the prescription drug record and the member submitted additional medical documentation.  The Medical Director from Horizon BCBSNJ indicated that his position did not change following the review of the additional documentation since the instances of sinusitis were not close in time to the surgical Rhinoplasty and there was nothing in the prescription drug history that changed his opinion.  Michael Malloy made a motion to deny this appeal. Susanne Culliton seconded the motion.  All voted in favor.

Case #060805(Member Present) This tabled NJ PLUS appeal concerned a denial of benefits for expenses for surgeries for a work related injury.  There is no medical report indicating the need for surgical correction of narrowing of nasal passage or correction of sense of smell.  Kevin Kelleher made a motion to deny this appeal. Susanne Culliton seconded the motion.  All voted in favor.

Case #060806 – Susanne Culliton made a motion to approve settlement proposal. Richard Dougherty seconded the motion. Approved,  Vote 3:1: Commissioners Culliton, Kelleher, and Dougherty voted in favor.  Commissioner Malloy abstained. 

There being no further appeals, a motion was made to return to open session by Kevin Kelleher, seconded by Richard Dougherty. All voted in favor. Kevin Kelleher inquired about the tiering of benefits under Chapter 62. Some education employers have a contract where they pay for single coverage for the first three years and then after that time they pay for family coverage. This can occur at anytime during the year. Florence Sheppard indicated that the Division would have to look into it; if it is done the Administrative Code would have to be modified. Kevin Kelleher will send a sample contract to Florence Sheppard. 

There being no further business, there was a motion to adjourn which was made by Kevin Kelleher, seconded by Susanne Culliton. All voted in favor. The State Health Benefits Commission meeting was adjourned at 1:38 PM.

                                                                  Respectfully submitted,

                                                                  Jean M. Williamson, CEBS
                                                                  Acting Secretary
                                                                  State Health Benefits Commission


Meeting No. 482
August 13, 2008
Minutes 9:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 9:11 AM, Wednesday, August 13, 2008. 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, R. David Rousseau
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Patrick Nowlan, representing AFL-CIO Representative for Local Government Employees.
Dudley Burdge, representing AFL-CIO Representative for State Government Employees

ALSO PRESENT: 

Eileen Den Bleyker, Deputy Attorney General
Jean Williamson, Acting Secretary
David Pointer, Chief, Operations, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives
Aetna Representatives
Aon Representatives

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

  1. Minutes – Meeting No. 481, June 11, 2008. Florence Sheppard made a motion to accept the minutes. 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 under Resolution A. Michael Malloy seconded the motion.  All voted in favor.

Case #080801(Member Present) This NJ PLUS appeal concerned a denial of an authorization for a proposed Bilateral MRI of the breast. This appeal had been denied by the Commission on May 14, 2008. The member attempted to notify the Division that she was unable to attend the May meeting due to illness, however, the Division staff did not receive the message until after the meeting. The Division made an administrative decision to have the Commission reconsider this appeal in order to give the member the opportunity to present her case in person. The medical director from Horizon Blue Cross Blue Shield of New Jersey indicated that the criteria were not met in order for an MRI to be a covered benefit.  Michael Malloy made a motion to deny this appeal. Florence Sheppard seconded the motion. Denied (Vote 3:1. Commissioner Burdge abstained). Since the member had previously requested that the appeal be forwarded to the Office of Administrative Law (OAL), Florence Sheppard made a motion to refer this case to OAL. Patrick Nowlan seconded the motion. Approved: All voted in favor.

Case #080802(Member Present) This Horizon-Traditional Plan and Aetna Dental Expense Plan appeal concerned the denial of benefits for orthodontic treatment. Michael Malloy made a motion to go into Executive Session. Dudley Burdge seconded the motion. All voted in favor. Michael Malloy made a motion to approve the appeal as an exception. Patrick Nowlan seconded the motion. Approved (Vote 3:1: Commissioner Sheppard nae).

Case #080803 (Member Present) This Horizon Traditional Plan appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for surgery. The Traditional Plan covers only reasonable and customary allowances. Dudley Burdge made a motion to deny this appeal. Michael Malloy. Denied:  All voted in favor.
                                   
Case #080804(Member Present) This Traditional Plan appeal concerned denial of benefits for expenses for speech therapy. The speech therapy services rendered did not fall under the definition of speech therapy benefits as defined in the SHBP Traditional Plan Member Handbook. Michael Malloy made a motion to deny this appeal. Florence Sheppard seconded the motion. Denied (Vote 3:1: Commissioner Burdge abstained).

Case #080805 – The member requested that the Commission’s previous denial of an appeal for benefits for the expenses for a surgical procedure deemed cosmetic in nature be forwarded to the Office of Administrative Law (OAL) for a hearing.  Michael Malloy motioned to approve this request for a hearing at the OAL.  Florence Sheppard seconded the motion.  Approved (Vote 3:1: Commissioner Nowlan abstained).

Case #080806 – OAL Initial Decision concerning a Horizon Traditional Plan appeal for in-patient stay at Three Springs' facility. Florence Sheppard made a motion to table this case to request transcripts referred to in OAL decision. Dudley Burdge seconded the motion. Approved: All voted in favor.

There being no further appeals, a motion was made to return to open session and reconvene at 11:30 by Dudley Burdge, seconded by Florence Sheppard. All voted in favor.

  1. Issues

The Commission reconvened in public session at 11:30. Edward Fox, Aon Consulting, gave a general overview of the rate renewal. Susan Marsh gave an overview of the 2009 Rate Renewal Recommendations for Medical/Rx for the Active Employees and Retirees of the State group, Active Employees and Retirees of the Local Government, and the Dental Plans. Also present from Aon Consulting were James Christ and Kristine Klepper.

The following summarizes Aon Consultants’ recommendation for the 2009 Medical/Rx Renewal for Active Employees and Retirees of the State Group, the Local Group, and the Dental Plans.

Recommended Plan Year 2009 Medical/Rx Renewal
For Active Employees and Retirees
Of the State Group


  • For Plan Year 2009, Aon is recommending premium rate changes that – in the aggregate – represent an overall increase of 4% for State Active Employees and Retirees:

clip2

  • This recommended renewal assumes:
    • Scheduled increases in the NJ DIRECT Rx copays and the out-of-pocket (OOP) maximum for Retirees;
    • $1 increase in HMO Retiree Rx Brand copays combined with the implementation of a $1,160 (same as NJ DIRECT) out-of-pocket maximum;
    • Aetna Medicare HMO coverage for medical claims will change from an ASO program which supplements Medicare to a fully insured Medicare Advantage program;
    • State Police and select Correction and Judiciary unions have not yet settled their contracts, so Employees in these unions (aka Legacy Employees) will continue with their current benefit plans;
    • Premium Rates for overage dependents will be reduced from 110% of the Single Employee rate to 41% of the Single Employee rate in compliance with new State Law;
    • No other changes in employee or retiree benefits;
    • State Employee enrollment will decrease 1.8% in Plan Year 2009, due to normal attrition combined with the August 2008 early retirement initiative; and
    • State Retiree enrollment will increase 6.6% in Plan Year 2009, due to normal retiree growth combined with the August 2008 early retirement initiative.
  • Aggregate differences in the rate changes for different benefit plans and between Actives and Retirees reflect the impact of:
    • Medicare Retiree medical trends have been below 5% in each of the past two years – much lower than industry norms, and we are projecting that the low trend levels will continue into Plan Years 2008 and 2009.
    • Historically, Early Retiree HMO rates were pooled with Active HMO rates to develop premiums.  Since there are now over 4,000 State Early Retirees enrolled in HMOs, the Plan Year 2009 Renewal Rates were adjusted to partially reflect the higher level of claim costs attributable to Early Retirees; and
    • HMO claim trends have averaged about 3% higher than Horizon trends over the most recent two years of experience, and we are projecting that HMOs will continue to trend at a higher rate than the Horizon plans.
  • Factors contributing to the overall favorable rate actions include:
    • Favorable experience for Plan Year 2007 and favorable experience projected for Plan Years 2008 and 2009;
    • Benchmark trends have decreased 1.5% for medical and 3% for Rx over the past two years; and
    • The new benefit landscape effective April 1, 2008, with the new PPO plans replacing NJ PLUS and the Traditional Plan for 88% of State Employees, as well as a reduction in the number of HMOs from 5 to 2, resulted in lower overall SHBP costs due to improved provider discounts, greater rebates, reduced vendor administrative fees, and an overall increase in managed care.
  • The premium levels for Plan Year 2009 are projected to match projected costs for that period, so no loss or gain is projected for this period.

Recommended Plan Year 2009 Medical/Rx Renewal
For Active Employees and Retirees
Of the Local Government Group


  • For Plan Year 2009, Aon is recommending premium rate changes that – in the aggregate – represent an overall increase of 4% for Local Government Active Employees and Retirees:

clip4

  • This recommended renewal assumes:
    • Scheduled increases in the NJ DIRECT Rx copays and the out-of-pocket (OOP) maximum for Retirees;
    • $1 increase in HMO Retiree Rx Brand copays combined with the implementation of a $1,160 (same as NJ DIRECT) out-of-pocket maximum;
    • Aetna Medicare HMO coverage for medical claims will change from an ASO program which supplements Medicare to a fully insured Medicare Advantage program;

    • Premium Rates for overage dependents will be reduced from 110% of the Single Employee rate to 41% of the Single Employee rate in compliance with new State Law;
    • No other changes in employee or retiree benefits; and
    • Local Government enrollment will increase 1.2% in Plan Year 2009, in continuation of the increases in enrollment in Plan Year 2008.
  • Aggregate differences in the rate changes for different benefit plans and between Actives and Retirees reflect the impact of:
    • Medicare Retiree medical trends averaged less than 5% over the past two years – much lower than industry norms, and we are projecting that the low trend levels will continue into Plan Years 2008 and 2009.
    • Historically, Early Retiree HMO rates were pooled with Active HMO rates to develop premiums.  Since there are now over 2,000 Local Government Early Retirees enrolled in HMOs, the Plan Year 2009 Renewal Rates were adjusted to partially reflect the higher level of claim costs attributable to Early Retirees; and
    • HMO claim trends have averaged about 5% higher than Horizon trends over the most recent two years of experience, and we are projecting that HMOs will continue to trend at a higher rate than the Horizon plans.
  • Factors contributing to the overall favorable rate actions include:
    • Favorable experience for Plan Year 2007 and favorable experience projected for Plan Years 2008 and 2009;
    • Benchmark trends have decreased 1.5% for medical and 3% for Rx over the past two years; and
    • The new benefit landscape effective April 1, 2008, with the new PPO plans replacing NJ PLUS and the Traditional Plan, as well as a reduction in the number of HMOs from 5 to 2, resulted in lower overall SHBP costs due to improved provider discounts, greater rebates, reduced vendor administrative fees, and an overall increase in managed care.
  • The premium levels for Plan Year 2009 are projected to result in a $28 million loss, which will reduce Local Government claim stabilization reserve to $181 million.  This is equivalent to 3.3 months of claims, which exceeds the target reserve of 3.0 months of claims.

Recommended Plan Year 2009
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 2009:
Dental Expense Plans
     
  Actives  0.0%
  Retirees   0.0%
     
Dental Plan Organizations
     
  Aetna, BeneCare, Community, Healthplex 3.5%
  CIGNA   2.0%
  Horizon 0.0%
  • For the Dental Expense Plans, 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 the DPOs, the maximum increase of 3.5% is the expected increase in dental claim costs from Plan Year 2008 to Plan Year 2009, based on the Dental Expense Plan trend analysis. The size of DPO renewal increase is based on their Value Ratios: DPOs with Value Ratios above 1.00 received the maximum increase of 3.5%, those with Value Ratios between .90 and 1.00 received a 2% renewal increase, and those below .90 received no renewal increase.
  • The Plan Year 2009 renewal assumes no change in Dental benefits or Dental vendors.
  • Aon is projecting a total claim stabilization reserve for the Employee Dental Expense Plan at the end of Plan Year 2009 of $14 million. This is equivalent to 3.0 months of claims, which exceeds the target reserve of 2 months of claims. Therefore, there is no margin included in the Plan Year 2009 Employee Dental Expense Plan premiums.
  • Aon is projecting a total accumulated claim stabilization reserve for the Retiree-pay-all Dental Expense Plan at the end of Plan Year 2009 of $5.7 million. This is equivalent to 1.9 months of claims, which is close to the target reserve of 2 months of claims. Therefore, there is no margin included in the Plan Year 2009 Retiree Dental Expense Plan premiums.
  • Aon is projecting very little change in Employee Dental enrollment between Plan Years 2008 and 2009:  62,000 employees enrolled in the Dental Expense Plan and 42,000 employees enrolled in the DPO plans. Retiree Dental Expense Plan enrollment is expected to increase 9% to 50,000 for Plan Year 2009.
  • Exhibit 9 of the Dental Plans Rate Renewal Recommendation Report is a strategic review of the dental programs and offers a number of recommendations to:
    • Increase member satisfaction with the Program;
    • Help manage the costs of the Program, and
    • Potentially increase enrollment in the lower-cost DPO component of the Program.

I announced that there would be a Special State Health Benefits Commission meeting on Thursday, August 21, 2008 @ 10:00.  There being no further business, Florence Sheppard made a motion to adjourn which was, seconded by Michael Malloy. All voted in favor. The State Health Benefits Commission meeting was adjourned at 12:35 PM.

Respectfully submitted,

Jean M. Williamson
Acting Secretary
State Health Benefits Commission

 

 

 


Meeting No. 483
August 21, 2008
Minutes 10:00 AM
Special Meeting of the
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:11 AM, Thursday, August 21, 2008. 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, David Rousseau
Neil Vance, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Patrick Nowlan, New Jersey Local AFL-CIO
Dudley Burdge, New Jersey State AFL-CIO

ALSO PRESENT: 

Eileen Den Bleyker, Deputy Attorney General
Fred Beaver, Director, Division of Pensions and Benefits
Florence J. Sheppard, Deputy Director
Jean Williamson, Acting Secretary
David Pointer, Chief, Operations, State Health Benefits Program

Aon Consultants:
Ed Fox
Susan Marsh
Jim Christ
Kris Kleeper

Commissioner Cullition asked if there were any additional questions concerning the 2009 Rate Renewals which were presented at the previous meeting on August 13, 2008. 

Commissioners Burdge and Nowlan had submitted questions concerning the 2009 Rate Renewals via e-mail prior to the meeting. Aon Consulting responded to all of the questions posed in writing. E-mails of those responses were forwarded to the Commission members and hard copies were available for them at the meeting. Ed Fox addressed the Commission members and asked if there were any additional questions that were not answered in the emails. 

Commissioner Burdge asked for and received clarification of the increase in copayments under the HMOs for retiree prescription drugs. Commissioner Burdge asked what the legislative mandates were for C375, P.L. 2005, as amended by C38, P.L. 2008.  Susan Marsh responded, “The Legislation mandates that the SHBP can not charge more for an adult child compared to a Parent/Child and Family coverage.”  Commissioner Burdge asked, “What is the difference the parent/adult child will see in rates?”  Susan Marsh responded a decrease in the range of 60%; half of what they paid last year. Ms. Marsh explained that as an optional benefit, you have to expect anti-selection. Forty percent is low to cover it.  Commissioner Burdge asked, “Do we have any information on the insured market?” Susan Marsh responded, “No, there is a significant loss for the SHBP as mentioned in the report.” Commissioner Vance added that the Department of Banking and Insurance has a little bit of information on the number of people enrolled in this program. There are a total of approximately 10,000 people covered. The rate is 60 – 80% of single rate in the commercial market. Enrollment is running higher in small groups verses large groups. 

Ed Fox advised the Commission the target date for an audit of Magellan is the end of Q1. 2009. Susan Marsh discussed Magellan’s Risk/Share Agreement. Commissioner Burdge stated that a large amount of people are going out-of-network for mental health behavioral benefits. Is there a review of the out-of-network claims? Ed Fox asked Dave Perry of Horizon Blue Cross Blue Shield of New Jersey if he would respond to that issue. Mr. Perry explained how the process was changed in 2007. Pre-certification for out-of-network Mental Health services must be requested before the 8th visit. When additional sessions are needed, the out-of-network provider is required to complete a Treatment Request Form (TRF) or post 8th visit claims will be declined.  Commissioner Nowlan asked, “Since the implementation has there been a cost savings?”  Dave Perry responded, “YES.”

Dudley Burdge made a motion to freeze generic drug copayment for various plans until 2010 or until there is a $15.00 difference between generic and brand name drugs. Patrick Nowlan seconded the motion. Eileen Den Bleyker advised the Commission that the motion was not on the agenda and should be tabled to the next commission meeting. Dudley Burdge withdrew the motion. In order to put an item on the agenda, a request should be given to the Chairperson.

Commissioner Culliton asked if there were any questions in reference to the Local Government Group Rates. Commissioner Vance asked, “What is the competitive nature of the SHBP rates verses market?”  Susan Marsh responded, “They have been kept as low as possible; the average is 3 - 4%. We expect a favorable response.”

Neil Vance made a motion to approve the 2009 Rate Renewals (all 3 sets:  State, Local Employer and Dental). Susanne Culliton seconded the motion. All voted in favor.

There being no further business to transact, a motion was madeto adjourn by Susanne Culliton, seconded by Neil Vance. All voted in favor. The State Health Benefits Commission meeting was adjourned at 11:05 AM.

                                                                  Respectfully submitted,

                                                                  Jean M. Williamson, CEBS
                                                                  Acting Secretary


Meeting No. 484
September 10, 2008
Minutes 1:00 PM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 1:09 PM, Wednesday, September 10, 2008.  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, R. David Rousseau
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Hope Cooper, Chair, Civil Service Commission
Patrick Nowlan, representing AFL-CIO Representative for State Government Employees.
Dudley Burdge, representing AFL-CIO Representative for Local Government Employees
(Commissioner Burdge left the meeting at 4:00 PM)

ALSO PRESENT: 

Eileen Den Bleyker, Deputy Attorney General
Florence J. Sheppard, Deputy Director
Frederick J. Beaver, Director, Pensions and Benefits
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.

Minutes – Meeting No. 483, August 21, 2008. Susanne Culliton made a motion to accept the minutes. Dudley Burdge seconded the motion. Approved (Vote 3:2: Commissioners Cooper and Malloy abstained.)

Issues

A. New Dental Code
The new code separates and clarifies a procedure that dentists are already performing.
Michael Malloy made a motion to approve the new dental code.  Hope Cooper seconded the motion.  All voted in favor.

B. COBRA Vision Rates 
Michael Malloy made a motion to approve the COBRA Vision Rates.  Hope Cooper seconded the motion.  Approved (Vote 4:1: Commissioner Burdge abstained.)

C. N.J.A.C. 17:9
Susanne Culliton removed herself as chairperson to be available for any questions pertaining to the regulations. Florence J. Sheppard replaced her as chairperson for this portion of the meeting.

The commission was to considering publishing the SHBP regulations. Due to the large agenda of the meeting, the commission requested more time to review. Patrick Nowlan motioned to table this issue to be heard at a Special State Health Benefits Meeting to be scheduled for the following week. Hope Cooper seconded the motion. All voted in favor. Susanne Culliton resumed her position as chairperson.

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

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

Case #090801 – This Horizon Traditional Plan appeal concerned a denial of in-patient residential treatment for a dependent child. The member did not meet ASAM PC-2R dimensional criteria for residential treatment. Susanne Culliton made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor.

Case #090802(Member Present) This Horizon-NJ PLUS Plan-Magellan Health Services appeal concerned the denial of benefits for continued inpatient residential treatment for member’s dependent child. On 3/11/08 the Level II appeal was heard by the Horizon Member Appeal Subcommittee, and it was determined that the criteria for residential treatment was met through 3/4/08. Based on the continued application of ASAM criteria, residential treatment was not met from 3/5/08 through 3/12/08. Dudley Burdge motioned to table this appeal to give the member time to get documentation from the Caron Foundation concerning the level of care received by the dependent child after March 4, 2008 through June 5, 2008 and a justification for that period of time. Member was given 30 days time to provide the documentation. Patrick Nowlan seconded the motion. All voted in favor.

Case #090803 (Member Present) This Horizon - NJ DIRECT 15 appeal concerned a denial of benefits for In Vitro Fertilization (IVF) treatment. Susanne Culliton made a motion to go into executive session under Resolution B. Hope Copper seconded the motion. All voted in favor. Dudley Burdge made a motion to approve this grandfather this appeal under NJ PLUS plan to complete the cycle. Patrick Nowlan seconded the motion. All voted in favor.
                                   
Case #090804 – The member requested that the Commission’s previous denial of an appeal for benefits for the expenses for a surgical procedure deemed cosmetic in nature be forwarded to the Office of Administrative Law (OAL) for a hearing.  Susanne Culliton motioned to approve this request for a hearing at the OAL. Michael Malloy seconded the motion. All voted in favor.

Case #090805 – An initial decision by the Office of Administrative Law (OAL) upholding the Commission’s previous denial of an appeal for Trigger Point Injections was considered. Susanne Culliton made a motion to accept the OAL decision.  Hope Cooper seconded the motion. All voted in favor.

Case #090806 – An initial decision by the Office of Administrative Law (OAL) that reversed the Commission’s previous denial of an appeal for Horizon-Traditional Plan for the stay of a dependent child at Three Springs, Inc., an ineligible facility was considered. Dawn Harris, DAG provided an overview of the appeal and a summary of the exceptions. Susanne Culliton made a motion to go into Executive Session under Resolution B. Michael Malloy seconded the motion and all voted in favor.  Upon returning to open session, Susanne Culliton made a motion to reject the OAL decision and issue a Final Administrative Determination (FAD). Hope Cooper seconded the motion.  Approved (Vote 3:2 Commissioners Burdge and Nowlan abstained).

Case #090807 – An initial decision by the Office of Administrative Law (OAL) that reversed the Commission’s previous denial of an appeal for Horizon-NJ PLUS for occupational and physical therapies was considered. Susanne Culliton made a motion to reject the OAL decision for the reasons set forth in the exceptions by the Deputy Attorney General and issue a Final Administrative Determination (FAD).  Hope Cooper seconded the motion. Approved (Vote 3:1, Commission Nowlan abstained).

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

There being no further business, Susanne Culliton made a motion to adjourn which was, seconded by Patrick Nowlan.  All voted in favor. The State Health Benefits Commission meeting was adjourned at 4:10 PM.

Respectfully submitted,

Jean M. Williamson, CEBS
Acting Secretary
State Health Benefits Commission

 

 

 


Meeting No. 485
September 18, 2008
Minutes 10:00 AM
Minutes of the Special Meeting of the
State Health Benefits Commission

The special meeting of the State Health Benefits Commission was called to order at 9:49 AM, Thursday, September 18, 2008. 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 Sheppard, representing State Treasurer, R. David Rousseau
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Hope Cooper, Chair, Civil Service Commission
Patrick Nowlan, representing AFL-CIO Representative for State Government Employees (Via telephone).
Dudley Burdge, representing AFL-CIO Representative for Local Government Employees (Commissioner Burdge left the meeting at 4:00 PM)

ALSO PRESENT: 

Eileen Den Bleyker, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Susanne Culliton, Assistant Director
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary

ISSUES

N.J.A.C. 17:9

The issue to consider publishing the SHBP regulations was before the Commission at its regular meeting on September 10, 2008. Due to the large agenda of that meeting, the Commission requested more time to review the regulations. A motion was passed to table the regulations and hold a Special State Health Benefits Meeting to be scheduled for the following week. 

Susanne Culliton indicated that questions from Dudley Burdge were received concerning the regulations via e-mail.  Below are the questions in italics and the answers that were given during the meeting.

  • Upon further review of the proposed NJAC 17:9-1.1(c)  it appears that the deletion of language pertaining to the employee representatives (or the Public Employees’ Committee of the AFL-CIO or the New Jersey Education Association) now makes this section read that only ex-officio members can designate an alternate.
  • 17:9-1.1(b)  What is the reason that two classes of Commission members are created for the purpose of a quorum (ex-officio and labor representatives)? Where in the statutes adding members representing public employees is such a distinction authorized?

Susanne Culliton indicated that this is a change It first came up when the Department of Personnel was decimated.  The question arose, “can the Civil Service Commission Chairperson designate someone to attend State Health Benefits Commission meetings”? The Attorney General’s Office advised the Division that the statute authorizes the Treasurer and Commissioner of the Department of Banking and Insurance to send a designee. Eileen Den Bleyker said that this was the first time advice was sought on this issue.  She explained that there needs to be express statutory authority to send designees; therefore it is appropriate to change the regulation.  Commissioner Burdge asked for it in writing. Frederick Beaver said that he sent a letter to Charlie Wowkanech explaining this change. 

  • 17:9-2   I believe that language should be added to reflect the current practice of posting agendas and Commission minutes on-line in addition to the procedure for viewing paper copies at the Division.

Susanne Culliton explained that the regulations are to show who holds the official record. Dudley Burdge said it may save time and effort. Susanne Culliton replied that there have been no requests. 

  • General Question -- how can all references to the Traditional Plan and NJ PLUS be eliminated when some state workers continue in those plans?

Susanne Culliton replied that the references to the Traditional Plan and NJ PLUS were removed from the Local Employer section, not the State section of the regulations.

  • 17:9-2.14 (adoption by reference of all policy provision in contracts) In the Micheletti decision by the Appellate Division, the court criticized this section as granting "unbridled discretion", recommended changing this regulation and spoke favorably of the DOBI regulations concerning Biologically Based Mental Illnesses (BBMI) as being unambiguous.  Was consideration given to this recommendation of the court? If so, what were the reasons for not adopting regulations concerning BBMIs similar to the DOBI regulations?

    What is the current policy and procedure in relation to coverage for medically necessary treatment of autism (i.e., speech therapy, occupational therapy, physical therapy, other services)?  What is the status of medically necessary treatment for autism and other BBMI's for treatment that was previously (or is currently) excluded on the basis that such treatments are "non-restorative" or that the treatments are for learning disabilities, behavioral problems, or developmental disorders?

Commissioner Burdge indicated that the court was critical of 17:9-2.14 because it is overly broad and gives the Commission unbridled discretion as compared to the DOBI regulation. He asked if consideration was being given to something more specific regarding BBMI.  Susanne Culliton stated that 2:14 is very general and is not meant to define levels of coverage; regulations would require changing every time the levels change. Since the member handbook is a part of the contract, changes are made to the handbook when benefits change. For example, a change was made to the handbook under Speech Therapy to show that speech therapy is covered as follows:

“Speech therapy to correct pre-speech deficiencies or to improve speech skills that have not fully developed are not covered except for Autism and Pervasive Development Disorder (PDD)”.

In the Micheletti appeal the Appellate Court said that ABA Therapy should be covered. Horizon Blue Cross Blue Shield of NJ doesn’t cover ABA Therapy for anyone because it is considered investigational. There was no opportunity for the Commission to develop a record on ABA Therapy so the best thing to do was to send the next case that came up to the OAL for a ruling.  A recent appeal for ABA Therapy has been sent to the OAL for a ruling on ABA Therapy.  As case law evolves, the handbook will be changed. So, the regulations are general and the handbooks are updated with benefit changes. Michael Malloy said he was not aware that 17:9-2:14 include the handbooks as part of the contract.

Michael Malloy requested that the following changes be made to the regulations:

  • Correct the acronym ‘HIPPA’ to ‘HIPAA”
  • Do a global search to replace ‘State Health Benefits Program’ with ‘SHBP’

He also inquired if the actuaries’ suggestion that the dental rates be increased would be implemented. David Pointer said that dental rates cannot be increased because they are negotiated with the unions.

Hope Cooper had a change to page 39; the first word should be “designated”.

Patrick Nowlan did not have any changes to the regulations.

Florence Sheppard made the following motion:

BE IT RESOLVED THAT:

The State Health Benefits Commission (the “Commission”) hereby approves proposed readoption of N.J.A.C. 17:9, which proposal is set forth in the attachment hereto. 

The Commission hereby authorizes the Director of the Division of Pensions and Benefits to submit the attached Notice of Proposed Readoption with Amendments to the Office of Administrative Law for publication and hereby delegates to staff of the Commission and the Division of Pensions and Benefits the authority to make technical revisions to the Notice as required and as shall be made upon the advice of the Attorney General.

This resolution shall take effect immediately.

Hope Cooper seconded the motion. A roll call vote was taken: Approved (Vote 3:2):

Florence Sheppard Aye
Dudley Burdge Nay
Hope Cooper  Aye
Michael Malloy Aye
Patrick Nowlan  Nay

Jean Williamson announced that the time of the next regular Commission meeting on October 8, 2008 would be changed from 10:00 to 1:00.

There being no further business, Michael Malloy made a motion to adjourn which was seconded by Hope Cooper.  All voted in favor. The State Health Benefits Commission meeting was adjourned at 10:30 PM.

Respectfully submitted,

Jean M. Williamson, CEBS
Acting Secretary
State Health Benefits Commission

 



                                                                 


Meeting No. 486
October 8, 2008
Minutes 1:00 PM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 1:14 PM, Wednesday, October 8, 2008.  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 Sheppard, representing State Treasurer, R. David Rousseau for Opening of the meeting, the Issue “N.J.A.C. 17:9-6.10 Retiree Prescription Drug Plan” and the first appeal on the agenda
Susanne Culliton, representing State Treasurer, R. David Rousseau for the remainder of the meeting
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Hope Cooper, Chair, Civil Service Commission
Patrick Nowlan, representing AFL-CIO Representative for Local Government Employees.
Dudley Burdge, representing AFL-CIO Representative for State Government Employees

Also present: 

Eileen Den Bleyker, Senior Deputy Attorney General
Rubin Weiner, Deputy Attorney General
Frederick Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Horizon Blue Cross Blue Shield of NJ Representatives
Aetna Representatives
CIGNA HealthCare Representatives
Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

Minutes – Meeting No. 484, September 10, 2008. Hope Cooper made a motion to accept the minutes. Patrick Nowlan seconded the motion. Approved (Vote 4: 0: 1 Commissioner Sheppard abstained.)

Commissioner Cooper motioned to go out of order, with the first issue to be N.J.A.C. 17:9-6.10 Retiree Prescription Drug Plan, and the second, the first appeal on the agenda. Patrick Nowlan seconded the motion. All voted in favor.  Florence Sheppard represented State Treasurer Rousseau and acted as chairperson for the opening and this portion of the meeting. Susanne Culliton represented State Treasurer Rousseau and acted as chairperson for the remainder of the meeting.

ISSUES

In Vitro Fertilization (IVF):  This issue was tabled to the next Commission meeting.

N.J.A.C. 17:9-6.10 Retiree Prescription Drug Plan: Michael Malloy made a motion to adopt the revisions to the regulations. Hope Cooper seconded the motion. Approved (Vote 3: 2: 0 Commissioner Burdge and Nowlan voted nay).

Prescription Drug Plan:  This issue was tabled to the next Commission meeting.

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 under Resolution A. Hope Cooper seconded the motion. All voted in favor.

Case #100801(Member & Attorney Present) This CIGNA HealthCare appeal concerned a denial of authorization for additional physical therapy.  The denial explanation from CIGNA was that the member has achieved a functional level of activity; therefore, continued physical therapy is not considered medically necessary.  Member’s attorney stated that the treating physicians, surgeons and therapist of the members did not check that the functional goal has been reached.  Attorney also stated that there is no clear explanation of the word “functional”.  Michael Malloy made a motion to deny this appeal.  Florence Sheppard seconded the motion. Failed (Vote 2: 2: 1 Commissioners Cooper and Nowlan voted nay.  Commissioner Burdge abstained). Hope Cooper motioned to table this appeal to give the member time to get specific documentation from surgeons and therapist on progress of therapy and expected functional goal within 20 days.  Patrick Nowlan seconded the motion.  Approved (Vote 4: 0: 1 Commissioner Malloy abstained).

Case #100802(Member Present) This Aetna Dental Expense Program appeal concerned the denial of orthodontic treatment of member’s dependent child based on the dental plan’s waiting period for orthodontic services. The Member stated that she and her dentist office were never advised of a ten month waiting period for orthodontic procedures.  Aetna representatives indicated that the Dentist office contacted Aetna in July 2007 and was advised at that time that there was a ten month waiting period. Coverage for orthodontic procedures would take effect in January 2008. Susanne Culliton motioned to go into Executive Session.  Hope Cooper seconded the motion. All voted in favor. Upon return from Executive Session, Susanne Culliton made a motion to deny this appeal.  Hope Cooper seconded the motion. Denied (Vote 3: 1: 1; Commissioner Burdge: nay. Commissioner Nowlan abstained). 

Case #100803 (Member Present) This Horizon-NJ PLUS/NJ DIRECT15 appeal concerned a denial of benefits for Growth Hormone Therapy. There are no studies demonstrating that Norditropin (Somatropin)is useful in treating Primary Lateral Sclerosis/Amyotrophic Lateral Sclerosis. The treatment has not been proven in clinical trials. Commissioner Burdge asked, “What is the likelihood that a clinical study will be done”? Dr. Yen responded, “There probably won’t be one, there are not enough cases to study (approximately 500 people in the country with this condition)”. Hope Cooper made a motion to go into executive session under Resolution B.  Susanne Culliton seconded the motion. All voted in favor. Upon returning to closed session, the member was advised by the Commission that growth hormone therapy would not be considered investigational if there was a Growth Hormone Deficiency. Commissioner Culliton asked the member if he was willing to stop the Growth Hormone Therapy for three to four days and then be tested for Growth Hormone Deficiency. The member said he was willing to stop the treatment for a short period but if the test does not show a deficiency he still wants the therapy as an exception as made in the Micheletti case. Michael Malloy motioned to table the appeal to give member time to stop the Growth Hormone Therapy for three to four days and then have the hormone deficency test done.  Susanne Culliton seconded the motion. All voted in favor.

Case #100804 – This CIGNA HealthCare appeal concerns a denial of benefits for expenses for reimbursement for transgender surgery performed on September 27, 2005. Commissioner Culliton stated that the surgery took place in Montreal, Canada and was out-of-network. She asked CIGNA representatives why the issues of using an ineligible provider and having elective surgery (not emergency) out of the country were not used as reasons for denial by CIGNA.  CIGNA’s medical director explained that they first determine if it is a covered benefit. If it is not a covered benefit, it is denied at that point; it doesn’t go any further to determine eligibility of provider, etc. Hope Cooper made a motion to deny this appeal on basis of services that it is not a covered benefit, there are no out-of-network benefits in this plan, and the procedure was elective, not an emergency and was performed out of the country. Michael Malloy seconded the motion. All voted in favor.
 
Case #100805 – A Final Administrative Determination (FAD) was drafted for the Commission’s approval. The FAD rejects the recommendations of the Administrative Law Judge and reaffirms the Commission’s decision in which it denied benefits for expenses for the stay of a dependent child at Three Springs, Inc. because it is an ineligible provider.  Susanne Culliton made a motion to approve the FAD. Hope Cooper seconded the motion. Approved (Vote 4: 0: 1, Commission Nowlan abstained).

Case #100806  - A Final Administrative Determination (FAD) was drafted for the Commission’s approval.  The FAD rejects the recommendations of the Administrative Law Judge and reaffirms the Commission’s decision in which it denied benefits for expenses for occupational and physical therapies for a dependent child under the exclusionary language:  To promote development beyond any level of function previously demonstrated. Susanne Culliton made a motion to approve the FAD.  Hope Cooper seconded the motion.  Approved (Vote .3: 1: 1, Commission Burdge: nay; Commissioner Nowlan abstained).

Case #100807 – A settlement offer was before the Commission to consider paying CPT 27848 and CPT 64708 as separate from rather than incidental to the procedures already reimbursed and to reimburse for these procedures as we would for other covered charges. Michael Malloy made a motion to deny the offer. Susanne Culliton seconded the motion. Failed, (Vote 2: 0: 3: Commissioners Cooper, Burdge and Nowlan abstained). Michael Malloy made a motion to reject the settlement proposal. Susanne Culliton seconded the motion. Approved (Vote 3: 0: 2: Commissioners Burdge and Nowlan abstained). 

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

Susanne Culliton made a motion to table the remaining issues; In Vitro Fertilization (IVF) and Prescription Drug Plan.  Dudley Burdge seconded the motion and all voted in favor.

There being no further business, Michael Malloy made a motion to adjourn which was, seconded by Patrick Nowlan.  All voted in favor. The State Health Benefits Commission meeting was adjourned at 4:18 PM.

Respectfully submitted,

Jean M. Williamson, CEBS
Acting Secretary
State Health Benefits Commission

 

 

 


Meeting No. 487
Revised Minutes
November 18, 2008
1:00 PM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 1:14 PM on Tuesday, November 18, 2008. 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, R. David Rousseau
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Hope Cooper, Chair, Civil Service Commission
Patrick Nowlan, representing AFL-CIO Representative for Local Government Employees.
Dudley Burdge, representing AFL-CIO Representative for State Government Employees

ALSO PRESENT:  

Eileen Den Bleyker, Senior Deputy Attorney General
Rubin Weiner, Deputy Attorney General
Frederick Beaver, Director, Pensions and Benefits
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, PBS2
Horizon Blue Cross Blue Shield of NJ Representatives
CIGNA HealthCare Representatives

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

Minutes – Meeting No. 486, October 8, 2008 and Meeting No. 485, September 18, 2008 - Susanne Culliton made a motion to go into executive session under Resolution B. Hope Cooper seconded the motion. All voted in favor. Upon return to public session, Hope Cooper made a motion to accept the minutes with the change to the Executive Minutes for Meeting No. 486, October 8, 2008. Michael Malloy seconded the motion. Approved (Vote 5: 0: 0)

Commissioner Cooper motioned to go out of order to hear the first appeal on the agenda. Susanne Culliton seconded the motion. All voted in favor.

The following case, due to HIPAA regulations, was heard in closed session.

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

Case #SH110801 (Attorney Present). Susanne Culliton recused herself from this appeal. This CIGNA HealthCare appeal concerned a denial of authorization for additional physical therapy and was tabled at the October 8, 2008 Commission meeting. The Commission had granted the member 20 days time to get specific documentation from the doctor and therapist on the progress of physical therapy and the expected functional goal. The member’s attorney brought additional documents with her to the meeting. CIGNA’s medical director, Dr. Nicoll quickly scanned the information and advised that the only material from the treating physician was a prescription for physical therapy. Hope Cooper motioned to table this appeal to give CIGNA the opportunity to review it. Patrick Nowlan seconded the motion. All voted in favor. Approved (Vote 4: 0: 0). Following the vote, Dr. Nicoll requested that the member get the following specific documentation from the treating physician and therapist: The results of a recent evaluation and examination including information that would help determine if further physical therapy would be useful.  The information, at a minimum, should include:

  1. Results of current exam and any changes over last several months
  2. Treatments currently being received (including a home exercise program as is usually prescribed when physical therapy active treatment ends) and the results of such treatments/home programs etc.
  3. If no home exercise program was undertaken, why not.
  4. Some estimation of current capacity and how it might improve with PT with reference to why it might now improve when it appeared that patient stopped improving in past and has had no clinical change in 6 months.

He also requested an explicit prescription from the treating physician and treatment plan from the physical therapist as to how they would be implemented. David Pointer asked for the documentation to be provided within two weeks. 

Hope Cooper made a motion to return to open session. Michael Malloy seconded the motion. All voted in favor. Approved (4: 0: 0).

ISSUES

A. Health Insurance Portability and Accountability Act (HIPAA) – Exemption from the Mental Health Parity Requirements:  Michael Malloy asked if there are criteria that have to be met. David Pointer responded no.  Frederick Beaver said that we expect to have Federal regulations for 2010. Hope Cooper made a motion to approve the exemption.  Michael Malloy seconded the motion. Approved (Vote 3: 2: 0 Commissioners Burdge and Nowlan voted nay).
 
B. In Vitro Fertilization (IVF) – Dudley Burdge commented that it depends on who you are which IVF policy is better. He expressed concern that during contract negotiations with the union they were told that the benefits under NJ DIRECT would be the same as under NJ PLUS. David Pointer indicated that members who had begun a cycle prior to April 1, 2008 were grandfathered under the old policy to enable the member to complete the cycle.  Susanne Culliton motioned to recognize the implementation of Ch. 236, PL 2001with regard to IVF effective April 1, 2008 with the commencement of the new health benefits plans. Hope Cooper seconded the motion. Approved (Vote 3: 2: 0 Commissioners Burdge and Nowlan voted nay noting that a change in benefits is subject to negotiations).

C. Prescription Drug Plan – The Commission members received a copy of a power point presentation from Aon Consulting.  Dudley Burdge indicated that it was well done and noted the progress made in increasing generic usage. He had made a motion at the August 21, 2008 meeting, which was subsequently withdrawn, to freeze copayments until a difference of $20.00 was reached. Frederick Beaver advised that this discussion should be a part of the rate renewal for 2010. David Pointer indicated that we may be able to see the effect of the freeze from this year. Frederick Beaver said we could ask Aon Consulting if freezing the copayments until a difference of $20.00 is reached should be considered as an alternative for next year.

D. 2009 Meeting Schedule – There was some discussion about the proposal of meeting every other month.  It was agreed that meetings can be added to the schedule at a later date if necessary. Michael Malloy made a motion to approve the 2009 meeting dates which will be held every other month. Susanne Culliton seconded the motion. All voted in favor. Approved (Vote 5: 0: 0).

The following cases, due to HIPAA regulations, are heard in closed session.

Dudley Burdge made a motion to go into closed session under Resolution A. Susanne Culliton seconded the motion. All voted in favor. Approved (Vote 5: 0: 0).

Case #SH110802 – The Commission considered the recommendation of DAG Dawn Harris in a previously denied appeal concerning expenses above the Reasonable and Customary (R & C) for surgery. DAG Harris’ memo to Jean Williamson, Acting Secretary, requested that the Commission adjust the R & C allowance for CPT code 1961-50 to reflect the valid charge data for the procedure that was not available when the Commission originally denied this appeal on March 6, 2007. Susanne Culliton made a motion to approve the recommendation. Hope Cooper seconded the motion. All voted in favor. Approved (5: 0: 0). 

Case #SH110803 – The member requested that the Commission’s previous denial of an appeal for expenses above the reasonable and customary amount allowed be forwarded to the Office of Administrative Law (OAL) for a hearing. Susanne Culliton motioned to approve this request for a hearing at the OAL. Hope Cooper seconded the motion. All voted in favor.  Approved (5: 0: 0). 

Case #SH110804 – The member requested that the Commission’s previous denial of an appeal for expenses for speech therapy for his son be forwarded to the Office of Administrative Law (OAL) for a hearing. Michael Malloy motioned to approve this request for a hearing at the OAL. Dudley Burdge seconded the motion. All voted in favor. Approved (5: 0: 0). 

Case #SH110805 –  Susanne Culliton made a motion to approve the settlement proposal of $2,500.00. Patrick Nowlan seconded the motion. Approved (Vote 4: 0: 1, Commissioner Malloy abstained).

Case #SH110806  –  Susanne Culliton motioned to table this settlement proposal to obtain information concerned what the end result was for the member and if any payment was received. Dudley Burdge seconded the motion. All voted in favor.  Approved (5: 0: 0).

There being no further appeals, a motion was made to return to open session by Hope Cooper, seconded by Patrick Nowlan. All voted in favor.

David Perry, Horizon Blue Cross Blue Shield of NJ, indicated that there was going to be a meeting on Friday, November 21, of upper management (Horizon BCBSNJ and CHOP). There is an informal agreement between them to temper the publicity. While members will continue to be able to utilize CHOP as an in-network facility in PA, CHOP’s satellite facilities in NJ will be out-of-network if agreement is not reached.

Patrick Nowlan asked Mr. Perry to give an update of Horizon BCBSNJ’s proposed conversion to a for-profit health insurer. Mr. Perry indicated that Horizon BCBSNJ has filed with the Department of Banking and Insurance (DOBI), which has a certain amount of time to review the request. The DOBI can receive an extension and ask questions. The process is expected to go on well into 2009.

There being no further business, Susanne Culliton made a motion to adjourn which was seconded by Patrick Nowlan. All voted in favor. The State Health Benefits Commission meeting was adjourned at 2:15 PM.

Respectfully submitted,

Jean M. Williamson, CEBS
Acting Secretary
State Health Benefits Commission

 

                                                                 

 


Meeting No. 488
December 11, 2008
Minutes 10:00 AM
State Health Benefits Commission

The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:28 AM, Thursday, December 11, 2008.  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, R. David Rousseau from the opening of the meeting through the Issues “A through E” on the agenda
Susanne Culliton, representing State Treasurer, R. David Rousseau for the remainder of the meeting
Michael Malloy, representing Commissioner, Steven M. Goldman, Department of Banking & Insurance
Hope Cooper, Chair, Civil Service Commission
Patrick Nowlan, Representative for State Government Employees.
Dudley Burdge, Representative for Local Government Employees

Also present: 

Eileen Den Bleyker, Senior Deputy Attorney General
Rubin Weiner, Deputy Attorney General
Florence J. Sheppard, Deputy Director
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, Pensions Benefits Specialist
Horizon Blue Cross Blue Shield of NJ Representatives

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

Minutes - Meeting No. 487, November 18, 2008. Hope Cooper made a motion to accept the minutes. Michael Malloy seconded the motion.  Motion failed (Vote 2: 2: 1 Commissioners Burdge and Nowlan voted nay and Commissioner Ridolfino abstained.)  Hope Cooper made a motion to accept the minutes as amended by Patrick Nowlan. Michael Malloy seconded the motion. Approved (Vote 4: 0: 1: Commissioner Ridolfino abstained.)

ISSUES

(A) Authorization to prepare Request for Proposals (RFP) for Prescription Benefits Management (PBM) Services:  Patrick Nowlan made a motion to approve the Division to prepare the RFP for the PBM contract.  Hope Cooper seconded the motion. All voted in favor. Approved (Vote 5: 0: 0). Dudley Burdge read from a prepared statement (attached). David Pointer interrupted him and asked if he has researched any other Prescription Managed Care Vendors.  He also expressed a concern that CVS/CareMark is being tainted before the RFP is even prepared.

Hope Cooper made a motion to go into Executive Session under Resolution B to discuss legal issues pertaining to Issues B through D on the agenda.  David Ridolfino seconded the motion. All voted in favor.

(B) Authority to adjust the maximum out-of-pocket for in-network services in NJ DIRECT10 to include co-pays to in-network providers:  Dudley Burdge made a motion to approve the adjustment. Hope Cooper seconded the motion. All voted in favor.  Motion passed (Vote 5: 0: 0).

(C) Authority to allow the coordination of benefits between NJ DIRECT10 and NJ DIRECT15. Dudley Burdge made a motion to approve coordination of benefits between NJ DIRECT10 and NJ DIRECT15.  Hope Cooper seconded the motion. All voted in favor. Motion passed (Vote 5: 0: 0).

(D) Authority to enter into an agreement regarding transition program for school employees, covered under NJ DIRECT10.  Hope Cooper made a motion to approve. Patrick Nowlan seconded the motion. All voted in favor. Motion passed (Vote 5: 0: 0).

(E) Carrier Updates:

NJ DIRECT:

David Pointer advised the Commission that Bayonne Medical Center is terminating as an in-network facility effective February 7, 2009.  Dudley Burdge asked if there were any negotiations presently going on between the hospital and Horizon Blue Cross Blue Shield of NJ (Horizon BCBSNJ) and Carol Banks responded, “No”. In addition, Memorial Sloan Kettering at Basking Ridge became an in-network facility effective December 1, 2008. Finally, Newton Hospital terminated effective November 22, 2008.

Hope Cooper made a motion to go into closed session under Resolution A. David Ridolfino seconded the motion. All voted in favor. (5: 0: 0). David Ridolfino left the meeting and Susanne Culliton acted as chairperson for the remainder of the meeting.

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

Case #SH120801(Member Present) This Horizon-NJ DIRECT15 appeal concerned a denial of pre-certification of benefits for In Vitro Fertilization (IVF) treatment. The member requested to be grandfathered under the former IVF policy because she had an appointment in February 2008 but postponed it until April 2008 not knowing that the policy was changing effective April 1, 2008. In addition, she said that the Member Handbook was not available until April 1, 2008.  Dudley Burdge asked the member where she worked. The member responded that she works at NJIT. Commissioner Burdge inquired if she had asked the Human Resource representative if there were any changes to the benefits. Member said that she had not but that she had called Horizon and was advised that no referral is required for this service. She said she was not told about the exclusion and that she had done everything she could. Dudley Burdge asked the member if she is union represented and the member responded yes. Dudley Burdge made a motion to approve this appeal.  Patrick Nowlan seconded the motion. Failed (Vote 2: 3: 0; Commissioners Malloy, Cooper and Culliton voted nay).  Susanne Culliton made a motion to deny this appeal. Hope Cooper seconded the motion. Approved (Vote 3: 2: 0; Commissioners Burdge and Nowlan voted nay).

Case #SH120802(Member Present) This Horizon-NJ DIRECT15 appeal concerned a denial of pre-certification of benefits for In Vitro Fertilization (IVF) treatment. The member indicated that she understood the policy. However, she requested that the Commission make an exception to the exclusion of the IVF policy due to her individual circumstances.  Susanne Culliton made a motion to deny this appeal. Hope Cooper seconded the motion. Approved (Vote 4: 1: 0; Commissioner Nowlan voted nay).

Case #SH120803 (Member Present) This Horizon-NJ PLUS–NJ DIRECT15 appeal concerned a denial of expenses for growth hormone therapy to treat Primary Lateral Sclerosis/Amyotrophic Lateral Sclerosis. It was tabled at a previous meeting so that the member could be tested for growth hormone deficiency. Based on the laboratory report and a letter from member’s physician the Medical Director at Horizon maintained the denial. Susanne Culliton asked Dr. Yee if the growth hormone level was low would the growth hormone therapy be indicated. In addition, is there any benefit?  Is it medically established?  Dr. Yee responded that there is nothing in the literature that GH is useful in treating primary lateral sclerosis. Later in the discussion, Dr. Yee said that there are no strict measures because there have not been studies of this rare disease.  He also said that the test that was done is not the “gold standard”. According to the letter from Dr. Schaer, the insulin tolerance test (ITT) is considered the “gold standard”, but was not done because it carries significant risks for the member.  Susanne Culliton made a motion to go into Executive Session. Hope Cooper seconded the motion. All voted in favor. Upon return from Executive Session, Patrick Nowlan made a motion to approve growth hormone therapy to treat the deficiency. All voted in favor. Approved (Vote 5: 0: 0).

Case # SH120804 – The member’s attorney requested that the Commission’s previous denial of an appeal for benefits for expenses for gender reassignment surgery be forwarded to the Office of Administrative Law (OAL) for a hearing. Susanne Culliton motioned to deny this request for a hearing at the OAL and issue a Final Administrative Decision because there was no dispute of material fact. Hope Cooper seconded the motion. Approved (Vote 4: 0: 1; Commissioner Burdge abstained).   
 
Case #SH120805 – A settlement offer that was tabled from last month’s meeting was before the Commission.  Susanne Culliton made a motion to again table the settlement proposal pending additional information from ACS Recovery Services’ attorney and a copy of the Worker’s Compensation settlement agreement. Hope Cooper seconded the motion. All voted in favor. Motion passed (Vote 5: 0: 0).

There being no further appeals, a motion was made to return to open session by Patrick Nowlan, seconded by Dudley Burdge. All voted in favor.

There being no further business, Patrick Nowlan made a motion to adjourn, which was seconded by Dudley Burdge.  All voted in favor. The State Health Benefits Commission meeting was adjourned at 12:40 PM.

                                                                  Respectfully submitted,

                                                                  Jean M. Williamson, CEBS
                                                                  Acting Secretary
                                                                  State Health Benefits Commission

Statement on PBM RFP Adobe PDF (10K) (Dudley Burdge)

 
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