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Pensions and Benefits
HEALTH BENEFITS COMMISSION
MEETING MINUTES 2012
 

*Meeting of August 16, 2012 will begin at 1:00 P.M.. 

To view 2011 Health Benefit Commission Meeting Minutes (and prior years), click here.


Meeting No. 521
Minutes
February 8, 2012, 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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, February 8, 2012 at 1:13 PM.  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, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Robert M Czech, Chair, Civil Service Commission
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

Also present: 

Diane Weeden, Deputy Attorney General
Jean Williamson, Acting Secretary
Barb Scherer, State Health Benefits Program
Katherine Impellizzeri, Aetna Health Plan
Katherine Mulligan, Aetna Health Plan
Patrick Currie, Aetna Health Plan
Alan Eisenberg, Aetna Health Plan

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

Meeting No. 520, December 14, 2011:Chairperson Culliton made a motion to accept the minutes. Commissioner Czech seconded the motion.  Motion passed (4: 0: 1 Commissioner Nowlan abstained).  

ISSUES

  1. Carrier Updates:

Aetna Dental Expense Network–Aetna representatives were present at the request of Commissioner Burdge.  Katherine Impellizzeri, the Aetna Account Manager introduced herself and the Aetna team:  Katherine Mulligan, Alan Eisenberg and Patrick Currie. She reminded the Commission that at the last meeting there were some questions and some subsequent follow-up information that was provided with respect to Aetna’s Dental's PPO network and provider counts.  Aetna representatives were asked to attend today’s meeting to address specific questions pertaining to provider network participation.  

Ms. Mulligan provided three reasons why providers may choose not to participate in the network:  1) The dentist is unwilling to reduce his or her fees; 2) Some dentists prefer to have no affiliation with any dental insurance plan; and 3) Some dentists feel their practice is busy enough and they don't want to open the doors to an influx of additional patients that might come to them if they were participating in a network.  A discussion ensued highlighting the differences between physicians and dentists insofar as participation in a network is concerned. 

Ms. Impellizzeri said the next item she wanted to address concerned patients with specific health care issues such as autism who need access to a dentist who is trained to address that particular need.  She said if a member has a specific need for treatment and it is not available in-network within the specified target access, Aetna will reimburse those expenses at the in-network benefit level.  

Commissioner Burdge asked what Aetna anticipates in terms of increasing the network size this year.  Ms. Mulligan said growth has been in the neighborhood of 10 to 15 percent annually over the last five years. Aetna has made their growth goal every year and is confident the network will grow that much this year.
                                               
Aetna Hospital Terminations:  Jean Williamson advised the Commission that Jersey Medical Center was terminating their contract with Aetna effective February 15, 2012.  There are 310 members (109 Education, 68 State and 133 Local) that had services rendered at the hospital last year.  Ms. Impellizzeri added Aetna and Jersey Medical Center were still engaged in active negotiations however the termination was firm.  Ms. Impellizzeri also provided an update on negotiations with UMDNJ.  The termination date of March 1, 2012 was extended to April 30, 2012, while they continue active negotiations.  Finally, Ms. Impellizzeri provided an update on negotiations with Cooper Hospital University Medical Center.  The termination date of March 1, 2012 was extended to April 1, 2012, while they continue negotiations.   

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

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

Case #SH021201 – The Member made a request that the denial of benefits for chartered air transportation 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 5: 0: 0).

Case #SH021202 – A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related.  The lien amount was $28,384.75.  Chairperson Culliton made a motion to authorize Socrates to negotiate a resolution as described in John Fedorko’s memo of January 23, 2012.  Commissioner Czech seconded the motion.  Approved (Vote 5: 0: 0).

Case# SH021203 A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related.  The lien amount was $2,516.88.  Chairperson Culliton made a motion to authorize Socrates to negotiate a resolution as described in John Fedorko’s memo of May 27, 2011.  Commissioner Nowlan seconded the motion.  Approved (Vote 5: 0: 0).

Case #SH021204 – A settlement recommendation was before the Commission which is pending in the Office of Administrative Law (OAL) in a case involving denial of benefits for Residential Rehabilitation Treatment for a dependent child.  The total amount in dispute was $56,526.00 and the settlement proposed was an estimate of the value of the level of care that the Plan would have provided at the time of the initial admission under ASAM Guidelines.   The details of the settlement represent the following care:  six weeks of Intensive Out-Patient Treatment at four sessions a week at $349.50 per session for a total of $8,388.00 and twelve weeks of Out-Patient Treatment at three sessions a week at $97.50 per session for a total of $3,510.00.   Chairperson Culliton made a motion to accept the settlement recommendation described in Thomas R. Hower’s memo of February 2, 2012.  Commissioner Nowlan seconded the motion.   Approved (Vote 5: 0: 0).

Case #SH021205 – A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related.  The lien amount was $46,957.21.   Chairperson Culliton made a motion to authorize Socrates to demand recovery as described in John Fedorko’s memo of May 27, 2011.  Commissioner Czech seconded the motion.  Approved (Vote 5: 0: 0).

Case #SH021206 – A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related. The lien amount was $33,587.98.   Chairperson Culliton made a motion to accept the settlement proposal as described in John Fedorko’s memo of February 2, 2012.  Commissioner Nowlan seconded the motion.  Approved (Vote 5: 0: 0).

Case #SH021207 – A settlement offer was before the Commission in a case involving denial of benefits for an injury deemed work related. The lien amount was $1,120.00.   Chairperson Culliton made a motion to accept the settlement proposal as described in John Fedorko’s memo of December 22, 2011.  Commissioner Nowlan seconded the motion.  Approved (Vote 5: 0: 0).

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

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 1:47 PM.

  Respectfully submitted,
 

 

 

  Jean M. Williamson, CEBS
Acting Secretary
School Employees’ Health Benefits Commission

 


Meeting No. 522
Minutes
March 14, 2012, 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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, March 14, 2012 at 10:10 AM.  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, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Robert M Czech, Chair, Civil Service Commission (arrived at 10:37)
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

ALSO PRESENT: 

Diane Weeden, Deputy Attorney General
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ)
Rosemary Middlebrook, Horizon BCBSNJ
Cheryl Eagan, Horizon BCBSNJ
Dr. Steven Wolinsky, Medical Director, Horizon BCBSNJ

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

Jean Williamson announced that Commission Czech’s office notified her that he would be arriving about 30 minutes late.

Meeting No. 521, February 8, 2012:Chairperson Culliton made a motion to approve the minutes.  Commissioner Nowlan seconded the motion.  All voted in favor (4: 0: 0 Commissioner Czech was absent).

ISSUES

  1. Carrier Updates:  David Pointer gave a brief summary of the status of the Medical RFP.  He said the deadline for potential bidders to ask questions was March 7 and responses to the questions were anticipated to be posted on March 16.  The bidders’ proposals are due on April 25.  Contract awards are anticipated to be made in July.

  2. 2012 Revised Meeting Schedule –There was a brief discussion that the rate renewals would not be ready in July as planned.  In addition, only one rate renewal meeting will be held in August because of the short timeframe prior to open enrollment.  The rate renewal meeting will be held on August 16, 2012.  The July 18th meeting and the August 8th meeting will be cancelled.  The Commissioners requested that the rate renewal reports be given to them at least a week in advance of the meeting.  Commissioner Nowlan made a motion to approve the changes to the meeting schedule.  Chairperson Culliton seconded the motion. All voted in favor (4: 0: 0 Commissioner Czech was absent).

  3. Other:  There was a brief discussion on the Generics Advantage through Medco which provides copay waivers for Lexapro.  In addition, Medco has edits in place to cover preventive drugs.

    Horizon BCBSNJ provided a handout “Using Preventive Care for a Healthier Life” and it was discussed.  Commissioner Nowlan asked if Accountable Care Organizations (ACO) were being utilized in New Jersey.  A discussion ensued concerning Patient Centered Medical Homes which are similar to ACOs.  Dr. Wolinsky, Medical Director, Horizon BCBSNJ, provided a considerable amount of information and suggested having a separate presentation on these topics.  Chairman Culliton said a special Commission meeting would need to be held in order for the Commission to meet.  Cheryl Eagan, Horizon BCBSNJ, will draft an agenda for the special meeting.

The following cases, due to HIPAA regulations, are heard in closed session. Commissioner Czech arrived in time to hear the following cases.

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

Case# SH031201 (Member Present) - This Horizon NJ DIRECT15 appeal concerned the denial of Pre-certification for Intra-Articular Cervical Facet Injections.   The member gave an overview of the appeal.  She said she received a second opinion from another doctor which agreed with her that the injections were necessary and not investigational.  She stated her condition affects her daily living including sleeping.  She also stated a nerve block will not correct the problem; she wants to receive the correct treatment for her condition.  Dr. Wolinsky, Medical Director, Horizon BCBSNJ, presented an overview of the case and also explained Horizon BCBSNJ’s policy which considers these injections investigational.  Commissioner Czech made a motion to deny the appeal because the injections are considered investigational.  Chairperson Culliton seconded the motion and all voted in favor.

Case# SH031202 (Member Present) - This Horizon NJ DIRECT15 appeal concerned the denial of a request to receive the in-network level of benefits from an out-of-network provider and proposed biomedical testing.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  Commissioner Burdge seconded the motion and all voted in favor.  Upon return from Executive Session, Chairperson Culliton asked the member if her husband knew she was appearing before the Commission on behalf of their minor child and the member answered yes.  The member gave an overview of the appeal on behalf of her son who has a PDD-NOS diagnosis as well as eczema.  She explained the out-of-network provider is performing services and providing information to her that are not available in-network.  Therefore, she would like an exception to have this provider available to her son as if he were in-network.  Dr. Wolinsky, Medical Director, Horizon BCBSNJ, presented an overview of the case and stated that the physician is practicing outside of the accepted treatment for autism.  He said the standard approach is ABA therapy.  He also stated there are in-network physicians available to treat the child’s medical conditions.  In addition, he suggested a Horizon pediatric case manager may be of assistance to the member.  Commissioner Czech made a motion to deny the proposed biomedical testing as investigational/experimental and to deny the request to receive the in-network level of benefits for an out-of-network provider because the treatment is not consistent with the generally, accepted standard of medical practice for the child’s diagnosis.  Chairperson Culliton seconded the motion and all voted in favor.

Case# SH031203 - Final Administrative Determination (FAD) – Chairperson Culliton made a motion to approve the FAD draft concerning the denial of benefits for chartered air transportation.  Commissioner Czech seconded the motion.  All voted in favor.

Case# SH031204 - Chairperson Culliton made a motion to adopt the initial decision of the Office of Administrative Law (OAL) rendered on February 9, 2012 before ALJ McGee concerning an ineligible provider.  Commissioner Czech seconded the motion.  All voted in favor.

Chairperson Culliton made a motion to go into Executive Session under Resolution B to hear workers’ compensation settlement proposals.  Commissioner Nowlan seconded the motion and all voted in favor.  Upon return from Executive Session, Chairperson Culliton made a motion to accept each of the three workers’ compensation settlement proposals.  Commissioner Nowlan seconded the motion and all voted in favor.

There being no further appeals or business, a motion was made to return to open session and to adjourn by Commissioner Burdge and seconded by Commissioner Nowlan. All voted in favor.
The State Health Benefits Commission meeting was adjourned at 12:37 PM.

  Respectfully submitted,
 

 

 

  Jean M. Williamson, CEBS
Acting Secretary
School Employees’ Health Benefits Commission

Meeting No. 523
Minutes
May 9, 2012
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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on April 10, 2012.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, May 9, 2012 at 10:10 AM.  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, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Robert M Czech, Chair, Civil Service Commission
Dudley Burdge, Representative for Local Government Employees (via telephone:  1st half hour)
Patrick Nowlan, Representative for State Government Employees (via telephone)

ALSO PRESENT: 

Diane Weeden, Deputy Attorney General
David Pointer, Assistant Director, Health Benefits
Jean Williamson, Acting Secretary
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ)
Dave Perry, Horizon BCBSNJ
Sue Rizzni, Horizon BCBSNJ/Magellan
Dr. Lou Parrott, Medical Director, Horizon BCBSNJ/Magellan
Katherine Impellizzeri, Aetna Health Plan
Dr. Kay Eckroth, Medical Director Aetna Dental Expense Plan (via telephone)
Pat Buzbee, Aetna Dental Expense Plan (via telephone)

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

Meeting No. 522, March 14, 2012:Commissioner Czech made a motion to approve the minutes.  Chairperson Culliton seconded the motion.  All voted in favor.

ISSUES   

A. Carrier Updates:  David Pointer gave an update concerning Aetna’s network.  Cooper Hospital will terminate on June 1, 2012 and UMDNJ (Newark) Hospital terminated on May 1, 2012.

Other Issues: 

Mr. Pointer reported that six companies bid on the medical RFP by the deadline of April 25th.  The six bidders are:  Aetna, Amerihealth, Cigna, Horizon, Magna Care and United Healthcare.

During the first quarter, three external appeals went to an IRO from Horizon BCBSNJ.  One was denied and two were partially modified.  Commissioner Burdge asked if the Commission would be receiving a synopsis of the appeals from the IRO.  Mr. Pointer responded no, all we receive is the number of appeals and the decision.

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# SH051201 (Member Present) - This Aetna Dental appeal concerned the denial of a replacement crown within the five year waiting period. Chairperson Culliton recused herself from this appeal.  The member presented his case and supplied a letter from his dentist stating that the crown was replaced on June 9, 2011, two months before the five year period had elapsed.  The letter indicated there was decay that could have caused a need for a root canal and could possibly cause an infection if the crown was not replaced.  Dr. Kay Eckroth, Medical Director, and Pat Buzbee, Aetna Dental Expense Plan gave a summary of Aetna’s position and answered questions from the Commission.   Commissioner Czech made a motion to deny this appeal because the five year period for a replacement crown had not elapsed.  Commissioner Allen-Ware seconded the motion.  Motion failed (2: 2: 0, Commissioners Burdge and Nowlan voted nay).  Commissioner Czech made a motion to table this appeal until an alternate State Treasurer representative was present.  Commissioner Burdge seconded the motion and all voted in favor.

Case# SH051202 This Horizon NJ DIRECT10 appeal concerned the denial of a continued partial hospitalization request for treatment at Discovery Institute for Addictive Disorders.  Dr. Parrott, Medical Director, Magellan Health Services, presented an overview of the case and answered questions from the Commission.  Commissioner Czech made a motion to deny this appeal because the American Society of Addiction Medicine (ASAM) criteria for medical necessity had not been met.  Commissioner Nowlan seconded the motion and all voted in favor.

Commissioner Burdge made a motion to go into Executive Session under Resolution B to hear details of two settlement proposals.  Commissioner Nowlan seconded the motion and all voted in favor. 
Case# SH051203 Upon return from Executive Session, Chairperson Culliton made a motion to approve the settlement as detailed in a May 2, 2012 memo from Thomas Hower, DAG to Jean Williamson.  Commissioner Nowlan seconded the motion and all voted in favor.

Case# SH051204 Chairperson Culliton made a motion to authorize the workers’ compensation settlement as recommended in John Fedorko’s memo of February 24, 2012.  Commissioner Nowlan seconded the motion and all voted in favor.

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

The State Health Benefits Commission meeting was adjourned at 11:00 AM.

  Respectfully submitted,
 

 

 

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

 

Meeting No. 524
Minutes
June 13, 2012
10:00 AM
Joint Meeting of the
State Health Benefits Commission (Regularly scheduled meeting) and the
Special School Employees’ Health Benefits Commission

Adequate notice of this meeting has been provided through the annual notice of the schedule of regular meetings of the State Health Benefits Commission filed with and prominently posted in the offices of the Secretary of State.  The 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on April 10, 2012.  In addition, notice of the special joint meeting of the School Employees’ Health Benefits Commission with the regularly scheduled State Health Benefits Commission of June 13, 2012 was provided to the Secretary of State, Star Ledger and the Trenton Times on May 15, 2012.

The Joint meeting of the State Health Benefits Commission (SHBC) and the School Employees’ Health Benefits Commission (SEHBC) of New Jersey was called to order on Wednesday, June 13, 2012 at 10:12 AM.  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

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

State Health Benefits Commission (SHBC)

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Robert M Czech, Chair, Civil Service Commission (Left at 11:53)
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees (Arrived After Roll Call)

School Employees’ Health Benefits Commission (SEHBC)

Joseph Del Grosso, Commissioner (via telephone)
Thomas Gallagher, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Cynthia Jahn, Commissioner (via telephone)
Kevin Kelleher, Commissioner
Wendell Steinhauer, Commissioner

ABSENT:

Robert Peden, SEHBC, representing State Treasurer Andrew P. Sidamon-Eristoff
David Earling, Chairman, SEHBC

ALSO PRESENT: 

Jean Pierce, School Employees’ Health Benefits Program Plan Design Committee
Diane Weeden, Deputy Attorney General
Jean Williamson, Acting Secretary
Barb Scherer, State Health Benefits Program
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ)
Linda Schwimmer, Director of Strategic Relationships & External Affairs, Horizon Healthcare Innovations
Dr. Steven Peskin, MD, MBA, FACP, Senior Medical Director of Clinical Innovations, Horizon Healthcare Innovations

Issues:  Patient Centered Medical Homes and Accountable Care Organizations

A presentation was given by Dave Perry, Horizon Blue Cross Blue Shield of New Jersey (Horizon) and Dr. Steven Peskin and Linda Schwimmer from Horizon Healthcare Innovations on Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACO).  Horizon distributed a handout to the Commissions concerning transforming health care delivery in New Jersey with PCMHs and ACOs.  Mr. Perry gave an overview of the PCMH and ACO health care models. Afterward, he introduced Dr. Steven Peskin and Linda Schwimmer who discussed how the PCMH and ACO models afford better care at lower costs.   Currently, there are over 21,700 members in PCMHs and the number is expected to grow to 180,000 by January 2013. The presentation was interactive and the Commissioners were able to ask and receive answers to their questions.  The Joint Meeting of the State Health Benefits Commission and the School Employees’ Health Benefits Commission was adjourned at 12:10 PM. 

  Respectfully submitted,
 

 

 

  Jean M. Williamson, CEBS
Acting Secretary
State Health Benefits Commission and
School Employees’ Health Benefits Commission

Meeting No. 525
Minutes
July 11, 2012
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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on April 10, 2012.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, July 11, 2012 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.

ROLL CALL

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
John Megariotis, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff  (SH071201 appeal only)
Robert M Czech, Chair, Civil Service Commission
Sylvia Allen-Ware, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees (arrived shortly after roll call at 1:13 PM and departed the meeting at 2:40 PM.)

ABSENT

Patrick Nowlan, Representative for State Government Employees

ALSO PRESENT: 

Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pension and Benefits (Onsite Clinic Presentation only)
David Pointer, Assistant Director, Health Benefits
Jean Williamson, Acting Secretary
Kierney Corliss, State Health Benefits Program
Barbara Scherer, State Health Benefits Program
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ)
Rosemary Middlebrook, Horizon BCBSNJ
Dave Perry, Horizon BCBSNJ
Dr. Steven Wolinsky, Medical Director, Horizon BCBSNJ
Katherine Impellizzeri, Aetna Health Plan
Jennifer Pruchnic, Aetna Health Plan
Michael North, Aetna Health Plan
Dr. Kay Eckroth, Medical Director Aetna Dental Expense Plan (via telephone)
Patricia Buzbee, Aetna Dental Expense Plan (via telephone)
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. 523, May 9, 2012:Commissioner Czech made a motion to approve the minutes.  Chairperson Culliton seconded the motion.  All voted in favor.

Meeting No. 524, June 13, 2012:Commissioner Czech made a motion to approve the minutes.  Chairperson Culliton seconded the motion.  All voted in favor.

Issues

A. Carrier Updates:  David Pointer gave an update concerning Aetna’s network.  Contract negotiations with Cooper Hospital University Medical Center and Meridian Health have been extended to September 1, 2012.  Summit Anesthesia Associates has a new three year agreement and has rejoined Aetna’s network effective July 1, 2012.

B. Mr. Pointer advised the Commission the Local Employers 2012 year-to-date Report for New Local Government Employers and Termination of Local Government Employers was handed out at the beginning of the meeting. There were 22 new employers who joined the program and seven employers who terminated from the program.  There was no discussion.

C. Mr. Pointer gave a brief overview of the performance standards report memo which includes the ratings on the performance standards of each of the carriers.  The report is distributed annually.

D. A presentation was given by Dave Perry, Horizon BCBSNJ on Worksite Medical Homes. Horizon BCBSNJ distributed a handout to the Commission that explained how Worksite Medical Homes combine the benefits of a Patient Centered Medical Home (PCMH) with the convenience and cost benefits of the work site health center.  The presentation was interactive and the Commissioners were able to ask and receive answers to their questions.   

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 Czech seconded the motion.  All voted in favor.

Case# SH071201– (Member Present) - This tabled Aetna Dental appeal concerned the denial of a replacement crown within the five year waiting period.  Chairperson Culliton recused herself from this appeal. John Megariotis was present to represent the State Treasurer. The member presented his case and supplied two pages of dental records covering the period of December 29, 2008 through November 2, 2011.  A copy of the dental records was faxed to Dr. Kay Eckroth, Medical Director, and Patricia Buzbee, Aetna Dental Expense Plan.  Dr. Eckroth acknowledged receipt of the fax and stated that she reviewed the records. She noted there was nothing in the new document that was different than what was reviewed previously.  Ms. Buzbee read the provisions of the plan concerning replacing a crown and stated the five year period is a contract provision, not an average time period for crown replacement. Commissioner Czech made a motion to deny this appeal based on plan provisions.  Chairperson Megariotis seconded the motion.  Motion passed (3: 1: 0, Commissioners Burdge voted nay).
 
Chairperson Megariotis exited the meeting and Chairperson Culliton returned for the remainder of the meeting.   

Case# SH071202– (Member Present via telephone) - This Express Scripts/Medco appeal concerns a request to fill a prescription for Propecia, a medication indicated for androgenetic alopecia (male pattern baldness) which is a medication used for cosmetic purposes and therefore ineligible for coverage under the prescription drug plan.  The member provided a brief overview of his appeal. He is not taking Propecia for cosmetic reasons, but to treat an enlarged prostate. The underlying ingredient, finasteride, is the same as the drug Proscar, which is FDA approved to treat an enlarged prostate. The difference is that Propecia is 1mg whereas Proscar is 5mg.  Bhavesh B. Modi, RPh, Express Scripts/Medco, explained that because Propecia is only FDA approved to treat male pattern baldness, it is not an eligible drug under plan provisions.  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 deny this appeal based on plan provisions that exclude cosmetic drugs.  Commissioner Czech seconded the motion.  Motion passed (3: 1: 0, Commissioner Burdge voted nay). 

Commissioner Burdge exited the meeting at 2:40 PM.

Case# SH071203 – (Member Present) - This Horizon NJ DIRECT15 appeal concerns a denial of benefits for expenses for a stay at The Watermark at Logan Square from May 6, 2010 to May 10, 2010.  The member provided the Commission with a copy of a letter dated July 5, 2012 to Dr. Wolinsky, Medical Director, Horizon, from his physician, Dr. Carol L Shields.  The member provided a brief history of the appeal.  Wendy Burns, Horizon, presented an overview of the case and answered questions from the Commission.  A discussion took place between the member, the Commission and Horizon’s representatives.  Chairperson Culliton made a motion to deny this appeal because there was no precertification received and the facility is not eligible for reimbursement under the plan. Commissioner Allen-Ware seconded the motion.  All voted in favor.

Case# SH071204 – (Member Present with Attorney) – This Division appeal concerns the denial for enrollment in the Retired State Health Benefits Program.  Commissioner Czech made a motion to deny this appeal because the member had a break in coverage between termination of employment and retirement.  Chairperson Culliton seconded the motion.  All voted in favor.

Case# SH071205 - The Member made a request that the denial of precertification for an in-network level of benefits for an out-of-network provider be forwarded to the Office of Administrative Law (OAL) for a hearing.  Chairperson Culliton made a motion to grant the OAL hearing and issue a letter to the member clarifying that there are two issues present: 1) the in-network level of benefits for an out-of-network provider and 2) the services being considered experimental and investigational.  Commissioner Czech seconded the motion. All voted in favor.

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

The State Health Benefits Commission meeting was adjourned at 3:38 PM.

  Respectfully submitted,
 

 

 

  Jean M. Williamson, CEBS
Acting Secretary
School Employees’ Health Benefits Commission

 


Meeting No. 526
Minutes
August 16, 2012
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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on May 15, 2012.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Thursday, August 16, 2012 at 1:13 PM.  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
Neil Vance, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Robert M Czech, Chair, Civil Service Commission
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

ABSENT

None

ALSO PRESENT: 

Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
David Pointer, Assistant Director, Health Benefits
Kierney Corliss, Acting Secretary
Jean Williamson, State Health Benefits Program
Barbara Scherer, State Health Benefits Program
Edward W. Fox, Aon-Hewitt Consultants
Susan Marsh, Aon-Hewitt Consultants
James Christ, Aon-Hewitt Consultants
Katherine Impellizzeri, Aetna Health Plan
Katherine Mulligan, Aetna Health Plan
Mike North, Aetna Health Plan

David Pointer announced the results of the Medical Request for Proposal (RFP). Contracts were awarded to Horizon Blue Cross and Blue Shield of New Jersey (Horizon) and Aetna for the PPO, HMO, and High Deductible plan designs. The following benefit plans will be offered in Plan Year 2013: NJ DIRECT1O, Aetna PPO1O, NJ DIRECT15, Aetna PPO15, NJ DIRECT1525, Aetna PPO1525, NJ DIRECT2030, Aetna PPO2030, legacy Horizon HMO, legacy Aetna HMO, Horizon HMO1525, Aetna HMO 1525, Horizon HMO2030, Aetna HMO2030, Horizon HD4000, Aetna HD4000, Horizon HD1500 and Aetna HD1500. There is a ten business day protest period which will end August 28, 2012.    
 
ISSUES

Aetna Dental Expense Network - Aetna representatives were present to answer questions previously submitted by Commissioners Burdge and Nowlan. Katherine Impellizzeri, the Aetna Account Manager, introduced herself and the Aetna team:  Mike North, Katherine Mulligan and Alan Eisenberg.

Ms. Impellizzeri provided the following data for claims paid In-network and Out-of-Network from January 1, 2012 through June 30, 2012 (all figures are approximate):

 

Total claims paid

In-Network

Out-of-Network

Active

$23 million

$10 million

$13 million

Retired

$2.5 million

$1 million

$1.5 million

When the retired group moved from a passive plan to a true PPO plan it resulted in an eleven percent savings.  Preliminary results for the active group show a seven percent reduction in claim dollars paid for the first six months of 2012 when compared to the first six months of 2011.
                 
The following represents the number of unique in-network dentists in the plan over the past three years in New Jersey, Pennsylvania and New York:

 

NJ

PA

NY

2009

3,389

3,595

5,937

2010

3,463

3,911

6,016

2011

3,594

4,071

6,060

Below shows the number of dentists who joined and terminated in 2011 from the plan for NJ, PA and NY:

 

NJ

PA

NY

Joined

186

205

320

Terminated

115

171

278

The New Jersey network averages three to four percent growth each year. Ms. Mulligan said Aetna sets goals for network growth each year. Each year Aetna has exceeded their goal and is confident it will succeed again this year. 

Rate Renewal Recommendations for plan year 2013 - Edward Fox, Aon-Hewitt Consulting, introduced himself and the Aon-Hewitt team: Susan Marsh and James Christ. Mr. Fox gave an overview of the 2013 proposed rates. Ms. Marsh reviewed the 2013 Rate Renewal Recommendations for Medical/Rx for the Active Employees and Retirees of the State Group, Active Employees and Retirees of the Local Government Group and the Dental Plans of the State Health Benefits Program (SHBP).

The following is a summary from Aon-Hewitt Consulting:       

Recommended Plan Year 2013
Medical/Rx Rate Renewal Recommendation
for Active Employees and Retirees
of the State Group

  • For Plan Year 2013, Aon Hewitt is recommending State Group premium rate changes of 6.9% for Active Employees, 15.2% for Early Retirees, and 9.0% for Medicare Retirees.  In the aggregate, the recommended rate actions represent an overall increase for the State Group of 8.1%.

                                                                                                          Early                     Medicare
                                                           Employees                      Retirees                     Retirees

Medical                                          6.9%                       16.4%                        10.1%
Prescription Drug                             7.0%                       11.0%                         8.0%
Total                                             6.9%                       15.2%                         9.0%

Attachment A provides additional details on the components of these increases.

  • The larger increases for Early Retirees are due to a decrease in ERRP credits for Plan Year 2013 as compared to Plan Year 2012.
  • This recommended rate renewal assumes:
    • The Retiree Rx copays and Out-Of-Pocket Maximum for SHBP PPOs and HMOs will be frozen at the Plan Year 2012 levels;

    • A new benefit landscape for Plan Year 2013, resulting from the recently-concluded Medical RFP, with Horizon and Aetna providing the PPO, HMO, and HDHP options and Express Scripts (formerly known as Medco) continuing as the PBM;

    • The revised Employee contribution schedule that went into effect on July 1, 2011 had little impact on Employee enrollment for Plan Year 2012, since the current 1.5% of salary floor exceeded contributions generated by the new schedule for all Employees in the first year of the new schedule.  In fact, only about 300 Employees/Retirees enrolled in the new plan options for Plan Year 2012.  In the second year of the Chapter 78 contribution schedule (which began July 1, 2012), many Employees experienced increased contributions and will experience another increase in contributions on July 1, 2013.  As a result, we are projecting a significant increase in the percentage of Employees enrolling in the “new” plan options for Plan Year 2013, although the actual numbers of Employees/Retirees enrolled will still be a very small percentage of overall State Group enrollment in the SHBP.  Additionally, the Plan Year 2013 renewal projections assume that a small number of Employees will drop SHBP coverage in response to the increased Employee contributions.

    • 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 Federal Health Care Reform, the SHBP will be impacted by:

        • Coverage of Dependent Children to Age 26 (which was effective January 1, 2011 and increases costs $12 million);

        • Elimination of Benefit Maximums (which increases costs $7 million);

        • Early Retiree Reinsurance Program (which reduces Early Retiree claim costs by $7 million);

        • Coverage of certain additional preventive care services for women (which increases costs by $7 million), and

        • The Comparative Effectiveness Fee of $2 per member per year in Plan Year 2013 (which increases costs by $0.6 million).

        The renewal report summarizes a number of benefit plan design changes, each of which could further reduce plan costs.

    • Plan Year 2013 State Employee enrollment will remain at the same level as Plan Year 2012, while State Retiree enrollment will increase about 5%.

  • Aggregate differences in the rate changes for different benefit plans and coverage tiers, and between Actives and Retirees, reflect the impact of:

    • Medicare Retiree medical trends have been below industry norms for the past few years and we are projecting that the low trend levels will continue into Plan Years 2012 and 2013.

    • HMO claim trends had averaged about 3% higher than Horizon trends for a number of years.  However, they appear to be moderating and we are therefore projecting that HMOs will trend at a rate less than the PPO plans in Plan Year 2013.

    • Projected Retiree costs have been reduced $23 million due to projected savings from the change to EGWP+Wrap and from the Early Retiree Reinsurance Program.
    • For Active premiums, increases vary by coverage tier, since the differences in costs by coverage tier have been revised based on actual SHBP experience.  Specifically, the Employee+Child(ren) coverage tier will receive approximately an additional 5% increase for Plan Year 2013, which will change its cost relative to Single coverage from 148% to 156%.  This adjustment will make the Employee+Child(ren) rate more consistent with actual experience, which shows that the Child(ren) coverage claim costs are 80% of the cost of Employee coverage, an increase from the pre-Health Care Reform level of 72%.

  • Factors contributing to the recommended rate actions include:

    • 8.3% average trend increase from Plan Year 2012 to Plan Year 2013, which is lower than industry trends;

    • Higher trends for Early Retirees, which are partially offset by the Early Retiree Reinsurance credit, and

    • EGWP+Wrap savings which reduce Medicare Retiree projected costs.

  • Plan Year 2013 projected costs for the State Group are $2.13 billion ($1.58 billion for Actives and $.55 billion for Retirees).  Plan Year 2013 renewal premiums are set to match the projected $2.13 billion costs, so there is no loss or gain projected for the State Group for Plan Year 2013.

Attachment A
SHBP State Employee Group
Plan Year 2013 Rate Renewal Recommendations

two

Recommended Plan Year 2013
Medical/Rx Rate Renewal Recommendation
for Active Employees and Retirees
of the Local Government Group

  • For Plan Year 2013, Aon Hewitt is recommending Local Government premium rate changes of 7.9% for Active Employees, 15.2% for Early Retirees, and 9.1% for Medicare Retirees.  In the aggregate, the recommended rate actions represent an overall increase for the Local Government Group of 9.1%.

                                                                                                                                       Early                     Medicare
                                                                                          Employees                      Retirees                     Retirees

Medical                                                                   8.1%                        15.3%                      9.2%
Prescription Drug                                                      7.0%                         14.9%                     9.0%
Total                                                                      7.9%                         15.2%                     9.1%

Attachment A provides additional details on the components of these increases.

  • The larger increases for Early Retirees are due to a decrease in the ERRP credit for Plan Year 2013, as compared to Plan Year 2012.

  • This recommended rate renewal assumes:

    • The Retiree Rx copays and Out-Of-Pocket Maximum for SHBP PPOs and HMOs will be frozen at the Plan Year 2012 levels;

    • A new benefit landscape for Plan Year 2013, resulting from the recently-concluded Medical RFP, with Horizon and Aetna providing the PPO, HMO, and HDHP options and Express Scripts (formerly known as Medco) continuing as the PBM;

    • The revised Employee contribution schedule that went into effect in 2011 for some employees had little impact on Employee enrollment for the Plan Year 2012, since the 1.5% of salary floor exceeded contributions generated by the new schedule for all Employees in the first year of the new schedule.  In fact, only about 200 Employees/Retirees enrolled in the new plan options for Plan Year 2012.  In the second year of the Chapter 78 contribution schedule, many Employees will experience increased contributions and will experience another increase in contributions in the third year of the schedule’s phase-in.  As a result, we are projecting a significant increase in the percentage of employees enrolling in the “new” plan options for Plan Year 2013, although the actual numbers will still be a very small percentage of the overall SHBP enrollment.  Additionally, the Plan Year 2013 renewal projections assume that a small number of Employees will drop coverage, which is more than offset by new Local Government Employers joining the SHBP.

    • 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 was effective January 1, 2011 and increases costs $6 million);

      • Elimination of Benefit Maximums (which increases costs $4 million);

      • Early Retiree Reinsurance Program (which reduces Early Retiree claim costs by $5 million);

      • Coverage of certain additional preventive care services for women (which increases costs by $4 million), and

      • The Comparative Effectiveness Fee of $2 per member per year in Plan Year 2013 (which increases costs by $0.4 million)

        The renewal report summarizes a number of benefit plan design changes, each of which could further reduce plan costs.

    • Local Government Active Employee and Retiree enrollment will increase 13% in Plan Year 2013.

  • Aggregate differences in the rate changes for different benefit plans and coverage tiers, and between Actives and Retirees, reflect the impact of:
    • Medicare Retiree medical trends have been below industry norms for the past few years and we are projecting that the low trend levels will continue into Plan Years 2012 and 2013.

    • HMO claim trends had averaged about 3% higher than Horizon trends for a number of years.  However, they appear to be moderating and we are therefore projecting that HMOs will trend at a rate less than the PPO plans in Plan Year 2013.

    • Projected Retiree costs have been reduced $13 million due to projected savings from the change to EGWP+Wrap and from the Early Retiree Reinsurance Program.

    • For Active premiums, increases vary by coverage tier, since the differences in costs by coverage tier have been revised based on actual SHBP experience.  Specifically, the Employee + Child(ren) coverage tier will receive approximately an additional 5% increase for Plan Year 2013, which will change its cost relative to Single coverage from 148% to 156%.  This adjustment will make the Employee + Child(ren) rate more consistent with actual experience, which shows that Child(ren) coverage claim costs are 80% of the cost of Employee coverage, an increase from the pre-Health Care Reform level of 72%.

  • Factors contributing to the recommended rate actions include:

    • 8.2% average trend increase from Plan Year 2012 to Plan Year 2013, which is lower than industry norms;

    • Higher trends for Early Retirees, which are partially offset by the Early Retiree Reinsurance credit;
       
    • EGWP+Wrap savings which reduce Medicare Retiree projected costs, and

    • 2.0% margin added to the renewal rates, because the Claim Stabilization Reserve is below the recommended level of 2 months of Plan costs.

  • Plan Year 2013 projected costs for the Local Government Group are 1.278 billion ($885 million for Actives and $393 million for Retirees).  Plan Year 2013 renewal premiums are set to generate a gain of $25 million, which will be added to the Claim Stabilization Reserve to offset losses from Plan Year 2011 and bring the Claim Stabilization Reserve closer to the recommended level of 2.0 months of Plan costs. Attachment A

SHBP Local Government Employer Group
Plan Year 2013 Rate Renewal Recommendations

four

 

Recommended Dental Plans Rate Renewal
for Plan Year 2013

  • For the SHBP Dental Plans (Employee and Retiree Dental Expense Plans and Employee DPOs) for Plan Year 2013, Aon Hewitt recommends the following premium rate adjustments, which – in the aggregate – represent a 1.0% overall increase in program costs:

Dental Expense Plans

Actives                                      2.0%
Retirees                                      0.0%

The overall increase for the Dental Expense Plans is 1.2%

Dental Plan Organizations (DPOs)
Aetna                                                  1.4%
Benecare                                              1.5%
Cigna                                                   1.5%
Community                                            1.5%
Healthplex                                            -4.0%
Horizon                                                -0.6%
The overall increase for the DPOs is 0.8%.

  • For the Dental Expense Plans, this favorable rate action reflects a continuation of favorable SHBP Dental Expense Plan trends, which have averaged about 5% lower than industry norms since Plan Year 2003.
  • All 6 of the DPOs currently have a Value Ratio greater than 1.00, with the DPO average Value Ratio at 1.13.  4 DPOs requested rate increases ranging from a low of 1.4% to a high of 5.0%.  2 DPOs requested rate decreases (.6% and 4.0%).
  • For the DPOs that requested an increase, Aon Hewitt is recommending that the increase be capped at the lesser of the average DPO requested increase of 1.5% and the amount that would bring their Value Ratio to 1.00.
  • For DPOs requesting a decrease, Aon Hewitt recommends that those requests be honored.
  • This recommended rate renewal assumes no changes in benefits and no changes in DPO vendors. 
  • Aon Hewitt is projecting total Claim Stabilization Reserves of $12 million for Retirees at the end of Plan Year 2013, assuming that the Plan is fully funded.
  • Aon Hewitt is projecting that Employee Dental Expense enrollment will have minimal changes between Plan Years 2012 and 2013.  As a result, Plan Year 2013 projected Active Employee enrollment is:  60,700 Employees enrolled in the Dental Expense Plan and 37,100 Employees enrolled in the DPO plans.  Retiree Dental Expense Plan enrollment is expected to increase 10%, to 79,100 for Plan Year 2013, consistent with prior years.
  • Plan Year 2013 projected costs for the SHBP Dental Plans are $128 million, with $54.8 million attributable to the Employee Dental Expense Plan, $54.1 million attributable to the Retiree Dental Expense Plan, and $19.1 million attributable to the DPOs.

Settlement Proposals

Chairperson Culliton made a motion to go into Executive Session under Resolution B to hear Workers’ Compensation settlement proposals.  Commissioner Nowlan seconded the motion and all voted in favor.  Upon return from Closed Session, Chairperson Culliton made a motion to settle as written for settlement proposal SH081201. Commissioner Nowlan seconded the motion. All voted in favor. Chairperson Culliton made a motion to table settlement proposal SH081202 to allow the Deputy Attorney General’s office to research information pertaining to the case.  Commissioner Burdge seconded the motion.  All voted in favor. 

There being no further business, a motion was made to adjourn by Chairperson Culliton and seconded by Commissioner Vance. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 2:49 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

Meeting No. 527
Minutes
August 21, 2012
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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on August 16, 2012.
.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Tuesday, August 21, 2012 at 1:47 PM.  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
Neil Vance, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Robert M Czech, Chair, Civil Service Commission (via telephone)
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

ABSENT

None

ALSO PRESENT: 

Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Jean Williamson, Acting Assistant Chief, Health Benefits Program
Kierney Corliss, Acting Secretary
Barbara Scherer, State Health Benefits Program
Edward W. Fox, Aon Hewitt Consultants
Susan Marsh, Aon Hewitt Consultants
James Christ, Aon Hewitt Consultants

Jean Williamson announced the meeting was postponed to 1:45 PM to allow Commissioner Czech’s attendance. 
 
ISSUES

Rate Renewal Recommendations for plan year 2013 For Approval – Kierney Corliss said the Commissioners’ questions since the last meeting were answered by Aon Hewitt. Replies to the questions had been distributed to the Commissioners prior to the meeting. Aon Hewitt Consultants Edward Fox, Susan Marsh and James Christ were present to answer any additional questions.  Ms. Marsh advised the Commission that the premium for Aetna’s PPO is 1% higher than Horizon’s PPO because there are slight differences in administrative fees, network discounts, and medical management of claims. The plan benefits are similar. David Pointer confirmed that a plan comparison chart will be available for members.  Commissioner Nowlan noted that in previous years the HMOs have trended higher than NJ DIRECT. He expressed concern that NJ DIRECT has had a slight surplus in recent years and was therefore subsidizing the other plans. Commissioner Nowlan made a motion to table the vote until Aon Hewitt could review lowering the PPO increases for State Active employees to see how it would impact the rates.  Commissioner Burdge seconded the motion.  Mr. Christ noted that the gains were only one half of one percent. Ms. Marsh pointed out that HMO trends have come down and although there is no loss or gain projected for the group as a whole for 2013, NJ DIRECT15 is projected at a .02% loss. Therefore reviewing the rates would not justify any decreases for NJ DIRECT15.

Jean Williamson announced there was an issue with the conference call and requested a break for a moment. 

Upon return from the break, Commissioner Nowlan repeated his motion to table the vote.  Commissioner Burdge seconded the motion again.  The motion failed (Vote 2: 3: 0; Chairperson Culliton and Commissioners Vance and Czech voted nay).

Commissioner Czech made a motion to approve the rates as presented.  Commissioner Vance seconded the motion.  Commissioner Burdge offered an amendment that the HDHP rates be calculated in the same risk pool as the other plans. He stated that otherwise, the HDHP plan design must go back to the Plan Design Committee for approval.  Commissioner Nowlan seconded the motion.  A discussion began concerning Commissioner Czech’s motion and the voting procedure for the amendment offered by Commissioner Burdge.  Commissioner Czech was asked whether he accepted the offered amendment.  Commissioner Czech declined.  Chairperson Culliton made a motion to go into Executive Session under Resolution B.  All voted in favor.  Upon return from Executive Session the Commission voted on Commissioner Burdge’s amendment.  Motion failed (Vote 2: 3: 0; Chairperson Culliton and Commissioners Vance and Czech voted nay).  

Commissioner Czech repeated his motion to adopt the rate increases as recommended by Aon Hewitt.  Commissioner Vance seconded the motion again. Commissioner Burdge offered another amendment to set the relative ratio of the parent/child tier at 1.5 to align with the 2.5 ratio for the family tier.  Commissioner Nowlan seconded the motion.  The amendment to change the parent/child ratio was approved (Vote 3; 2; 0, Commissioner Czech and Chairperson Culliton voted nay). 

A vote was taken on Commissioner Czech’s original motion to accept the rates as presented by Aon Hewitt.  The motion was approved. (Vote 4: 1: 0, Commissioner Nowlan voted nay). 

There being no further business, a motion was made to adjourn by Chairperson Culliton and seconded by Commissioner Nowlan. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 2:39 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission


Meeting No. 528
Minutes
September 12, 2012
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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on August 16, 2012.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, September 12, 2012 at 10:06 AM.  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 (with the exception of case SH091203)
John Megariotis, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff (case SH091203 only)
Neil Vance, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance (for rate discussions only)
Sylvia Allen-Ware, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance (except for rate discussions)
Robert M Czech, Chair, Civil Service Commission
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees (via teleconference, left at 12:23)

ALSO PRESENT: 

Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
David Pointer, Assistant Director, New Jersey Public Employees’ Health Benefits Programs
Jean Williamson, Acting Assistant Chief, Health Benefits Program
Kierney Corliss, Acting Secretary
Barbara Scherer, State Health Benefits Program
Susan Marsh, Aon Hewitt Consultants (via teleconference)
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Rosemary Middlebrook, Horizon Blue Cross Blue Shield of New Jersey
Dr. Steven Wolinsky, Medical Director, Horizon Blue Cross Blue Shield of New Jersey
Katherine Impellizzeri, Aetna
Jennifer Moyer, Aetna
Ian Carrucci, Aetna

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

Meeting No. 525, July 11, 2012: Chairperson Culliton made a motion to approve the minutes. Commissioner Burdge seconded the motion. Motion passed (4: 0: 1 Commissioner Nowlan abstained).

ISSUES

  1. Carrier Updates: David Pointer provided an update on contract negotiations between Aetna and Meridian Health. The termination date was extended to October 15, 2012 while negotiations continue. Mr. Pointer also advised the Commission that Cooper University Hospital will remain in the Aetna Network.  
  1. COBRA Vision Rates Plan Year 2013: Commissioner Allen-Ware recused herself and was replaced by Neil Vance. Susan Marsh from Aon Hewitt explained that a one percent claim adjustment is included so that the rates are based on claims that are incurred during the plan year rather than paid. Chairperson Culliton made a motion to approve the 2013 COBRA Vision rates as recommended by Aon Hewitt. Commissioner Czech seconded the motion. All voted in favor.
  1. Risk Pooling for the High Deductible Health Plans: Mr. Pointer advised the Commission that the State Health Benefits Plan Design Committee (Committee) met on September 10, 2012 and had asked that the Commission reconsider the risk-pooling for the High Deductible Health Plans (HDHP). The Commission was being asked to review the minutes from the October 5, 2011 Committee meeting in which the Committee had resolved that “no plan shall be offered for any plan year commencing plan year 2012 through plan year 2015 without further Committee action if the participants in such a plan are, by action of the State Health Benefits Commission, placed in a risk pool separate from the risk pools for participants in a plan that existed in plan year 2011.” The Committee was divided on whether the rates developed by Aon Hewitt had met the responsibility to put all individuals in the same risk pool. Chairperson Culliton made a motion to go into Executive Session under Resolution B to seek advice from the Deputy Attorney General. Commissioner Vance seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Burdge made a motion to reconsider the rates for the High Deductible Health Plans in light of the recommendation from the Plan Design Committee. Commissioner Nowlan seconded the motion. All voted in favor.

Chairperson Culliton asked Susan Marsh to address the recommendations of the Plan Design Committee. Ms. Marsh explained that when the rates were developed, the experience of all Horizon members, including the HDHP members, was pooled to develop a PPO increase. The experience of all Aetna and Cigna members, including the HDHP members, was pooled to develop an HMO increase. Then Aon Hewitt recommended that the HDHP rates be frozen because the enrollment in those plans is very low. She said that freezing the rates for the HDHP plans did not cause a greater increase for the other plans.

Commissioner Burdge expressed concern that the Plan Design Committee’s recommendation was not being followed. Commissioner Vance explained that a different rate increase for the HD plans did not mean they were placed in a separate risk pool. Chairperson Culliton pointed out that the Commission, not the Plan Design Committee, is responsible for setting the rates.

Commissioner Czech made a motion not to change the rates of the High Deductible Health Plans. Commissioner Vance seconded the motion. Motion passed (3: 2: 0, Commissioners Burdge and Nowlan voted nay).

Chairperson Culliton made a motion to go into Executive Session under Resolution B to receive advice from the Deputy Attorney General regarding retiree prescription copayments. Commissioner Czech seconded the motion. Motion passed (4: 0: 1, Commissioner Nowlan voted nay).

Upon return from Executive Session, Commissioner Vance was replaced by Commissioner Allen-Ware for the remainder of the meeting.

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 Burdge seconded the motion. All voted in favor.

Case #SH091203 – (Member Present with Attorney) Chairperson Culliton recused herself from this case and was replaced by John Megariotis. This Division appeal concerned the termination of retired health benefits for a member who did not enroll in Medicare B when eligible. The member stated that he retired on a disability retirement due to vision loss and was unable to read the application when he signed it, and was therefore unaware that he must enroll in Medicare B. Commissioner Burdge made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner Nowlan seconded the motion. All voted in favor.

Upon return from Executive Session, the Commission asked the member if he had enrolled in COBRA. The member said that he had enrolled but it is a financial hardship. He will not be eligible for Medicare B coverage until July 1, 2013.

Commissioner Burdge made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner Allen-Ware seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Burdge made a motion to table the case until the next meeting to allow the Deputy Attorney General to research some issues that had been raised. Commissioner Allen-Ware seconded the motion. All voted in favor.

Case #SH091204 – (Member Present) This Traditional Plan appeal concerned a denial of benefits for expenses for treatment of Lyme disease with intravenous antibiotics therapy. The precertification for the services was denied as not medically necessary on June 14, 2002 and the member subsequently started therapy on June 19, 2002. Dr. Steven Wolinsky, Medical Director, Horizon, explained that the precertification was denied due to the lack of medical records showing that the treatment was medically necessary. He said that upon the member’s appeal in 2007 the physician was contacted and the medical records were no longer available, even though medical records must legally be kept for seven years. Commissioner Burdge made a motion to deny the appeal. Chairperson Culliton seconded the motion. All voted in favor.

Case #SH091201 - These Aetna Dental appeals for a husband and wife concerned the amount of reimbursement for expenses for resin restorations on posterior teeth. Ian Carrucci from Aetna explained that the alternative benefit provision was applied. This provision states that reimbursement is to be based on the least expensive treatment for a particular condition, provided that the treatment meets acceptable dental standards. In these two instances, the least expensive clinically appropriate treatment was an amalgam filling. Chairperson Culliton made a motion to deny both of these appeals. Commissioner Burdge seconded the motion. Motion passed (4: 0: 0, Commissioner Nowlan was absent).

Case #SH091202- This Division appeal concerned a request to enroll the member’s disabled son, who was over the age of 26. Mr. Pointer explained that the son was removed from the coverage at the end of the calendar year in which he reached age 23, according to the dependent age requirements at that time. In a letter dated October 17, 2008, the member was notified that he had until January 31 of the following year to submit an application to continue coverage for a disabled dependent. No application was received by the Division. The member had the opportunity to enroll him on the coverage during Open Enrollment in October 2010, following the extension of to the dependent age limit to age 26. The Division did not receive an application at that time. Chairperson Culliton made a motion to deny enrollment. Commissioner Czech seconded the motion. . Motion passed (4: 0: 0, Commissioner Nowlan was absent).   

Chairperson Culliton made a motion to go into Executive Session in order to discuss a Settlement Proposal before the Commission. Commissioner Burdge seconded the motion. All voted in favor.

Case #SH091205- Upon return from Executive Session, Chairperson Culliton made a motion to approve the supplemental settlement proposal as described in the September 11, 2012 memo from Deputy Attorney General Thomas Hower to Acting Secretary Kierney Corliss. Commissioner Czech seconded the motion. . Motion passed (4: 0: 0, Commissioner Nowlan was absent).

 There being no further business, a motion to return to public session and adjourn was made by Chairperson Culliton and seconded by Commissioner Burdge. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 12:45 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission


Meeting No. 529
Minutes
September 21, 2012
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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on September 17, 2012.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Friday, September 21, 2012 at 1:08 PM.  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
Neil Vance, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance Robert M Czech, Chair, Civil Service Commission
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

ALSO PRESENT: 

Kellie Pushko, Deputy Attorney General
David Pointer, Assistant Director, New Jersey Public Employees’ Health Benefits Programs
Kierney Corliss, Acting Secretary
Barbara Scherer, State Health Benefits Program
Edward Fox, Aon Hewitt Consultants
James Christ, Aon Hewitt Consultants

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

ISSUES

  1. Reconsideration and Clarification of Retiree Premium Rates for Prescription Drug Benefits: David Pointer referred the Commissioners to the revised Rate Renewal Reports. He explained that the Employee/Child coverage tier received an additional 1% increase based on the relativity being adjusted from 148% to 150% of the Single coverage tier. He also advised the Commission that the retired group rates were adjusted in accordance with the indexing of the retiree prescription drug copayments.

Chairperson Culliton made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner Czech seconded the motion. Motion passed (3: 2: 0, Commissioners Burdge and Nowlan voted nay).

Upon return from Executive Session, Commissioner Burdge made a motion to table the vote on the proposed rates until the superconciliation process as outlined by Chapter 78, PL 2011 is completed. Commissioner Nowlan seconded the motion. Motion failed (2: 3: 0, Chairperson Culliton and Commissioners Czech and Vance voted nay).  

Commissioner Czech made a motion to approve the rates as presented in the revised report. Commissioner Vance seconded the motion. Motion passed (3: 2: 0, Commissioners Burdge and Nowlan voted nay).  

There being no further business, a motion to adjourn was made by Chairperson Culliton and seconded by Commissioner Czech. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 1:36 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


Meeting No. 530
Minutes
October 10, 2012, 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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on September 17, 2012.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, October 10, 2012 at 10:09 AM.  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, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Robert M Czech, Chair, Civil Service Commission
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

Also present: 

Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
David Pointer, Assistant Director, New Jersey Public Employees’ Health Benefits Programs
Kierney Corliss, Acting Secretary
Douglas Martucci, State Health Benefits Program
Thomas Hower, Deputy Attorney General
Cheryl Eagan, Horizon Blue Cross Blue Shield of New Jersey
Katherine Impellizzeri, Aetna
Alan Eisenberg, Aetna

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

Meeting No. 526, August 16, 2012: Commissioner Czech made a motion to approve the minutes. Chairperson Culliton seconded the motion. All voted in favor.

Meeting No. 527, August 21, 2012: Commissioner Burdge made a motion to approve the minutes. Commissioner Czech seconded the motion. All voted in favor.

Issues

  1. Carrier updates: David Pointer advised the Commission that Meridian Health had reached an agreement with Aetna and would remain in the Aetna network. Deborah Heart and Lung has terminated from the Aetna Network as of September 1, 2012. Negotiations with Deborah Heart and Lung are ongoing.
  1. Local Employers: Mr. Pointer advised the Commission the Local Employers 2012 year-to-date Report for New Local Government Employers and Termination of Local Government Employers was handed out at the beginning of the meeting. There were 24 new employers who joined the program and eight employers who terminated from the program. There was also one employer who would be joining in 2013. There was no discussion.
  1. Dental Services: Aetna representatives were present to answer questions previously submitted by Commissioner Burdge. Katherine Impellizzeri, the Aetna Account Manager, introduced herself and Alan Eisenberg.  Ms. Impellizzeri provided the following information:

Employee Dental Expense Plan

                                                                           2011                2010                2009

                         Average Plan Paid Amount               $901                $869                $873

                        Average Member Share                    $346                $340                $343

                        Member Share %                              28%               28%                 28%

                        # Reaching Max Benefit                   1,466               1,406               1,346
 

Retiree Dental Expense Plan

                                                                           2011                2010                2009

Average Plan Paid Amount   $616                $610                $687

Average Member Share        $506                $508                $429

Member Share %                  45%                45%                38%

# Reaching Max Benefit       5,088               4,370               5,944

 

DPO Copays Vs. Estimated Dentist Charges
                                                                       
2011                2010                2009

                         Average Annual Copays               $137                $132                $107

                        Average Annual Dentist Charges     $692                $658                $628

                        Copays as % of Charges                17%                17%                15%

Commissioner Burdge asked if the plan designs are identical for the Active and Retired Dental Expense Plans.  Ms. Impellizzeri responded that the Retiree plan has three benefit tiers while the Active Dental Expense plan has only one tier.  In addition, the Retiree plan went from a passive PPO to a true PPO as of January 1, 2010, with different benefit provisions for in-network and out-of-network providers. The Active plan changed from a passive PPO to a true PPO as of January 1, 2012. Ms. Impellizzerri further explained that retirees who do not have dental coverage prior to enrollment are enrolled in Tier 1, where they remain for one year. They then move into Tier 2, where they remain for one year before moving to Tier 3. Retirees who have dental coverage prior to enrollment are placed in Tier 3 as of their enrollment date.

Commissioner Burdge asked if the difference in member cost sharing between the active and retired plans could be accounted for by the tiering. Mr. Eisenberg said that would account for part of the difference. The Retiree plan also has an annual maximum of $1500 compared to the Active plan maximum of $3000, which would explain why more Retirees reach the annual maximum. In addition, the types of procedures needed for older populations are more expensive. Mr. Eisenberg also pointed out that network utilization is higher for Active members than it is for Retirees.

  1. David Pointer stated that we would skip issue D and go to Issue E, adult obesity screenings. Ms. Impellizzeri advised the Commission that the responses she had provided had focused on the 2003 U.S. Preventive Task Force recommendations instead of the newer 2012 recommendations. Aetna will provide a written response that reflects the 2012 recommendations. She said that Aetna was in the process of developing a provider communication regarding adult obesity screening, which would be sent sometime in the next couple of months. Ms. Impellizzeri also stated that as part of health care reform, there is no cost sharing for obesity screenings and weight loss counseling.  Aetna provides a disease management program for obesity or weight loss management, which may involve referrals to licensed practitioners to help with diet and nutrition; it may also involve referrals to a behavioral health program to help with behavior modification. Behavioral health services may also help identify another condition that may be contributing to obesity, for example, depression.

    The 2003 U.S. Preventive Task Force report did not recommend either for or against behavioral interventions. The 2012 report was more focused and found that there are definite benefits to have screenings and counseling. Commissioner Czech asked if there were more quantitative studies that show the benefits of these programs for an obese person. Ms. Impellizzeri said she would research the studies on effectiveness and also provide cost estimates to the Commission at a later date.
  1. David Pointer stated that Commissioners Burdge and Nowlan had a number of questions concerning the administration of mental health and substance abuse. Both Aetna and Horizon were present to answer any question arising from the responses. Commissioner Burdge asked if Horizon could address the changes to prior authorization requirements that the responses indicated would take effect in 2013. Cheryl Eagan from Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) stated that Magellan manages the mental health and substance abuse services. She explained that as of 2013, Magellan will not require all members to obtain an initial authorization for treatment. Magellan will identify cases that may require additional advocacy using algorithms that will examine diagnosis, frequency of visits, number of visits, and type of professionals the member is seeing. Magellan will then work with the providers and member to determine if additional interventions or a higher level of care are needed. The goal is to reduce the administrative burden for both members and providers.

    Commissioner Burdge asked why such a high percentage of mental health claims are paid to out-of-network providers. Ms. Eagan responded that one of the greatest drivers is the limited differential between member out-of-pocket costs for in-network and out-of-network services. Because the out-of-network cost is not significantly higher, there is less incentive to use an in-network provider.  Commissioner Nowlan asked how the introduction of the Treatment Request Form (TRF) process in 2009 impacted the average number of mental health visits. Ms. Eagan said that she would find out but that she did not believe it had changed dramatically.

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

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

Case #SH101201 - This Office of Administrative Law (OAL) decision concerned reimbursement for embryo-transfer procedures performed on the member’s spouse, who was over the age of forty-five. Thomas Hower, Deputy Attorney General, was present to discuss the case. Chairperson Culliton advised Mr. Hower and the Commission that due to administrative oversight, the Division did not ask for an extension within 45 days of the Initial Decision. Therefore, the Initial Decision of the Administrative law Judge is a Final Decision. Chairperson Culliton made a motion to go into Executive Session to seek advice from DAG Diane Weeden. Commissioner Burdge seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Burdge asked DAG Hower about theALJ’s decision. DAG Hower said the ALJ did not make a finding of age discrimination in the decision. The ALJ found that an exception to the Older Worker Benefits Protection Act was not triggered, but that there was not a finding of violation of that same statute. DAG Hower said that the decision is limited to this member, so the SHBP policy itself is not invalidated. DAG Hower said that the problem is the issue of the medical evidence on which the decision was based. The member had submitted a study, but there is no expert medical testimony in the record regarding the study.

Chairperson Culliton made a motion to recognize that by virtue of the procedural issue that had occurred by the passing of 45 days, the Commission is bound by the terms of the Initial Decision as a Final Agency Decision, however, the Commission does not agree with the ultimate determination of ALJ Strauss, and had the Commission been able to deal with it in a more timely manner, the Commission would have remanded the matter to the OAL for the issue of whether or not the Older Worker Benefits Protection Act exception was triggered and for additional fact finding on the medical issues given the fact that the judge relied upon written documentation which cannot be cross-examined. The motion was not seconded. Chairperson Culliton withdrew the motion.

Chairperson Culliton again made a motion to recognize that by virtue of the procedural issue that had occurred by the passing of 45 days, the Commission is bound by the terms of the Initial Decision as a Final Agency Decision, however, the Commission does not agree with the ultimate determination of ALJ Strauss, and had the Commission been able to deal with it in a more timely manner, the Commission would have remanded the matter to the OAL for the issue of whether or not the Older Worker Benefits Protection Act exception was triggered and for additional fact finding on the medical issues given the fact that the judge relied upon written documentation which cannot be cross-examined. Commissioner Czech seconded the motion. Chairperson Culliton then amended her motion to include that the decision is not precedential and the terms of the plan are not changing. Commissioner Czech seconded the amendment. Amended motion passed (3: 2: 0, Commissioners Burdge and Nowlan voted nay).

Chairperson Culliton made a motion to go into Executive Session to discuss three settlement proposals before the Commission. Commissioner Nowlan seconded the motion. All voted in favor.

Case #SH101202- Upon return from Executive Session, Chairperson Culliton made a motion to approve the settlement as recommended. Commissioner Nowlan seconded the motion. All voted in favor.

Case #SH101203- Chairperson Culliton made a motion to accept the recommendation as set forth. Commissioner Nowlan seconded the motion. All voted in favor.

Case #SH101204- Chairperson Culliton made a motion to permit Socrates to negotiate a resolution within the range set forth in the memo. Commissioner Nowlan seconded the motion. All voted in favor.

Chairperson Culliton made a motion to go into Executive Session to discuss procedural issues. Commissioner Czech seconded the motion. All voted in favor.

Upon return from Executive Session, Chairperson Culliton made a motion that the Division set a policy with regard to matters that are placed on the agenda, so that the items discussed are set by the Commission as a whole and that any requests that come from individual Commissioners come to the next meeting for such a discussion. Commissioner Czech seconded the motion. Motion passed (3: 0: 2, Commissioners Burdge and Nowlan abstained). 

There being no further business, a motion to adjourn was made by Chairperson Culliton and seconded by Commissioner Czech. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 11:54 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


Meeting No. 531
Minutes
November 14, 2012, 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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on September 17, 2012.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, November 14, 2012 at 10:09 AM.  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 (except for Case #SH111202)
John Megariotis, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff (Case #SH111202 only)
Sylvia Allen-Ware, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

Absent:

Robert M Czech, Chair, Civil Service Commission

Also present: 

Diane Weeden, Deputy Attorney General
Danielle Schimmel, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
David Pointer, Assistant Director, New Jersey Public Employees’ Health Benefits Programs
Kierney Corliss, Acting Secretary
Douglas Martucci, State Health Benefits Program
Cheryl Eagan, Horizon Blue Cross Blue Shield of New Jersey
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey
Rosemary Middlebrook, Horizon Blue Cross Blue Shield of New Jersey
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Dr. Lou Parrott, Horizon Blue Cross Blue Shield of New Jersey/Magellan
Katherine Impellizzeri, Aetna
Dr. Mark Friedlander, MD, Aetna
Mike North, Aetna
Dr. Kay Eckroth, Aetna (Via telephone)

Mitchell Decter, Lampf, Lipind, Prupis & Petigrow (Representing Montvale Surgical Center)

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

Meeting No. 528, September 12, 2012: Chairperson Culliton made a motion to approve the minutes. Commissioner Allen-Ware seconded the motion. All voted in favor.

Meeting No. 529, September 21, 2012: Chairperson Culliton made a motion to approve the minutes. Commissioner Allen-Ware seconded the motion. Motion passed (3: 0: 1, Commissioner Nowlan abstained).

Issues

C.  Updated CDT Dental codes: David Pointer advised the Commission that the Updated CDT dental codes would be discussed first as an Aetna representative was on the phone to explain the new codes. Kierney Corliss advised the Commission that there was a correction to be made to the document that had been presented: CDT code D4210 has a copayment of $0 and D4211 has a copayment of $60. Katherine Impellizzeri, Aetna, introduced herself and Dr. Kay Eckroth, who was on the telephone. Ms. Impellizzeri explained that the American Dental Association periodically reviews the procedure codes used for claims. Dr. Eckroth advised the Commission that some of the codes were newly created and had previously been billed under a different code. Other codes in the document were existing codes that had a descriptor change in order to more accurately reflect the procedure that the dentist performs. Chairperson Culliton made a motion to approve the CDT codes as presented and ask that the Deputy Attorney General research whether or not the codes need to go to the Plan Design Committee for review of the copayments. Commissioner Burdge seconded the motion. All voted in favor.

A. Carrier updates: Mr. Pointer advised the Commission that there were no carrier updated for the current month. Commissioner Burdge asked for an update on how many Cigna members had not yet selected a new health plan. Mr. Pointer advised the Commission that out of the approximately 10,000 Cigna members, about 3,800 had  not yet selected a new plan.

B. Autism: Ms. Corliss advised the Commission that Commissioners Burdge and Nowlan had submitted questions to Aetna and Horizon regarding autism. The responses had been provided to the Commission. Mr. Pointer advised the Commission that representatives from both Aetna and Horizon were present to answer any questions arising from the responses. Commissioner Burdge noted that the responses were lengthy and he was just starting to go through them. Chairperson Culliton made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner Nowlan seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Burdge made a motion to table the discussion on Autism until the Commissioners had sufficient time to review the responses. Commissioner Nowlan seconded the motion. All voted in favor.

D. 2013 Meeting Schedule: Chairperson Culliton made a motion to approve the 2013 meeting schedule as presented. Commissioner Burdge seconded the motion. All voted in favor.

E. Providers’ Standing for Appeals: Mitchell Decter from the Law Firm of Lampf, Lipkind, Prupis, and Petigrow introduced himself as representing Montvale Surgical Center. He asked if the attorney for Hackensack Surgical Center (Hackensack) had been notified of being on the agenda for today’s Commission meeting and Ms. Corliss responded that written notification had been sent. Mr. Decter provided a brief history of Montvale’s request for a declaratory meeting from the Commission regarding the reimbursement amounts for out-of-network surgery centers. The case had gone to the Appellate Division and was then consolidated with Hackensack’s case and remanded to the Commission. He confirmed that Montvale was an out-of-network provider and he stated that he represented the surgery center itself, not the individual members who received services at Montvale.

Danielle Schimmel, Deputy Attorney General, was present to represent the Commission in the Montvale case. She said that the question of standing is a factual question and she suggested a brief discovery period to establish a factual record. Mr. Decter disagreed that it was a factual issue. He stated the only issue to be adjudicated by the Commission is whether Montvale has standing to argue that the reimbursement policy is incorrect. Chairperson Culliton made a motion to go into Executive Session to seek advice from the DAG.

Upon return from Executive Session, Dave Perry from Horizon confirmed that the Horizon policy for reimbursement for out-of-network surgery centers at 160% of Medicare was put in place in 2009 because the Prevailing Healthcare Charges System (PHCS) did not have information specific to surgery centers as a place of service. He said he was not able to speak too much around specifics of the Montvale case because of other litigation that exists between Horizon and Montvale.

Chairperson Culliton made a motion that Montvale does not have standing in this matter and the Commission is therefore not in a position to issue a declaratory ruling. Commissioner Nowlan seconded the motion. All voted in favor.

F. Workers’ Compensation Proposal: Ms. Corliss referred the Commissioners to a memo in their binders from Dave Pointer. Mr. Pointer gave a brief summary of the memo. Both Aetna and Horizon currently have subcontractors that investigate claims that could be work related. These subcontractors are paid a contingency on any claims that are recovered from the State Workers’ Compensation fund. For State employees, when there is a Workers’ Compensation settlement, money is transferred from Risk Management to the SHBP. In order to conserve time and resources, the proposal was for a fixed amount of $2.06 per employee per year to be transferred from Risk Management to the SHBP, and the SHBP would not continue to pursue the liens for State employees. Chairperson Culliton made a motion to accept the new policy and authorize the transfer of money in lieu of seeking individual claims. Commissioner Nowlan seconded the motion. Motion passed (3: 0: 1, Commissioner Allen-Ware abstained.)

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. Chairperson Culliton seconded the motion. All voted in favor.

Chairperson Culliton made a motion to go into Executive Session to discuss a settlement proposal before the Commission. Commissioner Nowlan seconded the motion. All voted in favor.

Case #SH111201- Commissioner Nowlan made a motion to accept the recommendation as set forth. Commissioner Burdge seconded the motion. All voted in favor.

Case #SH111202- Chairperson Culliton recused herself from this case and was replaced by John Megariotis. This tabled Division appeal concerned the termination of retired health benefits for a member who did not enroll in Medicare B when eligible.  Commissioner Nowlan made a motion to go into Executive Session to receive advice from the Deputy Attorney General. Commissioner Burdge seconded the motion. All voted in favor.

Upon return from Executive Session, Chairperson Megariotis made a motion to deny the request. There was no second.

Commissioner Burdge made a motion to not apply the ineligibility to the member until that time that the member has the first opportunity to be enrolled in Medicare part B. Commissioner Nowlan seconded the motion. Chairperson Megariotis asked if the Commission had the authority to ignore the regulation. Commissioner Burdge made a motion to go into Executive Session. Commissioner Allen-Ware seconded the motion. All voted in favor. Upon return from Executive Session, the Commission voted on the motion. Motion failed (2: 2: 0, Chairperson Megariotis and Commissioner Allen-Ware voted nay).

DAG Diane Weeden advised the Commission that they needed to take action either to grant or deny the member’s appeal. Chairperson Megariotis again made a motion to deny the member’s appeal. There was no second.

Commissioner Nowlan made a motion to table the appeal. Commissioner Burdge seconded the motion. Motion failed. (2: 2: 0, Chairperson Megariotis and Commissioner Allen-Ware voted nay).

Chairperson Megariotis again made a motion to deny the member’s appeal. Commissioner Allen-Ware seconded the motion. Motion failed (2: 2: 0, Commissioners Burdge and Nowlan voted nay).

Commissioner Nowlan again made a motion to table the appeal. Commissioner Burdge seconded the motion. Motion failed. (2: 2: 0, Chairperson Megariotis and Commissioner Allen-Ware voted nay).

DAG Weeden noted that only four Commissioners were present, while there are typically five Commissioners present. If the case was reviewed at the next meeting where five members were present, then the chance of a tie would be unlikely. The member’s attorney requested that it be reviewed at the December meeting.

Case #SH111203- This Horizon appeal concerned the amount of reimbursement for an out-of-network assistant surgeon. Wendy Burns, Horizon, advised the Commission that it is part of the participating provider’s contractual obligation to have the member sign an out-of-network consent form, but the provider did not do that in this case. Dave Perry advised the Commission that Horizon does not have any recourse against the provider except to terminate participation in the network. Ms. Burns noted that the member advised Horizon that she has not been balance billed. Mr. Perry said that there is a statute that requires the member to be held harmless in situations such as this. Chairperson Culliton made a motion to table the case so that the Attorney General’s office could research the case. Commissioner Nowlan seconded the motion. All voted in favor.

Case #SH111204- This request for an Office of Administrative Law (OAL) hearing concerned a denied appeal for continued coverage for a member’s son. Chairperson Culliton made a motion to deny the request for an OAL hearing and instruct the Secretary of the Commission to issue a Final Administrative Determination. Commissioner Burdge seconded the motion. All voted in favor.

There being no further business, a motion to return to public session and adjourn was made by Chairperson Culliton and seconded by Commissioner Burdge. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 12:23.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


Meeting No. 532
Minutes
December 12, 2012, 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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on September 17, 2012.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, December 12, 2012 at 10:10 AM.  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 (except for Case #SH121201)
John Megariotis, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff (Case #SH121201 only)
Robert M Czech, Chair, Civil Service Commission
Sylvia Allen-Ware, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees (Via telephone); left at 11:20

Also present: 

Diane Weeden, Deputy Attorney General
Danielle Schimmel, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
David Pointer, Assistant Director, New Jersey Public Employees’ Health Benefits Programs
Kierney Corliss, Acting Secretary
Douglas Martucci, State Health Benefits Program
Edward Fox, Aon Hewitt
Susan Marsh, Aon Hewitt
James Christ, Aon Hewitt
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey
Rosemary Middlebrook, Horizon Blue Cross Blue Shield of New Jersey
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Dr. Lou Parrott, Medical Director, Horizon Blue Cross Blue Shield of New Jersey/Magellan
Susan Rizzni, Horizon Blue Cross Blue Shield of New Jersey/Magellan
Katherine Impellizzeri, Aetna

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

Meeting No. 530, October 10, 2012: Commissioner Czech made a motion to approve the minutes. Chairperson Culliton seconded the motion. All voted in favor.

Kierney Corliss asked the Commission to go out of order and hear a member’s appeal. Commissioner Czech made a motion to go into Closed Session. Chairperson Culliton seconded the motion. Motion passed (4: 1: 0, Commissioner Burdge voted nay).

Case #SH121201- Chairperson Culliton recused herself from this case and was replaced by John Megariotis. This tabled Division appeal concerned the termination of retired health benefits for a member who did not enroll in Medicare B when eligible.  Commissioner Czech stated that he was not present at the previous meeting and he asked DAG Diane Weeden to review what she had researched about the case. DAG Weeden advised the Commission that it did not appear that the Americans with Disabilities Act applied to this case.

Commissioner Czech asked if the Division of Pensions and Benefits relies upon retirees to self-identify when they become eligible for Medicare by reason of disability. David Pointer responded affirmatively. Chairperson Megariotis asked Ms. Corliss if she had received anything from the member’s attorney since the last meeting. She responded that she had not.

The member advised the Commission that he was enrolled in Medicare A in 2005, but had declined enrollment in Medicare B. He will not be permitted to enroll in Medicare B until the Open Enrollment period, which is from January 1 to March 31, 2013. Commissioner Burdge asked the member when he started his employment with Mercer County. The member responded that he began working part time for Mercer County in April of 2003. Commissioner Czech noted that the member was sent an offering letter in October of 2002 and he asked Mr. Pointer to read aloud the section of the notice that addressed the requirement for Medicare Enrollment. The member advised the Commission that he did not recall receiving that notice.

Commissioner Czech asked the member if he has been paying COBRA premiums. The member advised the Commission that the Township of Lawrence had been paying for his retired health benefits before they were terminated. He stated that the Township was currently giving him a payment for the amount of the retired health benefits, and the member was paying the Division for the COBRA premiums. The additional cost was being paid by the member.

Commissioner Czech made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner Allen-Ware seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Czech made a motion to deny the member’s appeal. Chairperson Megariotis seconded the motion. Motion passed (3: 2: 0, Commissioners Burdge and Nowlan voted nay).

Commissioner Burdge made a motion to return to Public Session. Chairperson Megariotis seconded the motion. All voted in favor.

Ms. Corliss stated that at Commissioner Nowlan’s request, the Commission would go out of order again to discuss Mental Health Parity.

Issues

D. Mental Health Parity: Ms. Corliss stated that Aon Hewitt was in attendance to give a presentation on Mental Health Parity. Edward Fox introduced himself, Susan Marsh, and James Christ. Mr. Fox gave a history of the Federal Mental Health Parity laws and advised the Commission that as a self-funded non-Federal governmental health plan, the SHBP has the ability to apply for an exemption from the Mental Health Parity laws. The purpose of the exemption would be to allow the day limits to remain in the plans for non-biologically based mental illnesses. Aon Hewitt estimated that the cost of not filing for the waiver would be approximately $7 million for Plan Year 2013.

Chairperson Culliton made a motion to go into Executive Session to discuss pending litigation. Commissioner Burdge seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Czech asked how many years the Commission has filed for the waiver. Mr. Fox responded that the SHBP has filed for the exemption since the Federal law was enacted in 1996.

Commissioner Burdge made a motion to go into Executive Session to receive advice from the Deputy Attorney General. Commissioner Nowlan seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Burdge made a motion to not apply for the mental health waiver for Plan Year 2013. Commissioner Nowlan seconded the motion. Motion failed (2: 3: 0, Chairperson Culliton, Commissioners Czech and Allen-Ware voted nay).

Commissioner Czech made a motion to file for the waiver for Plan Year 2013. Chairperson Culliton seconded the motion. Motion passed (3: 2: 0, Commissioners Burdge and Nowlan voted nay).

At this time, Commissioner Nowlan left the meeting.

A. Carrier updates: Mr. Pointer advised the Commission that Deborah Heart and Lung Center rejoined the Aetna network effective September 1, 2012.

B. Local Employers: Mr. Pointer advised the Commission that the latest local employer enrollment and termination reports had been provided to the Commissioners. He also stated that Open Enrollment had concluded. There were approximately 95 active employees and 200 retirees who had been enrolled in Cigna and neglected to select a new health plan. These members would not have coverage as of January 1, 2013. The Division is taking steps for a second notification to these members advising them to choose a new plan. Mr. Pointer also gave approximate enrollment numbers for each of the health plans.

D. Database for Reasonable and Customary Allowance: Dave Perry from Horizon advised the Commission that currently, out-of-network allowances were based on the 90th percentile of the Prevailing Health Care Charges System (PHCS), which was owned by United Health Care. The PHCS database was last updated in early 2011. Following a lawsuit by the New York Attorney General’s Office, United Health Care provided funding to create an independent organization to administer a new database known as FAIR Health.

Commissioner Burdge asked what Horizon is doing for its other business. Mr. Perry responded that in the individual and small employer markets have their own regulatory bodies and Horizon does not have the ability to make autonomous changes.  Changes for those bodies will be directed by the respective boards. For their other business Horizon is moving towards a model that is based on a percentage of CMS reimbursement, which is a resource-based system instead of a charge-based system.

Chairperson Culliton made a motion to authorize Horizon to use FAIR Health in accordance with NJSA 52:14-17.29(C) (3), which states: "Reasonable and customary charges" means charges based upon the 90th percentile of the usual, customary, and reasonable (UCR) fee schedule determined by the Health Insurance Association of America or a similar nationally recognized database of prevailing health care charges.” After DAG Weeden mentioned that Aetna would also need to move to FAIR Health and Mr. Pointer confirmed that Aetna was not on the agenda separately, she then amended her motion to include all plan administrators. Commissioner Burdge seconded the motion. Motion passed (4: 0: 0, Commissioner Nowlan was absent).
 
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 Burdge seconded the motion. All voted in favor.

Case #SH121202 (member’s representative present)- This tabled Horizon NJ DIRECT10/Magellan appeal concerned the denial of benefits for expenses for residential treatment for an eating disorder at Timberline Knolls. The claims had originally been denied for lack of medical necessity, and upon receipt of the second level appeal, Magellan discovered that the member had reached her annual maximum and therefore did not review the case for medical necessity. The appeal had been tabled in order to allow Magellan to review the case again for medical necessity.

A health insurance advocate from the member’s attorney’s office was in attendance to represent the member. She stated that the head of the National Institute of Mental Health has identified eating disorders as biologically based mental illnesses. She advised the Commission that the member was under the impression that the plan would cover treatment for the eating disorder as a biologically based mental illness. She also stated that the member’s treatment team recommended residential treatment as the appropriate level of care.

Dr. Lou Parrott, Medical Director, Magellan, advised the Commission that Magellan had reviewed the second level appeal as requested. The member was in a Partial Hospitalization Program (PHP) at Overlook Medical Center just prior to her admission to Timberline Knolls. Dr. Parrott stated that the member needed to meet several criteria for medical necessity. The member met one of the criteria but not the other four. Dr. Parrott acknowledged that the member was having some troubles in the PHP but that the PHP was still the appropriate level of care based on the medical necessity criteria. Dr. Parrot stated that a request for precertification for treatment was received on September 3, 2010 and denied the same day. Chairperson Culliton noted that the member was admitted to Timberline Knolls two days earlier, on September 1, 2010.

The member’s advocate advised the Commission that the member was also being treated for major depressive disorder and anxiety at Timberline Knolls. She stated that there was conflict at home which created a stressful environment for the member. Commissioner Czech asked Dr. Parrott what impact the conflict would have on Magellan’s analysis of medical necessity. Dr. Parrott said that one way to handle it is to look at each diagnosis on its own and match those up with levels of care within the medical necessity criteria. He stated that the member did not meet the medical necessity criteria for mental health residential treatment at the time of admission to Timberline Knolls.

Chairperson Culliton made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner Burdge seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Czech made a motion to table the case in order to allow Magellan to review the medical records to determine what diagnoses were being treated and the appropriate level of care for each diagnosis. Commissioner Burdge seconded the motion. Motion passed (4: 0: 0, Commissioner Nowlan was absent). Chairperson Culliton also asked Horizon to determine the exact amount that is being appealed.

Case #SH121203- Commissioner Burdge recused himself from this appeal. This Division appeal concerned a denial of a refund of the employee contribution towards health benefits premiums for a member who did not submit a waiver form when he was first eligible for health benefits. Chairperson Culliton made a motion to deny the appeal. Commissioner Czech seconded the motion. Motion passed (3: 0: 0, Commissioner Nowlan was absent).

Case #SH121204- This Office of Administrative Law (OAL) decision concerned reimbursement for expenses above the reasonable and customary charges under the Traditional Plan. The Commission was not able to consider the Initial Decision within the required forty-five (45) day timeframe, therefore the Commission was required to accept the Initial Decision as a Final Decision in accordance with NJSA 52:14B-10. Chairperson Culliton made a motion to acknowledge the findings of fact and suggested conclusions of law as proposed in the exceptions, but due to a procedural error recognize that the Initial Decision was already adopted but does not reflect the Commission’s position with regard to the ultimate issue.. Commissioner Burdge seconded the motion. Motion passed (4: 0: 0, Commissioner Nowlan was absent).

There being no further business, a motion to return to public session and adjourn was made by Chairperson Culliton and seconded by Commissioner Burdge. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 12:45.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 

 
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