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Pensions and Benefits
STATE HEALTH BENEFITS COMMISSION
MEETING MINUTES 2014
 
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 2013 Health Benefit Commission Meeting Minutes (and prior years), click here


State Health Benefits Commission
Minutes, Meeting No 546
January 8, 2014; 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 January 6, 2014. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, January 8, 2014 at 10:12 AM.  The meeting was held at 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Robert M Czech, Chair, Civil Service Commission (left at 11:05)
Sylvia Allen-Ware, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees (via telephone, joined at 10:19)
Patrick Nowlan, Representative for State Government Employees (via telephone, disconnected at 11:15)

ALSO PRESENT: 

Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
David Pointer, Assistant Director
Mark Cipriano, Division of Pensions and Benefits
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Sue Rizzni, Magellan
Dr. Lou Parrott, Magellan
Rosemary Middlebrook, Horizon Blue Cross Blue Shield of New Jersey

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

ISSUES

Carrier Updates: Acting Secretary Kierney Corliss distributed a summary of changes to the Preferred Drug Step Therapy program for 2014. There was no discussion.

Philip Yucht vs. SEHBC: David Pointer asked the Commission to table the case until the School Employees’ Health Benefits Commission had taken action on it. Chairperson Culliton made a motion to table the matter. Commissioner Nowlan seconded the motion. Motion passed (4: 0: 0, Commissioner Burdge was absent).

Chairperson Culliton made a motion to go into Closed Session to hear member appeals. Commissioner Czech seconded the motion Motion passed (4: 0: 0, Commissioner Burdge was absent).

At this time, Commissioner Burdge joined the meeting.

Case #011401 (member’s representative present)— This NJ DIRECT10/Magellan appeal concerned the denial of benefits for expenses for residential treatment for an eating disorder at Avalon Hills due to lack of medical necessity. The member’s representative gave a background of the case to the Commission. Magellan had approved 25 days of residential treatment. After 25 days, continued residential treatment was denied, and Magellan stated that a Partial Hospitalization Program (PHP) was the appropriate level of care. The member’s representative stated that the member did not have a supportive home environment and was not able to return home at that time; she was at risk for relapse.

Dr. Louis Parrott, Medical Director, Magellan, advised the Commission that at the time of the denial, there was concern that the facility was not exploring alternative housing for the member, considering her home environment. As a result, she did not meet the continued stay criteria D: the treatment plan can reasonable expect to bring about significant improvement. She also did not meet criteria F; inability to adhere to a meal plan.

At this time, Commissioners Burdge, Czech and Nowlan exited the meeting. Chairperson Culliton stated that the meeting needed to be adjourned and this appeal rescheduled. Commissioner Burdge rejoined the meeting. Chairperson Culliton made a motion to table the matter until the next meeting. Commissioner Allen-Ware seconded the motion. Motion passed (3: 0: 0, Commissioners Czech and Nowlan were absent).

Chairperson Culliton made a motion to return to public session. Commissioner Allen-Ware seconded the motion. Motion passed (3: 0: 0, Commissioners Czech and Nowlan were absent).

Chairperson Culliton made a motion to adjourn. Commissioner Allen-Ware seconded the motion. Motion passed (3: 0: 0, Commissioners Czech and Nowlan were absent).

The State Health Benefits Commission meeting was adjourned at 11:20 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 547
March 12, 2014; 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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2014. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, March 12, 2014 at 10:20 AM.  The meeting was held at 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
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
Mark Cipriano, Division of Pensions and Benefits
David Pointer, Division of Pensions and Benefits
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Dr. Lou Parrott, Magellan
Rosemary Middlebrook, Horizon Blue Cross Blue Shield of New Jersey
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey
Katherine Impellizzeri, Aetna
Dr. Kay Eckroth, Aetna

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

Meeting No. 539, July 10, 2013: Chairperson Culliton made a motion to approve the minutes. Commissioner Burdge seconded the motion. All voted in favor.

Meeting No. 540, July 18, 2013: Chairperson Culliton made a motion to approve the minutes. Commissioner Czech seconded the motion. All voted in favor.

Meeting No. 541, August 14, 2013: Chairperson Culliton made a motion to approve the minutes. Commissioner Burdge seconded the motion. All voted in favor.

Meeting No. 543, September 30, 2013: Chairperson Culliton made a motion to approve the minutes. Commissioner Burdge seconded the motion. All voted in favor.

Meeting No. 544, November 13, 2013: Chairperson Culliton made a motion to approve the minutes. Commissioner Burdge seconded the motion. All voted in favor.

Issues

Carrier Updates: Acting Secretary Kierney Corliss advised the Commission that Kennedy Hospital, which had previously been terminated from Aetna’s network as of June 1, 2013, was now participating in Aetna’s network effective February 18, 2014.

PBM Contract Extension: Chairperson Culliton made a motion to go into Executive Session to discuss this item. Commissioner Burdge seconded the motion. All voted in favor. There was no discussion regarding this matter upon return from Executive Session.

Hackensack Surgery Center vs. SHBC: Dave Perry, Horizon Blue Cross Blue Shield of New Jersey, was present to explain the benefits of Horizon’s provider network and the results of Horizon’s outreach to the eight members involved in Hackensack’s appeal.

Mr. Perry stated that maintenance of the provider network is one of Horizon’s critical functions as a plan administrator. There are certain benefits afforded to in-network providers that are not available to out-of-network providers. One of these benefits is the right to appeal on behalf of the member. Another benefit is that participating providers are paid directly.

A member choosing to use a non-participating provider has a contractual relationship with that provider. The provider and Horizon have no contractual relationship. Horizon pays benefits directly to the member based on the provisions of the plan. As a courtesy to the member, if the amount of the payment exceeds $10,000, then the check is sent directly to the non-participating provider. This is done to reduce the financial burden on the member, so the member does not have to pay out of pocket and then wait for a reimbursement of that size. The SHBP does not accept assignments of benefits; the payment of the check to the provider is done solely based on the dollar threshold and not as a result of an assignment.

Chairperson Culliton asked if there were ever any instances that Horizon would pay the provider directly for an amount less than $10,000. Mr. Perry stated that for substance abuse claims, the threshold is $5,000. This is done because there is potential for an individual with a substance abuse problem to misuse the funds. 

Chairperson Culliton stated that the last time this matter was before the Commission, Horizon had been asked to reach out to the individual members that Hackensack claimed to be representing. She asked Mr. Perry to give an update on the outreach efforts. Mr. Perry advised the Commission that of the eight members, two had responded in writing that they were told by the facility that Horizon’s payment would be accepted as payment in full; they had not received balance bills. One member verbally confirmed that he had not been balance billed. One member requested that the letter be resent. Two members had not responded to either the letters or voice mails. Two members had not responded to the letters and did not have answering machines. None of the letters had been returned as undelivered.

Chairperson Culliton asked if any of the members themselves had appealed as a result of receiving a balance bill. Mr. Perry responded that they had not. Horizon had received only a letter from the facility, which was treated an inquiry, not as an appeal. A response was sent by Horizon advising Hackensack that the member would need to initiate an appeal.

Philip Yucht vs. SEHBC: Ms. Corliss advised the Commission that the draft resolution before the Commission would achieve the same result as the resolution that had been passed by the SEHBC. Commissioner Burdge made a motion to approve the resolution as drafted—Where a member provides proof of payment of coinsurance and amounts above the reasonable and customary charge, the Division of Pensions and Benefits and Horizon shall apply the Yucht decision retroactively 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 January 1, 2009. Commissioner Nowlan seconded the motion. All voted in favor.

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

Case #011401 (member’s representative present)— This tabled NJ DIRECT10/Magellan appeal concerned the denial of benefits for expenses for residential treatment for an eating disorder at Avalon Hills due to lack of medical necessity. The member’s representative discussed the background of the case. Dr. Louis Parrott, Magellan, advised the Commission that he participated in the Level 2 Panel Review with Horizon on November 16, 2011. At that time, the facility indicated that the member was following her meal plan. The facility stated that the member was not able to return home because of conflict that existed within the family. However, they advised that they were not looking for alternative housing for the member at that time. The medical charts supported the statement that alternative housing was not being sought. Therefore, the member was not meeting the continued stay criterion that required that the treatment plan can be reasonably expected to bring about improvement.

Magellan’s recommendation for the appropriate level of care would have been 60 days of Partial Hospitalization treatment followed by 55 days of intensive outpatient treatment. >

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

Upon return from Executive Session, Commissioner Czech made a motion to authorize payment as follows: for partial hospitalization from October 10, 2011 through December 31, 2011 in the amount of $44,542.20; intensive outpatient treatment from January 1, 2012 through March 20, 2012 in the amount of $22,850.30; less an overpayment for residential services from March 1, 2012 through March 20, 2012, for a total of $52,242.52. Chairperson Culliton seconded the motion. Motion passed (4: 1: 0, Commissioner Burdge voted nay).

Case #011402 (member present)—This Aetna Dental appeal concerned the denial of benefits for labial veneers. The member advised the Commission that the bonding was for the purpose of reducing the spaces between her son’s four front teeth, which were causing him discomfort when he ate. She stated that the procedure was done to reduce her son’s pain and prevent decay.

Dr. Kay Eckroth, Dental Director, Aetna, stated that bonding for the purpose of changing the dimensions of the teeth is not covered because it is not treating decay.

Commissioner Burdge made a motion to deny the appeal based on plan provisions. Chairperson Culliton seconded the motion. All voted in favor.

Case #011403 (member present)—This Aetna Dental appeal concerned the denial of benefits for replacement dentures within five years of the date that the existing appliance was placed.

The member stated that she had received an appliance in 2008, which the plan paid for. She had the appliance replaced in 2009; Aetna denied the claim for the replacement because it was within five years of the date the original was replaced. She stated that she felt the plan should pay for a replacement because she paid out of pocket for the most recent appliance.

Katherine Impellizzeri, Aetna, confirmed that the claim from 2009 was denied. She advised the Commission that a claim was received in July 2013 for another denture, which was denied. The five-year frequency limitation is based on the date the existing appliance was placed. This limitation still applies even though Aetna had not paid for the most recent appliance.

The member stated that she did not receive a new appliance in 2013; she started the procedure but it was not completed because she could not afford to pay out of pocket. Ms. Corliss noted that the claim form received from the provider did not indicate that it was a request for predetermination. Ms. Impellizzeri confirmed that the claim had been processed as if services were actually rendered.

Chairperson Culliton noted that if the services were never provided, then the member could wait until the five year period had elapsed, which would be December 2014.

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

Upon return from Executive Session, Chairperson Culliton stated that since no services had been provided, the Commission would treat the appeal as a request for predetermination. She made a motion to deny the request for predetermination due to the five year frequency limitation. Commissioner Czech seconded the motion. Motion passed (4: 0: 1, Commissioner Burdge abstained).

Commissioner Burdge made a motion to return to public session. Commissioner Nowlan seconded the motion. All voted in favor.

Case #011404—Chairperson Culliton made a motion to authorize Socrates to resolve the matter in the amounts specified in the memo dated January 28, 2014. Commissioner Nowlan seconded the motion. All voted in favor.

Case #011405— Chairperson Culliton made a motion to authorize Socrates to accept the amount specified in the memo dated January 31, 2014. Commissioner Nowlan seconded the motion. All voted in favor.

Case #011406— Chairperson Culliton made a motion to authorize Socrates to accept the amount specified in the memo dated September 30, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

Commissioner Czech made a motion to adjourn. Commissioner Nowlan seconded the motion. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 12:50 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 548
May 14, 2014; 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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2014. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, May 14, 2014 at 10:05 AM.  The meeting was held at 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
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: 

Diane Weeden, Deputy Attorney General
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
David Pointer, Division of Pensions and Benefits
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

NJ WELL: Douglas Martucci, Division of Pensions and Benefits, gave a brief presentation on NJ WELL, the incentive-based Wellness Program for active SHBP members.

Hackensack Surgery Center vs. SHBC: This case had been remanded from the Appellate Division of the Superior Court. The Commission had previously passed a motion denying standing to Hackensack Surgery Center. The Commission had been provided with a draft resolution of a Final Administrative Determination for approval. Benjamin D. Light of Callagy Law appeared on behalf of Hackensack Surgery Center. Mr. Light stated that he had declined to engage in a discovery period until the Commission has issued a written opinion as to whether or not Hackensack has standing to appear before the Commission. 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 approve the Final Administrative Determination as presented. Commissioner Czech seconded the motion. All voted in favor.

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

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

Case #051401 — This Division appeal concerned a State Employee who had not submitted a waiver for health benefits coverage when he was hired. As a result, a health benefits contribution of 1.5% of his salary was being deducted from his paychecks. The member was notified by the Division that he must submit a waiver in order to stop the deductions. He had submitted a waiver and was now requesting a retroactive refund. Commissioner Czech asked if the employer had been contacted. Ms. Corliss responded that she had called the employer and asked that the members records be reviewed. There was no evidence in the member’s personnel file that he had submitted a waiver prior to September of 2013. The member claimed he had submitted a waiver upon being hired, but he did not have proof. Chairperson Culliton made a motion to deny the appeal. Commissioner Czech seconded the motion. Motion passed (3: 1: 1, Commissioner Nowlan voted nay; Commissioner Burdge abstained). >

Commissioner Burdge made a motion to return to public session. Commissioner Nowlan seconded the motion. All voted in favor.

Case #051402—Chairperson Culliton made a motion to authorize Socrates to resolve the matter as proposed. Commissioner Burdge seconded the motion. All voted in favor.

Case #051403— Chairperson Culliton made a motion to authorize Socrates to resolve the matter as proposed. Commissioner Czech seconded the motion. All voted in favor.

Case #051404— Chairperson Culliton made a motion to authorize Socrates to accept the amount specified in the memo dated September 30, 2013. Commissioner Nowlan seconded the motion. All voted in favor.

Chairperson Culliton made a motion to adjourn. Commissioner Nowlan seconded the motion. All voted in favor. >
The State Health Benefits Commission meeting was adjourned at 10:40 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


 

State Health Benefits Commission
Minutes, Meeting No 549
July 9, 2014; 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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2014. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, July 9, 2014 at 1:10 PM.  The meeting was held at 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Robert M Czech, Chair, Civil Service Commission
Gale Simon, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance (for appeals)
Neil Vance, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance (for rate renewals)
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, Division of Pensions and Benefits
Edward Fox, Aon Hewitt
Susan Marsh, Aon Hewitt
Jeffrey Chanin, Aon Hewitt
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey (Horizon)
Dave Perry, Horizon
Dr. Louis Parrott, Magellan

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

Issues

2015 Rate Renewals: Ed Fox, Aon-Hewitt Consulting, introduced Susan Marsh and Jeffrey Chanin. Mr. Fox gave an overview of the 2015 proposed rates. Mr. Chanin reviewed the 2015 Rate Renewal Recommendations for Medical/Rx for the Active Employees and Retirees of the State Group and Active Employees and Retirees of the Local Government Group of the State Health Benefits Program (SHBP). The following is a summary of the presentation:

Recommended Plan Year 2015 Medical/Rx Rate Renewal Recommendation for Active Employees and Retirees of the State Group

  • For Plan Year 2015, Aon Hewitt is recommending State Group overall premium rate changes of 8.0% for Active Employees, 7.7% for Early Retirees, and 6.9% for Medicare Retirees. In the aggregate, the recommended rate actions represent an overall increase for the State Group of 7.8%, slightly below the Plan Year 2014 recommended renewal action of 8.1%. Following are our recommended premium rate changes by plan type:

 

                                                                    Early               Medicare       
                                       Employees        Retirees          Retirees

Medical PPO                  8.7%                5.2%                3.0%
Medical HMO                 3.9%                6.9%                0.0%
Prescription Drug PPO     8.4%               14.0%              10.0%
Prescription Drug HMO    8.4%               18.5%              15.0%
Total                           8.0%                7.7%                6.9%

 

  • This recommended Plan Year 2015 rate renewal assumes:
    • The Retiree Rx copays and Out-Of-Pocket Maximum limits for SHBP PPOs and HMOs will increase based on formulas as specified by regulation (these changes are projected to decrease prescription drug costs by 2.0%);
    • No change in the benefit landscape for Plan Year 2015, with Aetna and Horizon both offering PPO, HMO, and HDHP options, and Express Scripts continuing as the SHBP’s PBM;
    • SHBP Medicare Prescription Drug Integration will continue as EGWP Plus Wrap;
    • State employees experienced increases in employee contributions on July 1, 2014, as a result of Chapter 78. Therefore, we are projecting a small increase in the percentage of Employees enrolling in the lower-cost plan options for Plan Year 2015, although the actual numbers of Employees/Retirees enrolled are expected to remain very small percentages of overall State Group enrollment, with only 3% of Actives and 1% of Retirees enrolling in the new plans.
    • NJWELL is projected to increase Plan Year 2015 net costs $5 million, with savings anticipated for future years.
    • The New Jersey State Breast Evaluation and Other Medically-Necessary Testing mandate is projected to increase medical costs by 0.5%.
    • 2.0% decrease in projected prescription drug trends as a result of better pricing terms anticipated in the ESI contract extension.
    • Overall, Plan Year 2015 State Employee enrollment will decrease approximately 1% from the Plan Year 2014 level, while State Retiree enrollment will increase approximately 3%.
    • The following components of Federal Health Care Reform impact the SHBP in Plan Year 2015:
      • In-Network Out-Of-Pocket Maximum – It is expected that the In-Network medical and prescription drugs will have a combined out-of-pocket maximum of $6,600 Single and $13,200 Family as allowed by Federal Health Care Reform. The impact of changing the maximum limits is expected to have an insignificant cost impact on the SHBP.
      • The Transitional Reinsurance Fee ($44 per Non-Medicare member), assessed to employer group health plans such as the SHBP to help stabilize the cost of individual and small-group coverage through the state health insurance exchanges that were implemented in 2014, is projected to add $12 million to SHBP State Group plan costs in Plan Year 2015.
      • The estimated Comparative Effectiveness Fee of $2.25 per member per year in Plan Year 2015 is projected to increase costs by $0.7 million.
  • The renewal report summarizes, in Exhibit 8, a number of possible benefit plan design changes, each of which could further reduce plan costs in Plan Year 2015 and beyond.
  • Differences in the rate changes among Actives and Retirees, benefit plans and coverage tiers 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 2014 and 2015. The Medicare retiree medical trend has been lowered from 5.0% to 4.5%. The low trend combined with favorable experience results in very low medical premium increases for Plan Year 2015.
    • In recent years, HMO medical trends have been lower than the PPO trend. For Plan Year 2015, PPO trend is projected to remain at 8.3% but the HMO trend has been lowered from 7.5% in the 2014 Renewal report to 7.0%. The lower HMO trend combined with favorable experience results in lower premium increases for HMO as compared to PPO.
    • Rx trends are expected to increase to 11.5% for retirees and 9.0% for active employees. The higher Rx trends are due to increasing frequency of high-cost compound drugs and new high-cost specialty drugs.
    • The Retiree HMO Rx recommended premium increases are greater than the PPO Rx recommended premium increases based on experience. The Retiree HMO Rx loss ratio is 19% higher than PPO Rx loss ratios. This is due to the Legacy HMO plan which has lower copays than the Legacy PPO plans, but premium levels that are relatively too low.
    • New federal regulations have reduced the projected 2014 and 2015 EGWP credits, although EGWP still provides significant savings with projected credits of $70 million for Plan Year 2015.
    • 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 is recommended to increase from 59% of the Single coverage rate to 69%. This will increase Plan Year 2015 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 adjustment will make the Employee+Child(ren) rate more consistent with actual experience, which shows that the Child(ren) coverage claim costs are 87% of the cost of Employee coverage, an increase from the pre-Health Care Reform level of 72%.
    • Plan Year 2015 projected costs for the State Group are $2.45 billion ($1.81 billion for Actives and $.64 billion for Retirees). Plan Year 2015 renewal premiums are set to match the projected $2.45 billion costs, so there is no loss or gain projected for the State Group for Plan Year 2015.

Recommended Plan Year 2015 Medical/Rx Rate Renewal Recommendation for Active Employees and Retirees of the Local Government Group

  • For Plan Year 2015, Aon Hewitt is recommending Local Government overall premium rate changes of 8.1% for Active Employees, 5.5% for Early Retirees, and 6.1% for Medicare Retirees. In the aggregate, the recommended rate actions represent an overall increase for the Local Government Group of 7.4%, almost 1% greater than the Plan Year 2014 renewal of 6.5%. Following are our recommended premium rate changes by plan type:

 

                                                                               Early               Medicare
                                                  Employees       Retirees           Retirees
Medical PPO                         8.9%                5.0%                1.9%
Medical HMO                        4.4%                5.0%                3.0%
Prescription Drug PPO            7.5%               11.0%              10.0%
Prescription Drug HMO           7.5%               16.0%              10.0%
Total                                  8.1%                5.5%                6.1%

  • This recommended Plan Year 2015 rate renewal assumes:
    • The Retiree Rx copays and Out-Of-Pocket Maximum limits for SHBP PPOs and HMOs will increase based on formulas as specified by regulation (these changes are projected to decrease prescription drug costs by 2.0%);
    • No change in the benefit landscape for Plan Year 2015, with Horizon and Aetna providing the PPO, HMO, and HDHP options and Express Scripts continuing as the SHBP’s PBM;
    • SHBP Medicare Prescription Drug Integration will continue as EGWP Plus Wrap;
    • Local Government employer groups experienced increases in employee contributions on July 1, 2014, as a result of Chapter 78. Therefore, we are projecting a small increase in the percentage of employees enrolling in the lower-cost plan options for Plan Year 2015, although the actual numbers of Employees/Retirees enrolled are expected to remain very small percentages of the overall Local Government enrollment, with only 3% of Employees and 4% of Retirees enrolling in the new plans.
    • NJWELL is projected to increase Plan Year 2015 net costs $3 million, with savings anticipated for future years.
    • The New Jersey State Breast Evaluation and Other Medically-Necessary Testing mandate is projected to increase medical costs by 0.5%.
    • 2.0% decrease in projected prescription drug trends as a result of better pricing terms anticipated in the ESI contract extension.
    • Overall, Plan Year 2015 Local Government Active Employee enrollment will increase approximately 1% and Retiree enrollment will increase approximately 6%.
  • The following components of Federal Health Care Reform impact the SHBP in Plan Year 2015:
    • In-Network Out-Of-Pocket Maximum – It is expected that the In-Network medical and prescription drugs will have a combined out-of-pocket maximum of $6,600 Single and $13,200 Family as allowed by Federal Health Care Reform. The impact of changing the maximum limits is expected to have an insignificant cost impact on the SHBP.
    • The Transitional Reinsurance Fee ($44 per Non-Medicare member), assessed to employer group health plans such as the SHBP to help stabilize the cost of individual and small-group coverage through the state health insurance exchanges that were implemented in 2014, is projected to add $7 million to the SHBP Local Government Employer Group plan costs in Plan Year 2015.
    • The estimated Comparative Effectiveness Fee of $2.25 per member per year in Plan Year 2015 is projected to increase costs by $0.4 million.
  • The renewal report summarizes, in Exhibit 8, a number of possible benefit plan design changes, each of which could further reduce plan costs in Plan Year 2015 and beyond.
  • Differences in the rate changes among Actives and Retirees benefit plans and coverage tiers 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 2014 and 2015. The Medicare Retiree medical trend has been lowered from 5.0% to 4.5%. The low trend combined with favorable experience, results in very low medical premium increases for Plan Year 2015.
    • In recent years, HMO medical trends have been lower than the PPO trend. For Plan Year 2015, PPO trend is projected to remain at 8.3% but the HMO trend has been lowered from 7.5% in the 2014 Renewal report to 7.0%. The lower HMO trend combined with favorable experience results in lower premium increases for HMO as compared to PPO.
    • Rx trends are expected to increase to 11.5% for retirees and 9.0% for active employees. The higher Rx trends assumptions are due to increasing frequency of high-cost compound drugs and new high-cost specialty drugs.
    • The Retiree HMO Rx recommended premium increases are greater than the PPO Rx recommended premium increases based on experience. The Retiree HMO Rx loss ratio is 10% higher than PPO Rx loss ratios. This is due to the Legacy HMO plan which has lower copays than the Legacy PPO plans, but premium levels that are relatively too low.
    • New Federal regulations have reduced the projected 2014 and 2015 EGWP credits, although EGWP still provides significant savings with projected credits of $41 million for Plan Year 2015.
    • 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 is recommended to increase from 59% of the Single coverage rate to 69%. This will increase Plan Year 2015 premiums for Employee+Child(ren) an additional 6% and Family coverage an additional 4%. (See Attachment A for premium increases by coverage tier). This adjustment will make the Employee + Child(ren) rate more consistent with actual experience, which shows that Child(ren) coverage claim costs are 87% of the cost of Employee coverage, an increase from the pre-Health Care Reform level of 72%.
    • Plan Year 2015 projected costs for the Local Government Group are $1.466 billion ($984 million for Actives and $482 million for Retirees).
    • The 12/31/15 Claim Stabilization Reserve projected at 2.0 months of projected Plan costs which matches the target reserve, so Plan Year 2015 premiums include no margin and are set to produce no loss or gain.

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 #071401 (member present) — This Horizon/Magellan appeal concerned the denial of residential treatment for substance abuse. The member gave a presentation explaining why he felt residential treatment was necessary. Dr. Louis Parrott, Magellan, explained that it was Magellan’s position that medical necessity criteria had not been met for residential treatment; however, the member met criteria for the intensive outpatient level of care (IOP).  While the member had been attending outpatient counseling sessions, he had not been attending an IOP program as defined by the American Society of Addiction Medicine (ASAM).

Commissioner Czech made a motion to reimburse the member at the rate that the SHBP would have paid for IOP treatment for the 30 day period. Chairperson Culliton seconded the motion. Motion passed (3: 2: 0; Commissioners Burdge and Nowlan voted nay).

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

Chairperson Culliton made a motion to adjourn. Commissioner Nowlan seconded the motion. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 3:30 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission


State Health Benefits Commission
Minutes, Meeting No 550
July 17, 2014; 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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2014. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Thursday, July 17, 2014 at 1:10 PM. The meeting was held at 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Robert M Czech, Chair, Civil Service Commission
Neil Vance, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance (for rate renewals)
Gale Simon, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance (for appeals)
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, Division of Pensions and Benefits
Edward Fox, Aon Hewitt
Susan Marsh, Aon Hewitt
Jeffrey Chanin, Aon Hewitt
Dave Perry, Horizon

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

Minutes, Meeting No. 545, December 11, 2013: Commissioner Czech made a motion to adopt the minutes. Chairperson Culliton seconded the motion. All voted in favor.

Minutes, Meeting No. 546, January 8, 2014: Commissioner Vance made a motion to adopt the minutes. Commissioner Burdge seconded the motion. All voted in favor.

Issues

Local Employer Updates: Acting Secretary Kierney Corliss distributed a summary of new employers joining the State Health Benefits Program (SHBP) and those terminating their participation in the SHBP for 2014. There was no further discussion.

2015 Rate Renewals: Commissioner Czech made a motion to set the rates for 2015 as recommended for State and Local Government in the reports as presented by the consultants for both medical and prescription. Commissioner Vance seconded the motion. Motion passed (3: 2: 0; Commissioners Burdge and Nowlan voted nay).

Commissioner Vance made a motion to formally thank Susan Marsh for her many years of service as the consulting actuary for the Commission, and to wish her well in her retirement. Chairperson Culliton seconded the motion. All voted in favor.

At 2:36 PM, Commissioner Vance left the meeting and was replaced by Commissioner Simon.

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

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

Case #071403 (member present) — This Division appeal concerned eligibility for health benefits for a State employee who works for a County Board of Taxation. The member’s health benefits were terminated after the Division received information from the employer indicating that the member’s position was not full time. Commissioner Burdge made a motion to deny the appeal. Chairperson Culliton seconded the motion. All voted in favor.

Case #071404  — This Division appeal concerned eligibility for health benefits for a State employee who works for a County Board of Taxation. The member’s health benefits were terminated after the Division received information from the employer indicating that the member’s position was not full time. Chairperson Culliton made a motion to deny the appeal. Commissioner Burdge seconded the motion. All voted in favor.

Case #071405  — This Division appeal concerned eligibility for health benefits for a State employee who works for a County Board of Taxation. The member’s health benefits were terminated after the Division received information from the employer indicating that the member’s position was not full time. Chairperson Culliton made a motion to deny the appeal. Commissioner Burdge seconded the motion. All voted in favor.

Case #071406  — This Division appeal concerned eligibility for health benefits for a State employee who works for a County Board of Taxation. The member’s health benefits were terminated after the Division received information from the employer indicating that the member’s position was not full time. Chairperson Culliton made a motion to deny the appeal. Commissioner Burdge seconded the motion. All voted in favor.

Case #071407  — This Division appeal concerned eligibility for health benefits for a State employee who works for a County Board of Taxation. The member’s health benefits were terminated after the Division received information from the employer indicating that the member’s position was not full time. Chairperson Culliton made a motion to deny the appeal. Commissioner Burdge seconded the motion. All voted in favor.

Case #071408  — This Division appeal concerned the termination of retired health benefits for a member who was not enrolled in the full Medicare program. Commissioner Simon made a motion to deny the appeal. Commissioner Czech seconded the motion. All voted in favor.

Case #071409  — This OAL request concerned a member who requested reimbursement of health benefits contributions that had been deducted from his paychecks. Chairperson Culliton made a motion to issue a Final Administrative Determination. Commissioner Czech seconded the motion. All voted in favor.

Case #071410  — This OAL request concerned the denial of expenses for residential treatment for an eating disorder. Chairperson Culliton made a motion to grant the hearing request. Commissioner Burdge seconded the motion. All voted in favor.

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

Case #071411  — Chairperson Culliton made a motion to authorize Socrates to accept the amount specified in the memo dated June 27, 2014. Commissioner Nowlan seconded the motion. All voted in favor.

Case #071412  — Chairperson Culliton made a motion to authorize Socrates to accept the amount specified in the memo dated June 24, 2014. Commissioner Nowlan seconded the motion. All voted in favor.

Commissioner Burdge made a motion to adjourn. Commissioner Nowlan seconded the motion. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 2:55 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission



State Health Benefits Commission
Minutes, Meeting No 551
September 10, 2014; 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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2014. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, September 10, 2014 at 10:15 AM.  The meeting was held at 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

Roll Call

Mary Ann Ryan, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Robert M Czech, Chair, Civil Service Commission
Gale Simon, 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
Mark Cipriano, Division of Pensions and Benefits
Edward Fox, Aon Hewitt
Alex Jaloway, Aon Hewitt
Dave Perry, Horizon
Katherine Impellizzeri, Aetna
Bart Gerber, Express Scripts
Paul Anzano, Pringle, Quinn, and Anzano
Michael O’Connell, Pringle, Quinn, and Anzano
John Giampolo, Independent Pharmacy Alliance
Carlo Benedetti, Olden Pharmacy
Dr. Charles Stewart, Dental Director, Aetna (via telephone)

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

Minutes, Meeting No. 547, March 12, 2014: Chairperson Ryan made a motion to adopt the minutes. Chairperson Nowlan seconded the motion. All voted in favor.

Minutes, Meeting No. 548, May 14, 2014: Chairperson Ryan made a motion to adopt the minutes. Chairperson Nowlan seconded the motion. All voted in favor.

Issues

Dental Rates: Acting Secretary Kierney Corliss introduced Edward Fox and Alex Jaloway, Aon Hewitt. Mr. Fox and Mr. Jaloway presented the proposed dental rates for Plan Year 2015. The following is a Summary of their presentation:

For the SHBP Dental Plans (Employee and Retiree Dental Expense Plans and Employee DPOs) for Plan Year 2015, Aon Hewitt recommends the following premium rate adjustments, which – in the aggregate – represent an overall decrease in premium of 12%, or approximately $16 million from Plan Year 2014 premium levels:


Dental Expense Plans
Actives            -3.3%
Retirees           -2.4%
The combined decrease for the Dental Expense Plans is 2.8%.

Dental Plan Organizations (DPOs)
Aetna               -5.9%
Cigna               -9.8%
Healthplex       -50.0%
Horizon            +0.8%
The combined decrease for the DPOs is 14.9%.

  • This vendor landscape reflects the result of the recent Dental Program RFP, i.e.:
    • Aetna will continue as the administrator for the Active and Retiree Dental Expense Plans;
    • The number of Dental Plan Organizations (DPOs) will be reduced from 6 to 4, with four incumbents (Aetna, Cigna, HealthPlex, and Horizon) retained for Plan Year 2015, and
    • Effective January 1, 2015, retirees will be offered DPO options for the first time, and retirees will continue to be allowed to enroll in the DEP as well.
  • The aforementioned $16 million savings results from a combination of:
    • Lower administrative fees for the Dental Expense Plans (a 17% reduction, or $0.5 million);
    • Improved guaranteed claim discounts for the Dental Expense Plans;
    • Reductions in premium rates for three of the incumbent DPOs, and a modest increase for the fourth incumbent; and
    • The assumption that approximately 26% of Retirees will migrate to DPOs (Retirees pay the full cost of dental coverage and DPO premiums range from 23% to 63% of the premium cost of the Dental Expense Plan).
  • This recommended rate renewal assumes no changes in benefits, other than Retirees being offered DPO coverage for the first time.
  • Aon Hewitt is projecting a Retiree Claim Stabilization Reserve of $16 million at the end of Plan Year 2014, assuming that the Plan is fully funded. This will protect the SHBP against a potential increase in retiree Dental Expense Plan enrollment as a result of the Open Enrollment which is planned to introduce the Retiree DPO options.
  • Aon Hewitt is projecting that total Employee Dental enrollment will have minimal changes between Plan Years 2014 and 2015 and that the DPO share of Active Employee enrollment will increase 1.3%. As a result, Plan Year 2015 projected Active Employee enrollment is: 62,500 Employees enrolled in the Dental Expense Plan and 36,900 Employees enrolled in the DPO plans. Retiree enrollment is expected to increase 10.0%, with 69,400 Retirees enrolled in the Dental Expense Plan and a projected 25,000 Retirees enrolled in the DPO plans.
  • Plan Year 2015 projected costs for the SHBP Dental Plans are $125.2 million, with $54.9 million attributable to the Employee Dental Expense Plan, $46.9 million attributable to the Retiree Dental Expense Plan, and $23.4 million attributable to the DPOs.

Commissioner Czech made a motion to approve the dental rates as presented. Chairperson Ryan seconded the motion. All voted in favor.

COBRA Vision Rates: Commissioner Nowlan made a motion to approve the Plan Year 2015 COBRA Vision Rates as presented. Chairperson Ryan seconded the motion. All voted in favor.

Express Scripts Pharmacy Payments: Paul Anzano and Michael O’Connell from the law firm of Pringle, Quinn, and Anzano spoke on behalf of the Independent Pharmacy Alliance (IPA). Mr. Anzano stated that members of the IPA have noticed that it is taking longer to receive payments from Express Scripts. Carlo Benedetti, Olden Pharmacy, stated that the delay in payments has negatively affected his business.

Bart Gerber, Express Scripts, stated that Olden Pharmacy contracts with a third party Pharmacy Services Administrative Organization (PSAO). Express Scripts sends the payment to the PSAO, and the PSAO in turn pays the pharmacy. Express Scripts reviewed a sample of claims and determined that they were in compliance with contractual terms that require them to make payment within an average of 30 days.

Chairperson Ryan made a motion to go into Closed Session. Commissioner Simon seconded the motion. All voted in favor.

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

Case #091401  — This Division appeal concerned health benefits coverage for an employee who was on a leave of absence. Her health benefits were terminated because required payments were not received during her leave. The member was requesting to have her child placed on the coverage for the period during which she was on leave. Chairperson Ryan made a motion to deny the appeal. Commissioner Simon seconded the motion. Motion passed (4: 0: 1; Commissioner Burdge abstained).

Case #091402  — This Retiree Dental Expense appeal concerned the denial of coverage for dental implants. Chairperson Ryan made a motion to deny the appeal. Commissioner Nowlan seconded the motion. All voted in favor.

Case #091403 (member present)  — This Retiree Dental Expense appeal concerned the denial of coverage for dental implants. Commissioner Burdge made a motion to deny the appeal. Chairperson Ryan seconded the motion. All voted in favor.

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

Case #091404  — Chairperson Ryan made a motion to authorize Socrates to accept the amount specified in the memo dated August 22, 2014. Commissioner Nowlan seconded the motion. All voted in favor.

Case #091405  — Chairperson Ryan made a motion to authorize Socrates to accept the amount specified in the memo dated July 10, 2014. Commissioner Nowlan seconded the motion. All voted in favor.

Commissioner Nowlan made a motion to adjourn. Chairperson Ryan seconded the motion. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 12:25 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


 State Health Benefits Commission
Minutes, Meeting No 552
September 16, 2014; 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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2014 and a revised notice was sent on September 12, 2014. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Tuesday, September 16, 2014 at 1:08 PM.  The meeting was held at 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

Roll Call

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Robert M Czech, Chair, Civil Service Commission (via telephone
Gale Simon, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance (via telephone)
Dudley Burdge, Representative for Local Government Employees (via telephone)
Patrick Nowlan, Representative for State Government Employees (via telephone)

Also present: 
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Mark Cipriano, Division of Pensions and Benefits
Resolutions B (Executive Session) was read in its entirety.
Issues

Dental Rates: Corrected 2015 dental rates were distributed to the Commission. Chairperson Culliton made a motion to approve the rates. Commissioner Nowlan seconded the motion. All voted in favor.

Commissioner Nowlan made a motion to adjourn. Chairperson Culliton seconded the motion. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 1:11 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 553
November 12, 2014; 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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2014 and a revised notice was sent on September 12, 2014. 

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, November 12, 2014 at 10:25 AM.  The meeting was held at 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

Roll Call

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Robert M Czech, Chair, Civil Service Commission
Thomas Gallagher, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Debra Davis, Representative for State Government Employees

Also present: 
Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Mark Cipriano, Division of Pensions and Benefits
David Pointer, Assistant Director, Division of Pensions and Benefits
Wendy Burns, Horizon
Donna Ruotola, Horizon
Dave Perry, Horizon
Dr. Steven Wolinsky, Medical Director, Horizon
Resolutions A (Closed Session) and B (Executive Session) – were read in their entireties.
Issues

2015 Meeting Schedule: Chairperson Culliton made a motion to approve the schedule. Commissioner Burdge seconded the motion. All voted in favor.

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

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

Case #111401 (member present) — This Horizon appeal concerned the denial of contact lenses for a member with a diagnosis of left eye trauma and secondary glaucoma. Chairperson Culliton made a motion to deny the appeal based on plan exclusions. Commissioner Gallagher seconded the motion. All voted in favor.

Case #111402  —This Horizon appeal concerned the denial of benefits for the purchase of frozen donor eggs for infertility treatments. Dr. Steven Wolinsky, Medical Director, Horizon, advised the Commission that cryopreservation was not a covered benefit. In addition, although the provider’s office coded the claim as a claim for cryopreservation, they had advised Horizon that the expense was actually for the purchase of the frozen oocytes. Dr. Wolinsky stated that this was a nonmedical cost and therefore also excluded from coverage. Commissioner Gallagher made a motion to deny the appeal based on plan exclusions. Chairperson Culliton seconded the motion. All voted in favor.

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

Case #111403  — Chairperson Culliton made a motion to approve the request to send the case to the Office of Administrative Law. Commissioner Burdge seconded the motion. Motion passed (4: 0: 1; Commissioner Davis abstained).

Case #111404  — Chairperson Culliton made a motion to deny the request for an OAL hearing and issue a Final Administrative Determination. Commissioner Gallagher seconded the motion. All voted in favor.

Case #111405  — Chairperson Culliton made a motion to deny the request for an OAL hearing and issue a Final Administrative Determination. Commissioner Burdge seconded the motion. All voted in favor.

Case #111406  — Chairperson Culliton made a motion to deny the request for an OAL hearing and issue a Final Administrative Determination. Commissioner Burdge seconded the motion. All voted in favor.

Case #111407  — Chairperson Culliton made a motion to authorize Socrates to negotiate the settlement as proposed. Commissioner Czech seconded the motion. All voted in favor.

Case #111408  — Chairperson Culliton made a motion to authorize Socrates to negotiate the settlement as proposed. Commissioner Czech seconded the motion. All voted in favor.

Commissioner Burdge made a motion to adjourn. Commissioner Davis seconded the motion. All voted in favor.

The State Health Benefits Commission meeting was adjourned at 10:55 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 

 

 
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