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Pensions and Benefits
STATE HEALTH BENEFITS COMMISSION
MEETING MINUTES 2013
 
Unless otherwise noted, meetings are held at 10:00 a.m. at the Division of Pensions and Benefits, 50 West State Street, Trenton, NJ.
*RENEWAL MEETINGS - START TIME IS 1:00 P.M.

To view 2012 Health Benefit Commission Meeting Minutes (and prior years), click here.


State Health Benefits Commission Minutes
Meeting No 533

January 9, 2013; 10:00 AM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, January 9, 2013 at 10:16 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:

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidomon-Eristoff 
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)

Absent:

Robert M Czech, Chair, Civil Service Commission

Also present: 

Diane Weeden, Deputy Attorney General
Danielle Schimmel, Deputy Attorney General
Susan Barrett, Acting Secretary
Douglas Martucci, State Health Benefits Program
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Rosemary Middlebrook, Horizon Blue Cross Blue Shield of New Jersey

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

Meeting No. 533, January 9, 2013: Acting Secretary Barrett advised the Commission that the minutes from the December 12, 2012 meeting were unavailable and would be provided before the next scheduled meeting.

Issues

Carrier Updates: Ms. Barrett informed the Commission that, after a thorough RFP process, Horizon has chosen ValueOptions as its new mental health/substance abuse administrator. The transition to the new company will begin during plan year 2014. The Division will provide updates on the transition as they become available.

Provider Standing for Appeals: Chairperson Culliton made a motion to go into Executive Session under Resolution B to seek advice from the Deputy Attorney General. Commissioner Burdge seconded the motion. All voted in favor.

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

Chairperson Culliton made a motion, having reviewed the document provided by DAG Schimmel, to authorize the release of the document to the attorney representing the Hackensack Surgery Center (“Hackensack”) and to permit a period of discovery so that DAG Schimmel may receive documents related to the assignments submitted by Hackensack and any other relevant information. The provider’s attorney shall be allowed to seek discovery from DAG Schimmel in return. After the 60-day discovery period, the case will go before the Commission and any other relevant testimony from Horizon and Aetna will be heard in order for the Commission to render a final administrative determination. Commissioner Burdge seconded the motion. All voted in favor.

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

Case # 011301 - This was a previously tabled case wherein the member is appealing the denial of expenses above the reasonable and customary allowance for a surgical procedure. The Attorney General’s office was researching whether the law requires the Commission to make the member whole. Chairperson Culliton asked DAG Weeden if there was an answer to the question. DAG Weeden advised that the law specifically refers to payments to facilities, not individual providers. Chairperson Culliton noted that this was planned surgery, not an emergency. Mr. Perry agreed, adding that the patient had more time to research whether all providers involved were in-network.  He noted the Fair Health’s website advises members to inquire whether all providers involved in the procedure are in-network Ms. Burns added that Horizon has made several attempts to reach the member, with no response from the member except to say that she had not been balance-billed by the provider. Ms. Burns also noted that the office manager at the surgeon’s office stated that the member was informed that the assistant surgeon was out-of-network.

Chairperson Culliton made a motion to deny the appeal. Commissioner Burdge seconded the motion. Motion passed (3:0:1, Commissioner Nowlan abstained).

Case # 011302 - Final Administrative Decision (FAD) - Chairperson Culliton made a motion to approve the FAD draft concerning the denial of enrollment of a disabled dependent. Commissioner Allen-Ware seconded the motion. Motion approved (3:0:1, Commissioner Burdge abstained).

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 # 011303 - Upon return from Executive Session, Chairperson Culliton made a motion to authorize the workers’ compensation settlement as recommended in John Fedorko’s memo of January 2, 2013.  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 Nowlan.  All voted in favor.

The State Health Benefits Commission meeting was adjourned at 11:28 AM.

 

  Respectfully submitted,
 

 

 

  Susan Barrett
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 534
February 13, 2013; 10:00 AM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, February 13, 2013 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
Robert M Czech, Chair, Civil Service Commission
Sylvia Allen-Ware, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

Also present: 

Diane Weeden, Deputy Attorney General
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
David Pointer, Assistant Director, State Health Benefits Program
Douglas Martucci, State Health Benefits Program
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Rosemary Middlebrook, 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
Mike North, Aetna
Ian Carrucci, Aetna
Jillian Romaniello, Lampf, Lipkind, Prupis & Petigrow

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

Meeting No. 531, November 14, 2012: Commissioner Czech made a motion to approve the minutes. Commissioner Burdge seconded the motion. All voted in favor.

Meeting No. 532, December 12, 2012: Czech made a motion to approve the minutes. Chairperson Culliton seconded the motion. Motion passed (4: 0: 1, Commissioner Nowlan abstained).

Meeting No. 533, January 9, 2013: Kierney Corliss advised the Commission that the minutes from January 9th needed to be amended to remove the word “Acting” now that Kenneth Kobylowski has been confirmed as Commissioner of Banking of Insurance. Commissioner Burdge made a motion to approve the minutes as amended. Commissioner Nowlan seconded the motion. Motion passed (4: 0: 1, Commissioner Czech abstained).

Issues

Carrier Updates: David Pointer provided information on two hospital terminations from the Aetna Network: Kennedy Memorial Hospital in Cherry Hill, Stratford, and Turnersville terminated effective February 1, 2013. Negotiations have ended. Saint Joseph’s Regional Medical Center and Saint Joseph’s Wayne Hospital are scheduled to terminate on March 15, 2013. Negotiations are continuing.

Mr. Pointer also provided the Commission with an update of current membership for State and Local employees and retirees as of February 1, 2013. He stated that approximately 150 Cigna members have still not chosen a new plan, about 50 of which are retirees.

Request for Declaratory Ruling: The Commission had been provided with a draft of a Final Administrative Determination for Montvale Surgical Center’s request for a declaratory ruling. Dave Perry, Horizon Blue Cross Blue Shield of New Jersey, was in attendance to discuss Horizon’s network. He explained that when a provider contracts with Horizon, they must agree to the contracted rates, which are lower than out-of-network providers are paid, therefore reducing plan costs. Horizon also has a credentialing process and ongoing performance reviews to ensure high quality providers are in the network. In exchange, the provider is paid directly and benefits from a higher volume of patients as a result of the plan directing members to participating providers. In-Network providers are also allowed to request claims reviews. For non-participating providers, there is a  charge based system to generate reasonable and customary allowances so there is  no market force to drive the charges down and therefore incentive to inflate charges.

Mr. Pointer asked if Horizon is aware of any out-of-network providers that waive member balance billing. Mr. Perry said that some out-of-network providers are satisfied with the amount that the plan reimburses them, and therefore do not aggressively pursue the coinsurance. From the patient’s perspective, this negates the financial impact of using an out-of-network provider.

Jillian Romaniello from Lampf, Lipkind, Prupis & Petigrow was present on behalf of Montvale Surgical Center. She noted that there is a difference between balance billing and collecting coinsurance. Coinsurance is the member’s 20 or 30 percent of the Reasonable and Customary (R & C) charges approved by the plan, while balance billing is holding the member responsible for any amounts above the R & C.

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 Allen-Ware asked Mr. Perry to elaborate on the reasons for building a network, the credentialing process, the recruitment process, and how Horizon monitors physician performance.

Mr. Perry explained that the credentialing is based on National Committee for Quality Assurance (NCQA) criteria, such as medical licensing and board certification. Providers are re-evaluated on an ongoing basis. He said the main reason to have a network is controlling costs; what the carriers do is aggressively pursue the best financial arrangements on behalf of plan sponsors.  He stated that allowing providers who do not participate to have recourse to seek additional monies beyond what is prescribed in the program is a detriment to recruiting efforts because it removes the provider’s incentive to participate. Mr. Perry also stated that Horizon has a formal physician recognition program which has a number of metrics associated with it. One example of a measured item is the generic prescribing rate. The results are shared with the physicians. If a physician does not meet the qualifications, he or she may be terminated from the network.

Chairperson Culliton made a motion to direct the Division to modify the Final Administrative Determination (FAD) that had been presented to include specific references to recruiting efforts, credentialing, and performance monitoring of in-network providers; the motion also included a request to schedule a teleconference before the next Commission meeting for the purpose of approving the revised FAD. Commissioner Nowlan seconded the motion. All voted in favor.

Chairperson Culliton made a motion to go into closed session to hear member appeals. Commissioner Burdge seconded the motion. All voted in favor.

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

Case #021301 (member’s representative present) – This tabled Horizon NJ DIRECT/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. Magellan re-reviewed the case at the request of the Commission and upheld the denial for lack of medical necessity. The case was tabled at the December 2012 meeting to allow Magellan to reevaluate what diagnoses the member was being treated for and the appropriate level of care for each diagnosis.

Dr. Lou Parrott, Medical Director, Magellan, advised the Commission that the medical records indicated that the member’s primary diagnosis was anorexia and secondary were depression and anxiety. He confirmed that the appropriate level of care would have been partial hospitalization, and that residential treatment was not medically necessary. Sue Rizzni, Magellan, stated that since the treatment occurred in 2011, there was a $15,000 maximum for non-biologically based mental illnesses(BBMI), which the patient had already exceeded. Wendy Burns, Horizon, stated that Horizon used the list of disorders as provided in the New Jersey Mental Health Mandate to determine what diagnoses would be considered biologically based. As a result, eating disorders are considered non-BBMI.

Commissioner Nowlan asked if the secondary diagnoses of depression and anorexia were being treated. Dr. Parrott explained that any mental health facility treating the member should be treating all of the diagnoses; however, the primary diagnosis is the main focus. He stated that he had reviewed the clinical information and the member did not meet medical necessity criteria for residential treatment for depression or anxiety. Partial hospitalization would have been the appropriate level of care for those diagnoses as well.

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, Chairperson Culliton asked Magellan to address the member’s statement that she was told the treatment would be covered. Ms. Rizzni responded that the call that was received for precertification from Timberline Knolls was on September 3, 2010, after the member had already been admitted. The member’s advocate stated that the member’s parents, as well as Overlook, where the member initially received treatment, had called Magellan prior to admission at Timberline Knolls.

Ms. Rizzni said that on August 26, 2010, Overlook called to inquire if mental health parity applied to the member’s benefits. They told the representative they wanted to refer the member to a residential facility. The representative asked if Overlook was inquiring if the member had reached her limit. The representative transferred the call to the claims area so they could explain about the maximums but Overlook hung up while on hold for the claims line.

Ms. Rizzni also said that the member’s parents called on July 2, 2010 to inquire about the maximum and were advised verbally. They called again on July 7, 2010 to request the information in writing. On August 27, 2010, the member’s father called again to ask if there was an in-network facility close to home. He was going to check with the facility to find out what the primary diagnosis was and was given the phone number to call back and speak with the care manager. Ms. Rizzni also referenced a letter dated July 27, 2010 which provided information about the benefit maximums being met in 2009. Ms. Rizzni provided a copy of the letter to the Commission. Chairperson Culliton pointed out that the July 27, 2010 letter stated that anorexia is not considered a BBMI.

There was a question about the dollar amount of the claims. Ms. Burns stated that the participating facility rate was approximately $9,000.00 for 25 days of treatment.

Commissioner Czech made a motion to go into Executive Session. Commissioner Burdge seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Czech made the following motion: for settlement purposes only and in light of the parameters for plan maximums, the motion would be to agree with the settlement amount not to exceed $9,029.50 for treatment of the biologically-based disorders of anxiety and depression. Commissioner Burdge seconded the motion. All voted in favor.

Case #021302- This Aetna Dental appeal concerned the denial of expenses for proposed crowns and crown buildups. Ian Carrucci, Aetna Dental, advised the Commission that the benefits for five crowns and crown buildups were denied because they were not necessary to correct fracture or decay. The dental provider indicated that the crowns were recommended for the correction of attrition or abrasion, which are excluded by the plan provisions. Dr. Kay Eckroth confirmed that the dental records stated that the erosion was due to bruxism and the appropriate treatment would be an occlusal guard. Chairperson Culliton made a motion to deny the appeal. Commissioner Czech seconded the motion. All voted in favor.

Commissioner Nowlan made a motion to go into Executive Session in order to discuss five Settlement Proposals before the Commission. Commissioner Burdge seconded the motion. All voted in favor.

Case # 021303- Upon return from Executive Session, Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended in John Fedorko’s memo of February 7, 2013.  Commissioner Nowlan seconded the motion. All voted in favor.

Case # 021304- Upon return from Executive Session, Chairperson Culliton made a motion to accept the settlement as recommended in John Fedorko’s memo of January 25, 2013.  Commissioner Nowlan seconded the motion. All voted in favor.

Case # 021305- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended in John Fedorko’s memo of January 23, 2013.  Commissioner Nowlan seconded the motion. All voted in favor.

Case # 021306- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended in John Fedorko’s memo of February 1, 2013.  Commissioner Nowlan seconded the motion. All voted in favor.

Case # 021307- Chairperson Culliton made a motion to accept the settlement as recommended in John Fedorko’s memo of January 29, 2013.  Commissioner Czech seconded the motion. All voted in favor.

There being no further appeals or 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 12:53 PM

 

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 536
March 13, 2013; 10:00 AM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012 and a revised notice was sent February 27, 2013. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, March 13, 2013 at 10:16 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
Robert M Czech, Chair, Civil Service Commission
Sylvia Allen-Ware, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

Also present: 

Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
David Pointer, Assistant Director, State Health Benefits Program
Susan Barrett, State Health Benefits Program
Cheryl Eagan, Horizon Blue Cross Blue Shield of New Jersey
Dr. Lou Parrott, Medical Director, Horizon Blue Cross Blue Shield of New Jersey/Magellan
Katherine Impellizzeri, Aetna
Mike North, Aetna
Dr. Mark Friedlander, Aetna

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

Kierney Corliss advised the Commission that the minutes from the February 13, 2013 were not available for review.

Issues

Carrier Updates: David Pointer advised the Commission that Aetna had reached a three year agreement with St. Joseph’s Regional Medical Center and St. Joseph’s Wayne Hospital. As the contract had been renewed prior to termination, there was no interruption of service to members.

Commissioner Nowlan noted that at the February 13, 2013 meeting, Mr. Pointer had stated that Kennedy Memorial Hospital in Cherry Hill, Stratford, and Turnersville was terminating from the Aetna network. Commissioner Nowlan said that Kennedy Memorial Hospital is a teaching hospital for the School of Osteopathic Medicine, which is currently part of the University of Medicine and Dentistry of New Jersey (UMDNJ) and will be part of Rowan University effective July 1, 2013. He expressed concern that there may be some confusion for employees of UMDNJ who are affiliated with that hospital as a result of their employment. Commissioner Nowlan asked if there was anything to be done to reach an agreement with the hospital so that it remains in-network, considering that the State already has an agreement with Kennedy Memorial to be a teaching hospital.

Mr. Pointer responded that under the current contract with Aetna, the SHBP does not have the authority to require that specific providers remain in-network. Commissioner Burdge asked if Aetna expected that Kennedy Memorial would rejoin the network any time soon. Katherine Impellizzeri, Aetna, stated that Aetna is continuing to reach out to the hospital but Kennedy Memorial was not currently willing to entertain negotiations.

Coverage of autism under the SHBP:

Commissioner Burdge had previously provided a list of questions for Aetna and Horizon regarding coverage for benefits related to a diagnosis of autism. Responses had been provided at the November 14, 2012 meeting. Both Aetna and Horizon were present to answer any questions arising from the responses.

Aetna: Katherine Impellizzeri introduced herself; Mike North, Vice President of Client Management; and Dr. Mark Friedlander, Medical Director. Commissioner Burdge expressed concern about the number of Certified Behavioral Therapists and Analysts that were in Aetna’s network and asked about plans for network growth. Dr. Friedlander stated that Aetna is committed to grow the network and has worked with the Behavior Analyst Certification Board (BACB) in recruitment efforts. He stated that one challenge is that many of the providers are relatively unfamiliar with commercial insurance coverage because they work predominately with Medicaid or in educational facilities. Dr. Friedlander advised the Commission that if there is a need in a particular geographic location where there is not a provider in the network, then Aetna will negotiate with an out-of-network provider on a case-by-case basis so there is no undue burden on the member.   

Commissioner Burdge asked if there was a specific goal for the number of analysts that Aetna would like to have in their network. Dr. Friedlander stated that the goal is not only to have a robust network in terms of size, but to have providers with a variety of specialties so that members can be directed to a provider that best suits their needs.

Commissioner Burdge asked if Aetna was aware of providers declining to join the network because the providers felt the reimbursement rates were too low. Dr. Friedlander responded that that is a universal challenge for any network, not just specific to Board Certified Behavioral Analysts (BCBA). However, he stated that the Aetna rates are competitive and they are based on the market and practice expenses.

Commissioner Burdge noted that a relatively small number of members had submitted claims to Aetna for Applied Behavioral Analysis (ABA) services, considering the prevalence of autism diagnoses in the population. Dr. Friedlander agreed that although approximately one percent of children have at least one claim that indicates a diagnosis on the autism spectrum, only a small percentage are accessing ABA services. This is consistent with what is occurring nationwide. However, the number of members accessing ABA services has continued to increase each year since 2008. Chairperson Culliton asked if part of the reason that the number of ABA claims is low could be that children are receiving the services through school districts. Dr. Friedlander responded affirmatively.

Commissioner Burdge asked if Aetna has different standards for medical necessity than the school districts have. Dr. Friedlander responded that Aetna has medical necessity criteria for coverage that has been developed with input from the academic and provider communities. In the education system the services that are available may differ from one district to another because each district sets its own standards. In many cases these standards are dependent on the amount of funding available.

Commissioner Burdge asked about the average dollar amount per claim. Dr. Friedlander responded that the about 70 percent of the claims were less than $1,000 per year. About one percent of individuals with a diagnosis on the autism spectrum have very severe autism and may require intensive therapy that costs hundreds of thousands of dollars per year. These cases are rare. Aetna monitors these cases to make sure the medical necessity criteria is met and that the child is progressing. The amount and type of therapy needed is dependent on the symptoms that the child exhibits—for example, when a child has deficits in social skills, a group setting is beneficial. A child who is aggressive or exhibits self-injury may need more intensive services.

Dr. Friedlander also noted that many licensed behavior health practitioners are competent to treat individuals with autism even though they are not certified as ABA practitioners—for example, clinical psychologists.

Commissioner Nowlan asked if Board Certified Assistant Behavioral Analysts (BCABA) can work independently. Dr. Friedlander responded that the main difference between a BCBA and a BCABA is that a BCBA can supervise others while the BCABA cannot.

Dr. Friedlander stated that Aetna has been working very closely with two advocacy groups: the Autism Society of America and Autism Speaks. He also stated that it is sometimes difficult to determine which claims are ABA claims because there are no specific billing codes for ABA therapy. Aetna has identified 66 codes that could be considered ABA; when paired with an autism diagnosis then the claim is paid as an ABA claim.

Horizon: Cheryl Eagan, Horizon, introduced Dr. Louis Parrott, Medical Director, Magellan. Commissioner Burdge noted that the Horizon claims experience showed that a greater percentage of children are accessing ABA services than Aetna’s claims experience indicated. However, he expressed the same concerns regarding the size of Horizon’s network. Dr. Parrott stated that Horizon is making efforts to build the network but he said that some providers feel they have enough business through other channels and are therefore not interested in joining a network.

Commissioner Burdge asked how the out-of-network providers are currently being paid, and if the member’s cost sharing is at the in-network level. Dr. Parrott confirmed that currently, nonparticipating ABA providers are reimbursed at their billing charges. One of the challenges is that FAIR Health does not have a clear payment structure for ABA treatment so it is difficult to develop reasonable and customary rates for reimbursement. Developing an amount for reimbursement instead of paying the billed charges would provide an incentive for providers to join the network.

Commissioner Burdge asked about future plans for the network. Ms. Eagan echoed Dr. Parrott’s statement about not having an allowance for out-of-network services. She stated that having no cap on out-of-network reimbursements creates an incentive for providers to remain out of network. Implementing a differential between in-network and out-of-network cost sharing would help drive members in-network. The challenge is that there is no FAIR Health or CMS data for ABA services.

Commissioner Burdge asked about the time it takes for members to receive reimbursement for ABA expenses. Dr. Parrott stated that during the authorization process, Magellan educates the members and providers on what documentation is needed in order for the authorization to be granted. Once all documents are received, an authorization is usually granted within 24 hours. Ms. Eagan stated that part of the authorization process is designed to identify what the services are and help the providers know what codes to use when submitting the claims. If the member uses a participating provider, there should be no financial impact to the member.

Pharmacy Benefits Manager Request for Proposal:

Mr. Pointer reminded the Commission that the current contract for the Pharmacy Benefits Manager (PBM) expires December 31, 2014. He asked the Commission to give authorization to the Division of Purchase and Property to develop and issue the Request for Proposal (RFP) for the PBM contract to be effective January 1, 2015. Chairperson Culliton made the motion to authorize the development and issuance of the RFP.

Commissioner Czech seconded the motion. Commissioner Burdge asked about the involvement of the Plan Design Committee. Mr. Pointer responded that if the Plan Design Committees wish to make changes to the current plan design, then those changes will be incorporated into the RFP. The RFP will be issued with the current plan design and will contain a caveat that the Plan Design Committees can change the design of the plan.  Commissioner Nowlan asked if the Commission could wait until both the State Health Benefits Plan Design Committee and the School Employee’s Health Benefits Plan Design Committee have any suggestions for the RFP prior to the Commission authorizing the release. Chairperson Culliton noted the preparation of the RFP is a long process and if the Plan Design Committees have changes to make, the RFP can be amended before its release. Mr. Pointer stated the RFP will not be released before the April meetings of the Plan Design Committees. Motion passed (3: 0: 2, Commissioners Burdge and Nowlan abstained).  

Case #031301 – Ms. Corliss advised the Commission that the Borough of Brooklawn was requesting that their retirees be permitted to enroll in the State Health Benefits Program under the provisions of Chapter 330, P.L. 1997. Mr. Pointer asked the Commission to allow the Division to obtain additional information regarding this case. Chairperson Culliton made a motion to allow the Division to obtain additional information and to handle this case administratively. Commissioner Nowlan seconded the motion. All voted in favor.

Case #021302- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated February 28, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

There being no further appeals or 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 11:25 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 537
April 10, 2013; 10:00 AM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012 and a revised notice was sent February 27, 2013. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, April 10, 2013 at 10:16 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
Robert M Czech, Chair, Civil Service Commission
Sylvia Allen-Ware, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees (via teleconference)
Patrick Nowlan, Representative for State Government Employees

Also present: 

Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Douglas Martucci, State Health Benefits Program
Cheryl Eagan, Horizon Blue Cross Blue Shield of New Jersey
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Rosemary Middlebrook, Horizon Blue Cross Blue Shield of New Jersey
Dr. Steven Wolinsky, Horizon Blue Cross Blue Shield of New Jersey
Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

Meeting No. 534, February 13, 2013: Commissioner Czech made a motion to approve the minutes. Chairperson Culliton seconded the motion. All voted in favor.

Issues

Carrier Updates: Kierney Corliss advised the Commission that there were no carrier updates to report.

Chairperson Culliton made a motion to go into closed session to hear member appeals. Commissioner Nowlan seconded the motion. All voted in favor.

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

Case #041301 (member present)– This Horizon appeal concerned a denial for surgical and radiological services performed by a provider who had opted out of Medicare. The member’s husband stated that the provider’s office had advised them that there were other members in the same circumstances for which the same procedure had been paid, however, no additional information was given by the provider. The member stated that she called Horizon and was given the names of four other doctors to inquire if they could perform the same procedure. The member contacted three of the doctors, and was told that none of them could perform the same procedure.

Chairperson Culliton asked Horizon if they were aware of any circumstances in which this type of surgery by this physician had been covered under NJ DIRECT. Wendy Burns, Horizon, stated that she would need the names and ID numbers in order to investigate. Ms. Burns stated that NJ DIRECT contains a specific provision that if Medicare is the member’s primary coverage, and the provider opts out of Medicare, then there are no benefits available under NJ DIRECT. The member was advised this via telephone on several different occasions.

Dr. Steven Wolinsky, Medical Director, Horizon, described the procedures that had been performed. The first part of the operation would have been paid if the provider had participated with Medicare. The second part of the operation is considered investigational and is not a covered procedure. However, this was only discovered upon review of the operative reports, as the physician did not bill the part that is considered investigational. So it is possible that, had the provider participated with Medicare, the entire claim may have been considered for payment, because the specific code for the investigational portion was omitted. Likewise, if the claim had been received for a member who was not eligible for Medicare, the claim may have been considered for payment.

The member’s spouse advised the Commission that the doctor’s office had been in contact with Horizon prior to the operation. Ms. Burns stated that the doctor’s office was told that Medicare was primary for this particular member, and that the procedure code given during those phone calls was not the procedure code that was billed, nor was it the code for the procedure that was performed.  Similarly, the name of the procedure that the member was given by the physician, and subsequently inquired about from the other four doctors, did not accurately describe the procedure.

Chairperson Culliton reminded the member that the main reason for the denial is that the provider did not participate with Medicare. The member acknowledged that she was aware of that prior to the procedure being performed; however, the doctor’s office indicated that there was a chance that it would be paid because it had been paid for other people in the same circumstances.

Commissioner Czech asked Horizon what amount would have been paid for the non-investigative portion, if the provider had been registered with Medicare. Ms. Burns stated that it is dependent upon the Medicare allowance, and she did not have that information with her at that time.

Commissioner Allen-Ware asked Horizon to confirm the following: (1) that the member was advised by Horizon on four different dates that no payments would be made to a provider who has opted out of Medicare; (2) that an additional discussion occurred regarding out-of-network providers being treated as in-network if there were no participating providers available within 50 miles; (3) that a request must be submitted to the Utilization Management department to have the exception made; and (4) that no such request was received by Horizon. Ms. Burns confirmed that the telephone transcripts indicated that this information had been given, and that no request was received for an exception.

Chairperson Culliton made a motion to deny the appeal based on the following: (1) the physician opted out of Medicare; (2) the physician used techniques that are considered experimental or investigational by Horizon; and (3) Horizon provided the member with the names of four physicians within 50 miles of the member’s home that could have treated the member, all of whom were registered with Medicare and participated in Horizon’s Managed Care network. Commissioner Czech seconded the motion. All voted in favor.

Case #041302- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated March 28, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

Case #041303- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated February 4, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

Case #041304- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated April 5, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

Case #041305- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated March 14, 2013. Commissioner Czech seconded the motion. All voted in favor.

Case #041305- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated March 11, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

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

The State Health Benefits Commission meeting was adjourned at 11:08 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 538
June 12, 2013; 10:00 AM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012 and a revised notice was sent April 26, 2013. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, June 12, 2013 at 10:08 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
Robert M Czech, Chair, Civil Service Commission
Sylvia Allen-Ware, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Patrick Nowlan, Representative for State Government Employees

Absent:

Dudley Burdge, Representative for Local Government Employees

Also present: 
David Pointer, Assistant Director, State Health Benefits Program
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Douglas Martucci, State Health Benefits Program

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

Issues

Carrier Updates: David Pointer advised the Commission that they had been provided with the latest drug list for the Preferred Drug Step Therapy Program administered by Express Scripts. He explained that the program had been in effect since February 1, 2010; the Division will provide regular updates to the Commission.

Commissioner Czech made a motion to go into closed session to hear member appeals. Commissioner Nowlan seconded the motion. All voted in favor.

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

Case #061301 (member present)– This Division appeal concerned the denial of a refund of health benefits deductions taken from the member’s paychecks. The member stated that he completed a waiver request when he was hired on November 19, 2011, because he has health coverage through his spouse, who is not a member of the SHBP. He noticed that the deductions were still being taken from his checks and completed another waiver form on September 27, 2012. Deductions ceased on Pay Period 24, November 23, 2012.

Commissioner Nowlan asked if the member’s employer was able to locate the form that the member completed in 2011. The member said the employer was not. Commissioner Czech noted that the contributions are required by statute and asked if the Division had any confirmation of the member’s earlier request. Kierney Corliss responded that the Division has no record of receiving a waiver request until November 14, 2012.

Mr. Pointer stated that although the member submitted the waiver on September 27, 2012, the employer did not sign it until November 8, 2012. The member was not enrolled in a health plan, however, the deduction is required by statute, regardless of whether the member completes an application to enroll in a specific health plan. Mr. Pointer advised the Commission that federal Health Care Reform will require automatic enrollment in a health plan starting in 2014. He asked the member if he had kept a copy of the waiver request dated November 19, 2011. The member stated that he had not.

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

Upon return from Executive Session, Commissioner Nowlan asked the member if he had any evidence that he provided the waiver form to his employer when he was hired. The member responded that he did not.

Commissioner Czech made a motion to reimburse the member back to his waiver filing date in September 2012. Chairperson Culliton seconded the motion. All voted in favor.

Case #061302- This Division appeal concerned the denial of continuance of coverage for an overage disabled dependent. The continuance was denied because the dependent does not live with the member. Mr. Pointer advised the Commission that the dependent has not lived with the member for some time but was allowed to continue on the coverage due to a clerical error.

Commissioner Czech questioned how the dependent was able to live alone in Manhattan if she needs help with bathing, dressing, and toileting as indicated on the member’s application for continuance. The dependent’s siblings live a few blocks away and are therefore not always readily accessible, and the member lives in the Bronx. Chairperson Culliton asked if the dependent would be eligible for continuation had she lived with the member. Ms. Corliss stated that this case has been reviewed by Horizon on an annual basis since 2008, but it had not been reviewed by a Medical Director in 2013 because it was discovered that the dependent did not live with the member. The dependent was terminated from the member’s coverage and has enrolled in COBRA. Chairperson Culliton made a motion to table this appeal so that Horizon can review whether or not the dependent would meet the requirements for a disabled dependent had she been residing with the member. Commissioner Nowlan seconded the motion. All voted in favor.

Chairperson Culliton made a motion to return to Public Session. Commissioner Nowlan seconded the motion. All voted in favor.
Meeting No. 535, March 1, 2013; Meeting No. 536, March 13, 2013: Commissioner Nowlan offered a correction to the minutes for March 13, 2013; the time of adjournment should be 11:25 AM. Chairperson Culliton made a motion to approve both sets of minutes as corrected. Commissioner Czech seconded the motion. All voted in favor.

Case #061303- Chairperson Culliton made a motion to accept the offer as recommended by Socrates in the memo dated May 30, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

Case #061304- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated April 23, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

Case #061305- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated June 6, 2013. Commissioner Czech seconded the motion. All voted in favor.

Case #061306- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated June 6, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

Case #061307- Chairperson Culliton made a motion to accept the offer as recommended by Socrates in the memo dated May 30, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

Case #061308- Chairperson Culliton made a motion to accept the offer as recommended by Socrates in the memo dated June 6, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

There being no further appeals or 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 10:58 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission



 State Health Benefits Commission
Minutes, Meeting No 539
July 10, 2013; 1:00 PM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012 and a revised notice was sent April 26, 2013. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, July 10, 2013 at 1:22 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
Robert M Czech, Chair, Civil Service Commission
Neil Vance, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

ALSO PRESENT: 

David Pointer, Assistant Director, State Health Benefits Program
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Douglas Martucci, State Health Benefits Program
Edward Fox, Aon-Hewitt Consulting
James Christ, Aon-Hewitt Consulting
Susan Marsh, Aon-Hewitt Consulting

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

ISSUES

2014 Rate Renewals: Ed Fox, Aon-Hewitt Consulting, introduced James Christ and Susan Marsh. 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 2014
Medical/Rx Rate Renewal Recommendation
for Active Employees and Retirees
of the State Group


  • For Plan Year 2014, Aon Hewitt is recommending State Group premium rate changes of 8.1% for Active Employees, 10.6% for Early Retirees, and 3.8% 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 PPO                                 8.4%                  10.5%                 6.0%
Medical HMO                                 7.0%                 10.5%                 4.0%                                      
Prescription Drug PPO                     8.1%                 11.0%                 2.5%       
Prescription Drug HMO                    8.1%                 12.5%                 0.5%     
Total                                           8.1%                 10.6%                 3.8%                 

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

  • This recommended rate renewal assumes:

    • The Retiree Rx copays and Out-Of-Pocket Maximum for SHBP PPOs and HMOs will increase based on experience trends;

    • No change in the  benefit landscape for Plan Year 2014, with Aetna and Horizon both offering PPO, HMO, and HDHP options, and Express Scripts continuing as the SHBP’s PBM;

    • SHBP Medicare Integration will continue as EGWP Plus Wrap;

    • On July 1, 2014, the 4th and final year of the Chapter 78 Employee premium contribution schedule will go into effect. As a result, we are projecting an increase in the percentage of Employees enrolling in the lower-cost plan options for Plan Year 2014, although the actual numbers of Employees/Retirees enrolled will still be a very small percentage of overall State Group enrollment in the SHBP, with 98% of Actives and 99% of Retirees remaining in the legacy plans. 

    • 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 $40 million);

      • Elimination of Benefit Maximums (which increases costs $8 million);

      • Coverage of certain additional preventive care services for women (which increases costs by $6 million);

      • The Transitional Reinsurance Fee, assessed to employer group health plans like the SHBP to help stabilize the cost of individual and small-group coverage through the health insurance exchanges that will be implemented in 2014, which adds $18 million to SHBP State Group plan costs in Plan Year 2014, and

      • The Comparative Effectiveness Fee of $2 per member per year in Plan Year 2013 (which increases costs by $0.7 million).>

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

    • The health insurance exchanges mandated by federal health care reform will be effective in 2014, but should have minimal impact on enrollment or cost levels in the SHBP.

    • Plan Year 2013 State Employee enrollment will remain at the same level as Plan Year 2013, while State Retiree enrollment will increase about 4%.

  • 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 2013 and 2014.

    • HMOs have trended higher than NJ DIRECT for a number of years.  However, they appear to have moderated somewhat and we are therefore projecting that HMOs will trend at a rate less than the PPO plans in Plan Year 2014.

    • Projected Retiree costs have been reduced $23 million due to projected savings from the change to EGWP+Wrap.

    • 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 load for Child(ren) coverage will increase from 50% of the Single coverage rate to 59%.  This will increase Plan Year 2014 premiums for Employee+Child(ren) coverage an additional 6% and Family coverage an additional 4%.  (See Attachment A for premium increases by coverage tier).  This change will make the load for Child(ren) coverage more consistent with actual experience, which shows that the Child(ren) coverage claim costs are 81% 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:

    • 7.9% average annual trend increase over the two most recent years of experience, which is lower than industry trends;

    • Loss of the ERRP credit for Early Retirees, and

    • EGWP+Wrap savings, which reduce Medicare Retiree projected costs.
  • Plan Year 2014 projected costs for the State Group are $2.30 billion ($1.71 billion for Actives and $.59 billion for Retirees).  Plan Year 2014 renewal premiums are set to match the projected $2.30 billion costs, so there is no loss or gain projected for the State Group for Plan Year 2014.

Attachment A

SHBP State Employee Group
Plan Year 2014 Rate Renewal Recommendations

imagea

Recommended Plan Year 2014
Medical/Rx Rate Renewal Recommendation
for Active Employees and Retirees
of the Local Government Group


  • For Plan Year 2014, Aon Hewitt is recommending Local Government premium rate changes of 7.8% for Active Employees, 5.4% for Early Retirees, and 1.6% for Medicare Retirees.  In the aggregate, the recommended rate actions represent an overall increase for the Local Government Group of 6.5%.

                                                                                                     Early               Medicare
                                                                  Employees             Retirees             Retirees
    Medical PPO                                  8.4%                     5.0%                3.0%
   Medical HMO                                 9.0%                     7.0%                5.0%
   Prescription Drug PPO                      3.8%                     5.0%                0.0%
   Prescription Drug HMO                     3.8%                     7.0%                0.0%
   Total                                            7.8%                     5.4%                1.6%       

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

  • This recommended rate renewal assumes:

    • The Retiree Rx copays and Out-Of-Pocket Maximum for SHBP PPOs and HMOs will increase based on experience trends;

    • No change in the benefit landscape for Plan Year 2014,  with Horizon and Aetna providing the PPO, HMO, and HDHP options and Express Scripts continuing as the SHBP’s PBM;

    • SHBP Medicare Integration will continue as EGWP Plus Wrap;

    • Local Government employer groups will experience increases in employee contributions as a result of Chapter 78. As a result, we are projecting an increase in the percentage of employees enrolling in the lower-cost plan options for Plan Year 2014, although the actual numbers will still be a very small percentage of the overall SHBP enrollment, with 98% of Employees and 96% of Retirees remaining in the legacy plans. 

    • 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 $22 million);

      • Elimination of Benefit Maximums (which increases costs $5 million);

      • Coverage of certain additional preventive care services for women (which increases costs by $3 million);

      • The Transitional Reinsurance Fee, assessed to employer group health plans like the SHBP to help stabilize the cost of individual and small-group coverage through the health insurance exchanges that will be implemented in 2014, which adds $10 million to the SHBP Local Government Employer Group plan costs in Plan Year 2014, 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 enrollment will increase 5% and Retiree enrollment will increase 8% in Plan Year 2014.

    • The health insurance exchanges mandated by federal health care reform will be effective in 2014, but should have minimal impact on enrollment or cost levels in the SHBP.

  • 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 2013 and 2014.

    • HMOs are trending at a higher rate than NJ DIRECT, especially in the more recent experience and we are therefore projecting higher trends for HMOs in Plan Year 2014.

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

    • 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 load for Child(ren) coverage will increase from 50% of the Single coverage rate to 59%.  This will increase Plan Year 2014 premiums for Employee+Child(ren) coverage an additional 6% and Family coverage an additional 4%.  (See Attachment A for premium increases by coverage tier).  This change will make the load for Child(ren) coverage more consistent with actual experience, which shows that Child(ren) coverage claim costs are 81% 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:

    • 7.9% average annual trend increase over the two most recent years of experience, which is lower than industry norms;

    • Loss of the ERRP credit for Early Retirees, EGWP+Wrap savings which reduce Medicare Retiree projected costs, and

    • 1.0% margin added to the renewal rates, to bring the Claim Stabilization Reserve to the recommended level of 2 months of Plan costs.

  • Plan Year 2014 projected costs for the Local Government Group are 1.381 billion ($949 million for Actives and $432 million for Retirees).  Plan Year 2014 renewal premiums are set to generate a gain of $10 million, which will be added to the Claim Stabilization Reserve to bring the Claim Stabilization Reserve to the recommended level of 2.0 months of Plan costs.

Attachment A

SHBP Local Government Employer Group
Plan Year 2013 Rate Renewal Recommendations

imageb

 

Recommended Dental Plans Rate Renewal
for Plan Year 2014


  • For the SHBP Dental Plans (Employee and Retiree Dental Expense Plans and Employee DPOs) for Plan Year 2014, Aon Hewitt recommends the following premium rate adjustments, which – in the aggregate – represent an overall decrease in program costs of less than 1/10 of 1%. Please note that, given the impending Dental RFP , these rate actions are subject to change on July 1, 2014:

Dental Expense Plans

Actives                                   0.0%
Retirees                                  0.0%

The overall increase for the Dental Expense Plans is 0.0%

Dental Plan Organizations (DPOs)

Aetna                                   -2.0%
Benecare                                2.0%
Cigna                                     3.0%
Community                              3.0%
Healthplex                             -1.3%
Horizon                                 -2.2%

The overall decrease for the DPOs is 0.3%.

  • 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 for the past decade.

  • Aetna has agreed to reductions in the ASO fees for the Active Dental Expense Plan and Retiree Dental Expense Plan of 3.6% and 3.9%, respectively.

  • We have recalibrated the Value Ratio for the DPOs, resulting in the DPO average Value Ratio again being 1.00.  This is largely the result of a change in the method for developing DPO dental charges.  We are now using In-Network Dental Expense Plan incurred claims to develop an average charge amount per service, which is a departure from the historical approach of using the 50th percentile of dental charges from the Ingenix database.  As a result, the DPO value ratios now range from a high of 1.07 to a low of .89.

  • The DPOs requested rate renewals ranging from 4.6% to -2.2. For the DPOs that requested an increase, Aon Hewitt is recommending that the increase be capped at the lesser of the DPO vendor requested increase and the projected dental trend of 3.0%.

  • 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 vendors. 

  • Aon Hewitt is projecting a Retiree Claim Stabilization Reserve of $15 million 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 2013 and 2014.  As a result, Plan Year 2014 projected Active Employee enrollment is:  64,800 Employees enrolled in the Dental Expense Plan and 36,100 Employees enrolled in the DPO plans.  Retiree Dental Expense Plan enrollment is expected to increase 9.4%, to 86,400 for Plan Year 2014, consistent with prior years’ increases.

  • Plan Year 2014 projected costs for the SHBP Dental Plans are $136.5 million, with $58.3 million attributable to the Employee Dental Expense Plan, $59.6 million attributable to the Retiree Dental Expense Plan, and $18.6 million attributable to the DPOs.

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 2:30 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 540
July 18, 2013; 1:00 PM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012 and a revised notice was sent April 26, 2013. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, July 18, 2013 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
Robert M Czech, Chair, Civil Service Commission
Neil Vance, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

ALSO PRESENT: 

David Pointer, Assistant Director, State Health Benefits Program
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Susan Barrett, State Health Benefits Program
Edward Fox, Aon-Hewitt Consulting
James Christ, Aon-Hewitt Consulting
Susan Marsh, Aon-Hewitt Consulting
Carol Banks, Horizon Blue Cross Blue Shield of New Jersey

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

ISSUES

2014 Rate Renewals: Kierney Corliss stated that the Commissioners had previously provided some questions to Aon-Hewitt regarding the 2014 Rate Renewal Reports, and Aon-Hewitt had responded in writing. Edward Fox, James Christ, and Susan Marsh, all from Aon-Hewitt, were present to discuss the responses.

Commissioner Burdge asked Aon-Hewitt to elaborate on the response to the following questions: What was the claim experience to date for 2013 and how does it compare to the prediction made at the time of the Plan Year 2013 Rate Renewals? How does that compare with the amount of claims paid thus far in 2013? Ms. Marsh responded that at the time of the 2013 Rate Renewals, the estimate amount of incurred claims for 2013 was $2.074 billion. The revised estimate is $2.019 billion. At the present time, 20% of the estimated incurred claims for 2013 have been paid. Commissioner Burdge asked if, when claims are lower than anticipated, the required premium sharing results in employees paying a higher percentage of the total costs. Ms. Marsh responded that the difference in cost is approximately 0.1-0.2%, which does not have a dramatic impact on employee cost sharing. Mr. Fox stated that in years where costs are greater than anticipated, it results in employees paying a lower percentage of the total costs.

Commissioner Burdge asked Aon-Hewitt to discuss the impact of Local Government employers joining the SHBP and how the Affordable Care Act will affect the ability of Local Government employers to select against the plan. Ms. Marsh responded that typically a new employer has higher claim levels for the first year after joining the SHBP, but after that, claims tend to moderate. The Affordable Care Act places restrictions on experience rating for small group employers (less than 50 employees) so it may be more difficult for small Local Government employers to select against the plan; the only permitted ratings are now based on the age of the employees. Commissioner Vance stated that the rating principles introduced in the Affordable Care Act have already been in effect in New Jersey since the early 1990’s.

Commissioner Burdge asked how the mental health network would be impacted by Horizon’s switch from Magellan to ValueOptions, which will be effective in July 2014. Carol Banks, Horizon, responded that Horizon holds the individual provider agreements for mental health, so the network will remain the same.

Commissioner Burdge asked if the ScreenRx program that was being considered by the Plan Design Committee includes face-to-face contact. Mr. Christ responded that it is a telephonic outreach.

Commissioner Burdge asked where Aon-Hewitt gets the data for the wholesale index price for prescriptions. Ms. Marsh responded that Express Scripts sends monthly data feeds. The wholesale index price is based on the actual member claims paid by the SHBP and SEHBP.

Commissioner Burdge asked why the Aetna Medicare Advantage (MA) rate increases were higher than the Horizon rate increases, and if it had to do with the MA plans being fully-insured. Mr. Christ responded that Aetna does not offer a self-funded MA program. Although the premium increases were higher for the MA plans than the Horizon plans, the MA plans are still saving money for the SHBP.

Commissioner Nowlan asked Aon-Hewitt to elaborate on their response to the following question: If trend assumption for both State and Local Government prescription drugs is 8%, then why is the State premium increase 8% and the Local Government increase is 3.8%? Ms. Marsh responded that many State employees are not in the Preferred Drug Step Therapy Program, which results in reduced rebates. The Local Government group has a lower administrative fee per member because the administrative fees are charged per employee and the Local Government group has a higher member/employee ratio- that is, they have more dependents than the State group. The biggest difference is that the Local Government premiums for 2013 are higher than the State premiums, so a lower increase is required.

Commissioner Burdge made a motion to adopt the rates as presented by Aon-Hewitt, with the exception of the adjustment of the relative values for family and parent/child rates. Commissioner Nowlan seconded the motion. Motion failed (2: 3: 0, Commissioners Culliton, Czech, and Vance voted nay).

Commissioner Vance made a motion to adopt the rates as presented by Aon-Hewitt. Commissioner Czech seconded the motion. Motion passed (3: 2: 0, Commissioners Burdge and Nowlan voted nay).

Case #071301- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated July 3, 3013. Commissioner Nowlan seconded the motion. All voted in favor.

Case #071302- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated July 2, 3013. Commissioner Nowlan 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 Burdge.  All voted in favor.

The State Health Benefits Commission meeting was adjourned at 2:15 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


 State Health Benefits Commission
Minutes, Meeting No 541
August 14, 2013; 10:00 AM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012 and a revised notice was sent April 26, 2013. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, August 14, 2013 at 10:15 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
Robert M Czech, Chair, Civil Service Commission
Sylvia Allen-Ware, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees (via telephone)
Patrick Nowlan, Representative for State Government Employees (via telephone)

ALSO PRESENT: 

Florence Sheppard, Acting Director, Division of Pensions and Benefits
Diane Weeden, Deputy Attorney General
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Douglas Martucci, State Health Benefits Program
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey

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

Meeting No. 537, April 10, 2013: Commissioner Czech made a motion to approve the minutes. Chairperson Culliton seconded the motion. All voted in favor.

Meeting No. 538, June 12, 2013: Commissioner Czech made a motion to approve the minutes. Chairperson Culliton seconded the motion. All voted in favor.

ISSUES

Local Employer Updates: Kierney Corliss advised the Commission the Local Employers 2013 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 was no discussion.

Chairperson Culliton made a motion to go out of order and hear the Workers’ Compensation cases first. Commissioner Czech seconded the motion. All voted in favor.

Case #081301– Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated July 26, 2013. Commissioner Czech seconded the motion. All voted in favor.

Case #081302- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated July 22, 2013. Commissioner Czech seconded the motion. All voted in favor.

Case #081303- Chairperson Culliton made a motion to accept the offer as recommended by Socrates in the memo dated July 23, 2013. Commissioner Czech seconded the motion. All voted in favor. Chairperson Culliton amended her motion to authorize negotiation of the settlement as recommended by Socrates. Commissioner Czech seconded the amendment. All voted in favor.

Case #081304- Chairperson Culliton made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated August 1, 2013. Commissioner Czech seconded the motion. All voted in favor.

ISSUES

Hackensack Surgery Center v. SHBC- Deputy Attorney General Danielle Schimmel presented the background of the case to the Commission. The issue at hand was whether or not Hackensack Surgery Center (HSC) had standing to appear before the Commission. This case had been reviewed by the Commission at its meeting of January 9, 2013. At that time, DAG Schimmel presented the Commission with a memorandum detailing the Division’s opinion against granting HSC standing before the Commission. The Commission had authorized a 60 day discovery period so that DAG Schimmel could request documents such as: member assignments, payment records, proof of collection of coinsurance and/or balance billing, and any documents that had been presented to the members by HSC. The attorney for HSC, Benjamin Light, had advised DAG Schimmel that he would provide the requested documents, but that it may take longer than 60 days. Thereafter, Mr. Light advised DAG Schimmel that he would not provide the discovery documents unless the Commission recognized that HSC has standing to appear before the Commission.  

The Commission asked Dave Perry, Horizon Blue Cross Blue Shield of New Jersey, to discuss the impact of allowing out-of-network providers to appear before the Commission. Mr. Perry stated allowing out-of-network providers to appeal would impact the carriers’ ability to build and maintain a network. The network is a valuable asset; 85% of claim dollars in the NJ DIRECT plans are spent in-network. Benefits to members who use an in-network provider include a fixed copayment and no balance billing. When the member uses an out-of-network provider, the member is responsible for paying the provider and Horizon reimburses the member a percentage of the reasonable and customary costs.

In-network providers are not permitted to bill members for amounts above the contracted reimbursement. In-network providers have limited appeal rights with Horizon. Non-participating providers have no direct relationship with Horizon or the Commission; their relationship is with the members only. Mr. Perry stated that any action giving out-of-network providers standing before the Commission would give them more rights than in-network providers. This would compromise the integrity of the network and cause increased costs for the plan.

DAG Weeden stated that because the discovery documents were not provided, it is not known if the members suffered any financial harm. Mr. Light had set forth his arguments in letters from February 2011 and October 2011. In those letters, he referenced an unpublished case from the Appellate Division. DAG Schimmel’s memo from January 2013 sets forth arguments as to why that case is not relevant.

DAG Schimmel stated that her understanding from Mr. Light’s letter from December 2012 is that he is seeking a ruling as to whether HSC has standing on its own, without the member assignments.

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, Chairperson Culliton made a motion to deny standing for Hackensack Surgery Center both on the basis of its individual right to challenge the fee schedule as well as on the basis of the member assignments. Commissioner Czech seconded the motion. All voted in favor.

Chairperson Culliton made a motion to authorize Horizon to gather info from members to see if (1) there was balance billing; and (2) there was representation made that there would be no balance billing. Commissioner Czech seconded the motion. All voted in favor.

There being no further appeals or 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 11:08 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


 State Health Benefits Commission
Minutes, Meeting No 543
September 30, 2013; 1:00 PM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012 and a revised notice was sent September 23, 2013. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Monday, September 30, 2013 at 1:07 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
Robert M Czech, Chair, Civil Service Commission (via telephone)
Neil Vance, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees (via telephone)
Patrick Nowlan, Representative for State Government Employees (via telephone)

ALSO PRESENT: 

Florence Sheppard, Acting Director, Division of Pensions and Benefits
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Douglas Martucci, State Health Benefits Program
Susan Marsh, Aon Hewitt (via telephone)
James Christ, Aon Hewitt
Resolutions A (Closed Session) and B (Executive Session) – were read in their entirety.

ISSUES

Rates for New Plans for Plan Year 2014: James Christ, Aon Hewitt, gave the Commission an overview of the new PPO2035 and HMO2035 plans that were approved by the State Health Benefits Plan Design Committee on September 20, 2013. Susan Marsh, Aon Hewitt, explained that the premiums are approximately 86% of the premiums for the existing 2030 plans. The lower premiums are a result of member cost sharing on services that the existing plans cover with no cost sharing.

Chairperson Culliton made a motion to accept the rates as recommended by Aon Hewitt. Commissioner Nowlan 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 1:22 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 544
November 13, 2013; 10:00 AM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012 and a revised notice was sent September 27, 2013. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, November 13, 2013 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

John Megariotis, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff (Left at 10:50 AM)
Robert M Czech, Chair, Civil Service Commission
Sylvia Allen-Ware, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees (via telephone)

ALSO PRESENT: 

David Pointer, Assistant Director, Division of Pensions and Benefits
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey
Steven Peskin, Horizon Blue Cross Blue Shield of New Jersey
Joe O’Hara, Horizon Blue Cross Blue Shield of New Jersey
Katherine Impellizzeri, Aetna
Cathy Climo, Aetna

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

ISSUES

Carrier Updates: Kierney Corliss, Acting Secretary, provided the Commission with a report summarizing the cases that have gone to Independent Review Organizations (IRO) for Plan Year 2013. There was no discussion.

2014 Meeting Dates: Ms. Corliss stated that the number of member appeals being heard by the Commission has decreased significantly as a result of the IRO process. As a result, the Division of Pensions and Benefits recommends moving to an every-other-month schedule. Commissioner Nowlan made a motion to approve the proposed 2014 meeting schedule. Commissioner Burdge seconded the motion. All voted in favor.

Ms. Corliss stated that Chairperson Megariotis was unable to stay for the entire meeting and requested that the Commission go out of order to hear the Yucht case. Commissioner Czech made a motion to go out of order and move the presentations on Patient Centered Medical Homes (PCMH) and Accountable Care Organizations (ACO) to the end of the meeting. Commissioner Nowlan seconded the motion. All voted in favor.

Appellate Court Decisions

Philip Yucht vs. SEHBC: This Appellate Court Decision dealt with tiering for out-of-network mental health claims. Deputy Attorney General Danielle Schimmel stated that the Commission must decide on how to implement the Decision. She referred the Commission to a draft resolution that had been prepared for discussion.

Commissioner Czech asked what the impact on the program would be. Assistant Director David Pointer stated that if claims were processed retroactive to the date that the Commission implemented the tiering, the approximate cost would be between $40 million and $50 million. Commissioner Nowlan asked how many appeals had been made. Mr. Pointer responded that six appeals had come to the State Health Benefits Commission and School Employee’s Health Benefits Commission.  There were 22 first level appeals made through Horizon.

Commissioner Burdge asked if the SEHBC had taken action yet. Mr. Pointer stated that it was on the agenda for the next SEHBC meeting. Commissioner Nowlan made a motion to table action on the resolution until the December meeting so that the SEHBC could take action. Commissioner Burdge seconded the motion. All voted in favor.

Case #111301– Commissioner Czech made a motion to accept the offer as recommended by Socrates in the memo dated July 18, 2013. Commissioner Burdge seconded the motion. All voted in favor.

Case #111302 - Commissioner Czech made a motion to accept the offer as recommended by Socrates in the memo dated October 3, 2013. Commissioner Burdge seconded the motion. All voted in favor.

Case #111303 - Commissioner Czech made a motion to authorize negotiation of the settlement as recommended by Socrates in the memo dated April 5, 2013. Chairperson Megariotis seconded the motion. All voted in favor.

Case #111304 - Commissioner Czech made a motion to accept the offer as recommended by Socrates in the memo dated January 23, 2013. Commissioner Burdge seconded the motion. All voted in favor.

Patient Centered Medical Homes and Accountable Care Organizations: Representatives from Horizon and Aetna were present to discuss how Patient Centered Medical Homes and Accountable Care Organizations improve health care delivery by providing an incentive for physicians to improve member health outcomes. Dave Perry, Dr. Steven Peskin, and Joe O’Hara presented for Horizon. Katherine Impellizzeri and Cathy Climo presented for Aetna.

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

The State Health Benefits Commission meeting was adjourned at 1:00 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 545
December 11, 2013; 10:00 AM

Adequate notice of this meeting was 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 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012 and a revised notice was sent September 27, 2013. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, December 11, 2013 at 10:05 AM.  The meeting was held at Thomas Edison State College, 101 West State Street, Prudence Hall, 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
Robert M Czech, Chair, Civil Service Commission
Sylvia Allen-Ware, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees

ALSO PRESENT: 

David Pointer, Assistant Director, Division of Pensions and Benefits
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey
Mark Cipriano, Division of Pensions and Benefits
Douglas Martucci, Division of Pensions and Benefits

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

ISSUES

Local Employer Update: Acting Secretary Kierney Corliss distributed reports of Terminating Local Government Employers and New Local Government Employers for Plan Year 2013.  There were a total of 1,840 subscribers terminating locations and 4,861 subscribers from new locations. Ms. Corliss advised the Commission that these figures did not include dependents.

Open Enrollment Update: Ms. Corliss distributed a summary of membership in each of the health plans effective January 1, 2014. Commissioner Nowlan asked if the State Health Benefits Program (SHBP) had seen a decline in enrollment for part-time employees enrolled under the provisions of Chapter 172. David Pointer, Assistant Director, responded that current enrollment is less than 200 subscribers and that the Division would examine if there was a marked reduction in that group.

Wellness Program Update: Mr. Pointer advised the Commission that the Division gave a presentation on NJWELL at the League of Municipalities Convention in November 2013 and
It was well-received. An announcement mailer was sent in early fall and regional biometric screenings were in the process of being scheduled.

Horizon Laptop Thefts: Dave Perry, Horizon Blue Cross Blue Shield of New Jersey, advised the Commission that two laptops had recently been taken from a Horizon office. He stated that Horizon believed that this was a theft of hardware only. Results of a forensic analysis indicate that there was a maximum of 10,094 SHBP/SEHBP members whose information may have been on the computers. Horizon is in the process of reassessing their encryption and security processes.

Minutes: Ms. Corliss advised that the minutes were not ready. Commissioner Nowlan made a motion to table the minutes. Commissioner Burdge seconded the motion. All voted in favor.

Appellate Court Decisions

Philip Yucht vs. SEHBC: This Appellate Court Decision dealt with tiering for out-of-network mental health claims. Ms. Corliss reminded the Commission that they had tabled this case at the last meeting so that the SEHBC could act on it. The November 27, 2013 SEHBC meeting had been cancelled for lack of a quorum. 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 Burdge made the following motion:

Whereas on September 3, 2013, the Superior Court of New Jersey, Appellate Division issued its opinion in I/M/O Philip Yucht, A-6298-10T1; and

Whereas N.J.S.A. 52:14-27.29(c) requires the SHBC to offer a successor plan, and a state managed care plan that reimburses 80% or 70%, respectively, of the charges of out of network providers, or the reasonable and customary charges, whichever is less;

Therefore, be it resolved that the Division of Pensions and Benefits and its third-party administrators shall apply the Yucht decision prospectively and reimburse payment of behavioral health claims using the reasonable and customary allowance set forth in the national database of charges to claims incurred on or after September 3, 2013.

Commissioner Nowlan seconded the motion. Motion failed (2: 2: 1, Commissioners Culliton and Czech, nay; Commissioner Allen-Ware, abstain).

Commissioner Czech made a motion to approve the Resolution as written and placed on the agenda. Chairperson Culliton seconded the motion. Motion failed (2: 2: 1, Commissioners Burdge and Nowlan, nay; Commissioner Allen-Ware, abstain).

Case #121301– Chairperson Culliton made a motion to accept the offer as recommended by Socrates in the memo dated November 8, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

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

The State Health Benefits Commission meeting was adjourned at 10:52 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

 

 

 
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