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Pensions and Benefits
STATE HEALTH BENEFITS COMMISSION
MEETING MINUTES 2015
 
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.
**Indicates Change Due to Holiday or Conflict of Original Schedule

To view 2014 Health Benefit Commission Meeting Minutes (and prior years), click here


State Health Benefits Commission
Minutes, Meeting No 554
January 14, 2015; 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 2015 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2015.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, January 14, 2015 at 10:11 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
Holly Gaenzle, 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
Bart Gerber, Express Scripts
Kristie Weinert, Express Scripts
Resolutions A (Closed Session) and B (Executive Session) – were read in their entireties.

Issues

Local Employer Update: Acting Secretary Kierney Corliss distributed final 2014 summaries for terminations and new employers for 2014. There was no discussion.

IRO reports: Ms. Corliss distributed a summary of Independent Review Organization (IRO) cases for 2014. Commissioner Burdge asked how the plan administrators determine which IRO to use. Assistant Director David Pointer responded that the IROs are assigned on a rotating basis.

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

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

Case #011501 — This Express Scripts appeal concerned the denial of an additional quantity of Levitra above the limit of 4 per month. Commissioner Burdge asked if there were any exceptions to the limit for conditions other than erectile dysfunction (ED). Kristie Weinert, Express Scripts, stated there were no exceptions; Levitra is only FDA approved for treatment of ED. Chairperson Ryan made a motion to deny the appeal. Commissioner Czech seconded the motion. Motion passed (3: 1: 1; Commissioner Davis voted no, Commissioner Burdge abstained).

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

Case #011502  — Chairperson Culliton made a motion to authorize Socrates to negotiate the settlement as proposed. Commissioner Czech seconded the motion. All voted in favor.

Case #011503  — Chairperson Culliton made a motion to authorize Socrates to negotiate the settlement as proposed. Commissioner Czech seconded the motion. All voted in favor.

Chairperson Ryan made a motion to adjourn. Commissioner Davis seconded the motion. All voted in favor.
The State Health Benefits Commission meeting was adjourned at 10:30 AM.

 

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 State Health Benefits Commission
Minutes, Meeting No 555
March 11, 2015; 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 2015 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2015.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, January 14, 2015 at 10:11 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
Holly Gaenzle, 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
Joseph Dorfler, Deputy Attorney General
Kierney Corliss, Acting Secretary
Mark Cipriano, Division of Pensions and Benefits
David Pointer, Assistant Director, Division of Pensions and Benefits
Jen Moyer, Aetna
Cheryl Egan, Horizon
Resolutions A (Closed Session) and B (Executive Session) – were read in their entireties.

Issues

The first agenda item was a letter to the Commission from attorney Justin Schwam requesting that the Commission extend the deadline for reimbursements due to members as a result of the past practice of tiering the payment of out of network behavioral health claims. Chairperson Culliton made a motion to go into executive session. Commissioner Davis seconded the motion. All voted in favor.

Upon returning to public session, Chairperson Culliton made a motion to table the request made in the letter of December 3, 2014 and directed the Division of Pensions and Benefits to provide the Commission with information regarding the number of claims for the original time period, and number of claims in each of the subsequent extensions. Commissioner Czech seconded the motion. All voted in favor.

Commissioner Burdge made a motion to go into closed session. Commissioner Davis seconded the motion. All voted in favor.

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

Case #031501 — This administrative appeal concerned a request to add an overage disabled dependent back onto a members coverage following a waiver period. SHBP regulations state that overage disabled dependent children who cease coverage with the SHBP are no longer eligible for coverage as an overage disabled dependent. Commissioner Gaenzle asked if the member’s daughter was eligible for Medicaid. The member said he wasn’t sure. Commissioner Burdge asked if the member’s daughter was on Medicare. The member said no.  Commissioner Burdge made a motion to approve the appeal. Commissioner Davis seconded the motion. Motion failed (2-3 Chairperson Culliton, Commissioner Czech, and Commissioner Gaenzle voted no) Commissioner Czech made a motion to deny the appeal. Chairperson Culliton seconded the motion. Motion passed (3:2; Commissioner Davis and Commissioner Burdge voted no).

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

Case #031502  — Chairperson Culliton made a motion to deny the OAL request for appeal and directed the secretary to draft a final administrative determination. Commissioner Davis seconded the motion. All voted in favor.

Case #031503  — Chairperson Culliton made a motion to approve the settlement request as stated in the memo. Commissioner Burdge seconded the motion. All voted in favor.

Case #031504  — Chairperson Culliton made a motion to authorize the settlement request as stated in the memo. Commissioner Burdge Seconded the motion. All voted in favor.

Case #031505  — Chairperson Culliton made a motion to authorize Socrates to settle in the range suggested. Commissioner Burdge seconded the motion. All voted in favor.

Case #031506  — Chairperson Culliton made a motion to authorize Socrates to settle for not less than the amount stated in the memo in lieu of the authority to litigate. Commissioner Burdge seconded the motion. All voted in favor.

Case #031507  — Chairperson Culliton made a motion to authorize the attorney to settle the matter somewhere in between the two amounts he offered as acceptable range. Commissioner Davis seconded the motion. All voted in favor.

Case #031508  — Chairperson Culliton made a motion to authorize the attorney to counter the offer for the amount he suggests in his memo. Commissioner Davis seconded the motion. All voted in favor.

Case #031509  — Chairperson Culliton made a motion to authorize the attorney to settle the matter for somewhere between the amounts suggested in the memo. Commissioner Burdge seconded the motion. All voted in favor.

Chairperson Culliton made a motion to adjourn. Commissioner Burdge seconded the motion. All voted in favor. The State Health Benefits Commission meeting was adjourned at 11:27 AM.

 

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

State Health Benefits Commission
Minutes, Meeting No 556
May 13, 2015; 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 2015 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2015.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, May 13, 2015 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
Holly Gaenzle, 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: 

Eileen Schlindwein Den Bleyker, Deputy Attorney General
Joseph Dorfler, Deputy Attorney General
Kierney Corliss, Acting Secretary
Mark Cipriano, Division of Pensions and Benefits
Donna Rutola, Horizon Blue Cross Blue Shield NJ
Cheryl Eagan, Horzon Blue Cross Blue Shield NJ
Dr. Steven Wolinsky, Horizon Blue Cross Blue Shield NJ

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

Issues

Chairperson Culliton made a motion to approve the minutes for the July 9, 2014 meeting. Commissioner Davis seconded the motion. All voted in favor.

Commissioner Czech made a motion to approve the minutes for the July 13, 2014 meeting. Commissioner Davis seconded the motion. All voted in favor.

Commissioner Czech made a motion to approve the minutes from the September 10, 2014 meeting. Commissioner Burdge seconded the motion. All voted in favor.

Commissioner Davis made a motion to approve the September 16, 2014 meeting minutes. Chairperson Culliton seconded the motion. All voted in favor.

Chairperson Culliton made a motion to approve the November 12, 2014 meeting minutes. Commissioner Davis seconded the motion. All voted in favor.

The next agenda item was tabled from the March Commission meeting, regarding a request from an attorney for the Communications Workers of America and various Social Worker groups to extend the deadline for reimbursements for behavioral health services claims that were under paid based on the Commission’s former stance on tiering claim payments to behavioral health service providers. Acting Secretary Corliss advised the Commission that there were a total of 887 requests for reimbursement received by Horizon Blue Cross Blue Shield of NJ. 211 were received prior to the original deadline of September 30, 2014. 520 were received before the extended deadline of December 31, 2014. To allow time for delivery, claims post-marked by December 31, 2014, and received by January 9, 2015, were accepted, and there were 115 claims received by January 9, 2015.  41 claims were denied for missing the deadline to file.  Chairperson Culliton made a motion to authorize the Commission secretary to prepare a response to the letter in accordance with the advice of the Deputy Attorney General that a response was necessary. She clarified that advice would be in executive session but the claims data presented to the Commission in open session could be included in the letter, and that the letter should clarify that there would be no further action taken by the Commission.  Commissioner Czech seconded the motion.  All voted in favor.

Commissioner Davis 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 #051501 — This appeal concerned a member disputing the amount he was reimbursed for an out of network surgical procedure he underwent. Horizon representatives explained that the reimbursement was calculated based on the Fair Health database. Chairperson Culliton made a motion to deny the appeal based on the fact that the reimbursement amount was correct based on the provider’s zip code and the allowances in the Fair Health database. Commissioner Czech seconded the motion. All voted in favor.

Case #051502  — This was a Horizon appeal concerning a denial for a frozen embryo transfer. Horizon representatives explained that the plan covers embryo transfers and egg retrievals for a total of 4 IVF cycles. The embryo transfer that was denied was a result of a 5th, non-covered IVF cycle. Chairperson Culliton made a motion to go into executive session. Commissioner Burdge seconded the motion. All voted in favor.

Upon return from executive session Chairperson Culliton made a motion to deny the appeal based on the language in the member handbook explaining the exclusion. Commissioner Burdge seconded the motion. All voted in favor.

Case #051503  — This appeal was related to a Horizon denial of continuation of coverage for an Overage Disabled Dependent. The denial was based on the fact that there was not sufficient proof that the member continues to be disabled. Dr. Wolinsky from Horizon advised that the member had a car accident in 1995 and had subsequently been treating it on and off with physical therapy and with a pain doctor. The patient’s application for coverage as an overage dependent was mainly based on back pain.  According to a letter from the patient’s mother, who is the insured member, the patient applied for but was denied Social Security Disability Insurance. The mother indicated that the patient was receiving charity care or Medicaid coverage. It was explained that Horizon had asked the member to provide additional medical documentation to show the extent of the patient’s current condition and all that was provided  were letters from the patient’s physical therapist as well as the pain management doctor dated May of 2014and  documentation from the emergency room late in 2014/early 2015 which do not relate to his claim of back pain. Per the medical record, it appears that the disability has resolved and the back problem is long-standing and would not prevent him from doing sedentary work. Chairperson Culliton made a motion to deny the request for continuation of coverage. Commissioner Gaenzle seconded the motion. The motion passed (3-1-1; Commissioner Burdge voted no, Commissioner Davis abstained).

Case #051504  — This case concerned a prior Commission appeal denial that was subsequently upheld by an Independent Review Organization. The member’s attorney was not able to be present at the meeting, and thus requested that the Commission’s decision be postponed until a later date. Commissioner Davis made a motion to table the appeal. Chairperson Culliton seconded the motion. All voted in favor.

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

Case #031505  — Chairperson Culliton made a motion to approve the matter as presented by Socrates. Commissioner Burdge seconded the motion. All voted in favor. Chairperson Culliton made a motion to approve the second request for settlement in the same case. Commissioner Czech seconded the motion. All voted in favor.

Case #031506  — Chairperson Culliton made a motion to authorize Socrates to proceed with the settlement within the range they suggested. Commissioner Burdge seconded the motion. All voted in favor.

Case #031507  — Chairperson Culliton made a motion to approve the settlement. Commissioner Davis seconded the motion. All voted in favor.

Chairperson Culliton made a motion to adjourn. Commissioner Burdge seconded the motion. All voted in favor. The State Health Benefits Commission meeting was adjourned at 11:16 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


 State Health Benefits Commission
Minutes, Meeting No 557
July 8, 2015; 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 2015 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2015.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, July 8, 2015 at 10:06 AM.  The meeting was held at the Division of Pensions and Benefits, 50 West State St in Trenton, 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 Acting Commissioner Richard J. Badolato, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Debra Davis, Representative for State Government Employees

Also present: 

Christin Deacon, Deputy Attorney General
Joseph Dorfler, Deputy Attorney General
Kierney Corliss, Acting Secretary
Mark Cipriano, Division of Pensions and Benefits
Donna Ruotola, Horizon Blue Cross Blue Shield NJ
Cheryl Eagan, Horizon Blue Cross Blue Shield NJ
Jennifer Moyer, Aetna
Dr. Kay Eckroth, Aetna

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

Issues

Acting Secretary Corliss noted that the Rate Renewal presentations had been delayed, and that the reports should be presented at the Friday, July 17 Commission meeting.

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

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

Case #071501 (member representative present) — This Horizon appeal concerned the level of treatment approved by Horizon/Magellan for behavioral health/substance abuse services. The appeal had already been reviewed and the level of treatment approved by Horizon/Magellan upheld by Allmed, an Independent Review Organization (IRO) per the guidelines set forth by the Affordable Care Act. Donna Ruotola, Horizon, noted that partial hospitalization had been approved from January 13, 2014-February 26, 2014, and that a subsequent request to continue partial hospitalization on February 26th was denied. A request for an expedited first level appeal was made on February 27, 2014. The appeal was conducted on February 28th and the denial was upheld. An expedited second level appeal was heard by the Horizon Member Advisory Committee on March 3, 2014. The second level appeal also upheld the original denial. The member was provided a letter outlining their rights to have the appeal conducted by an IRO at that time. On May 16, 2014, Horizon received the request from the member to proceed with an IRO appeal. Information was sent to the IRO on May 19, 2014 and that same day the IRO sent the member letter of acknowledgement, which included a request for the member to provide any additional information relevant to the appeal. On June 28, 2014, the IRO made the decision to uphold the denial and sent a written determination to the member. Chairperson Culliton made a motion to go into Executive Session. Commissioner Burdge seconded the motion. All voted in favor (5-0-0). Upon return from Executive Session, Chairperson Culliton made a motion to deny the appeal based on the information that was provided to the Commission by Horizon and Allmed. Commissioner Gallagher seconded the motion. The motion passed (3-2-0; Commissioner Burdge and Commissioner Davis voted no). Commissioner Culliton made a motion to authorize the matter to be transmitted to a full factual hearing. Commissioner Davis seconded the motion. All voted in favor (5-0-0).

Case #071502  — This Division appeal concerned a member request to switch health plans/carriers from Aetna to Horizon outside of the regular open enrollment period. The member was enrolled in Aetna effective March 24th, and made the request to change carriers on April 3rd. The member noted that she was an adjunct professor at Rutgers and paid the full cost of premiums for her coverage.  Chairperson Culliton made a motion to go into Executive Session. Commissioner Burdge seconded the motion. All voted in favor. (5-0-0)

Upon return from Executive Session Chairperson Culliton made a motion to deny the appeal based on the fact that the request to change insurance plans/carriers was made outside of the regular open enrollment period. Commissioner Davis seconded the motion. The motion passed, (4-0-1; Commissioner Burdge abstained).

Case #071503  —  This Horizon appeal concerned a denial of a request for payment for nutritional counseling services that occurred out of network and in excess of the SHBP benefit limit of three (3) visits with a licensed nutritional counselor per calendar year. The member advised that her dependent/daughter’s Licensed Clinical Social Worker (LCSW) had advised that regular visits to a nutritionist were necessary for the treatment of the daughter’s anorexia.  She also noted that she was unable to find any specialists for eating disorders in-network, even after contacting Horizon. Donna Ruotola, Horizon, advised that the SHBP only pays for nutritional counseling services when they are provided by in-network providers, and she did identify specialists in-network.  Chairperson Culliton made a motion to go into executive session. Commissioner Davis seconded the motion. All voted in favor (5-0-0).

Upon return from executive session, Commissioner Gallagher made a motion to deny the appeal based upon the benefit limitations in the SHBP. Chairperson Culliton seconded the motion.  Commissioner Gallagher noted that the Commission does not have the authority to change the plan and he will ask the Commission to make a recommendation to the SHBP Plan Design Committee that they consider a benefit change in conjunction with this issue. During discussion, it was noted by Commissioners Burdge and Davis that the member’s presentation was compelling and that they hoped that changes to the benefit limitations could be enacted.  All voted in favor of the denial (5-0-0).

Case #071504  — This Aetna Dental appeal concerned denial of a request for replacement of a crown earlier than SHBP benefit limitations allow. The member received his first crown in 2010. Dr. Kay Eckroth and Jennifer Moyer, Aetna, referred to the plan limitation as listed on page 32 of the member handbook, which states that replacement of a crown is only covered after a five (5) year period measured from the date on which the crown was placed. It was noted that Aetna was not, in their denial, contradicting the member’s dentists’ determination that a replacement crown was medically necessary, but was based solely upon the benefit limitations of the SHBP.  Chairperson Culliton made a motion to deny the appeal, based on the benefit limitations listed in the handbook. Commissioner Burdge seconded the motion. All voted in favor (5-0-0).

Commissioner Davis made a motion to return to Public Session. Commissioner Burdge seconded the motion. All voted in favor (5-0-0).

Upon return to public session, Commissioner Gallagher made a motion to accept the recommendations regarding workers compensation settlements for the following cases: Case #071505, Case #071506, Case #071507, Case #071508, Case #071509, Case #071510,  Case #071511, Case #071512, and Case #071513. Commissioner Davis seconded the motion. All voted in favor (5-0-0).

Commissioner Gallagher made a motion to request that the SHBP Plan Design Committee consider a change to the benefit limitation for nutritional counseling. Commissioner Davis seconded the motion. All voted in favor (5-0-0).

There being no further business, Chairperson Culliton made a motion to adjourn. Commissioner Burdge seconded the motion. All voted in favor (5-0-0). The meeting was adjourned at 12:14 p.m.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


 

State Health Benefits Commission
Minutes, Meeting No 558
July 17, 2015; 1:00 p.m.

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 2015 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2015 and June 24, 2015.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Wednesday, July 17, 2015 at 10:08 AM.  The meeting was held at the Division of Pensions and Benefits, 50 West State St in Trenton, 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
Felix Shirripa, representing Acting Commissioner Richard J. Badolato, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Debra Davis, Representative for State Government Employees

Also present: 

Eileen Schlindwein Den Bleyker, Deputy Attorney General
Christin Deacon, Deputy Attorney General
Kierney Corliss, Acting Secretary
Mark Cipriano, Division of Pensions and Benefits
Donna Ruotola, Horizon Blue Cross Blue Shield NJ
Cheryl Eagan, Horizon Blue Cross Blue Shield NJ
Dr. Steven Wolinski, Horizon Blue Cross Blue Shield NJ
James Christ, Aon Hewitt
Barry Shane, Aon Hewitt
Alex Jaloway, Aon Hewitt

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

Issues

SHBP Rate Renewal for Plan Year 2016 —  Acting Secretary Corliss noted that James Christ, Barry Shane, and Alex Jaloway from Aon Hewitt were present to discuss the proposed rate renewal with the Commission.  Mr. Christ gave an overview of the proposed rates. Mr. Shane reviewed the 2016 rate renewal recommendations for Medical/Rx for the Active Employees and Retirees of the State Group, Tiered Network plans for Active Employees, and Active Employees of the Local Government Group. The following is a summary of the presentation.

State Group

Plan Year 2016 Medical/Rx Rate Renewal Recommendation

  • For Plan Year 2016, Aon is recommending State Group overall premium rate changes of 4.5% for Active Employees, 10.8% for Early Retirees, and 8.1% for Medicare Retirees.
    • In aggregate, the recommended rate actions represent an overall increase for the State Group of 5.9%, approximately two percentage points below the Plan Year 2015 recommended renewal action of 7.8%.
    • Following are the recommended premium rates changes by plan type:

 

  Active Employees Early Retirees Medicare Retirees

Medical PPO                       5.0%                8.6%               2.1%
Medical HMO                      5.5%                8.6%               2.1%
Prescription Drug PPO          2.4%                18.6%              13.1%
Prescription Drug HMO         2.4%                18.6%              13.1%
Total                                4.5%                10.8%              8.1%

The Plan Year 2016 Renewal assumes the following:

  • The Retiree Rx copays and Out-of-Pocket Maximum limits for SHBP PPOs and HMOs will revert to Plan Year 2012 levels.
  • No change in the benefit landscape for Plan Year 2016, with Aetna and Horizon both offering PPO, HMO, and HDHP options, and Express Scripts continuing as the State’s PBM.
  • The SHBP Plan Design Committee approved the following plan changes for the SHBP. These changes are projected to reduce premium increase rates by approximately 3.5 percentage points for Plan Year 2016.
    • Implement Compound Drug Exclusions and Hepatitis C Viekira Pak solution for the Prescription Drug plans which saves approximately $102 million in Plan Year 2016.
    • Restrict plan payments for out-of-network chiropractic and acupuncture services to drive in-network utilization which produces projected savings of $3 million.
    • Increase Emergency Room copays by $25 (for all ER copays currently under $100). This plan design change is projected to save $3 million.
    • Patient Centered Medical Home (PCMH) Pilot Program and Rutgers-Robert Wood Johnson Partners Pilot Program. As this program is voluntary and will be offered in only pilot form during Plan Year 2016, no cost impact for this program has been included in the renewal.
    • Please note that the SHBP PDC has approved the Tiered Network option for Plan Year 2016 for both Aetna and Horizon. Details and related pricing will follow shortly.
  • SHBP Medicare Prescription Drug Integration will continue as EGWP Plus Wrap.
  • State Active Employees are fully phased into the Chapter 78 contribution schedule. Plan Year 2016 enrollment projections assume that 0.5% of the Active enrollment and 0.5% of the Retiree enrollment in NJ DIRECT15 will migrate to lower-cost plans as a result of these contribution changes. While Chapter 78 does not apply to current Retirees, migration projections are mostly due to self-pay Retirees (about 10% of the population).
  • NJWELL is projected to decrease Plan Year 2016 net costs $0.1million, with further savings anticipated in future years.
  • The New Jersey State Breast Evaluation and Other Medically-Necessary Testing mandate is projected to increase medical costs by 0.5%.
  • Infertility mandate clarification is not expected to increase projected costs.
  • The Autism and Other Developmental Disabilities Mandate is projected to increase medical costs by 0.1%.
  • The contract extension with Express Scripts is projected to reduce overall Plan Year 2016 prescription drug costs by approximately 3.0%.
  • Overall, Plan Year 2016 State Active Employee enrollment will decrease approximately 4.0% from the Plan Year 2015 level, while State Early Retiree enrollment will decrease approximately 2.0% and Medicare Retiree enrollment will increase approximately 6.0%.
  • The following components of Federal Health Care Reform impact the SHBP in Plan Year 2016:
    • In-Network Out-of-Pocket Maximum for medical and prescription drug benefits combined will be no greater than $6,850 Single / $13,700 Family combined. The SHBP will have separate medical and prescription drug Out-of-Pocket Maximums. This is projected to have an insignificant cost impact on the SHBP.
      • The Transitional Reinsurance Fee ($27 per non-Medicare member in Plan Year 2016), is projected to add $6.9 million to SHBP State Group plan costs.
      • The Patient Centered Outcomes Research Institute (PCORI) Fee is assumed to increase at a 6% medical inflation rate from the Plan Year 2015 cost of $2.20 per member per year. This is projected to increase SHBP State Group plan costs by $0.7 million.
      • Differences in the rate changes among Actives and Retirees, benefit plans and coverage tiers reflect the impact of:
      • Rx Rebates have been much higher than projected in Plan Years 2014 and 2015. Plan Year 2016 Rx Rebates are projected to increase to $111 million from $91 million in Plan Year 2015.
      • Plan Year 2015 prescription drug trends are expected to increase to 18.0% for Actives, compared to 9.0% in the Plan Year 2015 Renewal Report, and 18.0% for Retirees, compared to 11.5% in the Plan Year 2015 Renewal Report. These higher trends are due to the increasing frequency of high-cost compound drugs and new high-cost specialty drugs.
      • Due to the compound drug plan design changes, the prescription drug trend has been lowered from 18.0% to 12.0% in Plan Year 2016.
      • Since the two-year average benefit adjusted experience trend for Horizon Actives is approximately 5.9%, the PPO medical trend for Actives has been reduced to 7.5% from the Plan Year 2015 Renewal PPO medical trend of 8.3%.
      • PPO Trends for Horizon Early Retirees have been lower than those for Actives in recent years, so the PPO medical trend for Early Retirees is equal to 7.0%, which is 50 basis points less than the PPO Active medical trend of 7.5%.
      • Due to the continued favorable experience for the Horizon Medicare Retiree group, the Aon Hewitt recommended PPO medical trends have been reduced from 4.5% in the Plan Year 2015 Renewals to 3.5%.
      • No change is recommended for HMO Trends for Actives and Early retirees and they remain the same at 7.0%.
      • Projected 2016 EGWP credits are projected to increase from $70 million in Plan Year 2015 to $77 million for Plan Year 2016.
      • For Active premiums, increases vary by coverage tierbecause 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 69% of the Single coverage rate to 79% (See Attachment A for premium increases by coverage tier). This adjustment will make the Employee + Child(ren) rate more consistent with actual experience.
      • Plan Year 2016 projected costs for the State Group are $2.4billion ($1.7billion for Actives and $0.7 billion for Retirees). Plan Year 2016 renewal premiums are set to match the projected costs, so there is no loss or gain projected for the State Group for Plan Year 2016.

State Health Benefits Program Plan Year 2016 Tiered Network Rates State Employee Group:

  • The State Health Benefits Program (SHBP) Plan Design Committee approved a Tiered Network plan option for State Active Employees for Plan Year 2016. Plan Year 2016 Employee Plan Option Summary Tiered Network Option The Tiered Network Plan will be offered by both Horizon and Aetna. The Tiered Network Plan product will replace the HMO1525, 2030 & 2035 products and will only be offered to Active Employees. The Tiered Network Plan will offer no out-of-network coverage. The Plan will provide the same prescription drug benefit as the one provided in the HMO1525 product in Plan Year 2015. Horizon and Aetna will each create a Tier 1 network of providers and facilities that have strong health outcomes and provide medical services at a cost-effective level. Many of the Tier 1 providers and facilities will be Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs). Tier 1 providers and facilities are expected to provide an enhanced patient experience and improve population health. Tier 1 providers will offer extended hours and preferred scheduling, among other enhancements. There will be no referrals required in either tier. Tier 2 providers and facilities will be those who are currently in-network for the Aetna and Horizon PPO products offered to the SHBP. Tiered Network Plan enrollees who use Tier 1 providers will have lower out-of-pocket cost-sharing than enrollees who use Tier 2 providers. Services such as hospice, delivery and inpatient mental health/substance abuse will be offered at no cost when provided by a Tier 1 provider/facility.  

Tiered Network Rate Assumptions:
 
The following drivers were evaluated to develop the Tiered Network option rates:

  • Plan designs for Tier 1 and Tier 2 benefits
  • Provider discounts and care management models
  • No out-of-network coverage

The resulting Tiered Network medical rates are set at 75% of NJ Direct15 Plan medical rates.

Local Government Group Plan Year 2016 Medical/Rx Rate Renewal Recommendation

  • For Plan Year 2016, Aon is recommending Local Government Group overall premium rate changes of 6.0% for Active Employees, 5.4% for Early Retirees, and 4.8% for Medicare Retirees.
    • In aggregate, the recommended rate actions represent an overall increase for the Local Government Group of 5.8%, several percentage points below the Plan Year 2015 recommended renewal action of 7.4%.
    • Following are the recommended premium rates changes by plan type:
  Active Employees Early Retirees Medicare Retirees

Medical PPO                       6.8%                            3.3%                           0.2%
Medical HMO                      7.3%                            3.3%                           0.2%
Prescription Drug PPO          3.1%                            13.4%                          8.9%
Prescription Drug HMO         3.1%                            13.4%                          8.9%
Total                                6.0%                            5.4%                           4.8%

The Plan Year 2016 Renewal assumes the following:

  • The Retiree Rx copays and Out-of-Pocket Maximum limits for SHBP PPOs and HMOs will revert to Plan Year 2012 levels.
  • No change in the benefit landscape for Plan Year 2016, with Aetna and Horizon both offering PPO, HMO, and HDHP options, and Express Scripts continuing as the State’s PBM.
  • The SHBP Plan Design Committee approved the following plan changes for the SHBP. These changes are projected to have a minimal impact on the rates for Plan Year 2016.
    • Implement Compound Drug Exclusions and Hepatitis C Viekira Pak solution for the Prescription Drug plans which saves approximately $50million in Plan Year 2016.
    • Restrict plan payments for out-of-network chiropractic and acupuncture services to drive in-network utilization which produces projected savings of $2 million.
    • Increase Emergency Room copays by $25 (for all ER copays currently under $100). This plan design change is projected to save $2million.
    • Patient Centered Medical Home (PCMH) Pilot Program and Rutgers-Robert Wood Johnson Partners Pilot Program. As this program is voluntary and will be offered in only pilot form during Plan Year 2016, Aon has not included any cost impact of this program in the renewal.
    • Please note that the SHBP PDC has approved the Tiered Network option for Plan Year 2016 for both Aetna and Horizon. Details and related pricing will follow shortly.
  • SHBP Medicare Prescription Drug Integration will continue as EGWP Plus Wrap.
  • Plan Year 2016 enrollment projections assume that 0.5% of the Active enrollment and 0.5% of the Retiree enrollment in NJ DIRECT15 will migrate to lower-cost plans as a result of these contribution changes. While Chapter 78 does not apply to current Retirees, migration projections are mostly due to self-pay Retirees (about 10% of the population).
  • NJWELL is projected to increase Plan Year 2016 net costs $0.3 million, with savings anticipated in future years.
  • The New Jersey State Breast Evaluation and Other Medically-Necessary Testing mandate is projected to increase medical costs by 0.5%.
  • Infertility mandate clarification is not expected to increase projected costs.
  • The Autism and Other Developmental Disabilities Mandate is projected to increase medical costs by 0.1%.
  • The contract extension with Express Scripts is projected to reduce overall Plan Year 2016 prescription drug costs by approximately 3.0%.
  • Overall, Plan Year 2016 Local Government Active Employee enrollment will decrease approximately 3.5% from the Plan Year 2015 level, while Early Retiree enrollment will decrease approximately 2.5% and Medicare Retiree enrollment will increase approximately 4.0%.
  • The following components of Federal Health Care Reform impact the SHBP in Plan Year 2016:
    • In-Network Out-of-Pocket Maximum for medical and prescription drug benefits combined will be no greater than $6,850 Single / $13,700 Family combined. The SHBP will have separate medical and prescription drug Out-of-Pocket Maximums. This will have an insignificant cost impact on the SHBP.
    • The Transitional Reinsurance Fee ($27 per non-Medicare member in Plan Year 2016), is projected to add $3.8 million to SHBP Local Government Group plan costs.
    • The Patient Centered Outcomes Research Institute (PCORI) Fee is assumed to increase at a 6% medical inflation rate from the Plan Year 2015 cost of $2.20 per member per year. This is projected to increase SHBP Local Government Group plan costs by $0.4 million.
  • Differences in the rate changes among Actives and Retirees, benefit plans and coverage tiers reflect the impact of:
    • Rx Rebates have been much higher than projected in Plan Years 2014 and 2015. Plan Year 2016 Rx Rebates are projected to increase to $56 million from $43 million in Plan Year 2015.
    • Plan Year 2015 prescription drug trends are expected to increase to 18.75% for Actives, compared to 9.0% in the Plan Year 2015 Renewal Report, and to 18.0% for Retirees, compared to 11.5% in the Plan Year 2015 Renewal Report. These higher trends are due to the increasing frequency of high-cost compound drugs and new high-cost specialty drugs.
    • Due to the compound drug plan design changes, the prescription drug trend has been lowered from 18.0% to 12.0% in Plan Year 2016.
    • Based on expected terminations of the Local Government active employers from the SHBP, the active medical and prescription drug trends include an additional 75 basis points to reflect the anti-selection risk (i.e. employers with good experience are terminating which will affect the SHBP’s loss ratio).
    • Since the two-year benefit adjusted average experience trend for Horizon Actives is approximately 7.40%, the PPO medical trend has been reduced to 8.25% (with the anti-selection load) from the Plan Year 2015 Renewal PPO medical trend of 8.3%.
    • PPO Trends for Horizon Early Retirees have been lower than those for Actives in recent years, so the PPO medical trend for Early Retirees is equal to 7.0%, which is 50 basis points less than the baseline PPO Active medical trend of 7.5% (without the anti-selection load).
    • Due to the continued favorable experience for the Horizon Medicare Retiree group, the Aon Hewitt recommended PPO medical trends have been reduced from 4.5% in the Plan Year 2015 Renewals to 3.5%.
    • No change is recommended for HMO Trends for Actives and Early retirees and they remain the same at 7.0%.
    • Projected 2016 EGWP credits are projected to increase from $39 million in Plan Year 2015 to $42 million for Plan Year 2016.
    • 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 69% of the Single coverage rate to 79% (See Attachment A for premium increases by coverage tier). This adjustment will make the Employee + Child(ren) rate more consistent with actual experience.
  • Plan Year 2016 projected costs for the Local Government Group are $1,427 million ($959 million for Actives and $468 million for Retirees).
  • The 12/31/16 Claim Stabilization Reserve is projected at 2.2 months of projected Plan costs, slightly above the target reserve, so Plan Year 2016 premiums include no margin and are set to produce no loss or gain.

State Health Benefits Program Plan Year 2016 Tiered Network Rates Local Government Group

The State Health Benefits Program (SHBP) Plan Design Committee approved a Tiered Network plan
option for Local Government Active Employees for Plan Year 2016. Plan Year 2016 Employee Plan Option Summary

The Tiered Network Plan will be offered by both Horizon and Aetna. The Tiered Network Plan product will replace the HMO1525, 2030 & 2035 products and will only be offered to Active Employees. The Tiered Network Plan will offer no out-of-network coverage. The Plan will provide the same prescription drug benefit as the one provided in the HMO1525 product in Plan Year 2015. Horizon and Aetna will each create a Tier 1 network of providers and facilities that have strong health outcomes and provide medical services at a cost-effective level. Many of the Tier 1 providers and facilities will be Patient Centered Medical Homes (PCMHs) and Accountable Care Organizations (ACOs). Tier 1 providers and facilities are expected to provide an enhanced patient experience and improve population health. Tier 1 providers will offer extended hours and
preferred scheduling, among other enhancements. There will be no referrals required in either tier. Tier 2 providers and facilities will be those who are currently in-network for the Aetna and Horizon PPO products offered to the SHBP. Tiered Network Plan enrollees who use Tier 1 providers will have lower out-of-pocket cost-sharing than enrollees who use Tier 2 providers. Services such as hospice, delivery and inpatient mental health/substance abuse will be offered at no cost when provided by a Tier 1 provider/facility.

Tiered Network Rate Assumptions
The following drivers were evaluated to develop the Tiered Network option rates:

  • Plan designs for Tier 1 and Tier 2 benefits
  • Provider discounts and care management models
  • No out-of-network coverage

The resulting Tiered Network medical rates are set at 75% of NJ Direct15 Plan medical rates.

Commissioner Shirripa made a motion to adopt the rate increases as proposed by Aon Hewitt. Commissioner Czech seconded the motion. The motion passed (3-0-2 Commissioner Burdge abstained on the basis of the continued increase to the Employee and Child and the Family coverage tiers. Commissioner Davis abstained on the basis that there are no tier 1 service providers available outside of New Jersey.)

Questions regarding Behavioral Health Services— Commissioner Burdge made a motion to submit the questions regarding behavioral health services put forward by himself and Commissioner Davis to the insurance carriers for response. David Pointer advised that the Commission would not have the authority to enact any changes to the plan designs based on the carrier responses to the questions. Commissioner Burdge noted that the division of responsibilities and authority of the Commission and the Plan Design Committee can sometimes make it difficult administratively to decide what information is the responsibility of each respective body and withdrew the motion so that the issue could be forwarded to the Plan Design Committee.

Chairperson Culliton made a motion to go into closed session to hear member appeals. Commissioner Burdge seconded the motion. All voted in favor (5-0-0).

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

Case #071701 — Acting Secretary Corliss noted that the member was not available to be present, but did request that the Commission go ahead and consider the case anyway.  This case is an appeal from an IRO decision which denied coverage for the testing the member requested as experimental or investigational. Dr. Steven Wolinsky, Horizon, summarized the case for the Commission. The member has a family history of breast cancer and was requesting approval for a relatively new test called a cytogram. The standard management would be to do a mammogram, if anything suspicious is revealed in the mammogram, an ultrasound or MRI would be performed, and then, if necessary, a biopsy performed. Clinically, the biopsy is the only way to be certain whether the member has developed cancer. The member has had 3 biopsies in the past (all covered) that revealed benign tumors. He stated that the use of the cytogram doesn’t have enough positive predictive value or negative predictive value to make the biopsy unnecessary.

Commissioner Shirripa made a motion to uphold the denial. Commissioner Burdge seconded the motion.  All voted in favor (5-0-0).

Chairperson Culliton made a motion to return to public session. Commissioner Burdge seconded the motion. All voted in favor (5-0-0).

Case #071702 — Chairperson Culliton made a motion to approve the request from Socrates for the amount named in their memo. Commissioner Czech seconded the motion. All voted in favor (5-0-0).

There being no further business, Commissioner Davis made a motion to adjourn. Commissioner Burdge seconded the motion. All voted in favor (5-0-0).

The meeting was adjourned at 3:08 p.m.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


 State Health Benefits Commission
Minutes, Meeting No 559
August 13, 2015; 10:00 a.m.

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 2015 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2015 and June 24, 2015. A notice for this special meeting was sent on August 6, 2015

The meeting of the State Health Benefits Commission of New Jersey was called to order on Thursday, August 13, 2015 at 11:06AM.  The meeting was held at the Division of Pensions and Benefits, 50 West State St in Trenton, 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)
Holly Gaenzle, representing Acting Commissioner Richard J. Badolato, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees (via telephone)

Also present: 

Christin Deacon, Deputy Attorney General
Kierney Corliss, Acting Secretary
Barry Shane, Aon Hewitt (via telephone)
Alex Jaloway, Aon Hewitt (via telephone)

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

Issues

Revised 2016 Local Government Rates—

Barry Shane, Aon Hewitt, explained to the Commission that there was an error in the rates for local government employers that were passed at the preceding State Health Benefits Commission Meeting. Chairperson Culliton made a motion to approve the revised plan year 2016 rates for Local Government Employers. Commissioner Gaenzle seconded the motion. All voted in favor (4-0-0).

There being no further business, Chairperson Culliton made a motion to adjourn. Commissioner Burdge seconded the motion. All voted in favor (4-0-0). The meeting was adjourned at 11:11 a.m.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


State Health Benefits Commission
Minutes, Meeting No 560
September 9, 2015; 10:00 a.m.

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 2015 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2015 and June 24, 2015.

The meeting of the State Health Benefits Commission of New Jersey was called to order on Thursday, August 13, 2015 at 10:25 AM.  The meeting was held at the Division of Pensions and Benefits, 50 West State St in Trenton, 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)
Holly Gaenzle, representing Acting Commissioner Richard J. Badolato, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Debra Davis, Representative for State Government Employees

Also present: 

Christin Deacon, Deputy Attorney General
Joseph Dorfler, Deputy Attorney General
Kierney Corliss, Acting Secretary
Mark Cipriano, Division of Pensions and Benefits
Resolutions A (Closed Session) and B (Executive Session) – were read in their entireties.
Issues

Case #091501 — This case is before the Commission as a request for an OAL hearing.  Chairperson Culliton asked if there are any issues of fact for the case. DAG Dorfler advised no. Chairperson Culliton made a motion to approve the final administrative determination (FAD) and authorize its issuance. Commissioner Gaenzle seconded the motion. Commissioner Burdge asked what would be in the FAD. Chairperson Culliton stated that the case could go directly to the Appellate Division to appeal the Commission’s determination based on law, due to the fact that there are no issues of fact with the case. The motion passed, (4-0-1, Commissioner Burdge abstained).

Case #091502 — Chairperson Culliton made a motion to approve the FAD and authorize its issuance. Commissioner Burdge seconded the motion. All voted in favor (5-0-0).

Case #091503 — Chairperson Culliton made a motion to approve the final administrative determination and authorize its issuance. Commissioner Davis seconded the motion. All voted in favor (5-0-0).

Case #091504 — Chairperson Culliton made a motion to approve the FAD and authorize its issuance. Commissioner Gaenzle seconded the motion. All voted in favor (5-0-0).

Case #091505 — Chairperson Culliton made a motion to approve the FAD and authorize its issuance. Commissioner Davis seconded the motion. All voted in favor (5-0-0).

Case #091506 — Chairperson Culliton made a motion to approve the Worker’s Compensation settlement authority request as presented. Commissioner Burdge seconded the motion. All voted in favor.

There being no further business, Chairperson Culliton made a motion to adjourn. Commissioner Davis seconded the motion. All voted in favor (4-0-0). The meeting was adjourned at 10:30 a.m.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 


 State Health Benefits Commission
Minutes, Meeting No 561
November 10, 2015; 10:00 a.m.

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 2015 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 6, 2015 and June 24, 2015.

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

Roll Call

Susanne Culliton, Chairperson, representing Acting State Treasurer Ford M. Scudder
Robert M Czech, Chair, Civil Service Commission
Holly Gaenzle, representing Acting Commissioner Richard J. Badolato, Department of Banking & Insurance
Dudley Burdge, Representative for Local Government Employees
Debra Davis, Representative for State Government Employees

Also present: 

Joseph Dorfler, Deputy Attorney General
Kierney Corliss, Acting Secretary
Mark Cipriano, Division of Pensions and Benefits
Donna Ruotola, Horizon Blue Cross/Blue Shield NJ
Susan Mestres, Horizon Blue Cross/Blue Shield NJ
Katherine Impellizerri, Aetna
Dr. Kay Eckroth, Aetna
Ian Carucci, Aetna
Alex Jalloway, Aon Hewitt

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

Issues

2016 Meeting Schedule— Commissioner Davis made a motion to accept the 2016 meeting schedule as presented.  Commissioner Burdge seconded the motion. All voted in favor (5-0-0)

2016 COBRA Vision Rates— Commissioner Burdge inquired about the number of individuals opting for COBRA vision and whether vision is required when taking COBRA medical.  Alex Jalloway, Aon, indicated that vision coverage is not required with medical and that there are about 10,000 individuals in the program, including dependents. Commissioner Czech made a motion to approve the 2016 COBRA Vision rates as presented. Commissioner Burdge seconded the motion. All voted in favor (5-0-0)

Commissioner Burdge made a motion to go into closed session to hear member appeals. Commissioner Davis seconded the motion. All voted in favor (5-0-0).

Case #111501 — This Aetna Dental appeal concerned a denial of complete upper dentures. Ian Carucci, Aetna, explained that the denture in question was originally delivered on December 24, 2014, and that the member made a quality care complaint about the service that was fully investigated by Aetna. Aetna determined that the complaint was a matter of aesthetics, and found that the service provided was clinically acceptable. The member saw a total of four (4) different dentists over a two (2) year period. The first three (3) dentists refunded the money paid for the procedures to the member as well as Aetna. The fourth dentist felt he had delivered a clinically acceptable denture and did not refund the money. Commissioner Davis noted that it was unusual for porcelain teeth to be inserted in a denture, and stated that usually high-grade plastics are used. It was also noted that the dentist in question kept diligent records and noted that the condition of the bone in the member’s jaw would not allow for the perfectly natural fit that the member was seeking. Chairperson Culliton made a motion to deny the appeal. Commissioner Davis seconded the motion. All voted in favor (5-0-0).

Case #111502 — This Aetna dental appeal concerned a frequency denial for a replacement crown. Ian Carucci explained that the member had a crown placed on the tooth on May 31. Six months later, it was discovered that there was decay under the tooth. A separate dentist from the initial service provider cut the previous crown off to treat the decay that was under the crown. The second dentist submitted a request to replace the crown, which was denied, as crown replacements are only covered once every five (5) years. Commissioner Davis asked if there is an emergency rule in place that would allow them to treat the case as an exception. Mr. Carucci advised that no, there is not an emergency exception provision to the five (5) year rule for crowns. Dr. Kay Eckroth, Aetna, advised that if the member was in pain and went to their dentist having pupal symptoms, then there would be a covered benefit for endodontic treatment, which can be done through the existing crown. It was noted that typically, patients who have problems with a crown that quickly go back to the same dentist that placed the crown, and the dentist would treat it at no cost. But in this instance, the member stated that they had lost confidence in the original dentist and sought treatment with a new one. Chairperson Culliton asked Dr. Eckroth if she meant that the repair could have been done through the existing crown, rendering the replacement crown unnecessary in the first place. Dr. Eckroth clarified that pain caused by decay underneath an existing crown is often treated with a root canal, which is a covered benefit, and that often times the crown does not need to be replaced. The dentist who replaced the crown felt that the original crown needed to be replaced, however. It was again clarified that Aetna’s denial was not based on the medical necessity of the replacement crown, but was based solely on the contracted frequency limits of the plan. Chairperson Culliton made a motion to deny the appeal. Commissioner Gaenzle seconded the motion. All voted in favor (5-0-0).

Case #111503 (member and representative present) — This Horizon appeal concerned the denial of expenses above the reasonable and customary allowance. Donna Ruotola, Horizon, explained that the provider’s office where the member had their procedure completed called Horizon’s member services and was advised what the out-of-network benefits were for the procedure in question, namely that the reimbursement was based upon 90% of the FAIR Health Database, with a $100 deductible and a reimbursement of 70% of the FAIR Health charge, with the member being responsible for 30% of the FAIR Health charge, plus any balance billed amount above that total. The member’s representative (an employee of the provider’s office) disputed the dollar amount that Horizon provided as the FAIR Health reasonable and customary allowance. It was determined that the member’s representative/the provider’s office was using a charges database called OptumInsight, as opposed to FAIR Health, to determine what they believed was the reasonable and customary allowance, and that this was the reason that they believed that the reasonable and customary allowance was higher than what it actually is in the FAIR Health Database. Commissioner Burdge made a motion to deny the appeal. Commissioner Davis seconded the motion. All voted in favor (5-0-0).

At this time, Commissioner Davis made a motion to return to public session. Commissioner Burdge seconded the motion. All voted in favor (5-0-0).

Case #111504 — Chairperson Culliton made a motion to authorize the negotiation of a resolution based on the numbers provided in the memo. Commissioner Burdge seconded the motion. All voted in favor (5-0-0).

There being no further business, Chairperson Culliton made a motion to adjourn. Commissioner Davis seconded the motion. All voted in favor (5-0-0). The meeting was adjourned at 11:55 a.m.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
State Health Benefits Commission

 

 

 

 

 

 
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