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Pensions and Benefits
HEALTH BENEFITS COMMISSION
MEETING MINUTES 2009
 

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Special State Health Benefits Commission
Minutes, Meeting No. 489
January 29, 2009; 10:00 AM

The Special meeting of the State Health Benefits Commission (Commission) was called to order at 10:10 AM, Thursday, January 29, 2009. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

ROLL CALL

The meeting was attended by the following members of the Commission and Division staff:

David Ridolfino, Chairperson, 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, Representative for State Government Employees. (Attended by teleconference)
Dudley Burdge, Representative for Local Government Employees

Also present: 

Eileen Den Bleyker, Senior Deputy Attorney General
Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director
Florence J. Sheppard, Deputy Director
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, Pensions Benefits Specialist

ISSUES

1) Authorize entry of a Memorandum of Understanding (MOU) with the School Employees’ Health Benefits Commission for participation of school employees in NJ DIRECT and other State Health Benefits Programs – For Approval

Eileen Den Bleyker, DAG advised the Commission that the School Employees’ Health Benefits Commission (SEHBC) approved a revised Memorandum of Understanding at their meeting on January 28, 2009. She advised them that approval of the MOU and the contract amendment was necessary before February 9, 2009 for the Transition Program to become effective. She said that amendments to the MOU could be approved in the future if necessary. Hope Cooper made a motion to approve the amended Memorandum of Understanding with the SEHBC. David Ridolfino seconded the motion. Approved (Vote 5; 0; 0).

Dudley Burdge made a motion to approve the amendment to the Horizon Contract. Hope Cooper seconded the motion.  Approved (Vote 5, 0, 0).

2) Special Open Enrollment – For Approval

Dudley Burdge asked if this was due to the Commission’s approval of coordination of benefits (COB) between NJ DIRECT10 and NJ DIRECT15. David Pointer responded previous to this decision, there was no COB between the two plans. A Special Open Enrollment will allow members who are affected by this change in benefits to change medical plans. The Special Open Enrollment period will begin on February 1, 2009 and end on February 28, 2009 for active employees.  Retirees will have until March 20, 2009 to mail in a completed application to change plans. Mr. Pointer also added that this Special Open Enrollment is only for employees/retirees who have Family or Member and Spouse/Partner coverage. Members will not be permitted to add dependents or make any changes to dental or prescription drug coverage. Dudley Burdge made a motion to approve the Special Open Enrollment. David Ridolfino seconded the motion.  All voted in favor.

There being no further business to transact, a motion was made to adjourn by Hope Cooper, seconded by David Ridolfino.  All voted in favor. The State Health Benefits Commission meeting was adjourned at 10:20 AM.


Respectfully submitted,

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

 

                                                                 

 


Meeting No. 489
February 11, 2009
Minutes 1:00 PM
State Health Benefits Commission

Adequate notice of this meeting has been provided through the annual notice of the schedule of regular meetings of the Commission filed with and prominently posted in the offices of the Secretary of State. The 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 25, 2008.

The first portion of the meeting is open to the public. The second portion, in conformity with the Open Public Meetings Act, shall be closed to the public based upon the personal matters exception. Those matters are confidential unless expressly waived by the individual involved.

The meeting of the State Health Benefits Commission of New Jersey was called to order at 1:11 PM, Wednesday, February 11, 2009. 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, 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
Frederick J. Beaver, Director
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 New Jersey (Horizon BCBSNJ) Representatives
Magellan Representatives
HealthNet Representatives
CIGNA Representatives

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

Minutes – Meeting No. 487, December 11, 2008.  Hope Cooper made a motion to accept the minutes. Patrick Nowlan seconded the motion. Approved (Vote 4: 0: 1 Commissioner Culliton abstained.)

Meeting No. 488, January 29, 2009. Hope Cooper made a motion to accept the minutes. Patrick Nowlan seconded the motion.  Approved (Vote 4: 0: 1 Commissioner Culliton abstained.)

Issues

A. Request for Proposal (RFP) for a Prescription Benefits Manager (PBM) – Alice Small, Director, Division of Purchase and Property, addressed the Commission on procedural aspects of the process. Mary Lou Goho, Deputy Director, Division of Purchase and Property, also attended the meeting.  Ms. Small gave an overview of the way in which a RFP is conducted. She indicated that neither (Health Benefits) Commission would have direct input in the content of the RFP but that they could pose questions once the RFP is posted on the Purchase and Property website. Hope Cooper motioned to issue the RFP through the Division of Purchase and Property under their governing procedures N.J.S.A. 52:34:12.  Michael Malloy seconded the motion. Approved (Vote: 3: 2: 0 Commissioner Burdge and Nowlan voted nay).

Susanne Culliton made a motion to go out of order to hear appeals at 1:53 PM. Hope Cooper seconded the motion.  Approved (Vote: 3: 2: 0, Commissioner Burdge and Nowlan voted nay). 

Hope Cooper motioned to go into closed session. 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.

Old Business - Appeal

Case #SH020901(Member Present) This NJ PLUS appeal was tabled at a previous meeting and concerned a denial of benefits for expenses for continued inpatient residential treatment rendered for a dependent child. The Medical Director from Magellan gave the background and update of the appeal. The member presented additional documentation which was reviewed by Magellan’s Medical Director.  An erroneous payment of $20,597.00 was issued to the member and Horizon BCBSNJ delayed recapturing of the money pending the outcome of this appeal. Susanne Culliton motioned to go into Executive Session under Resolution B.  Patrick Nowlan seconded the motion. All voted in favor. Upon return from Executive Session, Hope Cooper made a motion to deny the appeal but to provide reimbursement for 10 days at the Partial Hospitalization level of reimbursement rate and 12 days (3 days/week for 4 weeks) at the Intensive Outpatient level of reimbursement for a total reimbursement of $5,272.00. The $5,272.00 will be subtracted from the amount that was erroneously paid to the member and Horizon BCBSNJ will recapture the difference ($20,597.00 – 4,272.00 = $16,325.00). Susanne Culliton seconded the motion. Approved (Vote: 3: 1: 1; Commissioner Burdge voted nay and Commissioner Nowlan abstained.)

New Business Appeals

Case #SH020902(Member Present) This HealthNet appeal concerned a denial of benefits for continued speech, physical and occupational therapies for a dependent child.  Healthnet’s Medical Director explained the reason for the denial is the therapies for the chronic condition were deemed developmental in nature and are, therefore, excluded from the plan.  HealthNet also denied expenses for Hippo Therapy which is considered investigational and therefore, is excluded from the plan.  Susanne Culliton made a motion to deny the appeal because the therapies were to treat a developmental delay and Hippo therapy is considered investigational. Hope Cooper seconded the motion. Approved (Vote: 4: 1: 0; Commissioner Burdge voted nay).

Patrick Nowlan made a motion to go back into Open Session.  Dudley Burdge seconded the motion. Motion passed. (Vote: 3: 2: 0; Commissioners Culliton and Cooper voted nay).

Hope Cooper made a motion to go back into Closed Session to finish remaining cases. Susanne Culliton seconded the motion. Motion passed (Vote: 3: 2: 0; Commissioners Burdge and Nowlan voted nay).

Case #SH020903 - This Horizon BCBSNJ appeal concerned denial for reimbursement of a claim that Horizon BCBSNJ indicated was already paid to the member. Horizon BCBSNJ representatives indicated that due to the age of the check, May 7, 1999, they are unable to obtain a copy. However, Horizon BCBSNJ has a trascript of a phone call with the member that took place on August 2, 1999 in which the member stated that she received the check. Dudley Burdge made a motion to deny this appeal. Patrick Nowlan seconded the motion. All voted in favor. Approved (Vote 5: 0: 0).

Case # SH020904 - This CIGNA appeal concerned denial of benefits for expenses for various charges incurred by the member’s spouse while living overseas. CIGNA’s Medical Director explained the plan is not designed for routine care with out-of-network providers. Overseas care is only considered in an urgent/emergent situation. Hope Cooper made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor. Approved (Vote 5: 0: 0 :).

Case # SH020905 - This NJ PLUS appeal concerned denial of benefits for expenses for dental services received by a member.  Horizon BCBSNJ representatives indicated that the member was informed that it would not be covered prior to the services being performed. There was discussion concerning if and why the cost of anesthesia was paid. Susanne Culliton made a motion to deny this appeal and recapture the money paid for the claim for anesthesia. Hope Cooper seconded the motion. Approved (Vote 3: 1: 1; Commissioner Burdge voted nay and Commissioner Malloy abstained).

Case # SH020906 - Final Administrative Determination –Susanne Culliton made a motion to accept the FAD draft concerning the denial of Transgender Surgery under the CIGNA Plan. Michael Malloy seconded the motion. All voted in favor.  Approved (Vote 5: 0: 0).  

Case # SH020907 - A settlement offer was before the Commission to consider reducing a lien of $7,036.90 by 20%. The Attorney refused to reimburse the Plan in full because he feels the only reason there is any recovery available for the Plan is only through his efforts in obtaining the lien and getting recoupment from the uninsured employer. In addition, the attorney maintains that the member had to pay attorney fees of 20% to recover this amount and therefore, the plan should at the very least reduce the lien amount by the 20%. Attorney will not voluntarily repay the Plan unless it agrees to reduce the lien by 20%; he is now offering the plan 80% of the lien or $5,652.24. Susanne Culliton made a motion to reject the settlement proposal and stated the settlement includes a judgment for $7,036.90. Hope Cooper seconded the motion. All voted in favor. Approved (Vote 5: 0: 0)

There being no further appeals, Susanne Culliton made a motion to return to open session to hear the remaining Issues. Michael Malloy seconded the motion. All voted in favor.

Issues (continued)

B. Dependent Eligibility Verification Audit (DEVA) – David Pointer addressed the Commission on the progress of DEVA.  Phase one of the audit has begun; letters have gone out to State employees and retirees. Dudley Burdge asked who authorized the audit. David Pointer responded authorization was not required for the audit. The SHBP member handbooks and the Summary Program Description all say that periodically, the SHBP performs audits on members to determine dependents eligibility under the plan. Dudley Burdge said it would have been helpful if notification was made prior to the mailing.  David Pointer replied that the following notifications were given: 1)  At the Commission meeting of August 13, 2008, Ed Fox, AON advised the Commission during his presentation of rate renewals that AON would be working with the Division to conduct the audit which they projected would remove a considerable number of ineligible dependents; 2). Notification was in all of the Fall 2008 editions of the Health Capsules; and 3) A letter from Florence Sheppard was sent to SHBP and SEHBP employers in December 2008 advising them of the audit. Commissioners Burdge and Malloy said they received negative feedback from employees and made some suggestions to the letter. David Pointer said that the letters were amended and waiting to be approved.  

C. “Grace’s Law” – Hearing Aids for Children - David Pointer advised the Commission that “Grace’s Law” takes effect on March 30, 2009. The law requires health benefits plans to provide coverage for medically necessary hearing aids for children 15 years of age or younger. The law requires coverage for hearing aid purchase for each ear that is medically necessary and is prescribed by a licensed physician or audiologist. The Division recommends a benefit limit of $1,000.00 per hearing aid for each ear every 24 months. Dudley Burdge made a motion to approve the benefit limit of the hearing aids. Patrick Nowlan seconded the motion. All voted in favor. Approved (Vote 5: 0: 0).
  
D. New Employers in the SHBP – A list of local government employers joining the SHBP was provided to the Commission.

E. Supplemental and Clarification to Amendment to the contract between SHBC and Horizon BCBSNJ for Preferred Provider Organization dated April 1, 2008 - Eileen Den Bleyker, DAG advised the Commission that the $10.00 co-payment for office visits to in-network providers and the $25.00 co-payment for emergency room services will be included in the in-network out of pocket maximum. Once the out-of-pocket maximum has been reached, the co-payments shall be reimbursed to the member in one payment on an annual basis upon the filing of a claim and certification by the member that he has not received reimbursement for the expense from any other source. Hope Cooper made a motion to approve.  Dudley Burdge seconded the motion. Approved (Vote: 4: 0: 1; Commissioner Culliton abstained).

F. Carrier Updates:  NJ DIRECT:

Children’s Hospital of Philadelphia (CHOP) - An agreement between Horizon BCBSNJ and CHOP has been reached.

Pilot Plan – Emergency Room Admission Review at Rahway and Newton Hospital - Cheryl Eagan, Horizon BCBSNJ advised the Commission under this pilot, Horizon BCBSNJ will manage admissions that occur through the emergency rooms of these non-participating hospitals. Generally, if you are admitted to the emergency room, the network status of the hospital does not matter because emergencies are covered as in-network admission. Under the pilot plan, cases will be reviewed to determine whether the admission is medically necessary. If not medically necessary, the member and attending physician are notified. If the member decides to stay in the hospital, the member will be obligated to pay in full.  The other scenario is assuming admission was medically necessary claims will be paid as in-network. Once it is clinically determined the member is stable and can be transferred, a letter is delivered to the member informing them they can either: (a) be transferred to a participating facility, and their whole hospital stay will be covered as in-network, or (b) remain at the non-participating hospital, and the remaining days will be paid at the out-of-network level. Dudley Burdge asked how many out-of-network hospitals are there. Cheryl Eagan replied three.

There being no further business, Susanne Culliton made a motion to adjourn which was, seconded by Hope Cooper. All voted in favor. The State Health Benefits Commission meeting was adjourned at 4:19 PM.

Respectfully submitted,

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

 

                                                                 

 


Special Meeting No. 490
April 1, 2009
Minutes 1:00 PM
State Health Benefits Commission

Adequate notice of this special meeting was mailed to the Secretary of State, Star Ledger and the Trenton Times on February 26, 2009.

The meeting of the State Health Benefits Commission of New Jersey was called to order at 1:10 PM, Wednesday, April 1, 2009.  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
Michael Malloy, representing Commissioner Steven M. Goldman, Department of Banking & Insurance
Hope Cooper, Chair, Civil Service Commission (Via telephone)
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
Frederick J. Beaver, Director
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, Pensions Benefits Specialist

Resolution B (Executive Session) – was read in its entirety.

Issues

Re-adoption with amendments of N.J.A.C. 17:9; proposed new rule N.J.A.C. 17:-1.9 and proposed Repeal and new rule: N.J.A.C. 17:9-5.9:

Susanne Culliton indicated that two comments were received during the public comment period from Paul L. Kleinbaum, Esquire, on behalf of the New Jersey State Police Benevolent Association.  Revisions were made to the regulations as a result of the comments.  Commissioner Nowlan posed several questions concerning the regulations.  1)  Clarification of a sentence on page 8 concerning Civil union partners.  The matter was discussed and edits were made to the text to make it clearer; 2)  What is meant by “eligible domestic partnerships” on page 12?  David Pointer explained domestic partnerships have been replaced by civil union partnerships in NJ; there are certain domestic partnerships that are eligible prior to the formation of the civil union law; 3) Explanation of the term “separation” on page 13.  David Pointer explained this pertained to a HIPAA qualifying event if there was a marriage separation; and 4) Explanation of NJAC 17:9-2.14 Policy provisions adoption on page 17.  Susanne Culliton gave an explanation and said that this has been in the regulations since before she worked with the Commission.  Commissioner Burdge asked how someone can get a copy of the contract.  Susanne Culliton said they can submit an Open Public Records Act (OPRA) request.

There being no further discussion, Commission Malloy made a motion to adopt the Readoption with amendments of N.J.A.C. 17:9; proposed new rule N.J.A.C. 17:-1.9 and proposed Repeal and new rule: N.J.A.C. 17:9-5.9.  Hope Cooper seconded the motion.  Rubin Weiner advised it would be better to use the drafted formal resolution to approve the regulations.  Commissioner Malloy withdrew his motion.  Chairman Ridolfino read the following resolution: 

BE IT RESOLVED THAT:

At a meeting of the State Health Benefits Commission (the “Commission”) held on April 1, 2009, the Members of the Commission approved the attached Notice of Readoption with Amendments of N.J.A.C.  17:9, Adoption of New Rule N.J.A.C. 17:9-1.9, and Repeal and Adoption of New Rule N.J.A.C. 17:9-5.9, regarding the State Health Benefits Program (the “Notice of Readoption”). 

The Commission hereby authorizes the Secretary of the Commission to submit the Notice of Readoption 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 of Readoption as required and as shall be made upon the advice of the Attorney General.

This resolution shall take effect immediately.

Commissioner Malloy motioned to adopt the resolution and Hope Cooper seconded the motion.  Approved (5:0:0).

There being no further business to transact, a motion was made to adjourn by David Ridolfino, seconded by Michael Malloy.  All voted in favor. The State Health Benefits Commission meeting was adjourned at 1:34 PM.

Respectfully submitted,

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

 

                                                                 

 


Meeting No. 491
Minutes
April 8, 2009
10:00 AM
State Health Benefits Commission

Adequate notice of this meeting has been provided through the annual notice of the schedule of regular meetings of the Commission filed with and prominently posted in the offices of the Secretary of State.  The 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 25, 2008.

The meeting of the State Health Benefits Commission of New Jersey was called to order at time   on Wednesday, April 8, 2009 at 10:10 AM.  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, Chairperson, representing State Treasurer R. David Rousseau
Michael Malloy, Commissioner, 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: 

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, State Health Benefits Program
Horizon Blue Cross Blue Shield of NJ Representatives
Aetna Representatives
CIGNA Representatives

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

Minutes – Meeting No. 489, February 11, 2009, Suzanne Culliton made a motion to accept the minutes. Hope Cooper seconded the motion.  Approved (Vote 5: 0: 0 motion passed)

Meeting No. 490, April 1, 2009 –   Suzanne Culliton made a motion to accept the minutes.        Hope Cooper seconded the motion.  Approved (Vote 5: 0: 0 motion passed)

Patrick Nowlan made a motion to go into closed session under Resolution A and Dudley Burdge seconded the motion.  Motion failed (Vote 2: 3: 0 Commissioners Culliton, Malloy and Cooper voted nay).

Susanne Culliton made a motion to go out of order and start with the issues on the agenda.  Hope Cooper seconded the motion.  All voted in favor.

Issues

A. The Memorandum of Understanding (MOU) between the School Employees’ Health Benefits Commission and the State Health Benefits Commission was presented to the Commission for approval.  Michael Malloy made a motion to approve the MOU between the two commissions.  Hope Cooper seconded the motion.  Approved (Vote 4: 0: 1, Commissioner Culliton abstained).

Michael Malloy made a motion to direct the MOU between the School Employees’ Health Benefits Commission and the State Health Benefits Commission to David Rudilfino for signature and execution.  Hope Cooper seconded the motion. Approved (Vote 4: 0: 1, Commissioner Culliton abstained).
 
B. New Employers – FYI:  A list of new local employers was provided to the Commission.

Susanne Culliton advised the commission the following two issues were requested to be put on the agenda by Dudley Burdge.

C. Discussion on Fees Paid to AON Regarding the Dependent Eligibility Verification Audit (DEVA).  Dudley Burdge said paying $4. 7 million over an eighteen month period to AON Consulting for the DEVA, given the financial situation of the State, is something we should consider.  He asked if the audit can be done in house by the Division.  Frederick Beaver said the last of State auditors’ report suggested this audit be done to ensure that the people who are covered in the SHBP/SEHBP are eligible to be covered.  The Division is short staffed; an audit could not be done in house.  Dudley Burdge said there are also concerns of personal documents being scanned in a company in Illinois.  Frederick Beaver said every document that comes into the Division is scanned.  He said the Commission has no jurisdiction over this matter.  As Director, he has the authority to assign special projects to Aon.  Susanne Culliton stated the DEVA was in the works before the legislation was in place; she asked Commission Burdge what he wants to discuss.  Dudley Burdge asked if it makes sense to pay this right now.  Susanne Culliton said the State Auditors told us it needs to get done.  David Pointer informed the Commission the Division now require proof of eligibility and proper documents must be submitted prior to enrollment.  Frederick Beaver indicated a number of people have voluntarily removed dependents from their coverage due to the DEVA so the savings has already started.  Patrick Nowlan asked for the status of the DEVA.  Frederick Beaver responded the letters are being amended.  Patrick Nowlan stated there is a need to have realistic deadlines for return of the documents requested.

D. Discussion on Fees Paid to AON Consulting for assisting in Preparing the Request for Proposal (RFP) for the Pharmacy Benefits Manager (PBM).  Dudley Burdge suggested there may be a conflict of interest of Aon assisting in the preparation of the RFP for the PBM.  He said Aon should be asked to disclose to this Commission their full relationships with each PBM they are involved with and any third party entities associated with those PBM’s.  Susanne Culliton asked why Aon should disclose the information to us; the Division of Purchase and Property is doing the bid.  Dudley Burdge said he understood that Purchase and Property is doing the bid but this commission is responsible for the contract of the PBM.  Patrick Nowlan made a motion that Aon Consulting, Inc. discloses their relationships with the PBMs with which they are involved.  Dudley Burdge seconded the motion.  Failed (Vote 2: 0: 3 Commissioners Culliton, Cooper and Malloy voted nay).

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

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

Old Business – Appeal

Case #SH040901(Member Present with Attorney) - Susanne Culliton recused herself from this appeal.  This CIGNA appeal was tabled at a previous meeting and concerned a denial of benefits for authorization for additional physical therapy.   Hope Cooper gave the Commission a summary of the appeal as it stood at the previous meeting.  Dr. Nicol, Medical Director, CIGNA, reviewed additional medical information received and indicated it did not include any improvement there was no evidence submitted that the member was doing any home therapy.  The member’s attorney, Mark Davis, indicated that the member has improved enough to return to work in January.  He also indicated that CIGNA paid for therapy in January but not during October 16 – December 31, 2008.  Hope Cooper asked Dr. Nicol if there was any reason why therapy was covered in January.  Dr. Nicol replied this was the first he heard about it.  Hope Cooper made a motion to table this appeal for additional information.  Patrick Nowlan seconded the motion.  All voted in favor.  Passed (4: 0: 0).

New Business Appeals

Case #SH040902 - (Member Present) - This Horizon-NJ DIRECT10 appeal concerned a denial of Prior Authorization for In Vitro Fertilization.  Aetna Health had given authorization to the member for one IVF cycle during the time period May 22, 2008 through August 22, 2008, and a determination was made to approve one IVF donor cycle under NJ DIRECT when the member switched medical plans.  Horizon representatives indicated the member is beyond the maximum age limit and has exceeded number of attempts which the plan allows.  Hope Cooper made a motion to deny this appeal.  Susanne Culliton seconded the motion. All voted in favor. Passed (Vote 5: 0: 0).

Case #SH040903 (Member Present) - This Horizon BCBSNJ Traditional plan appeal concerned a denial for Percutaneous Radiofrequency Intradiscal Disc Decompression with Fluoroscopy which was deemed experimental.  Susanne Culliton made a motion to deny this appeal. Michael Malloy stated he would not support recapture of overpayment.  Michael Malloy seconded the motion. Approved (Vote 3: 2: 0 Commissioners Burdge and Nowlan voted nay).  Patrick Nowlan made a motion not to capture the overpayment.  Michael Malloy seconded the motion.  Passed (Vote 3: 2: 0 Commissioners Culliton and Cooper voted nay).

Case #SH040904 (Member Present) - This Horizon BCBSNJ – Traditional plan appeal concerned denial for amount above the reasonable and customary allowance for surgery.  The member gave a short presentation of the appeal.  Horizon representatives gave an overview of how the claims were paid.  The claims were paid in accordance with the terms of the plan.  Susanne Culliton made a motion to deny this appeal.  Hope Cooper seconded the motion.  Approved (Vote 4: 0: 1 Commissioner Burdge abstained).

Case #SH040905 - (Member Present) - This Horizon BCBSNJ -NJ DIRECT10 appeal concerned a denial of benefits for In Vitro Fertilization.  Horizon representatives indicated the member had a total of 5 IVF attempts between Aetna and Horizon.  Susanne Culliton made a motion to deny this appeal. Hope Cooper seconded the motion. Passed (Vote 4: 0: 1Commissioner Burdge abstained).

Case #SH040906 - (Member Present) - This Horizon BCBSNJ-NJ DIRECT15 appeal concerned a denial of benefits for Interspinous Distraction Procedure for Lumbar Spinal Stenosis (X Stop) which was deemed experimental.  In his presentation, the member told the Commission that he does not want to undergo invasive surgery unless all more conservative options have been exhausted.  He indicated the characterization of this device as “investigational” or “experimental” is not borne out by the literature.  He also stated that other health care plans, including at least three Blue Cross Blue Shield (BCBS) plans now cover the procedure along with Medicare.  Dr. Smith, Medical Director, Horizon BCBSNJ, said just because the FDA approved the device does not mean it is not investigational.  The studies provided by the member are not long term studies.  Long term studies will not be available until 2010.  BCBS policies may vary in different geographical areas.  Dr. Smith said to his knowledge Medicare does not cover this device.  Michael Malloy made a motion to go into Executive session under Resolution B.  Patrick Nowlan seconded the motion.  All voted in favor.  The Commission returned from executive session back into closed session.  Hope Cooper made a motion to deny this appeal and also asked the three medical carriers to review policy.  Michael Malloy seconded the motion. Approved (Vote 3: 1: 1, Commissioner Nowlan abstained and Commissioner Burdge voted nay).

Case #SH040907 - This Aetna appeal concerned a denial for continuance of coverage for a disabled dependent.  Susanne Culliton made a motion to deny this appeal and to include Chapter 375 enrollment information in the denial letter. Hope Cooper seconded the motion. All voted in favor. Passed (Vote 5: 0: 0).

Case #SH040908 – The member requested that the Commission’s previous denial of an appeal for denied claims determined to be non-emergent care for spouse while living overseas be forwarded to the Office of Administrative Law (OAL) for a hearing. Hope Cooper made a motion to deny this request for a hearing at the OAL and to issue Final Administrative Determination.  Susanne Culliton seconded the motion. Approved (Vote 4: 1: 0, Commissioner Burdge voted nay).

Case #SH040909 -   Susanne Culliton made a motion to affirm the decision of Office of Administrative Law (OAL) and note the exceptions filed by counsel.  Hope Cooper seconded the motion. Approved (Vote 4: 0: 0, Commissioner Malloy recused himself).

Case #SH040910 –   A settlement offer was before the Commission in a case involving ABA Therapy.  Hope Cooper made a motion reject the settlement proposal.  Susanne Culliton seconded the motion.  All voted in favor.

Case #SH040911  - A settlement offer was before the Commission in a case involving a work related injury.  Susanne Culliton made a motion to reject the settlement proposal and direct the DAG to provide the Independent Medical Examiners’ (IME) report to the opposing attorney.  Michael Malloy seconded the motion.  All voted in favor.

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

There being no further business, Patrick Nowlan made a motion to adjourn which was seconded by Hope Cooper.  All voted in favor.

Respectfully submitted,

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

 

 

 


Meeting No. 492
Minutes
June 10, 2009
1:00 PM
State Health Benefits Commission

Adequate notice of this meeting has been provided through the annual notice of the schedule of regular meetings of the Commission filed with and prominently posted in the offices of the Secretary of State.  The 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 25, 2008.

The meeting of the State Health Benefits Commission of New Jersey was called to order at time   on Wednesday, June 10, 2009 at 1:11 PM.  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, Chairperson, representing State Treasurer R. David Rousseau
Michael Malloy, Commissioner, 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 (Arrived @ 1:22 PM)

Also present: 

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, 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.

Meeting No. 491, April 8, 2009 –   Susanne Culliton made a motion to accept the minutes. Michael Malloy seconded the motion.  Approved (Vote 4: 0: 0; Commissioner Burdge absent)

Jean Williamson advised the Commission they would go out of order for Fred Beaver to address the Commission concerning the Governor’s Press Release.

Fred Beaver thanked Michael Malloy for his service to Commission and wished him good luck in his up coming retirement from the Department of Banking and Insurance. 

Issues

Fred Beaver addressed the Commission concerning the Governor’s press release of May 22, 2009.  In the press release, the Governor asked that the two health benefits commissions to consider measures that would 1) suspend an employer’s ability to delay premium payments; 2) place a surcharge on employers who enter and leave the program; 3) terminate employers for non-payment of premiums; and 4) identify any new cost saving opportunities.  Mr. Beaver indicated that rate increases would likely be in the double digits for 2010.  Mr. Beaver also gave an example of an employer that left the health plan owing $500,000 and is now coming back into the plan.  Private insurance has termination dates when premiums are not received. 

Susanne Culliton made a motion to go into closed session under Resolution A and Hope Cooper seconded the motion.  Approved (Vote 4: 0: 0; Commissioner Burdge absent).  Commissioner Burdge joined the meeting at the beginning of the first appeal.

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

New Business Appeals

Case #SH060901(Member Present) – This Horizon-Traditional Plan appeal concerned denial of benefits for a Positron Emission Tomography (PET) deemed experimental in the diagnosis of dementia.  Commissioner Malloy asked Dr. Smith from Horizon if the SHBP paid for the PET scan in the past.  Dr. Smith replied, in cancer treatment we have paid for a PET, but not for the diagnosing of dementia.  The initial diagnostic approach to dementia does not, at this point, generally involve the use of neuroimaging.  Michael Malloy made a motion to deny this appeal.  Hope Cooper seconded the motion.  All voted in favor.  (Vote 5: 0: 0).

Case #SH060902 - (Member Present) – This Horizon-NJ DIRECT10 appeal concerned a denial of benefits for prior authorization of In Vitro Fertilization (IVF) treatment.  The Member and his spouse advised the Commission they were not aware that his health plan was going from the Traditional plan to the NJ DIRECT plan in October due to his employer joining the SHBP effective October 1, 2008.  They said that new ID cards to the NJ DIRECT plan were not received until January 2009.  They expressed concerned about receiving over $5,000.00 in medication for the treatment when it wouldn’t be covered.  The spouse said she spoke to numerous Horizon corporate representatives and at no time did any of them advise her of the plan change or that their coverage under the employer’s private plan was terminated.  When they received the denial for the IVF treatment, they contacted the employer who gave her the telephone number to request new ID cards.  Commissioner Burdge asked Horizon if this procedure would have been covered under the Traditional corporate plan [that the member was enrolled in until October 1, 2008].  Wendy Burns, Horizon, indicated it would. Commissioner Culliton made a motion to table this appeal and ask that Horizon provide phone records of Horizon corporate responses and Horizon SHBP responses to the member.  Patrick Nowlan seconded the motion.  All voted in favor.  Approved (Vote 5: 0: 0).

Case #SH060903 (Member Present with Attorney) – This Aetna appeal concerned denial of a request for continued skilled home private duty nursing for member’s daughter.  Member’s attorney advised the Commission that the child’s medical condition can change at any given moment.  He stressed how crucial the need for a constant skilled nursing is to the child’s survival and could very well result in death if it were not available.  Dr. Rosen, Aetna, gave an overview and background on this case.  He said the decision to deny private duty nursing because the information reviewed does not meet the criteria for continued care by a private duty nurse.  Dr. Rosen said the child does require constant adult supervision.  The member stated that the request to continue private duty nursing for the child had been denied twice in the past and both times the Members Appeals Committee (MAC) overturned the denial.  Commissioner Malloy asked what was different in this appeal.  Dr. Rosen replied the child is receiving care in school.  He also said although she is not seizure free, the seizures have lessened as she has grown.  The nurse’s notes indicate care that does not require a licensed skilled nurse; services represent custodial care.  Commissioner Culliton made a motion to go into Executive Session under resolution B.  Patrick Nowlan seconded the motion.  All voted in favor. The Commission returned from Executive Session back into closed session.  Commissioner Culliton made a motion to table this appeal for three months in order to have an Independent Medical Examiner (IME) do an evaluation of medical records and school records and a physical examination of the child, if necessary.  The motion also provided that private duty nursing be continued for the child until the appeal returned to the Commission in three months.  Hope Cooper seconded the motion.  All voted in favor.  

Case #SH060904 –FAD pulled from agenda; will be re-scheduled for next meeting in July.

Case #SH040905 –  An Appellate Decision was before the Commission for their information.  Wendy Burns, Horizon, advised the Commission that they do not have claims in the amount of $25,500.00 indicated in the Appellate Decision.  Horizon’s accounting of claims submitted is $23,300.00, some of which were unreadable.  Susanne Culliton made a motion to request the Attorney’s General’s office to seek accounting of bills totaling $25,500.00.  Dudley Burdge seconded the motion.  All voted in favor.

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.

Issues – continued

B. New Employers

Commissioner Burdge expressed concern that one part of Horizon encourages local employers to drop out of the State Health Benefits Program and a different part of Horizon encourages them to join.  What incentives motivate them to join the SHBP?   David Pointer replied Horizon would have to be willing to release that information.  Commissioner Burdge asked could we request that the local employers complete surveys?  Mr. Pointer stated we currently do not have the staff to accommodate a survey.  

C. Performance Standard Report –  Aetna failed to meet the Measured Data Standard for the Department of Banking and Insurance (DOBI) HMO Report Card.  The penalty for failing to meet this standard is 3% of the administrative fee or $887,200.98.  Aetna has been informed of this penalty and they are in agreement on the amount.  CIGNA failed to get an average or better on one of the Measured Data items – Testing of Breast Cancer.  Cigna met all standards and is preparing a correction plan for the one item missed.  The Division will work with improvement plans that will be submitted from Aetna and CIGNA.  Horizon Blue Cross Blue Shield of New Jersey met all performance standards for NJ DIRECT.

D. Dependent Eligibility Verification Audit update:  To date there are approximately 1,000 dependents that were voluntarily dropped from the program.  Commissioner Burdge inquired about the timeline.   Mr. Pointer replied Stage One ineligibles will be terminated effective September 1, 2009, Stage Two and Three ineligibles will be terminated effective October 1, 2009.  In addition Phase 2 will not start until January 2010.  We expect to wrap up the audit by July 2010.  Commissioner Nowlan asked about the security of the personal documents.  Mr. Pointer replied documents are destroyed after they are scanned.  They will be electronically sent to the Division.     

E.  X-Stop Interspinal Device.  At the previous meeting of the State Health Benefits Commission a motion was made to have the medical carriers review their policy on the X-Stop Interspinal Device.  All three medical carriers consider the device to be experimental/investigational.

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 3:09 PM.

Respectfully submitted,

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

 

 

 


Meeting No. 493
Minutes
July 14, 2009
10:00 AM
State Health Benefits Commission

The Special meeting of the State Health Benefits Commission of New Jersey was called to order on Tuesday, July 14, 2009 at 10:05 AM.  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, Chairperson, representing State Treasurer R. David Rousseau
Sylvia Allen-Ware, Commissioner, representing Commissioner Steven M. Goldman, Department of Banking & Insurance (For the appeals portion of the meeting)
Neil Vance, Commissioner, representing Commissioner Steven M. Goldman, Department of Banking & Insurance (For the rate renewal portion of the meeting)
Hope Cooper, Chair, Civil Service Commission
Patrick Nowlan, Representative for State Government Employees
Dudley Burdge, Representative for Local Government Employees

Also present: 

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, State Health Benefits Program
Mildred Brown, State Health Benefits Program
Representatives from Horizon BCBSNJ
Edward Fox, Aon Consulting
James Christ, Aon Consulting
Susan Marsh, Aon Consulting

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

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

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

Old Business Appeals

Case #SH070901(Member Present) This Horizon-NJ DIRECT10 appeal was tabled at a previous meeting and concerned a denial of pre-certification for In Vitro Fertilization (IVF) Treatment.  Horizon provided telephone call transcripts of calls from the member and provider to Horizon corporate and Horizon SHBP.  Commissioner Culliton recalled at the last meeting there was some confusion on the member’s part of which plan he was enrolled:  Traditional or NJ DIRECT.  Commissioner Culliton asked the member if he recalled completing the State Health Benefits application in August 2008 switching plans to NJ DIRECT.  He responded yes, but since he had not received any ID cards he did not know when the new plan started.  Commissioner Culliton said the telephone transcripts from Horizon show several calls were received from the member’s spouse and the provider’s office and both were told the reversal and the IVF were not covered.  A copy of the transcripts was provided to the member and Commissioner Culliton asked the member if they wished to have the appeal tabled for about 15 minutes to allow them time to review the telephone transcripts.  Member declined.  Commissioner Burdge stated, “Clearly, they were told the reversal was not covered, but the other treatments were covered but needed precertification”.  He then asked Horizon if this information was given out because the representatives are not properly trained.  Dave Perry. Horizon explained, “The services are a covered benefit, so we surely do not want the representatives advising them it’s not covered.  Members are advised that the doctor’s office should be contacting Horizon for the precertification of the services for the person who will be receiving the services.”   Since prescriptions were dispensed for the procedure because the medical and prescription drug plans are separate and there is no precertification for the prescription drugs, there was some discussion about revisiting authorizations for the prescriptions through Specialty Pharmacy.  Hope Cooper made a motion to deny this appeal.  Susanne Culliton seconded the motion.  Approved (Vote: 4: 0: 1; Commissioner Nowlan abstained).

Case #SH070902 - The member requested that the Commission’s previous denial of an appeal for benefits for prior authorization of In Vitro Fertilization (IVF) treatment be forwarded to the Office of Administrative Law (OAL) for a hearing.  Susanne Culliton made a motion to deny this request for a hearing at the OAL and to issue a Final Administrative Decision.  Hope Cooper seconded the motion.  All voted in favor.

Case #SH070903 - Susanne Culliton made a motion to approve the Final Administrative Determination for an appeal which the Commission denied concerning expenses for various claims for a dependent which were incurred overseas while enrolled in CIGNA.  Hope Cooper seconded the motion.  Approved  (Vote 4: 0: 1, Commissioner Allen-Ware abstained).

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

Issues

Edward Fox, Aon Consulting, gave a general overview of the 2010 rates. Susan Marsh, Aon Consulting gave an overview of the 2010 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 of the State Health Benefits Program (SHBP). Also present from Aon Consulting was James Christ.

The following is a summary from Aon Consulting:

Recommended Plan Year 2010
Medical/Rx Rate Renewal Recommendation
for Active Employees and Retirees
of the State Group

  • For Plan Year 2010, Aon is recommending premium rate changes that – in the aggregate – represent an overall increase of 11% for State Active Employees and Retirees:

 

Active Employees

Early Retirees

Medicare Retirees

NJ DIRECT10

NA

9%

9%

NJ DIRECT15

13%

9%

9%

Aetna HMO

9%

14%

9%

CIGNA HMO

9%

14%

9%

NJ PLUS

12%

NA

NA

Rx Card Plan

7%

NA

NA

Average Change

11%

10%

9%

  •  This recommended renewal assumes:
    • For Retiree Rx for NJ DIRECT and HMOs, the brand copays and Out-of-Pocket maximum will receive formula increases based on Retiree Rx experience;

    • Select unions have not yet settled their contracts, so Employees in these unions (aka Legacy Employees) will continue with the current benefit plans;

    • The Prescription Benefit Manager (PBM) RFP will result in a new contract, effective 1/1/10, that will reduce RX costs by a minimum of 2% to 5%.  Premium levels in the renewal report assume a 2% reduction in Rx costs

    • The Dependent Eligibility Verification Audit will generate Plan Year 2010 claim savings of $14 million through the elimination of coverage for ineligible dependents;

    • No other changes in Employee or Retiree benefits, other than those mandated by New Jersey or federal law, as outlined in the renewal report;

    • State Employee enrollment will decrease about 1% in Plan Year 2010, and

    • State Retiree enrollment will increase about 4% in Plan Year 2010.

  • 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 well below industry norms for the past few years and we are projecting that the low trend levels will continue into Plan Year 2009 and 2010.

    • Early Retiree medical trends have also been lower than industry norms for the past few years and we are projecting that the lower trend levels will continue into Plan Year 2009 and 2010.

    • Prior to Plan Year 2009, Early Retiree HMO costs were pooled with Active HMO costs to develop premiums.  Since there are now over 4,000 State Early Retirees enrolled in HMOs, the Plan Year 2010 renewal rates were adjusted to partially reflect the higher level of claim costs attributable to Early Retirees.

    • HMO medical trends have been higher than Horizon trends over the past few years and we are projecting that that will continue into Plan Year 2010.
  • Factors contributing to the recommended rate actions include:
    • 9% trend increase from Plan Year 2009 to Plan Year 2010;

    • NJ DIRECT benefit changes approved after the Plan Year 2009 renewal, which add about 1% to the increase, and

    • Mandated benefit enhancements, which add about 1% to the increase.
  • Plan Year 2010 projected costs for the State Group are $1.78 billion ($1.37 billion for Actives and $.41 billion for Retirees).  Plan Year 2010 renewal premiums are set to match the projected $1.78 billion costs, so there is no loss or gain projected for Plan Year 2010.

Recommended Plan Year 2010
Medical/Rx Rate Renewal Recommendation
for Active Employees and Retirees
of the Local Government Group

  • For Plan Year 2010, Aon is recommending premium rate changes that – in the aggregate – represent an overall increase of 16% for Local Government Active Employees and Retirees:

 

Active Employees

Early Retirees

Medicare Retirees

NJ DIRECT10

20%

7%

6%

NJ DIRECT15

20%

7%

6%

Aetna HMO

20%

25%

13%

CIGNA HMO

20%

25%

13%

Rx Card Plan

5%

NA

NA

Average Change

18%

11%

7%

  • This recommended renewal assumes:
    • For Retiree Rx for NJ DIRECT and HMOs, the brand copays and Out-of-Pocket maximum will received formula increases based on Retiree Rx experience;

    • The Prescription Benefit Manager (PBM) RFP will result in a new contract, effective 1/1/10, that will reduce Rx costs by a minimum of 2% to 5%.  Premium levels in the renewal report assume a 2% reduction in RX costs;

    • The Dependent Eligibility Verification Audit will generate Plan Year 2010 claim savings for the Local Government Group of $5 million through the elimination of coverage for ineligible dependents;

    • No other changes in Employee or Retiree benefits, other than those mandated by New Jersey or federal law, as outlined in the Renewal Report;

    • Active Employee and Retiree enrollment will increase in August 2009 at half the rate of July 2009 and then remain level from September 2009 through December 2010, and
  • 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 well below industry norms for the past few years and we are projecting that the low trend levels will continue into Plan Years 2009 and 2010.

    • Prior to Plan Year 2009, Early Retiree HMO costs were pooled with Active HMO costs to develop premiums.  Since there are now over 2,000 Local Government Early Retirees enrolled in HMOs, the Plan Year 2010 renewal rates were adjusted to partially reflect the higher level of claim costs attributable to Early Retirees.

    • HMO medical claim trends have averaged about 3% higher than Horizon trends over the past several years, and we are projecting that HMOs will continue to trend at a higher rate than the Horizon plans in Plan Year 2010.
  • Factors contributing to the recommended rate actions include:
    • 9% trend increase from Plan Year 2009 to Plan Year 2010;

    • Higher than previously anticipated trends for Plan Years 2008 and 2009;

    • NJ DIRECT benefit changes approved after the Plan Year 2009 renewal, which add 2% to the increase;

    • Mandated benefit enhancements, which add about 1% to the increase, and

    • Spend down of the accumulated Claim Stabilization Reserve, which adds about 4% to the increase.

  • Plan Year 2010 projected costs for the Local Government Group are $856 million ($632 million for Actives and $224 million for Retirees).  Plan Year renewal premiums are set to match the projected $856 million cost, so there is no loss or gain projected for Plan Year 2010.

Recommended Dental Plans Rate Renewal
for Plan Year 2010

  • For the SHBP Dental Plans (Employee and Retiree Dental Expense Plans and Employee DPOs), Aon recommends the following premium rate adjustments, which – in the aggregate – represent a 1% overall decrease in program costs:
Dental Expense Plans
Actives
2.0%
Retirees
-9.0%


Dental Plan Organizations (DPOs)
Aetna
-2.0%
Healthplex
-4.0%
BeneCare, CIGNA, Community, And 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.
  • Each of the DPOs currently has a Value Ratio greater than 1.0, so we would normally be recommending a premium increase for all of the DPOs.  However, given the State’s budgetary issues, we are recommending no increase for the 4 DPOs that requested modest increases and modest decreases for the 2 DPOs that indicated that they could accommodate a decrease in premium rates.
  • This recommended renewal assumes:
    • The Dental Expense Plans’ (both Active Employee and Retiree) network will be expanded to include Aetna’s PPOII network, resulting in a projected savings of .4%, and
    • No other changes in Dental benefits for Active Employees, but a change for Retirees from the current passive PPO to a true PPO, with different coinsurance for In-Network versus Out-of-Network providers.  This will result in projected savings of over 8% for the Retiree Dental Expense Plan.
  • Aon is projecting a total Claim Stabilization Reserve for the Retiree-Pay-All Dental Expense Plan at the end of Plan Year 2010 of $6.1 million.  This is equivalent to 2.1 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 2010 Retiree Dental Expense Plan premiums.
  • No margin has been included in the Plan Year 2010 Active Dental Expense Plan premiums, since this plan is 50% funded by the State and the State absorbs excess gains and would have to fund any plan losses.
  • Aon is projecting very little change in Employee Dental Expense enrollment between Plan Years 2009 and 2010:  62,500 Employees enrolled in the Dental Expense Plan and 41,000 Employees enrolled in the DPO plans.  Retiree Dental Expense Plan enrollment is expected to increase 4% to 54,000 for Plan Year 2010.
  • Plan Year projected costs for the SHBP Dental Plans are $115.9 million, with $59.2 million attributable to the Employee Dental Expense Plan, $36.5 million attributable to the Retiree Dental Expense Plan, and $20.2 million attributable to the DPOs.

Mental Health Parity was discussed.  There was a question concerning whether an exemption should include the HMOs.  Patrick Nolan made a motion to table a vote on the exemption.  Commissioner Burdge seconded it and all voted in favor.

There being no further business, Patrick Nowlan made a motion to adjourn which was seconded by Susanne Culliton.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 12:15 PM.

Respectfully submitted,

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

 

 

 


Meeting No. 494
Minutes
July 22, 2009
1:00 PM
Special State Health Benefits Commission

The Special meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, July 22, 2009 at 1:09 PM.  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, Chairperson, representing State Treasurer R. David Rousseau
Neil Vance, Commissioner, representing Commissioner Neil N. Jasey, Department of Banking & Insurance
Hope Cooper, Chair, Civil Service Commission
Patrick Nowlan, Representative for State Government Employees via telephone
Dudley Burdge, Representative for Local Government Employees

Also present: 

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
Jean Williamson, Acting Secretary
Barbara Scherer, State Health Benefits Program
Mildred Brown, State Health Benefits Program
Edward Fox, Aon Consulting
James Christ, Aon Consulting
Susan Marsh, Aon Consulting

Resolutions B (Executive Session) – was read in its entirety.

2010 Rate Renewals

Edward Fox, Aon Consulting, addressed the Commission and gave a made brief statements about the Presidents Health Care Reform Act 2010.  After introducing the Aon team, he turned it over to Susan Marsh, Aon Consulting.  Ms. Marsh gave an overview of her memo to Florence Sheppard dated July 21, 2009 which addressed follow-ups from questions that were raised at the meeting on July 14, 2009 concerning the recommendations for the 2010 Rate Renewals.
Commissioner Burdge asked for an explanation of why the Out-of-Network (OON) Ambulatory Surgery Center costs are so high.  Ms. Marsh explained that In-Network physicians have been referring their patients to these OON centers.  Some of the physicians may have an ownership with those particular centers.  Commissioner Vance asked Aon to advise the Commission in the future of other services that have escalated in OON utilization.  Ms. Marsh clarified that there are several reasons for higher claim costs to the plan such as cost shifting, increased rates based on expected inflation, members are utilizing their benefits more for fear that they may no longer be provided with those benefits and are getting services now that have been put off in the past.  
Hope Cooper made a motion to approve the 2010 Rate Renewals (State, Local Employer and Dental).  Susanne Culliton seconded the motion.  All voted in favor.

Mental Health Parity – For Approval

The Commission received a memo from Jean Williamson advising that the School Employees’ Health Benefits Commission (SEHBC) approved a motion the morning of July 22, 2009 to recommend that the SHBC not apply for an exemption for the Mental Health Parity.  Commissioner Burdge made a motion that this matter be tabled to September’s meeting for discussion.  Patrick Nowlan seconded the motion.  A question was raised concerning what would happen if the SEHBC voted against an exemption and the SHBC voted in favor of one.  Rubin Weiner, DAG , explained that under the Memorandum of Understanding (MOU) between the SHBC and the SEHBC this commission has the authority to file on behalf of the SEHBC.  Susanne Culliton made a motion to go into Executive Session under Resolution B.  Hope Cooper seconded the motion.  Approved (Vote: 4: 1: 0 Commissioner Burdge voted nay).  Upon return from Executive Session, Jean Williamson advised the Commission that there was a motion on the floor to table this issue and a vote was needed. Motion passed (Vote: 3: 2: 0 Commissioners Culliton and Cooper voted nay).   

There being no further business, Hope Cooper made a motion to adjourn which was seconded by Susanne Culliton.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 1:18 PM.

Respectfully submitted,

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

 

 

 


Meeting No. 495, Minutes
August 12, 2009, 10:00 AM
State Health Benefits Commission

Adequate notice of this meeting has been provided through the annual notice of the schedule of regular meetings of the Commission filed with and prominently posted in the offices of the Secretary of State.  The 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 25, 2008.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, August 12, 2009 at 10:08 AM.  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, Chairperson, representing State Treasurer R. David Rousseau
Sylvia Allen-Ware, Commissioner, representing Commissioner Neil N. Jasey, 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: 

Rubin Weiner, Deputy Attorney General
Florence J. Sheppard, Deputy Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, State Health Benefits Program
Mildred Brown, State Health Benefits Program
Representatives from Horizon BCBSNJ
Representatives from Aetna

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

Meeting No. 492, June 10, 2009 – Susanne Culliton made a motion to accept the minutes. Hope Cooper seconded the motion. Approved (Vote 4: 0: 1; Commissioner Allen-Ware abstained).

Meeting No. 493, July 14, 2009 – Susanne Culliton made a motion to accept the minutes. Hope Cooper seconded the motion. Approved (Vote 5: 0: 0).

Meeting No. 494, July 22, 2009 –   Susanne Culliton made a motion to accept the minutes. Hope Cooper seconded the motion.  Approved (Vote 4: 0: 1; Commissioner Allen-Ware abstained).

ISSUES

A. Carrier Updates:

David Pointer indicated that negotiations between Horizon and Helene Fuld Medical Center are on-going.  Commissioner Burdge asked what will happen if people go there after Saturday.  Mr. Pointer responded it will be an out-of-network hospital.  Of course in a medical emergency, you would always go to the nearest hospital, which would be considered in-network. 

B. COBRA Vision Rates – For Approval

Susanne Culliton made a motion to approve the COBRA Vision Rates.  Hope Cooper seconded the motion.  All voted in favor. Approved (Vote: 5: 0: 0).

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

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

NEW BUSINESS APPEALS

Case #SH080901(Member Present with attorney) This Horizon (Magellan Health Services) appeal concerned denial of benefits for expenses for Adolescent Substance Use Residential Rehabilitation and Extended Care program for the member’s daughter.  Commissioner Cooper recused herself from this appeal.  The member told the Commission of the events that lead up to his daughter’s admission into the Caron Foundation.  The member’s attorney advised the Commission that inaccurate information from Magellan was stated pertaining to the ASAM medical necessity criteria. Commissioner Culliton requested that Dr. Donnelly from Magellan give an overview of the case.  Dr. Donnelly gave a brief description of member’s daughter medical history from age thirteen.  He also advised the Commission that the subcommittee hearing agreed that his daughter’s treatment could have been safely accomplished in an intensive outpatient substance abuse treatment setting.  In addition, Magellan had not been contacted prior to admission.  Commissioner Culliton made a motion to go into executive session under Resolution B.  Commissioner Nowlan seconded the motion.  All voted in favor.   Upon return from executive session, Commissioner Culliton made a motion to deny this appeal.  Commissioner Nowlan seconded the motion. Approved (Vote: 3: 1: 0; Commissioner Burdge voted nay).    
Case #SH080902 - This Aetna appeal concerned denial of occupational therapy for dependent son.  The medical director from Aetna gave an overview of the appeal including a timeline of the events leading up to the appeal.  Therapy was denied at Sensational Kids because it is out-of-network and in-network therapy is available.  In addition, the sensory and auditory integration therapy is considered experimental/investigational.  Commissioner Cooper made a motion to deny this appeal based on the availability of in-network providers.  Commissioner Culliton seconded the motion.  All voted in favor.

Case #SH080903 –  (Member Present with Attorney) This Traditional plan appeal concerned a denial of benefits for expenses for Manipulation Under Anesthesia (MUA) rendered on member’s spouse.  Dr. Siegfried appeared before the Commission to answer questions on behalf of the member.  Mr. Rossi (attorney for the member) asked Dr. Siegfried questions concerning the case and Dr. Siegfried responded to them.  Commissioner Cooper made a motion to deny the appeal as experimental/investigational.  Commission Culliton seconded the motion.  All vote in favor.

Case SH080904 – This Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery for a member.  Commissioner Culliton made a motion to deny this appeal since payment was made in accordance with the reasonable and customary allowance.  Commissioner Burdge seconded the motion and all voted in favor.

Case SH080905(Member’s Spouse Present) This NJ DIRECT15 appeal concerns a copayment of $5.00 for a mail order prescription.  The member’s spouse gave an overview of her appeal and argued that only one prescription for 188 mcg of Synthroid was written by the doctor and member should only be required to pay one copayment.  Patrick Gill, Regional Pharmacist, Horizon BCBSNJ, indicated two separate strengths (88 mcg tablets and 100 mcg tablets) were dispensed.  Commission Nolan made a motion to approve this appeal.  Commission Burdge seconded it.  Failed (Vote: 2: 3: 0; Commissioners Culliton, Cooper and Allen-Ware voted nay).  Commissioner Culliton made a motion to deny this appeal.  Commissioner Cooper seconded it.  Approved (Vote: 3: 2: 0; Commissioners Burdge and Nowlan voted nay).    

Case SH080906 – Susanne Culliton made a motion to approve the Final Administrative Determination for a NJ DIRECT appeal which the Commission denied because the member is older than the maximum age of 46 for this treatment and has had the maximum number of attempts allowed under the plan.  Commissioner Cooper seconded the motion.  All voted in favor.

Case SH080907 – A settlement proposal for a case pending in Appellate Court was presented to the Commission.  Commissioners Culliton and Allen-Ware recused themselves from this matter.  The case involved Percutaneous Laser Disc Decompression (PLDD) which had been previously denied by the Commission on November 17, 2007.  Commissioner Cooper made a motion to go to Executive Session under resolution B.  Commissioner Nowlan seconded the motion and all voted in favor.  Upon return from Executive Session, Commissioner Cooper made a motion to deny the settlement proposal.  Commissioner Nowlan seconded the motion and all voted in favor.

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

Mental Health Parity was discussed.  There was a question concerning whether an exemption should include the HMOs.  Patrick Nolan made a motion to table a vote on the exemption.  Commissioner Burdge seconded it and all voted in favor.

There being no further business, Patrick Nowlan made a motion to adjourn which was seconded by Susanne Culliton.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 12:15 PM.     

Respectfully submitted,

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

 

 

 


Meeting No. 495, Minutes
October 14, 2009, 10:00 AM
State Health Benefits Commission

Adequate notice of this meeting has been provided through the annual notice of the schedule of regular meetings of the Commission filed with and prominently posted in the offices of the Secretary of State.  The 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 25, 2008.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, October 14, 2009 at 10:12 AM. 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, Chairperson, representing State Treasurer R. David Rousseau
Sylvia Allen-Ware, Commissioner, representing Commissioner Neil N. Jasey, Department of Banking & Insurance
Hope Cooper, Chair, Civil Service Commission
Patrick Nowlan, Representative for State Government Employees
Dudley Burdge, Representative for Local Government Employees via telephone

ALSO PRESENT: 

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, State Health Benefits Program
Mildred Brown, State Health Benefits Program
Horizon Representatives

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

Meeting No. 493, July 14, 2009 – Hope Cooper made a motion to accept the minutes. Susanne Culliton seconded the motion.  All voted in favor.

Meeting No. 494, July 22, 2009 – Hope Cooper made a motion to accept the minutes. Susanne Culliton seconded the motion.  All voted in favor.

ISSUES

A. Open Enrollment

David Pointer advised the Commission that Open Enrollment has begun.  Open Enrollment letters were sent to the employers in mid-September advising them the Open Enrollment Period for employees will begin on October 1, 2009 and end on October 30, 2009.  All changes to coverage made during this open enrollment will be effective on January 1, 2010 for local employees and on January 2, 2010 for State employees.  For changes made during this Open Enrollment, completed employer-certified Health Benefit Applications and/orDental Plan Applications should be forwarded to the Health Benefits Bureau as soon as they are received from employees.  Rosters of employees were mailed to the Employers in the past; however, this year employers can access the rosters on-line. 

B. Dependent Eligibility Verification Audit (DEVA)

David Pointer gave an update on the DEVA.  Approximately 4,000 employees have not responded.  There are approximately 12,000 dependents enrolled under the 4,000 employees.  The Division has reached out to the employers of the non-responsive employees for correct contact information.  Approximately 4,800 dependents have self declared that they are not eligible. 
 
C. New Legislation

David Pointer gave a brief overview of the following new legislation:

  • Chapter 113, P.L. 2009 (Maternity Services Reimbursement):  Plans in the State Health Benefits Program shall provide reimbursement in installments to an obstetrical provider licensed in New Jersey for maternity services rendered during the term of a pregnancy. 
  • Chapter 115, P. L. 2009 (Medically necessary therapies for members with Autism and other developmental disabilities).  Aon Consulting and the Division are still reviewing this to determine the impact it will have on the program. 
D. 2010 Meeting Schedule

Jean Williamson advised the Commission in 2010 the Commission meetings would begin at 1:00 PM during the first five months (January through May) and the meetings from June through December would begin at 10:00 AM.  Susanne Culliton made a motion to approve the 2010 meeting dates which will be held every 2nd Wednesday of the month.  Hope Cooper seconded the motion. All voted in favor.  Approved (Vote 5: 0: 0).

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

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

NEW BUSINESS - APPEALS

Case #SH100901 – This Horizon NJ DIRECT15 appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for surgery for the member.  Commissioner Culliton recused herself from this appeal.  Hope Cooper made a motion to deny this appeal.  Sylvia Allen-Ware seconded the motion.  Approved (Vote: 4: 0: 0; Commissioner Culliton recused).    

Case #SH100902 (1st Appeal) (Member Present) – This Horizon-NJ DIRECT15 (Magellan Health Services) appeal concerned a denial of benefits for level of reimbursement for an out-of- network mental health benefit provider for a dependent spouse.  The Member argued that Horizon had no justification for reducing Reasonable and Customary charges for an out-of-network provider.  He provided the Commission with Horizon’s Explanation of Benefits for services received from August 4, 2008 through March 26, 2009 for his spouse.  Susanne Culliton made a motion to go into Executive Session under Resolution B.  Hope Cooper seconded the motion.  All voted in favor. The Commission returned from executive session.  Susanne Culliton made a motion to table this appeal until the State Health Benefits Commission has the opportunity to review the fees at which point the claims will be adjusted or this appeal will be rescheduled.  Hope Cooper seconded the motion.  All voted in favor.

(2nd Appeal) – This Horizon NJ DIRECT15 appeal concerned denial of reimbursement for an embryo transfer.  The Member provided a handout with information about age discrimination for infertility. The Member gave a brief overview of his appeal.  The embryo retrieval had been done in 2007.  Commissioner Culliton pointed out that the member received a letter dated May 5, 2008 indicating that effective April 1, 2008 the plan was changed to NJ DIRECT15 and that the plan would follow the NJ Mandate for Infertility.  The letter also indicated that future IVF treatment and procedures, including embryo transfer are not eligible for consideration since your spouse is beyond the maximum age limit under the NJ Mandate for Infertility.  Commissioner Nowlan made a motion to go into Executive Session under Resolution B.  Commissioner Burdge seconded.  Motion did not carry (Vote: 2: 3: 0; Commissioner Culliton, Cooper and Allen-Ware voted nay).  Commissioner Culliton made a motion to deny this appeal.  Commissioner Cooper seconded the motion.  Approved (Vote: 3: 2: 0; Commissioner Burdge and Nowlan voted nay).

Case #SH100903 – This Horizon Employee Prescription Drug Plan appeal concerned a denial of benefits for expenses for Cialis beyond four Cialis pills per month/twelve pills in a 90-day period.  Commissioner Burdge recused himself from this appeal.  Dr. Smith, Medical Director, Horizon Blue Cross Blue Shield of NJ indicated the use of the inhibitors for rehabilitation after this surgery is considered investigational. There hasn’t been a sufficient amount of data proving it’s effective in the rehabilitation.  Commissioner Cooper made a motion to deny this appeal.  Commissioner Culliton seconded the motion.  Approved (Vote: 4: 0: 0; Commissioner Burdge recused).
  
Case #SH100904  (Member Present) – This Horizon Traditional Plan appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for surgery for the member.  The Member gave a brief presentation.  Commissioner Culliton made a motion to deny this appeal.  Commissioner Cooper seconded the motion.  All voted in favor. 

Case #SH100905 (1st Appeal) – This Horizon-NJ DIRECT15 (Magellan Health Services) appeal concerned a denial of benefits for amount above the reasonable and customary allowance for psychiatric diagnostic interview examination for an out-of- network mental health benefit provider. Wendy Burns, Horizon gave a brief explanation on how NJ DIRECT applies limits on these services.  Commissioner Culliton made a motion to deny this appeal.  Commissioner Cooper seconded the motion. Approved (Vote 3: 0: 2, Commissioner Nowlan and Burdge abstained). 

(2nd Appeal) – This Horizon NJ DIRECT15 appeal concerned denial of benefits for a chiropractor office visit. Commissioner Nowlan made a motion to go into Executive Session under Resolution B.  Commissioner Burdge seconded.  All voted in favor.  Upon return from executive session, Commissioner Culliton made a motion to approve this appeal.  Commissioner Cooper seconded the motion.  All voted in favor.   

Case #SH100906 – The member requested that the Commission’s previous denial of an appeal for benefits for continued stay/residential treatment for his dependent son be forwarded to the Office of Administrative Law (OAL) for a hearing. Commissioner Culliton made a motion to approve this request for a hearing at the OAL.  Commissioner Cooper seconded the motion. Approved (Vote 4: 0: 1, Commissioner Allen-Ware abstained).

Case #SH100907 – The member requested that the Commission’s previous denial of an appeal for benefits for continued stay/residential treatment for his dependent daughter be forwarded to the Office of Administrative Law (OAL) for a hearing. Commissioner Culliton made a motion to approve this request for a hearing at the OAL.  Commissioner Burdge seconded the motion. Approved (Vote 4: 0: 0, Commissioner Cooper recused herself).

Case #SH100908 – The member requested that the Commission’s previous denial of an appeal for benefits for occupational therapy for his dependent son be forwarded to the Office of Administrative Law (OAL) for a hearing. Commissioner Culliton made a motion to deny this request for a hearing at the OAL and to issue a Final Administrative Determination. Commissioner Cooper seconded the motion. Approved (Vote 4: 1: 0, Commissioner Burdge voted nay).

Case #SH100909 – The member requested that the Commission’s previous denial of an appeal for benefits for pre-certification for In Vitro Fertilization Treatment be forwarded to the Office of Administrative Law (OAL) for a hearing. Commissioner Culliton made a motion to approve this request for a hearing at the OAL.  Commissioner Nowlan seconded the motion. Approved (Vote 5: 0: 0).

Case #SH100910 – The member requested that the Commission’s previous denial of an appeal for benefits for mail order prescription drug co-payment for Synthroid tablets, 188mcg be forwarded to the Office of Administrative Law (OAL) for a hearing. Commissioner Culliton made a motion to deny this request for a hearing at the OAL and to issue a Final Administrative Determination. Commissioner Cooper seconded the motion. Approved (Vote 3: 2: 0, Commissioner Burdge and Nowlan voted nay).

Case #SH100911 -   Commissioner Culliton made a motion to affirm the decision of Office of Administrative Law (OAL).  Commissioner Cooper seconded the motion. Approved (Vote 3: 2: 0, Commissioner Burdge and Nowlan voted nay).

Case #SH100912  - A settlement offer was before the Commission in a case involving surgery that was deemed cosmetic in nature.  Susanne Culliton made a motion to accept the settlement proposal.  Commissioner Nowlan seconded the motion.  Approved (Vote 5: 0: 0).

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

There was a brief discussion about placing items on the agenda.

Dave Perry, Horizon BCBSNJ, indicated that East Orange General Hospital will be out of network at the end of the month (10/31/09).  The other hospitals that do not participate with Horizon BCBSNJ are:  Bayonne, Newton, Rahway, Palisades and Bergen Regional.  Ninety percent of the hospitals participate.

Commission Nowlan made a motion to put Magellan on the agenda concerning the OON-reimbursement (tiering).  Commission Cooper seconded the motion and all voted in favour.

There being no further business, Commission Culliton made a motion to adjourn which was seconded by Commissioner Nowlan.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 12:30.

Respectfully submitted,

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

                                                                 

 

 


Meeting No. 497
Minutes
December 9, 2009
10:00 AM
State Health Benefits Commission

Adequate notice of this meeting has been provided through the annual notice of the schedule of regular meetings of the Commission filed with and prominently posted in the offices of the Secretary of State. The 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 25, 2008.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, December 9, 2009 at 10:35 AM. 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, Chairperson, representing State Treasurer R. David Rousseau
Sylvia Allen-Ware, representing Commissioner Neil N. Jasey, 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: 
Rubin Weiner, Deputy Attorney General
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, State Health Benefits Program
Mildred Brown, State Health Benefits Program
Horizon Representatives
Magellan Representatives
Aetna Representatives

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

Chairperson Culliton made a motion to go out of order to hear member appeals first.  Commissioner Cooper seconded the motion. Motion Passed (Vote: 3: 2: 0; Commissioner Burdge and Nowlan voted nay).

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

Commissioner Cooper made a motion to go into closed session under Resolution A. Chairperson Culliton seconded the motion. Approved (Vote: 3: 2: 0; Commissioner Burdge and Nowlan voted nay).

Case #SH120901 This Aetna Dental Expense Plan appeal concerned a denial of benefits for expenses for replacement dentures outside of the five year waiting period. Aetna representatives indicated that their denial was based strictly on the contract limitation of a five year waiting period.  Chairperson Culliton made a motion to deny this appeal. Commissioner Cooper seconded the motion.  Approved (Vote: 5: 0: 0).    

Case #SH120902 (Member and Attorney Present) – This Horizon – Traditional Plan appeal concerned the denial of benefits for expenses for treatment at Williamsburg Place Farley Center and at Little Hill Foundation Alina Lodge. The member’s attorney gave a brief history of the member’s substance use beginning in 2000. She indicated that while the first facility provided inpatient treatment, the member required a more constricted facility. The Member spoke briefly on the history leading up to his treatments. Dr. O’Donnell, Magellan, gave a summary of the member’s appeal.  He said the member did not meet Magellan Behavioral Health Medical Necessity criteria for the requested level of care. When asked, the Member indicated he did not request a preauthorization for treatment.  Commissioner Cooper remarked that the member’s pre-admission forms do not show Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) as being responsible for payment, the disclosure of health insurance should have been presented at the time of the member’s admittance. The attorney advised the Commission that the member entered into a private monitoring agreement with the Professional Assistance Program of New Jersey (PAP-NJ) wherein he agreed to be assessed, referred to formal treatment and monitored for a minimum of two years to assist in his recovery and re-establish his competency to practice dentistry with the State Dental Board. Dr. O’Donnell stated the State Dental Board required treatment in order for him to get his license back but that does not necessarily make the level of treatment provided a medical necessity. Commissioner Cooper made a motion to deny this appeal. Chairperson Culliton seconded the motion. Approved (Vote: 3: 2: 0; Commissioners Burdge and Nowlan voted nay).

Case #SH120903  (Member Present) – This Horizon-NJ DIRECT15 appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for office visits and radiology. The Member indicated that under the Traditional Plan these services were paid in full and under the NJ DIRECT plan a smaller portion of the claim is being paid. He also pointed out that the definition of the Reasonable and Customary allowances in both member handbooks is identical.  The Horizon BCBSNJ representative explained that under the Traditional Plan, total charges were paid for office visits and under NJ DIRECT the PHCS fee schedule is used. Chairperson Culliton made a motion to deny this appeal.  Commissioner Cooper seconded the motion.  Approved (Vote: 3: 1: 1; Commissioner Nowlan voted nay, Commissioner Burdge abstained).

Case #SH100904  - (Member Present)  – This Horizon-NJ DIRECT15 appeal concerned a denial of benefits for unpaid claims for her son. The Member said she relied on the medical experts’ opinion for her son’s treatment. She said her son’s in-network pediatrician provided her with a referral to a provider for further diagnosis.  Pre-certification was never discussed.  Wendy Burns, Horizon BCBSNJ gave a summary of the denials. She indicated the behavioral testing claim was paid. Magellan determined that the additional testing performed was to assess for educational, academic and scholastic needs and therefore is excluded under NJ DIRECT. Ms. Burns also advised the Commission that pre-authorization was done after the tests were completed. Commissioner Cooper asked the member if she was informed at anytime that pre-authorization was not done.  Member replied, she did not know until she received the Explanation of Benefits (EOB) denying the claims. It was noted that the claims started out under NJ PLUS plan and in the middle of treatment the plan switched over to NJ DIRECT. Commissioner Cooper made a motion to go into Executive Session under Resolution B.  Commissioner Nowlan seconded the motion. All voted in favor. Upon returning from Executive Session, Chairperson Culliton made a motion to table this appeal to allow time for Horizon BCBSNJ to contact the provider concerning this issue. Commissioner Nowlan seconded the motion. Approved (Vote 5: 0: 0). 

Case #SH120905 – The Member requested that the Commission’s previous denial of an appeal for reimbursement for an Embryo Transfer be forwarded to the Office of Administrative Law (OAL) for a hearing. Chairperson Culliton made a motion to deny this request for a hearing at the OAL and to issue Final Administrative Determination. Commissioner Cooper seconded the motion. Approved (Vote 5: 0: 0).

Case #SH120906 – FAD pulled from agenda; will be re-scheduled for next meeting on January 13, 2010.

Case #SH120907 – Chairperson Culliton made a motion to affirm the decision of the Office of Administrative Law (OAL).  Commissioner Cooper seconded the motion. Approved (Vote 5: 0: 0).

Case #SH120908 – Final Administrative Determination –Chairperson Culliton made a motion to accept the FAD draft concerning the denial of reimbursement for five dollars for expenses for a mail order prescription drug co-payment. Commissioner Cooper seconded the motion. Approved (Vote 3: 0: 2, Commissioner Nowlan and Burdge abstained).

Case #SH120909 -   A settlement offer was before the Commission in a case involving ABA therapy for the dependent child. Commissioner Cooper made a motion to go into Executive Session under Resolution B.  Chairperson Culliton seconded the motion.  All voted in favor. Upon return from Executive Session, Chairperson Culliton made a motion to reject the settlement proposal and direct the DAG to provide the Commission with a proposed monetary settlement for bills up until the date that Chapter 115 becomes effective. Commissioner Nowlan seconded the motion. Approved (Vote 5: 0: 0).

There being no further appeals, a motion was made to return to open session by Chairperson Culliton, seconded by Commissioner Cooper. All voted in favor.

Jean Williamson advised the Commission the Executive Minutes for August 12, 2009 and October 14, 2009 meeting were not included with the minutes on today’s agenda. 

Meeting No. 495, August 12, 2009 – Commissioner Cooper made a motion to accept the regular minutes. Commissioner Nowlan seconded the motion. All voted in favor.

Meeting No. 496, October 14, 2009 –  Commissioner Cooper made a motion to accept the regular minutes. Commissioner Nowlan seconded the motion. All voted in favor.

Issues

A. Contract Extension to Aetna for Employees and Retiree Dental Expense Program Plans

David Pointer advised the Commission the Division Director has extended the contract with Aetna for one year for the Employee and Retiree Dental Expense Program Plans in accordance with the contract which permits two one year extensions. Commissioner Burdge said he believed the Commission has the authority to extend the contract and he asked DAG Weiner to reply. DAG Weiner said he would review the issue and report back next month.

B. Magellan Health Services Tiering

David Perry, Horizon BCBSNJ gave an overview of the issue.  Mr. Perry advised the Commission that periodically, Horizon BCBSNJ reviews reimbursement levels it pays to providers. During that review, Horizon updated its reimbursement methodology for out-of-network Mental Health/Substance Abuse (MHSA) claims that involve tiering based on the professional level of a provider. Currently, the Horizon BCBSNJ managed network professional fee schedule is broken down by professional level with rates which vary by level. Conversely, the out-of-network allowance was not broken down by professional level of the provider. As a result, the allowance for all out-of-network MHSA providers was essentially based on a higher professional level. This disparity between the in-network and out-of-network rates is inconsistent with industry standards. In order to align reimbursements with the treating provider’s professional level, it was necessary to update the out-of-network reimbursement methodology. This methodology is not discriminatory to those members who seek the services of a mental health provider.  It is consistent with the rating methodology used for health and dental reimbursements. Mr. Perry provided the following reimbursement rates for the different levels of providers: MD (Doctor of Psychiatry) 100%; PhD (Doctor of Psychology) 85%; Clinical Nurse Specialist 70%; and Licensed Clinical Social Worker, 65%. 
 
Chairperson Culliton made a motion to go into Executive Session under Resolution B and Commissioner Cooper seconded the motion. All voted in favor. Upon returning from Executive Session, Commissioner Burdge asked why this decision was not made by the Commission.  David Pointer replied this was not a benefit change. Commissioner Burdge disagreed and said it is a reduction in the payment of benefits. Mr Pointer referred to the statute which indicates the R&C is based on a nationally recognized database.  Commissioner Burdge stated Magellan is not a nationally recognized database. Mr. Perry stated that Horizon has over 50 million people to whom they provide services and can be considered a nationally recognized database. Chairperson Culliton made a motion to go into Executive Session under Resolution B and Commissioner Cooper seconded the motion. All voted in favor. Upon return from Executive Session Chairperson Culliton advised everyone that this issue was on the agenda as an FYI.  Commissioner Allen-Ware requested Mr. Perry if he would provide claims data and any other information that would show the extent of Magellan’s database. Chairperson Culliton added that as much documentation that can be provided will be helpful.

Commissioner Burdge made a motion that the other interested parties on Mental Health issues be heard. Commissioner Nowlan seconded the motion. Motion Failed (Vote 2: 3: 0, Chairperson Culliton, Commissioner Cooper and Allen-Ware voted nay).

C. Health Insurance Portability and Accountability Act (HIPAA) – Exemption from the Mental Health Parity Requirements

Commissioner Cooper made a motion to approve the exemption from the Mental Health Parity Requirements for NJ DIRECT10, NJ DIRECT15, NJ PLUS and Aetna and CIGNA HMO’s. Chairperson Culliton seconded the motion. Approved (Vote 3: 2: 0 Commissioners Burdge and Nowlan voted nay).

D. Surcharge

David Pointer told the Commission that pursuant to NJSA 52:14-17.38c, the State Treasurer is required to set an annual surcharge rate for insurers of school districts that do not participate in the School Employees’ Health Benefits Program (SEHBP). The Treasurer set the annual surcharge rate at 2.5 percent for 2010. The calculation utilized claims data from the SEHBP self-funded plans and takes into account revenue available from the rate differentiation for non-Medicare retirees approved by the School Employees’ Health Benefits Commission (SEHBC). The general methodology utilized by Aon Consulting follows that prescribed by the previously cited statue. Surcharge calculations for year 2009 and 2010 were provided to the Commission.    

Other:

David Pointer gave an update on the Dependent Eligibility Verification Audit (DEVA). The deadline for filing documents is December 11, 2009 for state employees.The state audit currently has approximately 5,900 subscribers representing 12,600 dependents that had not responded to the audit.  Another 8,000 subscribers representing 12,800 dependents have not submitted proper dependent documentation. These dependents will be terminated effective February 1, 2010. 
The Local Government audit will begin in February. 

David Pointer also gave an update on Medco implementation. He indicated that ID Cards would begin being mailed the week of 12/14/09.

There being no further business, Chairperson Culliton made a motion to adjourn which was seconded by Commissioner Cooper. All voted in favor. The State Health Benefits Commission meeting was adjourned at 2:53 PM.

Respectfully submitted,

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

 

 

 


 
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