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Pensions and Benefits
HEALTH BENEFITS COMMISSION
MEETING MINUTES 2010
 

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Meeting No. 498, Minutes
January 13, 2010, 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 23, 2009.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, January 13, 2010 at 1:13 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
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
Horizon Representatives
Magellan Representatives
Aetna Representatives

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

Meeting No. 495, August 12, 2009 Executive Session Only; Meeting No. 496, October 14, 2009 Executive Session Only; and  Meeting No. 497, December 9, 2009  Regular and Executive Sessions:  Chairperson Culliton made a motion to accept the minutes. Commissioner Cooper seconded the motion.  Motion Passed (Vote 5: 0: 0).

ISSUES

A. Dependent Eligibility Verification Audit (DEVA):  David Pointer advised the Commission that letters were sent out a week ago notifying members of the termination of approximately 20,000 dependents.  The reasons for the terminations are either the member did not respond or insufficient documentation was submitted.  Phase 2 of the DEVA will start in February for participating Local Government and Local Education members. A Certifying Officer letters will be going out to employers at the end of January outlining the correspondence employees can expect to receive from Aon and due dates for submission of documentation to Aon.  

B. CareCore – On the agenda in error.

C. Magellan Audit – David Pointer asked the Commission if they had any questions on the audit.  Commissioner Burdge suggested that this issue be brought back to February’s meeting as some of the Commissioners just received the information and have not had enough time to review the audit.  Commissioner Burdge asked how the cases were chosen for the audit.  Mr. Pointer offered to have a representative of Aon Consultants attend a future meeting to explain how they were chosen.

Commissioner Burdge requested an update on Medco.  Chairperson Culliton gave a brief explanation of the process to place an issue on the agenda and it could be discussed at the end of the meeting.  Commissioner Burdge made a motion to go out of the agenda’s order.  Commissioner Nowlan seconded the motion.  Failed (Vote: 2; 3: 0; and Commissioners Culliton, Cooper and Allen-Ware voted nay).

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

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

Case #SH011001 (Member’s Attorney Present) This Horizon-Traditional Plan appeal concerned a denial of benefits for surgery deemed work related.  The Member’s attorney gave the history of the injury and how the appeal came before the Commission. Commissioner Culliton asked Wendy Burns, Horizon, if they received any medical information about the injury leading to the surgery.  Ms. Burns replied that nothing had been submitted.  Chairperson Culliton made a motion to table this appeal to provide the member’s attorney the opportunity to provide medical documentation for review by Horizon.  Commissioner Cooper seconded the motion.  Approved (Vote: 5: 0: 0).    

Case #SH011002 (Member Present) – This Division appeal concerned the denial of enrollment for coverage for over aged disabled dependent.  Member and ex-spouse gave the history of the dependent’s medical coverage.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Commissioner Cooper seconded the motion. All voted in favor.  Upon returning from Executive Session, Commissioner Burdge asked the member if he had tried to continue medical coverage for the dependent after he turned 23.  Member said dependent had coverage under his ex-wife’s plan so he did not pursue it.  The member thought if his ex-wife’s coverage ended he could add him back on his coverage.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Commissioner Burdge seconded the motion.  All voted in favor.  Upon returning from Executive Session Commissioner Cooper made a motion to deny this appeal. Chairperson Culliton seconded the motion.  Approved (Vote: 4: 0: 1; Commissioner Nowlan abstained).
 
Case #SH011003 (Member Present) – This Horizon-NJ DIRECT10 appeal concerned a denial of benefits for services provided at an Alzheimer’s facility.  Member claimed she was not advised of the preauthorization requirement prior to admittance to the facility, and questioned why Horizon paid for physical therapy and certain portions of the stay but not other portions of the stay.  Chairperson Culliton asked Horizon to explain.  Wendy Burns from Horizon replied that Horizon will pay secondary as long as Medicare pays.  When Medicare stops paying, Horizon reviews the claims since they are primary.  Commission Allen-Ware asked if Horizon had done any concurrent review.  Ms. Burns responded that is not done when Medicare is the primary.  Commissioner Burdge asked when the pre-certification was denied.  Ms. Burns stated that the pre-certification was received May 2, 2009 and denied May 5, 2009.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Commissioner Cooper seconded the motion. All voted in favor.  Upon returning from Executive Session, Commissioner Burdge made a motion to approve this appeal.  Commissioner Nowlan seconded the motion.  Approved (Vote: 4: 1: 0; Chairperson Culliton voted nay).

Case #SH011004 - (Member Present)  – This Aetna Dental appeal concerned a denial of benefits for dental services rendered by a non-participating dental office without prior approval.
The member presented an overview of her appeal.  Aetna gave a summary of their position.   Commissioner Cooper made a motion to deny this appeal. Chairperson Culliton seconded the motion.   Approved (Vote 5: 0: 0). 

Case #SH011005 - (Member Present with Attorney) – This Horizon-Magellan Health Services appeal concerned a denial of benefits for services rendered by a non-participating facility for a dependent son.  The attorney presented the appeal.  Magellan representatives gave a summary of their position.  Horizon handed out a transcript of a phone call from the member indicating that she was given a list of in-network facilities and was told that pre-certification through Magellan was required.  Chairperson Culliton made a motion to deny this appeal. Commissioner Cooper seconded the motion. Approved (Vote 3: 1: 1; Commissioner Burdge voted nay and Commissioner Nowlan abstained).

Case #SH011006 – The Member requested that the Commission’s previous denial of an appeal for amounts above the reasonable and customary amount allowance for surgery 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 #SH011007 – The Member requested that the Commission’s previous denial of an appeal for amounts above the reasonable and customary amount allowance for psychiatric diagnostic interview examination be forwarded to the Office of Administrative Law (OAL) for a hearing. Chairperson Culliton made a motion to approve this request. Commissioner Nowlan seconded the motion. Approved (Vote 5: 0: 0).

Case #SH011008 –  Final Administrative Determination – Chairperson Culliton made a motion to accept the FAD draft concerning the denial of occupational therapy. Commissioner Cooper seconded the motion. Approved (Vote 5: 0: 0).

Case #SH011009 – Chairperson Culliton made a motion to affirm the decision of the Office of Administrative Law (OAL).  Commissioner Cooper seconded the motion. Approved (Vote 4: 0:1; Commissioner Burdge abstained).

Case #SH011010 – 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 #SH011011 -   A settlement offer was before the Commission in a case of denial of benefits as work related.   Jean Williamson advised the Commission that this was pulled from the agenda.

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

Upon return to open session Commissioner Burdge requested the Commission discuss issues concerning Medco.  He said he was unaware that letters would be going out denying coverage for certain drugs effective February 1, 2010.  Florence Sheppard advised him this was in the RFP.  Commissioner Burdge questioned why people are being denied the drugs now and not February 1, 2010.  David Pointer advised Commissioner Burdge without specific cases we cannot say why drugs were denied.  Commissioner Nowlan made a motion to go into Executive Session under Resolution B. Chairperson Culliton stated this issue is not on the agenda.  Commissioner Burdge seconded the motion. Motion Failed (Vote 2: 3; 0, Chairperson Culliton, Commissioners Cooper and Allen-Ware voted nay).

There being no further business, Commissioner Cooper made a motion to adjourn which was seconded by Commissioner Nowlan.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 12:45 PM.

Respectfully submitted,


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

 

 

 

 


Meeting No. 499, Minutes
March 10, 2010, 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 23, 2009.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, March 10, 2010 at 1:17PM. 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 Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, Commissioner, representing Acting Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, 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, Division of Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations, Division of Pensions and Benefits
Jean Williamson, Acting Secretary
Barbara Scherer, State Health Benefits Program
Horizon Representatives
Aetna Representatives

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

Meeting No. 498, January 13, 2010 Chairperson Culliton made a motion to accept the minutes. Commissioner Burdge seconded the motion. Approved (Vote 4: 0: 1, Commissioner Czech abstained).

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

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

Chairperson Culliton made a motion to go into Closed session under Resolution A. Commissioner Allen-Ware seconded the motion. Motion Passed (Vote: 5; 0: 0).

Case #SH031001 (Member Present) This Aetna plan appeal concerned a denial of benefits for private duty nursing (PDN) expenses for a dependent child. The Member advised the Commission of the child’s daily needs.  She requested the previous PDN allowance be restored. Aetna’s Medical Director, Dr. Rosen, advised the Commission that Aetna had reduced the PDN hours by 4 hours a day to 12 hours a day, 7 days a week, because the additional 4 hours of PDN care Monday – Friday was custodial in nature.  Upon formal receipt of the appeal, Aetna authorized continuation of the previous level of benefit, 16 hours a day PDN Monday through Friday and 12 hours a day on Saturday and Sunday, while the member went through the appeal process. Commissioner Burdge made a motion to table the appeal and requested an Independent Medical Examination (IME). The PDN hours will continue until the IME’s report is received and the appeal is heard by the Commission. Commissioner Nowlan seconded the motion. Approved (Vote: 3: 2: 0, Chairperson Culliton and Commissioner Czech voted nay).    

Case #SH031002 (Member Present) – This Horizon NJ DIRECT15 appeal concerned the denial of benefits above the reasonable and customary allowance for surgery. The Member stated that she requested a pre-determination of benefits twice and her doctor’s office requested it once.  However, a pre-determination from Horizon was not received by either the member or the doctor. The Member also said there was no in-network provider in the area to perform this type of surgery. Commissioner Allen-Ware asked Horizon to explain why there was no response to the request for pre-determination, and why there was no in-network doctor available to perform the surgery.  Wendy Burns, Horizon replied she was unable to find a pre-determination. There is a phone record that the Member called and asked what information was needed for a pre-determination of benefits. During the phone call the Member was advised of the out-of-network provider payment policy. There is no record that the Member requested information about in-network providers. Commissioner Allen-Ware 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, there was a brief discussion and the Member mentioned that she knew other patients who had their claims paid by Horizon at a higher reimbursement level for this surgery. Commissioner Czech asked if the Member could provide confirmation for those other patients’ claims that were paid by Horizon for this surgery. Chairperson Culliton made a motion to table this appeal for the Member to obtain the information requested. Commissioner Czech seconded the motion. Approved (Vote: 5: 0: 0).
 
Case #SH031003 (Member Present) – This Division appeal concerned a request to obtain a third tier prescription drug for a second tier copayment under the Retiree Prescription Drug Plan for the drug, Actonel. The Member stated that she cannot take the generic brand for Actonel for medical reasons and requested that an exception be made so that she could pay the lower copayment amount. There was discussion about the cost of the drug.  David Pointer indicated the cost of the drug is not a factor; it is the plan design and not a medical necessity issue. Commissioner Burdge indicated that there may be some confusion with the State active employees’ plan design which allows for a lower copayment for medical reasons. The Retiree Prescription Drug Plan does not have this feature in its design. Chairperson Culliton made a motion to deny this appeal. Commissioner Burdge seconded the motion. Approved (Vote: 5: 0: 0).

Case #SH031004 – Final Administrative Determination (FAD) – Commissioner Nowlan made a motion to go into Executive Session under Resolution B and Commissioner Burdge seconded it.  All voted in favor.  Upon return from Executive Session, Chairperson Culliton made a motion to accept the FAD draft concerning the denial of benefits for Embryo Transfer. Commissioner Czech seconded the motion. Approved (Vote 4: 0: 1, Commissioner Burdge abstained).

Case #SH031005 – The Member requested that the denial of benefits for expenses for treatment at out-of-network facilities be forwarded to the Office of Administrative Law (OAL) for a hearing. Chairperson 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 #SH031006 – Final Administrative Determination (FAD) – Chairperson Culliton made a motion to accept the FAD draft concerning the denial of benefits above the reasonable and customary allowance for surgery. Commissioner Czech seconded the motion. Approved (Vote 5: 0: 0).

Case #SH031007 – A settlement offer was before the Commission in a case involving denial of benefits as injury deemed work related.  The lien amount was $7,019.90 and the proposed settlement amount was $5,000.00.  Chairperson Culliton made a motion to accept the settlement proposal.  Commissioner Nowlan seconded the motion.  Approved (Vote 5: 0: 0).

Case #SH031008 – A settlement offer was before the Commission in a case involving denial of benefits as injury deemed work related. The lien amount was $4,769.10 and the proposed settlement amount was $2,500.00. Commissioner Czech made a motion to accept the settlement proposal. Commissioner Nowlan seconded the motion. Approved (Vote 4: 1: 0, Commissioner Burdge voted nay.)

Case #SH031009 – A settlement offer was before the Commission in a case involving denial of benefits as injury deemed work related.  The lien amount was $67,922.16 and the proposed settlement amount was $8,225.07.  Chairperson Culliton made a motion to table the settlement proposal and requested more information from ACS Recovery Services.  Commissioner Burdge seconded the motion.  Approved (Vote 5: 0: 0.)

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

Issues

  1. Carrier Updates:

Deputy Director Florence Sheppard clarified issues that have been raised concerning prescription drug coverage under Medco:

  • Rules concerning acne medication: All ages are covered if medically necessary however any person over the age of 36 needs prior approval for the medication. 
  • Refill too soon: Medco refills prescriptions when 75% of the drug is used.  In addition, Medco reviews the last 180 days of a member’s claim history, counting the days, the frequency of medication, and the total pills dispensed to determine when the current prescription should run out.  They base their refill-too-soon policy on those factors to prevent stockpiling of medication and to protect member safety. 
  • List of Step Therapy drugs: A list of drugs that require step therapy was emailed to the Commission. Commissioner Burdge asked how the step therapy program works.  Florence Sheppard responded there are preferred medications that must be tried first before the non-preferred medications are covered under the plan. The preferred medications are therapeutically equivalent to the non-preferred medications. Commissioner Burdge asked what the cost savings would be from this program. Ms. Sheppard indicated that she would have that answer for the next meeting.
  1. Dependent Eligibility Verification Audit (DEVA)

David Pointer provided an update on the DEVA.  He reported that Phase 2 of the DEVA project for Local Government/Education Employees/Retirees was well on its way, with 17, 000 responses received as of March 5, 2010 and 82 dependents self-declared ineligible.  He told the Commission that the deadline for receiving the documents is March 19, 2010, and that interim Non-Response Letters will be going out on April 7, 2010. The final documentation deadline is April 30, 2010.  Mr. Pointer added that appeals are still being processed from Phase 1; the deadline was March 8, 2010 for documents to be mailed.  

  1. Revised 2010 Meeting Schedule

Commissioner Nowlan made a motion to approve the amended 2010 meeting schedule. Chairperson Culliton seconded the motion. Approved (Vote: 5: 0: 0.)
 
There being no further business, Commissioner Czech made a motion to adjourn which was seconded by Commissioner Nowlan. All voted in favor. The State Health Benefits Commission meeting was adjourned at 3:35 PM.

Respectfully submitted,


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

 

 



Meeting No. 500
Revised - Minutes
April 14, 2010, 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 23, 2009.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, April 14, 2010 at 1:10PM. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, 1st floor Conference Room, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, Commissioner, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, 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
Edward Fox, Aon Consulting
Tom Will, Aon Consulting
Wendy Burns, Horizon Representative
David Perry, Horizon Representative

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

Meeting No. 499, March 10, 2010 Chairperson Culliton made a motion to accept the minutes. Commissioner Czech seconded the motion. Motion Passed (Vote 5: 0: 0.)

Chairperson Culliton made a motion to go out of order to hear from representatives from Aon Consulting on the Mental Health/Substance Abuse Medical Management Audit that was presented to the Commission on January 13, 2010. Commissioner Nowlan seconded the motion. Approved (Vote: 5: 0: 0.)

David Pointer announced Director Frederick Beaver resigned from his position and Florence J. Sheppard has been appointed Acting Director.

ISSUES

A. Magellan Audit Report-Tom Will, Aon Consulting gave a brief overview of how the sample was selected for the audit. There was some discussion concerning out-of-state treatment facilities in which Aon deferred the questions to David Perry, Horizon Blue Cross Blue Shield of NJ (Horizon).

B. Carrier Updates –Chiropractic Reimbursements, NJ DIRECT: David Perry advised the Commission the American Chiropractic Association (ACA) and the association of the New Jersey Chiropractors (ANJC) filed a complaint with the Department of Banking and Insurance (DOBI) in 2004 challenging Horizon’s reimbursement policies. The complaint focused on Horizon’s policy of bundling multiple services into a single reimbursement. DOBI referred the case to the Office of Administrative Law, requesting fact finding to assist them in evaluating Horizon’s actions. The judge concluded that Horizon’s actions were proper on each issue. In October 2009, DOBI issued its order compelling Horizon to change its policy regarding chiropractic reimbursements with respect to its private book of business. Horizon must separately consider E&M services as well as physical therapy codes for reimbursement when adjudicating chiropractic claims. In other words, they cannot be included in the global fee applicable to CMT reimbursements.

Horizon has determined to apply its new policy regarding chiropractic reimbursements to the State Health Benefits Program (SHBP) and the School Employees’ Health Benefits Program (SEHBP). The financial impact on the SHBP and the SEHBP is estimated to be less than $5 million in 2010. Horizon is implementing system changes as well as reviewing options to ensure that submitted E&M codes are medically appropriate for the services provided. The change takes effect on April 15, 2010 for SHBP/SEHBP claims.

Mr. Perry said that Horizon has contracted with a third party vendor to look at the chiropractor services being submitted. A standard needs to be set up to eliminate patient’s going beyond the required sessions to treat their condition.

C. Dependent Eligibility Verification Audit (DEVA): David Pointer advised the Commission Phase II of the audit has approximately 105,000 complete, 53,000 incomplete (of the 53,000, 25,000 are non-respondents), 1,050 dependents self-declared ineligible. The response rate is 82%.

The Commission asked how much the Programs would save with Medco as the Pharmacy Benefit Manager. Florence Sheppard responded that five hundred and forty million ($540 million) dollars would be saved over the next five years.

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

Chairperson Culliton made a motion to go into Closed session under Resolution A. Commissioner Allen-Ware seconded the motion. Approved (Vote: 5; 0: 0).

Case #SH041001 – (Member Not Present) This Division appeal concerned a denial of the prescription drug Tri-Luma which is used primarily for cosmetic reasons. Jean Williamson advised the Commission that the medication was being used to treat Melasma (dark spots on the skin). Chairperson Culliton made a motion to deny this appeal. Commissioner Czech seconded the motion. Approved (Vote: 5: 0: 0).

Case #SH041002 – The Member requested that the denial of benefits for dental services rendered by a non-participating dentist without prior approval 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 a Final Administrative Determination. Commissioner Czech seconded the motion. Approved (Vote 4: 1: 0; Commissioner Burdge voted against).

Case #SH041003 –The Member requested that the denial of benefits for expenses above the reasonable and customary allowance for office visits and a radiology procedure be forwarded to the Office of Administrative Law (OAL) for a hearing. Chairperson Culliton made a motion to approve this request for a hearing at the OAL. Commissioner Burdge seconded the motion. Approved (Vote 5: 0: 0).

Case #SH041004 – Chairperson Culliton made a motion to adopt and note exceptions and reply to the exceptions. Commissioner Czech seconded the motion. Approved (Vote 4: 0: 1, Commissioner Burdge abstained).

Case #SH041005 – Chairperson Culliton made a motion to table this action and directed Horizon to retain a medical expert in the mental health profession versed in pediatrics to review the case and determine medical appropriateness. Commissioner Nowlan seconded the motion. Approved (Vote 5: 0: 0).

Case #SH041006 - A settlement offer was before the Commission in a case involving denial of benefits for a back injury due to lifting computers which was deemed work related. The lien amount was $2,511.48 and the offer was $1,255.74 to satisfy the lien. Chairperson Culliton made a motion to accept the settlement proposal. Commissioner Nowlan seconded the motion. Approved (Vote 5: 0: 0).

Case #SH041007 – This settlement offer was before the Commission in a case involving the denial of expenses for ABA therapy for a dependent child. Chairperson Culliton made a motion to respond to DAG with the maximum settlement of $3,856.13 [70% of $5,508.75 (total for ABA therapy $4,248.75 plus copayments per visit for a total of $1,260.00)]. Commissioner Czech seconded the motion. Approved (Vote 5: 0: 0).

Case #SH041008 - A Compromise Request was before the Commission in a case involving denial of benefits for an injury from a motor vehicle accident during the course and scope of employment. The lien amount was $1,076.36 and the offer was $500 to satisfy the lien. Chairperson 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 Burdge, seconded by Commissioner Allen-Ware. All voted in favor

There being no further business, Commissioner Burdge made a motion to adjourn which was seconded by Commissioner Czech. All voted in favor. The State Health Benefits Commission meeting was adjourned at 2:29 PM.

Respectfully submitted,


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

 

 

 


Meeting No. 501
Minutes
May 12, 2010, 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, May 12, 2010 at 1:13 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 Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, Commissioner, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, 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
Horizon Representative
Magellan Representatives
Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

Meeting No. 500, April 14, 2010 - Chairperson Culliton made a motion to accept the minutes. Commissioner Burdge seconded the motion.  Approved (Vote 5: 0: 0)

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

Chairperson Culliton made a motion to go into Closed session under Resolution A.  Commissioner Czech seconded the motion.  Approved (Vote: 5; 0: 0).

Case #SH051001 (Member Present) – The Horizon-Magellan Health Services appeal concerned a denial of continued inpatient treatment at a non-participating facility (Menninger Clinic) for a dependent child and for transitional living in the Intensive Outpatient Program (IOP) at Silver Hill.  The Member gave an overview of his appeal.  Dr. Saldarini, Medical Director, Magellan Health Services, gave a summary of its position.  The appellant was denied reimbursement for inpatient treatment at the Menninger Clinic due to lack of medical necessity.  With respect to treatment at Silver Hill, the dependent was admitted to Silver Hill at the in-patient level of care.  This admission was authorized and those services were reimbursed.  The dependent was stepped down to the IOP level of care at Silver Hill.  Mental health treatment services at the IOP level of care were determined to be medically necessary and were authorized.   Upon receipt of additional information, Magellan conducted a review of the transitional living related to the Intensive Outpatient Treatment and determined that it is not covered under NJ DIRECT.  The member was aware this was not a covered benefit as they signed the Silver Hill payment agreement, which explained that transitional living was the patient’s responsibility and would not be covered by the member’s insurance. Therefore the room and board charges associated with the day program were not eligible for reimbursement. Chairperson Culliton made a motion to deny the appeal for reimbursement of the Silver Hill room and board.  Commissioner Czech seconded the motion.  Approved (Vote: 5: 0: 0). Chairperson Culliton made a motion to deny the appeal for reimbursement of the Menninger Clinic expenses, but authorized Horizon/Magellan to reimburse the member for the amount that would have been paid for the residential level of care at a participating facility ($12,375.00).  Commissioner Czech seconded the motion.  Approved (Vote: 5: 0: 0).
 
Case #SH051002 (Member Present) – The Horizon-NJ DIRECT15 appeal concerned a denial of benefits above the reasonable and customary allowance for surgery. The Member gave a brief overview of her appeal.  A discussion between the member and the Commission took place about the procedure and the facility type.  Commissioner Czech made a motion to deny this appeal.  Commissioner Burdge seconded the motion.  Approved (Vote: 5: 0: 0).    

Case #SH051003 (Member Present) - The Horizon-Magellan Health Services appeal concerned a denial of coverage for continued treatment by an ineligible provider.
The Member advised the Commission that Magellan has paid his claims up until May of this year despite knowing it was an ineligible provider.  Dr Saldarini, Magellan Health Services, stated that they had determined in 2008 that the provider was not an eligible provider, but it was not entered into the system properly so the claims were paid in error.   She indicated the member was advised at the beginning of April 2010, in writing, that he had a 30-day transition period to change to an eligible practitioner.  No claims would be paid beyond May 5, 2010 for services received by the ineligible provider.  The member advised the Commission that if the services were denied in the earlier stages of his treatment he still would have used the appeal process but would have been more receptive to the decision.  Since then a rapport has been established with this therapist. Member claimed Magellan’s continuous mistakes and errors have jeopardized his treatment program.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Commissioner Nowlan seconded the motion and all voted in favor.  Upon returning from Executive Session, Commissioner Czech made a motion to table this appeal pending additional information from the DAG’s office on legal precedent.  Chairperson Culliton seconded the motion.  Approved (Vote: 5: 0: 0).  

Case #SH051004 - (Member Present) This Division appeal concerned a denial of a benefits for the medication Limbrel.  A brief discussion took place between the member and the commission on other treatment available and the way Limbrel is labeled.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Commissioner Nowlan seconded the motion and all voted in favor.  Upon returning from Executive Session, Commissioner Czech made a motion to table this appeal to get additional information from Medco.  Commissioner Nowlan seconded the motion.  Approved (Vote: 5: 0: 0).    

Case #SH051005 – The Horizon-NJ DIRECT15 appeal concerned a denial of benefits above the reasonable and customary allowance for surgery.  This appeal had been tabled at the March 10, 2010 meeting in order to provide the member time to obtain the information requested.  The member and the Commission discussed issues on the appeal in detail and the timeline was established as to when the treatment began and when the decision was made to have the surgery.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Upon return from Executive Session, Chairperson Culliton made a motion to approve this appeal. Since the member began treatment prior to the implementation of the PPO product (NJ DIRECT) in April 2008, the Commission authorized Horizon to pay the claims as they would have been paid under NJ PLUS.   Commissioner Czech 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 and seconded by Commissioner Nowlan. All voted in favor.
 
Issues

David Pointer mentioned that a list of new and terminated Local Employers was on the table for the Commissioners for their information.  He also indicated that the Division of Purchase and Property issued a RFP for a Health Benefits Consultant on May 4, 2010 with an effective date of January 1, 2011.  The current contract with Aon Consultants ends December 31, 2010.

Mr. Pointer reported that Health Care Reform regulations were expected to be issued over the next several weeks and that the Division would provide additional information on the issues as it becomes available. Aon will adjust rate renewals as needed.

  1. Carrier Updates

David Pointer stated that Horizon BCBSNJ has expanded the Managed Care network and that NJ DIRECT members will now have access to a licensed acupuncturist or professional who performs acupuncture within 45 miles.  As a result, the in-and out-of-network acupuncture benefit will be implemented as initially intended.  Effective July 1, 2010, Horizon BCBSNJ will begin processing all acupuncture services performed by a non-participating provider according to the out-of-network benefit provisions of the contract. Any NJ DIRECT member who has submitted a claim for acupuncture services rendered by a non-participating provider during the most recent six month period will be notified of the network expansion and the application of the out-of-network benefit for acupuncture services performed by a non-participating provider on or after July 1, 2010. 

  1. Dependent Eligibility Verification Audit (DEVA)

David Pointer advised the Commission that Phase II of the audit had a response rate of 93%; 1,600 dependents were self declared ineligible; 3,400 households have not yet responded and 4,300 households returned incomplete information.  The audit closed April 30, 2010. A backlog of documents received is expected to be reviewed this week and during the early part of next week.   On June 9, 2010 members will be notified by letter of dependent terminations effective July 1, 2010.  Members will have 60 days to appeal the termination.  Aon Consultants will be handling the Phase II appeals.  Commissioner Allen-Ware asked when Aon’s contract ends.  Mr. Pointer said December 2010.

There being no further business, Commissioner Nowlan made a motion to adjourn which was seconded by Chairperson Culliton. All voted in favor.  The State Health Benefits Commission meeting was adjourned at 4:16 PM.           

Respectfully submitted,


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

 

 

 

                            


Meeting No. 502
Minutes
June 9, 2010, 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and was amended on March 10, 2010.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, June 9, 2010 at 1:12PM.  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 Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, Commissioner, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, 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
Wendy Burns, Horizon Representative
Rosemary Middlebrook, Horizon Representative
David Perry, Horizon Representative
Katherine Impellizzeri, Aetna Representative
Patrick Currie, Aetna Representative
Lisa Marie Hopkins, Aetna Representative
Dr. Joseph Thomas, Aetna Medical Director

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

Meeting No. 501, May 12, 2010: Chairperson Culliton made a motion to accept the minutes. Commissioner Allen-Ware seconded the motion. Approved (Vote 5: 0: 0).

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

Chairperson Culliton made a motion to go into Closed Session under Resolution A. Commissioner Nowlan seconded the motion. All voted in favor.

Case #SH061001 (Member Present) This Horizon-Magellan Health Services appeal concerned the level of reimbursement for an out-of-network licensed clinical social worker who provided mental health services to the Member. The Member said the level of reimbursement was changed without any notice to the members. David Perry, Horizon, explained the reasonable and customary fee which was historically paid to all providers for the service provided to the member was at the medical doctor level, even though certain providers (for example, licensed clinical social workers) did not have the same licensing/education requirements as medical doctors. Commissioner Czech made a motion to provide reimbursement at the prior reimbursement level through the end of May 2009, when the Member first received an Explanation of Benefits (EOB) advising of the change in reimbursement level, and to provide reimbursement at the adjusted level proposed by Horizon for services provided after May 2009.  Chairperson Culliton seconded the motion. Approved (Vote: 3: 2: 0; Commissioners Burdge and Nowlan voted Nay).    

Case #SH061002 – This Division appeal concerned a denial of benefits for the drug Polyeth Glyc 3350 N Pow Brec. David Pointer explained that this medication is available over the counter and, is therefore not eligible for coverage. Chairperson Culliton made a motion to deny this appeal. Commissioner Czech seconded the motion. Approved (Vote 4: 0: 1; Commissioner Burdge abstained).

Case #SH061003 – This Division appeal concerned a denial of benefits for expenses for more than 12 Cialis pills in a three month period. A short discussion was held regarding previous cases heard by the Commissions for similar appeals. Chairperson Culliton made a motion to deny this appeal. Commissioner Czech seconded the motion. Approved (Vote 4: 1: 0; Commissioner Burdge voted nay).

Case #SH061004 (Member Present) This Aetna appeal concerned the denial of benefits for Botox injections to treat Chronic Regional Pain Syndrome (CRPS). The Member gave a brief summary of the facts that led to the appeal. Dr. Thomas, Aetna’s Medical Director explained that the use of Botox for this condition is not supported by any medical documentation and that the use of Botox in this situation is considered investigational. Dr. Thomas said the treatment was covered prior to Aetna’s Policy Bulletin being established for this condition. A short discussion took place in which Dr. Thomas stated that he was unaware of any clinical studies to support the use of Botox to treat CRPS.  Chairperson Culliton made a motion to deny this appeal. Commissioner Nowlan seconded the motion. Approved (Vote 5: 0: 0).

Case #SH061005 – This Division appeal concerned a denial of benefits for the medication Imodium.  David Pointer explained that this medication is available over the counter and, therefore, not eligible for coverage. Commissioner Czech made a motion to deny this appeal. Chairperson Culliton seconded the motion. Approved (Vote 4: 1: 0; Commissioner Burdge voted nay).

Case #SH061006 – (Attorney Present) The Horizon-Traditional Plan appeal was for denial of benefits for surgery deemed work related which had been tabled from a previous Commission meeting.  Mr. Woods, the member’s attorney, submitted the transcript from the Worker’s Compensation (WC) case hearing to the Commission. The WC case was dismissed in 2004 pursuant to a Section 20 settlement. The Independent Medical Examiner (IME) stated the surgery was not related to the work injury. Commissioner Allen-Ware raised the issue that there are conflicting statements in the IME report. Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Commissioner Allen-Ware seconded the motion. All voted in favor. Upon returning from Executive session Chairperson Culliton made a motion to approve this appeal. Commissioner Burdge seconded the motion. Approved (Vote 5: 0: 0).

Case #SH061007 – (Member Present) – The Horizon-Magellan appeal for denial of additional reimbursement for an out of network provider was tabled from a previous Commission meeting. David Perry, Horizon, explained the reasonable and customary level of reimbursement which was historically paid to all providers for this type of service was at the medical doctor level, even though certain providers did not have the same licensing and/or education requirements as medical doctors.  He advised the Commission that the number of service complaints on this issue is very small:  74 complaints out of 50,000-60,000 claims processed. Commissioner Burdge 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, a discussion took place to determine when the member first received notice of the reimbursement level change.  Commissioner Czech made a motion to authorize the old level of reimbursement up until April when the notice was received.  Chairperson Culliton seconded the motion.  Motion Failed (Vote 2: 2: 1, Commissioners Burdge and Nowlan voted nay, Commissioner Allen-Ware abstained). Commissioner Czech made a motion to authorize the old level of reimbursement through May 2009. Chairperson Culliton seconded the motion. Commissioner Czech withdrew his motion.  Commissioner Allen-Ware 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, Commissioner Czech made a motion to reimburse the Member at the old rate through May 2009, when the Member first received notice of the change in reimbursement level, and to reimburse the Member for any services received after May 31, 2009 at the new level of reimbursement. Chairperson Culliton seconded the motion. Approved (Vote 3: 2: 0, Commissioners Burdge and Nowlan voted nay.)  

Case #SH061008 – (Member Present) – The Horizon-Magellan appeal for denial of coverage of future treatment by an ineligible provider was tabled from the May commission meeting pending research by the Deputy Attorney General on a legal precedent and receipt of additional information from Magellan concerning how the claims for psychoanalysis were paid and why. Chairperson Culliton 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, Commissioner Czech made a motion to deny this appeal because psychoanalysts are ineligible providers under the plan. Chairperson Culliton seconded the motion. Approved (Vote 3: 2: 0, Commissioners Burdge and Nowlan voted nay).

Case #SH061009 –The Division appeal was tabled from the May commission meeting pending receipt of additional information from Medco and the member for denial of benefits for the medication Limbrel.  Commissioner Burdge made a motion to deny this appeal.  Chairperson Culliton seconded the motion. Approved (Vote 5: 0: 0).

Case #SH061010 – The Member had requested that the denial of benefits for dental services rendered by a non-participating dental office without prior approval be forwarded to the Office of Administrative Law (OAL) for a hearing. Chairperson Culliton made a motion to approve a draft of the Final Administrative Determination (FAD). Commissioner Czech seconded the motion. Approved (Vote 3: 0: 2, Commissioners Burdge and Nowlan abstained).

Case #SH061011 –A settlement offer was before the Commission in a case involving denial of benefits for an injury that was the result of an incident that was deemed work related. Chairperson Culliton made a motion to accept the settlement proposal in the amount of $540.18 for a lien of $1,080.37. Commission Nowlan seconded the motion. Approved (Vote 5: 0: 0).

Case #SH061012 – A settlement offer was before the Commission in a case involving denial of benefits for an injury that was the result of an incident that was deemed work related. Chairperson Culliton made a motion to accept the settlement proposal in the amount of $8,225.07 for a lien of $67,922.16, in light of fact that the Medical Expert in the workers’ compensation case failed to relate the neck treatment from 2002 to date to a work related repetitive motion case. Commissioner Burdge seconded the motion. Approved (Vote 5: 0: 0). 

Case #SH061013 – Chairperson Culliton reported that the Appellate Decision affirmed the Commission’s decision to deny benefits for a dependent son at Three Springs, a therapeutic boarding school in Huntsville, Alabama, because it was not an approved facility.  

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

Commissioner Burdge left the meeting and joined by telephone. 

Issues

  1. Carrier Updates – Nothing specific about the Carriers was reported.

David Pointer advised the Commission that the Patient Protection and Affordable Care Act (PPACA) will affect the State Health Benefits Program (SHBP) in a number of ways. He stated that the PPACA legislation will extend coverage for children up to the age of 26, effective January 1, 2011. Each subscriber will be notified of the change and will be able to add their children during the Open Enrollment period.  Mr. Pointer stated that the Commission’s regulations will need to be changed to reflect the criteria in the PPACA legislation. Mr. Pointer reported that up until 2014 children are ineligible for coverage in the SHBP if they are eligible under their employer. Aon is assessing the additional cost, which will be reflected in the Rate Renewal Recommendations in July 2010.

The PPACA legislation permits the federal government to reimburse eligible plan sponsors for costs incurred above $15,000 and below $90,000 for early retirees. Early retirees are defined as those retirees between the ages of 55 and 65 (non-Medicare retirees). Five billion dollars is available for the program and is offered on a first come, first served basis. Aon is assisting the Division in the application and claims submission process. 

The legislation eliminates certain maximum benefit limits in 2011. The SHBP will be impacted with the elimination of lifetime maximums and out-of-network benefit maximums for mental health and substance abuse. Aon is assessing the cost which will be reflected in the Rate Renewal Recommendations in July 2010.

David Pointer also mentioned that Chapter 2, P.L. 2010 prohibits multiple coverage under the SHBP and/or SEHBP. A retiree or employee cannot be eligible for coverage as both a subscriber and a dependent under the SHBP and/or SEHBP. Letters will be sent directly to retirees starting the week of June 14, 2010 advising that multiple coverage is prohibited and immediate action is required. Active employees will be notified through their employers and those notices will begin towards the end of the week of June 14, 2010. 

David Pointer reported that a Mandatory Pre-Bidders conference was held on May 17, 2010 at Thomas Edison State College for the RFP for Consulting Services for Health Benefits. Approximately ten vendors attended. The Bid Submission Due Date is June 25, 2010; all interested vendors must submit bids by the deadline.

  1. Dependent Eligibility Verification Audit (DEVA)

David Pointer reported there were 3,140 households that did not respond to the DEVA audit and 4,379 households that sent incomplete information.  This will effect over 14,000 dependents.  On June 9, 2010 letters will go out to members who did not reply or who sent incomplete information.  Letters will identify the dependents that will no longer be eligible for coverage and will inform the members that coverage will be terminated as of July 1, 2010.  Notice of the appeal process and a list of acceptable documents will be included with the letter.  Aon will be handling the initial appeal process.  

  1. Performance Standard Rates

David Pointer advised the Commission that all participating plans, NJ DIRECT, and the Health Organizations (HMO’s) are held to agreed-upon performance standards each year.  At risk are 10% of their administrative fees.  Historically, there have been two distinct rating areas - a Satisfaction Survey and HEDIS Measured Data items. Failing to meet the standard for the Satisfaction Survey would carry a penalty of 2% of the administrative fee. Failing to meet the standard Measured Data items carries a penalty of 3% of the administrative fee. This year the report consisted only of HEDIS Measured Data items.  If a participating HMO failed to meet any individual Report Card standards, they are required to submit improvement plans to the Division. Aetna HMO failed to receive an average rating in three out of twelve Measured Data items; however, they received an average or above rating of 70% or higher in the remainder of the standard Measured Data items and therefore incurred no penalty. CIGNA Healthcare failed to receive an average rating in five out of twelve Measured Data items.  CIGNA Healthcare also failed to meet the Measured Data Standard for the DOBI HMO Report Card. The penalty for failing to meet this standard is 3% of the administrative fee or $172,451.76.  CIGNA has been informed of this penalty and is reviewing the data and preparing a response. The Division will work with improvement plans that will be submitted from Aetna and CIGNA. Horizon Blue Cross and Blue Shield of New Jersey met all performance standards for NJ DIRECT. 

I advised the Commission Horizon’s update on the background of the adjustments made to the reasonably and customary pricing for behavioral health services was in their commission books. She pointed out that no adjustments had any impact on MD’s but does allow reimbursement of lesser amounts for psychologists, licensed clinical social workers, clinical nurse specialists and licensed family therapists.   

There being no further business, Chairperson 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 4:03 PM.

 

Respectfully submitted,


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

 

 


 

 


Meeting No. 503
Minutes
July 14, 2010, 9:30 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and was amended July 8, 2010 with time and location change.

The meeting of the State Health Benefits Commission was called to order on Wednesday, July 14, 2010 at 9:49 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 Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, Commissioner, representing Commissioner Thomas B. Considine, Department of Banking & Insurance (For the appeals portion of the meeting)
Neil Vance, Commissioner, representing Commissioner Thomas B. Considine, Department of Banking & Insurance (For the rate renewal portion of the meeting)
Robert M Czech, 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, Acting Director, Pensions and Benefits
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, State Health Benefits Program
Representatives from Aetna
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.

Meeting No. 502, June 9, 2010 Chairperson Culliton made a motion to accept the minutes. Commissioner Allen-Ware seconded the motion. Approved (Vote 5: 0: 0)

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

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

OLD BUSINESS APPEALS

Case #SH071001(Member Present) This Aetna appeal was tabled at a previous meeting and concerned a denial of benefits for expenses for the reduction of hours for private duty nursing for a dependent child.  At its previous meeting, the Commission requested a review by an Independent Medical Examiners (IME). The IME report was submitted to the Commission for review.  Dr. Rosen, Aetna Medical Director, gave an overview of what was discussed at the previous meeting.  Commissioner Czech made a motion to deny this appeal.   Chairperson Culliton seconded the motion. All voted in favor.

Case #SH071002 - This Division appeal concerned a denial of benefits for expenses for Viagra beyond four pills per month/twelve pills in 90 day period following prostate surgery.  Jean Williamson reported that she had checked with Medco Health Services and Horizon Blue Cross Blue Shield of New Jersey prior to the meeting concerning their policy on the use of Viagra for post-prostatectomy treatment.  Both Medco and Horizon responded that it is not covered for such use; the studies concerning the use of Viagra have been too small to consider changing the policy at this time.  Chairperson Culliton made a motion to deny this appeal.  Commissioner Czech seconded the motion.  All voted in favor.

Case #SH071003 - This Division appeal concerned a denial of benefits for expenses for Cialis beyond four pills per month/twelve pills in 90 day period.  Commissioner Czech made a motion to deny this appeal.  Commissioner Nowlan seconded the motion.  All voted in favor.

Case #SH071004 - (Member Present) This Division appeal concerned a request to fill a prescription for Vaniqa cream.  The Division denied the request because the drug is used primarily for cosmetic purposes and is therefore specifically excluded from the Employee Prescription Drug Plan.  Member gave a brief history of her daughter’s treatment that led to the need for the use of the cream.  Member stated her daughter was not born with this condition but it developed after treatment for a brain stem glioma.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Commissioner Allen-Ware seconded the motion.  All voted in favor.  Upon return from executive session Chairperson Culliton made a motion to table this appeal in order to get more information from Horizon regarding why CVS/Caremark covered this drug prior to December 31, 2009.  Commissioner Nowlan seconded the motion.  All voted in favor.

Case #SH071005 - This Division appeal concerned a denial of benefits for expenses for Viagra beyond four pills per month/twelve pills in 90 day period. Chairperson Culliton made a motion to deny this appeal.  Commissioner Nowlan seconded the motion. All voted in favor.

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

The Commission took a 15 minute break and resumed for Aon’s Rate Renewal Presentation.  Commissioner Allen-Ware left the meeting and Commission Vance attended the remainder of the meeting.

ISSUES

Edward Fox, Aon Consulting, gave a general overview of the 2011 rates. Susan Marsh, Aon Consulting, gave an overview of the 2011 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 2011
Medical/Rx Rate Renewal Recommendation
for Active Employees and Retirees
of the State Group


  • For Plan Year 2011, Aon is recommending premium rate changes that – in the aggregate – represent an overall increase of 6.9% for State Active Employees and Retirees:
 
Employees
Early
Retirees 
Medicare
Retirees 
NJ DIRECT10 NA  10.4% 4.0%
NJ DIRECT15 6.1% 10.4% 4.0%
Aetna HMO  9.4% 14.4% 7.4%
CIGNA HMO 8.9% 13.9% 6.9%
Rx Card Plan 5.0% NA NA
       
Average Change 6.4% 11.5% 4.6%
  • This recommended rate 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;
    • Any remaining legacy enrollment in NJ PLUS will have migrated to NJ DIRECT by 1/1/11;
    • The selection of Medco as the Program’s Prescription Benefit Manager (PBM), effective 1/1/10, will result in a 9% reduction in Rx claim costs in Plan Years 2010 and 2011.  In Plan Year 2011, this translates into $43 million in savings as a result of deeper discounts and larger rebates than were available through the previous PBMs;
    • The Dependent Eligibility Verification Audit is projected to  generate Plan Year 2011 claim savings of $25 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.  Specific to Health Care Reform, the SHBP will be impacted by:
      • Coverage of Dependent Children to Age 26 (which increases costs $6 million)
      • Elimination of Benefit Maximums (which increases costs $7 million)
      • Early Retiree Reinsurance Program
    • State Employee enrollment will decrease about 3% in Plan Year 2011, and
    • State Early Retiree enrollment will increase about 1% in Plan Year 2011, and Medicare Retiree enrollment will not change.
  • 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 in Plan Years 2010 and 2011.
    • HMO claim trends have averaged about 3% higher than Horizon trends over the past few years, and we are projecting that HMOs will continue to trend at a higher rate than the Horizon plans in Plan Year 2011.
  • Factors contributing to the recommended rate actions include:
    • 9% trend increase from Plan Year 2010 to Plan Year 2011, which is slightly better than industry trends;
    • Mandated benefit enhancements, including New Jersey and federal mandates (including Health Care Reform), which add about 2% to the increases, and
    • 4% savings from the Dependent Eligibility Verification Audit and the transition to Medco.
  • Plan Year 2011 projected costs for the State Group are $1.80 billion ($1.38 billion for Actives and $.42 billion for Retirees).  Plan Year 2011 renewal premiums are set to match the projected $1.80 billion costs, so there is no loss or gain projected for Plan Year 2011.

Recommended Plan Year 2011
Medical/Rx Rate Renewal Recommendation
for Active Employees and Retirees
of the Local Government Group


  • For Plan Year 2011, Aon is recommending premium rate changes that – in the aggregate – represent an overall increase of 11.7% for Local Government Active Employees and Retirees:
 
Employees
Early
Retirees 
Medicare
Retirees 
NJ DIRECT10 12.2% 13.3% 4.0%
NJ DIRECT15 12.2% 13.3% 4.0%
Aetna HMO  12.7% 17.3% 8.7%
CIGNA HMO 12.2% 16.8% 8.2%
Rx Card Plan 6.6% NA NA
       
Average Change 11.6% 14.3% 4.5%
  • This recommended rate 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;
    • The selection of Medco as the Program’s Prescription Benefit Manager (PBM) will result in a 9% reduction in Rx claim costs in Plan Years 2010 and 2011.  In Plan Year 2011, this translates into $17 million in savings as a result of deeper discounts and larger rebates than were available through the previous PBMs;
    • The Dependent Eligibility Verification Audit is projected to generate Plan Year 2011 claim savings for the Local Government Group of $10 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.  Specific to Health Care Reform, the SHBP will be impacted by:
      • Coverage of Dependent Children to Age 26 (which increases costs $3 million)
      • Elimination of Benefit Maximums (which increases costs $4 million)
      • Early Retiree Reinsurance Program
    • Active Employee enrollment will decrease 4% in Plan Year 2011, and
    • Early Retiree enrollment will increase 2% in Plan Year 2011 and Medicare Retiree enrollment will not change.
  • 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 in Plan Years 2010 and 2011.
    • HMO 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 2011.
  • Factors contributing to the recommended rate actions include:
    • 10% trend increase from Plan Year 2010 to Plan Year 2011, which is close to the industry norm;
    • Mandated benefit enhancements, including New Jersey and federal mandates (including Health Care Reform), which add about 2% to the increases,
    • Higher than expected claim levels in the current experience period, which add about 3% to the increases, and
    • 3% savings from the Dependent Eligibility Verification Audit and the transition to Medco.
  • Plan Year 2011 projected costs for the Local Government Group are $869 million ($632 million for Actives and $237 million for Retirees).  Plan Year renewal premiums are set to match the projected $869 million cost, so there is no loss or gain projected for Plan Year 2011. 
  • The Claim Stabilization Reserve is projected to remain at the target level of 2 months of plan costs as of 12/31/11. 

Recommended Dental Plans Rate Renewal
for Plan Year 2011


  • For the SHBP Dental Plans (Employee and Retiree Dental Expense Plans and Employee DPOs) for Plan Year 2011, Aon recommends the following premium rate adjustments, which – in the aggregate – represent a 1.9% overall increase in program costs:

Dental Expense Plans

        Actives                                      2.0%
        Retirees                                     2.6%

The overall increase for the Dental Expense Plans is 2.2%

Dental Plan Organizations (DPOs)

        Aetna                                        0.0%
        Benecare                                   1.0%
        CIGNA                                       0.0%
        Community                                 0.0%
        Healthplex                                 -5.0%
        Horizon                                      2.0%

The overall increase for the DPOs is 0.1%.

  • 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, except CIGNA (at .98) currently has a Value Ratio greater than 1.0, so we would normally be recommending a premium increase for most of the DPOs.  The DPOs requested rate increases ranging from -5.0% to 6.0%.  However, given the State’s ongoing budgetary issues, we are recommending renewal increases that range from -5.0% to 2.0%, with the average being .1%.
  • This recommended rate renewal assumes no changes in benefits for either Active Employees or Retirees and no changes in DPO vendors.
  • Factors contributing to the favorable rate action include:
    • The Dental Expense Plans’ (both Active Employee and Retiree) network was expanded as of 1/1/10 to include Aetna’s PPOII network, resulting in a projected savings of .4%, and
    • The change for Retirees from the former passive PPO to a true PPO, with different coinsurance for In-Network versus Out-of-Network providers.  This change, effective 1/1/10, should result in projected savings of over 8% for the Retiree Dental Expense Plan in Plan Year 2011.
  • Aon is projecting total Claim Stabilization Reserves of $7 million for Actives and $6 million for Retirees at the end of Plan Year 2011.
  • Aon is projecting that Employee Dental Expense enrollment will decrease 3% between Plan Years 2010 and 2011.  As a result, Plan Year 2011 projected Active Employee enrollments is:  62,200 Employees enrolled in the Dental Expense Plan and 38,400 Employees enrolled in the DPO plans.  Retiree Dental Expense Plan enrollment is expected to increase 10% to 61,400 for Plan Year 2011.
  • Plan Year 2011 projected costs for the SHBP Dental Plans are $122.2 million, with $59.0 million attributable to the Employee Dental Expense Plan, $42.9 million attributable to the Retiree Dental Expense Plan, and $20.3 million attributable to the DPOs.

David Pointer updated the Commission on Phase 2 of the Dependent Eligibility Verification Audit (DEVA).

Mr. Pointer also gave an update on dual coverage that had been eliminated under Ch. 2, P.L. 2010.  Letters went out to retirees that have dual coverage. In addition, employers were provided lists of employees who had dual coverage and employers were requested to distribute instructions to affected employees on how to waive duplicate coverage.  The Division will choose coverage for those employees or retirees who are not responsive.  September 1, 2010 is the termination date of the coverage.  

Finally, Mr. Pointer reported the COBRA Federal Subsidy ended May 31, 2010. 

There being no further business, Chairperson 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 12:14 PM.

Respectfully submitted,


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

 

 

 

 


Meeting No. 504
Minutes
July 21, 2010, 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and was amended July 13, 2010 with time and location change.

The meeting of the State Health Benefits Commission was called to order on Wednesday, July 21, 2010 at 1:15 PM. The meeting was held at Thomas Edison State College, 101 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

John Megariotis, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Neil Sullivan, Commissioner, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, Chair, Civil Service Commission (Via Telephone)
Patrick Nowlan, Representative for State Government Employees
Dudley Burdge, Representative for Local Government Employees

ALSO PRESENT: 
Rubin Weiner, Deputy Attorney General
Florence J. Sheppard, Acting Director, Pensions and Benefits
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Edward Fox, Aon Consulting
James Christ, Aon Consulting
Susan Marsh, Aon Consulting

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

2011 Rate Renewals

Edward Fox, Aon Consulting, introduced the Aon team and turned the meeting over to Susan Marsh also of Aon Consulting.  Ms. Marsh gave an overview of her memo to Florence Sheppard dated July 19, 2010 which responded to questions that were raised at the meeting on July 14, 2010 concerning the recommendations for the 2011 Rate Renewals.  Commissioner Burdge made a motion to go into Executive Session under Resolution B.  Commission Nowlan seconded the motion.  Approved (3: 2: 0; Commissioners Megariotis and Sullivan voted nay).  Upon return from Executive Session, Ms. Marsh completed her review of the follow-up questions.  Chairman Megariotis made a motion to accept the State, Local Employer and Dental 2011 rate renewals as presented.  Commissioner Sullivan seconded the motion and all voted in favor.

Commissioner Czech made a motion to encourage the Governor’s Office and Office of Employee Relations (OER) to consider Aon’s recommendations (as outlined in the rate renewal reports) to offset cost increases in the future.  Commissioner Sullivan seconded the motion.  Approved (3: 2: 0; Commissioners Burdge and Nowlan voted nay).

There being no further business, Commissioner Burdge made a motion to adjourn which was seconded by Commissioner Megariotis.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 2:30 PM.             

Respectfully submitted,


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

 

 

 


Meeting No. 505
Minutes
August 11, 2010
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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and revised notice was sent on July 13, 2010.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, August 11, 2010 at 10:33 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 Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, 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, Acting Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, State Health Benefits Program
Horizon Representatives
Aetna Representative
Medco Representatives

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

Meeting No. 503, July 14, 2010:   Commissioner Czech made a motion to accept the minutes. Chairperson Culliton seconded the motion.  All voted in favor.

Meeting No. 504, July 21, 2010:   Commissioner Czech made a motion to accept the minutes. Chairperson Culliton seconded the motion.  All voted in favor.

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

Commissioner Czech made a motion to go into Closed Session under Resolution A.  Commissioner Allen-Ware seconded the motion.  All voted in favor.

Case #SH081001 (Member Present) – This tabled Division appeal concerned Medco’s denial for Vaniqa cream used for cosmetic reasons.  At its previous meeting, the Commission requested more information from Horizon Blue Cross Blue Shield of New Jersey (Horizon) regarding why CVS/Caremark covered this drug prior to December 31, 2009.  Staff reported that Caremark’s reason for covering the medication was that they believed they did not have the authority to limit some of the cosmetic drugs.  There was a brief discussion of what was said at the last meeting between the member and the Commission.  It was established that no medical documentation was provided to Medco connecting her daughter’s prior treatments to her present condition for which she uses the medication.  Commissioner Nowlan made a motion to table this appeal to allow the member time to seek medical documentation associating her daughter’s condition with her previous illness.  Commissioner Burdge seconded the motion.  Approved (Vote 4: 0: 1; Chairperson Culliton abstained).  Commissioner Czech requested more definitive information from CVS/Caremark.  Ms. Williamson agreed to make the request.        

Case #SH081002 (Member Present) -This Medco appeal concerned a request to fill a prescription for Actonel which was denied under the Preferred Drug Step Therapy program.   Medco’s letter dated August 10, 2010 to Dorothy Balalis, Appeals Coordinator was distributed at the meeting.  DAG Rubin Weiner advised the Commission that his office was concerned that Commissioner Burdge had a personal interest in this matter and should recuse himself from the case.  Commissioner Burdge made a motion to go into Executive Session under Resolution B. Commissioner Nowlan second the motion.  All voted in favor.  Upon return from Executive Session Commissioner Burdge said at the direction of the DAG he was recusing himself, and he left the room.  Member gave the Commission a history of his condition and his physician’s long list of credentials.  Member advised the Commission that his physician insists that he continue to take Actonel because of his very unusual form of osteoporosis. 

The Commission asked Bhavesh B Modi, RPh, of Medco Health Solutions to report Medco’s position.  Mr. Modi explained that Medco’s Appeal Committee reviewed this appeal.  The physician did not provide documentation that the member had tried other drugs and shown intolerance, so the coverage was denied.  Commissioner Czech made a motion to table this appeal in order for Medco to further review if the drugs are interchangeable for this individual in this specific case.  Chairperson Culliton seconded the motion.  All voted in favor.

Case #SH081003 –This Aetna Dental Expense Plan appeal concerned the amount of reimbursement received for his son’s orthodontics.  Katherine Mulligan, Aetna representative, advised the Commission under the Aetna Dental Expense Plan orthodontics are subject to a lifetime maximum benefit of $1000.00. 

Chairperson Culliton made a motion to deny this appeal.  Commissioner Czech seconded the motion.  All voted in favor.

Case #SH081004 – This Horizon-NJ DIRECT15 appeal concerned a denial of benefits for expenses for a surgery related to an automobile accident-related injury.  Ms. Burns, Horizon, explained the dependent child was driving and insured vehicle, though she was not named as the insured on the policy.  The insurance carrier denied reimbursement for the surgery saying it was not medically necessary.  Horizon reviewed a copy of an independent medical examination (IME).  Dr. Wolinsky, Horizon’s Medical Director, advised the Commission the member’s history clearly shows that the surgery was related to the accident.  Horizon’s Subcommittee has determined that the surgery is medically necessary; however, since the member and her attorney are pursuing benefits from the automobile insurance carrier, the subcommittee denied coverage for the surgery.  Horizon has made several attempts to obtain additional information from the insurance company. Horizon is unable to proceed with the appeal without additional information.   Chairperson Culliton made a motion to deny this appeal for coverage for reasons set forth in Horizon’s denial letter dated March 10, 2010.  Commissioner Czech seconded the motion.   Approved (Vote 3: 0: 2, Commissioner Burdge and Nowlan abstained).

Case #SH081005(Member Present) This Horizon-NJ DIRECT15 appeal concerned a denial of benefits above the reasonable and customary allowance for surgery.  Member advised the Commission prior to her surgery she was in close contact with the out-of-network provider for the approval of the surgery and was told the procedure would be covered.  Provider was well aware if there was any problem with approval for payment of the procedure she would be unable to have the surgery due to the cost.  A deposit of $5,000.00 was requested and paid; the Member was assured the surgery would be covered and the deposit would be refunded.  Wendy Burns, Horizon, stated an authorization was approved to pay at the out-of-network level.  She also stated that there are in-network providers in the area.  The Member was told how the out-of-network reimbursement works (after the deductible, the out-of-network level pays 70% of the reasonable and customary charges; after that the out-of-network provider can balance bill the Member for the outstanding balance).  Chairperson Culliton made a motion to deny this appeal.  Commissioner Czech seconded the motion.  Approved (Vote 4: 0: 1; Commissioner Nowlan abstained).
 
Case #SH081006 –This Medco appeal concerned a request to fill a prescription for Propecia which was denied for off label use.  Medco states that Propecia is not generally used for pelvic pain syndrome because the strength is so low and that other medications may be more effective than Propecia.  The lower strength Propecia was primarily used for hair growth rather than pain reduction.  Chairperson Culliton made a motion to deny this appeal based on the fact the drug is used primarily for cosmetic purposes.  Commissioner Czech seconded the motion.  Approved (Vote 4:1: 0, Commissioners Nowlan voted nay).  

Case #SH081007 – The Member had requested that the denial of benefits for Transitional Living Expenses related to Intensive Outpatient Treatment of his dependent daughter be forwarded to the Office of Administrative Law (OAL) for a hearing.  Chairperson Culliton made a motion to approve this request for a hearing at the OAL. Commissioner Allen-Ware seconded the motion. All voted in favor.

Case #SH081008 - The Member had requested that the denial of benefits for the prescription drug Limbrel 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 a Final Administrative Determination. Commissioner Czech seconded the motion. Approved (Vote 3: 0: 2, Commissioners Burdge and Nowlan abstained).

Commissioner Czech left the meeting at 12:40.

Case #SH081009 – A settlement offer was before the Commission in a case involving denial of benefits for an injury that was the result of an incident that was deemed work related.  Chairperson Culliton made a motion to accept the settlement proposal.  Commissioner Allen-Ware seconded the motion.  All voted in favor.

Case #SH081010 – A settlement offer was before the Commission in a case involving denial of benefits for an injury that was the result of an incident that was deemed work related.  A corrected version of an e-mail dated July 27, 2010 regarding the settlement was distributed at the meeting.  Chairperson Culliton made a motion to accept the settlement proposal as outlined in the corrected version of the e-mail dated July 27, 2010.  Commissioner Nowlan seconded the motion. All voted in favor. 

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

ISSUES

A. Carrier Updates - David Pointer advised the Commission that Aetna implemented a new I-Phone application to their website which will provide members global access.  This mobile application makes it easier for Aetna members to get their personal information and to find a participating doctor, dentist, or facility.  Members will also be able to view their ID card, look up claims, check drug prices and view their personal health records.   

David Perry, Horizon’s Director of Account Management and Finance, discussed Surgicenters.  Horizon has over one hundred internal out-of-network appeals for surgicenters.  Initially the idea of a surgicenter was to create cost savings.  Currently, less than half of the surgicenters in New Jersey are in-network and they charge considerably more than the allowed amount at hospitals.  To resolve this situation, Horizon proposed a fee schedule to reimburse for services received at surgicenters based on CMS’s charge system.

David Pointer advised the Commission preparations for notification to members and retirees’ regarding Patient Protection and Affordable Care Act (PPACA) legislation which extends coverage for children up to the age of 26 has begun.  October 2010 has been set aside by the SHBP as the period when parents may enroll/re-enroll children under age 26 as of December 31, 2010 if the adult child is not eligible to enroll in other employer-based coverage (aside from coverage through the parent).  Retirees will be notified by direct mail and those wishing to enroll/re-enroll an eligible adult child must submit a SHBP Retired Change of Status Application to the Health Benefits Bureau of the Division of Pensions and Benefits between October 1 and October 29, 2010.  Employees will receive enrollment information from their employers as part of the regular SHBP Open Enrollment communications and may submit a Health Benefits Application through their employer between October 1 and October 29, 2010.  Covered children who turn age 23 during 2010 will be continued to be covered automatically.

David Pointer reported the Early Retiree Reimbursement Program application was accepted by the Federal government.  The Federal government is drafting regulations on the process moving forward.

Commissioner Burdge had a request concerning the Generic Dispensing Rate as reported on Aon’s follow-up memo regarding the rate renewals.  He asked that Aon split retirees and active employees.

B. Chairperson Culliton made a motion to accept the 2011 COBRA Vision rates as presented.  Commissioner Nowlan seconded the motion and all voted in favor.

C. Dependent Eligibility Verification Audit (DEVA):  David Pointer reported 14,700 dependents were terminated from coverage under the plan on July 1, 2010 due to the audit.  The appeal process has allowed 7,500 of them to be reinstated retroactively.  Aon’s call center closed effective August 9, 2010. 

Commissioner Burdge asked if the RFP for a Health Benefits consulting firm was on track. David Pointer advised them that he expected the Health Benefits consultant would be selected in September  or October.

There being no further business, Chairperson 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 1:05 PM.

Respectfully submitted,


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

 

 

 


Meeting No. 506
Minutes
September 8, 2010
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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and revised notice was sent on July 13, 2010.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, September 9, 2010 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 Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, 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
Wendy Burns, Horizon Representative

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

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

Chairperson Culliton made a motion to go into Closed Session under Resolution A.  Commissioner Czech seconded the motion.  All voted in favor.

Case #SH09101 –Member had requested that the Horizon-Magellan Health Services denial of benefits for future treatment by an ineligible provider be forwarded to the Office of Administrative Law (OAL) for a hearing.  Chairperson Culliton made a motion to approve this request for a hearing at the OAL. Commissioner Nowlan seconded the motion.  Approved (Vote 5: 0: 0).

Update on Case #SH081002 –Tabled at the August 2010 meeting–David Pointer stated this appeal has been resolved.  After the Commission hearing, Medco requested an Endocrinologist review the appeal information submitted.  Chairperson Culliton asked DAG Weiner if this was the appeal that Commissioner Burdge recused himself and, if so, should he recuse himself again.  DAG Weiner said if the Commission wishes to discuss this matter, he should recuse himself.  Mr. Pointer reported that, after reviewing the appeal information, the endocrinologist considered the request for coverage reasonable based on the prescriber’s concern about the potential detrimental effect of changing drugs for this particular patient.  Based on the additional medical review, an administrative decision was made by Medco to place an authorization on the member’s account for the drug.   The Member was advised of this decision.  Medco’s decision made the appeal moot.     

Case #SH09102 –A settlement offer was before the Commission in a case involving a denial of benefits for an injury that was deemed work related.  Chairperson Culliton made a motion to authorize a settlement proposal in the amount of $2,868.07.  Commission Czech seconded the motion.  Approved   (Vote 5: 0: 0).

Case #SH09103 – David Pointer reported that the Appellate Decision affirmed the Commission’s decision that the procedure was an experimental or investigational procedure.   

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

ISSUES

  1. Carrier Updates - David Pointer advised the Commission the semiannual NJ DIRECT Managed Network Update was distributed at the meeting.  Commissioner Burdge asked if therapists were included.  Wendy Burns of Horizon Blue Cross Blue Shield said they would be under Specialists.  Ms. Burns pointed out to the Commission the largest growth was the Ancillary Providers (Durable Medical Equipment).

 Dave Pointer advised the Commission Aon’s memo dated August 11, 2010 provided Aon’s responses to the various questions raised at the July 21st Commission Meeting.  Commissioner Burdge asked if the retirees could be separated from the active members.  Mr. Pointer stated he would follow-up. 

  1. Dependent Eligibility Verification Audit (DEVA) - David Pointer reported August 9, 2010 ended the appeal process for terminated dependents.  Aon continued reviewing documents through August 19, 2010.  The audit terminated coverage for 14,708 dependents; 8,996 were approved for reinstatement; 5,712 remain terminated; 2,024 self declared ineligible. 

David Pointer advised the Commission notification letters to retirees’ regarding Patient Protection and Affordable Care Act (PPACA) legislation which extends coverage for children up to the age of 26 were being printed today and will be mailed out by the end of the week to retirees.  Active employees will receive enrollment information from their employers as part of the regular SHBP Open Enrollment communications.  Applications will be accepted from October 1 - 29, 2010 for enrollment of eligible children.  The effective date of coverage is January 1, 2011. 

The Division’s Early Retiree Reimbursement Program (ERRP) application was accepted by the federal government.  Federal regulations have not yet been done on the claims submission process.

There being no further business, Chairperson Culliton made a motion to adjourn which was seconded by Commissioner Burdge. All voted in favor.  The State Health Benefits Commission meeting was adjourned at 10:26 AM.

Respectfully submitted,


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

 

 

 

 


Meeting No. 507
Minutes
October 13, 2010
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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, October 13, 2010 at 10:11 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 Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, Commissioner, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, 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
Katherine Impellizzeri, Aetna Representative
Dr. Mark Friedlander, Aetna Medical Director
Patrick Currie, Aetna Representative

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

Meeting No. 505, August 11, 2010:  Chairperson Culliton made a motion to accept the minutes. Commissioner Czech seconded the motion.  All voted in favor.

Meeting No. 506, September 8, 2010:   Chairperson Culliton made a motion to accept the minutes. Commissioner Czech seconded the motion.  All voted in favor.

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

Commissioner Burdge made a motion to go into Closed Session under Resolution A.  Commissioner Nowlan seconded the motion.  All voted in favor.

The Commission agreed to go out of order to hear Case#SH101002 via teleconference with the member, member’s physician and another representative. 

Case #SH101001 (Member Present) - This Division appeal concerned a denial of benefits for expenses for Cialis beyond four pills per month/twelve pills in 3 month period. Commissioner Czech made a motion to deny this appeal based on the volume restrictions currently applicable to sexual dysfunction drugs.  Chairperson Culliton seconded the motion.  All voted in favor.

Case# SH101002  -  This Aetna appeal concerned a denial of benefits for Transcranial Magnetic Stimulation (TMS) therapy as experimental in nature.  Several unsuccessful attempts were made to contact member’s physician.  The member asked the Commission to allow him time to try and contact his physician.  The Commission agreed and Chairperson Culliton advised the member the Commission would hear his appeal at 10:40 AM.  At that time, the Member was not able to reach physician and asked if his appeal could be postponed.  Chairperson Culliton made a motion to postpone the appeal.  Commissioner Nowlan seconded the motion.  All voted in favor. The member was told he would receive a letter advising him of the date and time his appeal would be heard.  

Case #SH101003 (Member Present) - This Medco appeal concerned a denial of expenses for non-insulin syringes.  Member previously received the same medication through CVS/Caremark in the form of a patch.  The Member stated CVS/Caremark reached out to him and advised there would be a cost savings if he went to a bulk product requiring a syringe.  Member agreed and started receiving the medication in an injectable form.  At that time CVS/Caremark paid for the syringes.  Chairperson Culliton 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, Commissioner Czech made a motion to deny this appeal because the plan has an exclusion for non-insulin syringes and there is an alternative method to take the medication via patch.  Chairperson Culliton seconded the motion.  Approved (Vote: 4: 1: 0, Commissioner Burdge voted nay).  

Case #SH101004  – This Medco appeal concerned a denial to fill a prescription for Atacand which is a drug under the Preferred Drug Step Therapy Program.  DAG Weiner asked if Commissioner Burdge was going to recuse himself from this appeal and he did.  A discussion took place between the Commission and Bhavesh B Modi, RPh, Medco Health Solutions, concerning the reasons for Medco denying this drug.  Chairperson Culliton made a motion to table this appeal to allow Medco to request clarification from Dr. Seplowitz concerning his letter of May 21, 2010 in which he states ‘it would be ill advised on medical grounds to switch to an alternate class of antihypertensive medication”.   Commissioner Nowlan seconded the motion.  All voted in favor.

Case #SH101005  – The Member had requested that the Commission’s denial of benefits for expenses for reduction of hours of private duty nursing for dependent daughter be forwarded to the Office of Administrative Law (OAL) for a hearing.  Chairperson Culliton made a motion to approve this request for a hearing at the OAL. Commissioner Allen-Ware seconded the motion. All voted in favor.

Case #SH101006  -  The Member had requested that the Commission’s denial of expenses for Viagra beyond the four pills per month/twelve pills in a ninety day period be forwarded to the Office of Administrative Law (OAL) for a hearing.  Chairperson Culliton made a motion to approve this request for a hearing at the OAL. Commissioner Nowlan seconded the motion. All voted in favor.

Case #SH101007 – Final Administrative Determination (FAD) – Chairperson Culliton made a motion to accept the FAD draft concerning the denial of benefits for additional reimbursement for an out-of-network provider.   Commissioner Czech seconded the motion. Approved (Vote 3: 2: 0, Commissioners Burdge and Nowlan abstained).

Case #SH101008 – Final Administrative Determination (FAD) – Chairperson Culliton made a motion to accept the FAD draft concerning the denial of benefits for additional reimbursement for an out-of-network provider.  Commissioner Czech seconded the motion.  Approved (Vote 3: 2: 0, Commissioners Burdge and Nowlan abstained).

Case #SH101009 - Final Administrative Determination (FAD)
Jean Williamson announced the draft was not ready and would be postponed. 

Case #SH101010 - A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related in which the member is now deceased.  Chairperson Culliton made a motion to accept the recommendation that the lien be waived as presented. Commissioner Nowlan seconded the motion.  All voted in favor.
 
There being no further appeals, a motion was made to return to open session by Commissioner Burdge, seconded by Commissioner Nowlan. All voted in favor.

ISSUES

  1. Carrier Updates - David Pointer said the Pharmacy Benefits Program Review were given to the Commission in their handbooks for their information.  The review will be done every 6 months.  A GAP client list was distributed to the Commission per Commissioner Burdge requested prior to the meeting. 
  1. The Commission was provided the new CDT-2011 Dental Codes.  Commissioner Czech made a motion to approve the codes.  Commissioner Burdge seconded the motion.  All voted in favor.

There being no further business, Chairperson 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 12:05 PM.         

Respectfully submitted,


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

 

 

 


Meeting No. 508
Minutes
November 10, 2010
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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and revised notice was sent on July 13, 2010.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, November 10, 2010 at 10:13 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 Andrew P. Sidamon-Eristoff
(From beginning of meeting through 12:00)
Janice Nelson, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
(From 12:00 through end of meeting)
Sylvia Allen-Ware, Commissioner, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, 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
Katherine Impellizzeri, Aetna Representative
Sharon Cannon, Aetna Representative
Mike North, Aetna Representative
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Rosemary Middlebrook, Horizon Blue Cross Blue Shield of New Jersey
Bhavesh B Modi, RPh, Medco Health Solutions
Angela Pearson, Medco Health Solutions
Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

Meeting No. 507, October 13, 2010:   Chairperson Culliton made a motion to accept the minutes. Commissioner Czech seconded the motion.  All voted in favor.

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

Chairperson Culliton made a motion to go into Closed Session under Resolution A.  Commissioner Nowlan seconded the motion.  All voted in favor.

Case# SH111001 - (Member Present) - This tabled Division appeal concerned Medco’s denial for Vaniqa cream used for cosmetic purposes.  At its previous meeting, it was established that no medical documentation was provided to Medco connecting the dependent daughter’s prior treatments to her present condition for which she uses the medication. The Commission requested the member seek medical documentation associating her daughter’s condition with her previous illness.  Additional information was received by the Commission and reviewed.  The member and her daughter briefly spoke on the matter.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Commissioner Czech seconded the motion. All voted in favor.  Upon return from Executive Session Commissioner Czech made a motion to deny the appeal since prescription drugs used primarily for cosmetic purposes are specifically excluded from the Prescription Drug plan; however, based upon the equitable arguments raised by the member, he moved that the Commission approve reimbursement of amounts paid for Vaniqa on and after January 20, 2010, up to a maximum of 90 days’ supply.   Commissioner Nowlan seconded the motion.  All voted in favor. Jean Williamson said that she would advise Medco to process reimbursement.  

Case #SH111002 – This Medco appeal concerned a denial of benefits for expenses for Hydroquinone cream. Commissioner Czech made a motion to deny this appeal since prescription drugs used primarily for cosmetic purposes are specifically excluded from the Prescription Drug plan.  Chairperson Nelson seconded the motion.  All voted in favor.

Case #SH111003 This Medco appeal concerned a denial of benefits for expenses for Hydroquinone cream. Commissioner Burdge made a motion to deny this appeal since prescription drugs used primarily for cosmetic purposes are specifically excluded from the Prescription Drug plan, but to allow for reimbursement for up to 90 days transition as there was no notice of discontinuation of the drug being covered. Commissioner Nowlan seconded the motion.  All voted in favor.

Case #SH111004 (Personal Appearance by Member’s Representative) - This Medco appeal concerned a denial for request for Viagra over the plan’s 12 pills in a month period limit.  Chairperson Culliton recused herself from the case.  The representative gave a brief statement pertaining to Viagra being used to treat Pulmonary Arterial Hypertension.  Bhavesh B Modi, RPh, advised the Commission that the FDA has approved Sildenafil, which has the same chemical as Viagra and is covered under the plan, but not Viagra, for treating this condition.   Commissioner Nowlan made a motion to deny this appeal based on the drug being used for an off label purpose and the availability of another drug to treat this condition.  Commissioner Czech seconded the motion.  Approved (Vote 3: 0: 1, Commissioner Burdge abstained).

Case #SH111005 – This Medco appeal concerned a denial of benefits for expenses for Vaniqa cream. Chairperson Nelson made a motion to deny this appeal since prescription drugs used primarily for cosmetic purposes are specifically excluded from the Prescription Drug plan; however, based upon the equitable arguments raised by the member, he moved that the Commission reimburse the member for up to 90 days as a transition period as there was no notice of discontinuation of the drug being covered.  Commissioner Czech seconded the motion.  All voted in favor.

Case #SH111006 - This Medco appeal concerned a denial of benefits for expenses for Renova.  Commissioner Czech made a motion to deny this appeal because prescription drugs used primarily for cosmetic purposes are specifically excluded from the Prescription Drug plan and the condition is not an indicated use of this drug.  Commissioner Burdge seconded the motion.  All voted in favor.

Case #SH111007 – This Medco appeal concerned a denial of benefits for expenses for Hydroquinone cream. Chairperson Nelson made a motion to deny this appeal since prescription drugs used primarily for cosmetic purposes are specifically excluded from the Prescription Drug plan, but, based upon the equitable arguments raised by the member, to allow for reimbursement for up to 90 days as a transition period as there was no notice of discontinuation of the drug being covered.  Commissioner Nowlan seconded the motion.  All voted in favor.

Case #SH111008 This Medco appeal concerned a denial of benefits for expenses for MiraLax. Commissioner Czech made a motion to deny this appeal because over-the-counter drugs are excluded from the plan.  Commissioner Allen-Ware seconded the motion.  All voted in favor.

Case #SH111009 - This Medco appeal concerned a denial of benefits for expenses for Propecia for a dependent.  Chairperson Nelson made a motion to deny this appeal since prescription drugs used primarily for cosmetic purposes are specifically excluded from the Prescription Drug plan; however, but to allow for reimbursement for up to 90 days as a transition period as there was no notice of discontinuation of the drug being covered.  Commissioner Czech seconded the motion.  All voted in favor.

Case #SH111010 -This Medco appeal concerned a denial of benefits for expenses for Latisse. Commissioner Czech made a motion to deny this appeal since prescription drugs used primarily for cosmetic purposes are specifically excluded from the Prescription Drug plan.    Commissioner Burdge seconded the motion.  All voted in favor.

Case #SH111011 – This Medco appeal concerned a denial for a request for Viagra over the plan’s 12 pills in a month period limit. Commissioner Czech made a motion to deny this appeal based on the fact that the drug is not FDA approved for the condition on which it is being used.   The Commission noted the member should be notified that Sildenafil is covered under the plan to treat this condition.  Chairperson Nelson seconded the motion.  Approved (Vote 4: 0: 1, Commissioner Burdge abstained).
 
Case #SH111012  – The Member had requested that the Commission’s denial of benefits of a precertification for an Anterior Cervical Discectomy be forwarded to the Office of Administrative Law (OAL) for a hearing.  Chairperson Nelson made a motion to approve this request for a hearing at the OAL. Commissioner Nowlan seconded the motion. All voted in favor.

Case #SH111013  – The Commission previously upheld the administrative determination made by Horizon and the matter was later transferred to Office of Administrative Law (OAL) as a contested case, at the request of the member.  In preparation for the OAL hearing, the member’s file was reviewed by Horizon’s Medical Director, Steven Wolinsky, M.D.  Dr. Wolinsky determined that two of the CPT codes were eligible for separate reimbursement and he prepared a claim chart.  Based on this new information it was requested that the Commission reconsider payment of the claim as recommended by Horizon.  Commissioner Nowlan made a motion to make the payment at the recommendation of Horizon as described in the 10/8/10 letter to Dorothy Balalis, Division of Pensions and Benefits from Rosemary Middlebrook, Horizon. Commissioner Burdge seconded the motion. All voted in favor.

Case #SH111014 – Final Administrative Determination (FAD) – Commissioner Czech made a motion to accept the FAD draft concerning the denial of benefits for the drug Limbrel.   Commissioner Nelson seconded the motion. Approved (Vote 4: 0: 1, Commissioner Burdge abstained).

Case #SH111015 - A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related. Commissioner Nelson made a motion to authorize Socrates, Inc. to negotiate a resolution as presented.  Commissioner Nowlan seconded the motion.  All voted in favor.

Case #SH111016 - A settlement offer was before the Commission in a case involving denial of Applied Behavior Analysis (ABA) therapy for a dependent child by Childs Play.  Chairperson Nelson made a motion to accept the settlement as presented. Commissioner Nowlan seconded the motion.  All voted in favor.

Case #SH111017 - A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related. Chairperson Nelson made a motion to accept the settlement as presented. Commissioner Nowlan seconded the motion.  All voted in favor.

Case #SH111018 - A case was filed in the NJ Superior Court Law Division concerning payment for surgical assistant services provided to the Traditional Plan participants by nurses.  Commissioner Nowlan made a motion to go into Executive Session under Resolution B.  Commissioner Burdge seconded the motion. All voted in favor.  Upon return from Executive Session, Commissioner Burdge made a motion to schedule this appeal for a future date.  Commissioner Nowlan seconded it.  All voted in favor.

Case #SH111019 - A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related.  Chairperson Nelson made a motion to accept the settlement as presented. Commissioner Nowlan seconded the motion.  All voted in favor.

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

ISSUES

  1.  2011 Meeting Schedule – For Approval

Jean Williamson advised the Commission that meetings were scheduled for the second Wednesday of every month as usual for calendar year 2011.   Commissioner Burdge made a motion to approve the 2011 meeting dates.  Commissioner Allen-Ware seconded the motion. All voted in favor. 

  1. Carrier Updates                                                          

Katherine Impellizeri, Aetna advised the Commission due to Federal regulations, the Aetna Medicare Open Plan is being replaced by the Aetna Medicare Plan (HMO) as of January 1, 2011. 
Sharon Cannon, Aetna, gave an overview of the plan differences.

David Pointer said Horizon received a termination notice from Hackettstown Hospital for April 1, 2011.  Negotiations are presently taking place between the hospital and Horizon.  

David Pointer noted there was a list of the current Employers participating in the SHBP as of November 1, 2010 in the books this month.  This information will be provided on a quarterly basis to the Commission.

Commissioner Burdge asked how many re-enrollees of dependents were added during open enrollment.  David Pointer said it will be another month or two before that number can be provided because applications are still being processed.

There being no further business, Commissioner Nowlan made a motion to adjourn which was seconded by Commissioner Burdge.  All voted in favor.  The State Health Benefits Commission meeting was adjourned at 1:20 PM.

Respectfully submitted,


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

 

 

 

 


Meeting No. 509, Minutes
December 8, 2010, 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and a revised notice was sent on July 13, 2010.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, December 8, 2010 at 1:10 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 Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware
, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, 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
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Rosemary Middlebrook, Horizon Blue Cross Blue Shield of New Jersey
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey
Megan McKenzie, Horizon Blue Cross Blue Shield of New Jersey
Dr. Candace Saldarini, Medical Director, Magellan
Bhavesh B Modi, RPh, Medco Health Solutions
Angela Pierson, Medco Health Solutions

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

Meeting No. 508, November 10, 2010: Chairperson Culliton made a motion to accept the minutes. Commissioner Burdge seconded the motion.  All voted in favor.

Chairperson Culliton made a motion to go out of order to discuss the issue “Hackensack Surgery Center v. SHBP”. Commissioner Nowlan seconded the motion.  All voted in favor.  Chairperson Culliton made a motion to go into Executive Session under Resolution B to discuss this pending litigation.  Commissioner Nowlan seconded the motion. All voted in favor.  Upon return from Executive Session, Commissioner Czech made a motion to have Horizon Blue Cross Blue Shield of New Jersey (Horizon) give an overview of the basis of reimbursement to ambulatory surgery centers at the January 12, 2010 Commission meeting.  Commissioner Burdge seconded the motion. All voted in favor.

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

Chairperson Culliton made a motion to go into Closed Session under Resolution A.  Commissioner Nowlan seconded the motion.  All voted in favor.

Case# SH121001 - (Member present via telephone) - This Horizon NJ DIRECT10/Magellan appeal concerned a denial of continued residential treatment at Timberline Knolls for a dependent child.  The Member requested the Commission approve his appeal because he was not advised that an appeal was filed and denied to continue inpatient residential treatment for his daughter until 52 days after the appeal was denied.  It was determined during the discussion that Timberline Knoll is an in-network facility and is balance billing the member.  Chairperson Culliton made a motion to table this appeal and instructed Horizon to investigate why the facility is balance billing the member.  Commissioner Burdge seconded the motion.  All voted in favor.

Case #SH121002 –This Medco appeal concerned a denial of benefits for expenses for Polyethylene glycol 3350.  Chairperson Culliton made a motion to deny this appeal because over-the-counter drugs are excluded from coverage under the prescription drug plan.  Commissioner Czech seconded the motion.  All voted in favor.

Case #SH121003 –This Horizon NJ DIRECT15/Magellan appeal concerned denial of twice weekly individual outpatient therapy for an out-of-network mental health provider.  Chairperson Culliton made a motion to deny this appeal because medical necessity was not met.  Commissioner Czech seconded the motion.  All voted in favor.

Case #SH121004 –This Medco appeal concerned a denial of benefits for expenses for Polyethylene glycol 3350.  Chairperson Culliton made a motion to deny this appeal because over-the-counter drugs are excluded from coverage under the prescription drug plan.  Commissioner Burdge seconded the motion.  All voted in favor.

Case #SH121005 - This Medco appeal concerned a denial of benefits for expenses for Polyethylene glycol 3350. Chairperson Culliton made a motion to deny this appeal because over-the-counter drugs are excluded from coverage under the prescription drug plan.  Commissioner Burdge seconded the motion.  All voted in favor.

Case #SH121006 - (Member Present) - This Division appeal concerned a request for reinstatement of a subscriber’s spouse to coverage who had been terminated through the Dependent Eligibility Verification Audit so there would be no break in service. The subscriber was also requesting that a dental claim incurred during the break in service would be reimbursed. A discussion took place between the member and the Commission, after which Commissioner Nowlan made a motion to go into Executive Session under Resolution B.  Commissioner Burdge seconded the motion. All voted in favor.  Upon return from Executive Session, Commissioner Czech made a motion to approve this appeal pending receipt of copies of documents from Aon and confirmation from member’s employer verifying payroll deductions for Member/Spouse coverage continued at least through April 2010.  Commissioner Burdge seconded the motion.  Approved (Vote 4: 1: 0, Chairperson Culliton voted nay).

Case #SH121007 - This Medco appeal concerned a denial of benefits for expenses for Miralax. Commissioner Burdge made a motion to deny this appeal because over-the-counter drugs are not covered by the plan.  Chairperson Culliton seconded the motion.  All voted in favor.

Case #SH121008 –This Medco appeal concerned a denial of benefits for expenses for Polyethylene glycol.   Commissioner Burdge made a motion to deny this appeal because over-the-counter drugs are excluded from coverage under the prescription drug plan.  Commissioner Czech seconded the motion.  All voted in favor.

Case #SH121009–This Medco appeal concerned a denial of benefits for expenses for Polyethylene glycol. Commissioner Czech made a motion to deny this appeal because over-the-counter drugs are excluded from coverage under the prescription drug plan.   Commissioner Nowlan seconded the motion.  All voted in favor.

Case #SH121010 –This Horizon NJ DIRECT10 appeal concerned a denial of benefits for expenses for an additional eye exam rendered by Pediatric Ophthalmology Associates for a dependent child. Chairperson Culliton made a motion to deny this appeal based on the plan limitation of one eye exam per year.   Commissioner Czech seconded the motion.  Approved (Vote 4: 0: 1, Commissioner Burdge abstained).

Case #SH121011 - A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related.  Chairperson Culliton made a motion to authorize Socrates, a Horizon recovery subcontractor, to negotiate a resolution that calls for recovery of between $3,423.05 and $4,000.00. Commissioner Nowlan seconded the motion.  All voted in favor.

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

ISSUES

A.
Carrier Updates - David Pointer informed the Commission that the Acting Director of the Division of Pensions and Benefits had approved a one year extension of the Aetna Dental Expense contract as permitted under the Request for Proposals (RFP).   A RFP will be developed and bid in 2011 to award a new dental contract effective January 1, 2012.
 
B.
David Pointer drew the Commission’s attention to the DEVA Executive Summary Report that was provided in their binders.  Mr. Pointer requested that any questions the Commissioners may have on the report for Aon to be sent to the Division.
 
C.
Hackensack Surgery Center:  Heard this issue at the beginning of the meeting.
 
D.
It was recommended by the Acting Director that the Commission continue to file an exemption for calendar year 2011 from the HIPAA mental health parity requirements for NJ DIRECT10, NJ DIRECT15, and Aetna and Cigna HMOs.  The purpose of the exemption is to preserve the day limits on certain mental health services provided under the plans.  Due to federal health care reform, the dollar limits on mental health maximum plan covered expenses in NJ DIRECT will no longer be in effect beginning in 2011.  Aon has estimated that failure to opt-out of the federal mental health parity requirements would cost the SHBP/SEHBP $6M in 2011. DAG Rubin Weiner suggested the Commission approve an exemption for the day limits as well as the dollar limits in the event that either requirement is modified in the future. Commissioner Czech made a motion to approve the exemption from the HIPAA Mental Health Parity requirements. Chairperson Culliton seconded the motion. Approved (Vote 3: 0: 2, Commissioners Burdge and Nowlan abstained).
 
E.
David Pointer told the Commission that pursuant to NJSA 52:14-17.38c, the State Treasurer set an annual surcharge rate for insurers of school districts that do not participate in the School Employees’ Health Benefits Program (SEHBP) at 2.5 percent for 2011. 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.

There being no further business, Chairperson Culliton made a motion to adjourn which was seconded by Commissioner Czech. All voted in favor. The State Health Benefits Commission meeting was adjourned at 4:22 PM.

Respectfully submitted,


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

 

 
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