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Pensions and Benefits
School Employees' Health Benefits Commission
Meeting Minutes 2009

School Employees’ Health Benefits Commission
Minutes, Meeting No. 5
January 28, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The first portion of the meeting is open to the public.  The second portion, in conformity with the Open Public Meetings Act, shall be closed to the public based upon the personal matters exception.  Those matters are confidential unless expressly waived by the individual involved.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:12 AM, Wednesday, January 28, 2009. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

ROLL CALL

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

Jane Oates, Chairperson
Joseph Del Grosso, Commissioner
Thomas Gallagher, representing Commissioner Steven M. Goldman, Department of Banking & Insurance
James Geiger, Commissioner
Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner

Absent:

Richard Quinn, Commissioner

Also present: 

Eileen Den Bleyker, Deputy Attorney General
Rubin Weiner, Deputy Attorney General
Florence J. Sheppard, Deputy Director, Pensions and Benefits (via telephone)
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations, Pensions and Benefits
Barbara Scherer, Pensions and Benefits
Horizon Representatives (via telephone)

Minutes – Meeting No. 3, October 29, 2008.  Wendell Steinhauer made a motion to accept the amended minutes. Cynthia Jahn seconded the motion. Approved (Vote 7: 0: 1: Commissioner Del Grosso abstained).

Minutes – Meeting No. 4, December 15, 2008.  Wendell Steinhauer made a motion to accept the minutes. Cynthia Jahn seconded the motion. All voted in favor

ISSUES

A. Authorize entry of a Memorandum of Understanding (MOU) with the State Health Benefits Commission for participation of school employees in NJ DIRECT and other SHBC programs.- For Approval

Eileen Den Bleyker gave a broad overview of the MOU indicating that the MOU does two things:  1) it allows the school employees to continue to receive coverage under the SHBC contracts and 2) it allows the two Commissions to work out the details of the short-term transition program that will end on December 31, 2009.  There was discussion concerning the Request for Proposal (RFP) for the Pharmacy Benefits Manger (PBM).  David Pointer indicated that the Division would be working with the Division of Purchase and Property to prepare the RFP and the resulting contract would not be held by either Commission.  After much discussion on the specifics of the MOU, it was decided that additional time for review by the Commission was needed as to the PBM contract, the actuary contract and the dental plans.  A future MOU could be written or this one could be amended.  An amended MOU could be considered at the next meeting, but the remaining sections must be approved at this meeting in order to meet the February 9, 2009 deadline for the Transition Program.  A motion was made by Chairwoman Oates to approve the MOU with the following changes:  strike the last paragraph on Page 2 and the top three paragraphs on Page 3.  On Page 5, strike paragraphs numbered two through four. Renumber No. 5 Appeals as No. 2, remove “and the Dental Program contracts” from the second line and delete the last sentence.  Renumber No. 6 Effective Date as No. 3 and include a termination date in the last paragraph.  Commissioner Geiger seconded the motion.  All voted in favor.

B. Special Open Enrollment

David Pointer advised the Commission a Special Open Enrollment period will be held during the month of February 2009 due to the approval of coordination of benefits (COB) between NJ DIRECT10 and NJ DIRECT15 pending approval by the SHBC on January 29, 2009.  A Special Open Enrollment will allow members who are affected by this change in benefits to change medical plans.  The effective date will be May 1, 2009.  Once the SHBC approved the Special Open Enrollment, documentation will go out to participating employers.  Applications will be due back from the employers on March 6, 2009.  David Pointer indicated that a newsletter will go out to retirees notifying them of the change.  Since the newsletter will not be mailed until mid-February, retirees have from mid-February until March 20, 2009 to change plans by submitting a completed application.

C. Carrier Updates:

NJ DIRECT:

Children’s Hospital of Philadelphia (CHOP
An agreement between Horizon BCBSNJ and CHOP has been reached.

Pilot Plan – ER Admission Review at Rahway and Newton Hospital
Dave Perry from Horizon advised the Commission under this pilot, Horizon BCBSNJ will manage admissions that occur through the emergency rooms of these hospitals.  Generally, if you are admitted to the emergency room, the network status of the hospital won’t matter; it’s covered as an in-network admission.  Under the pilot plan cases will be reviewed to determine whether the admission is medically necessary.  If not medical necessary, the member and attending physician are notified and if they decide to stay in the hospital, they will be obligated to pay in full.  The other scenario is assuming admission was medically necessary claims will be paid as in-network.  Once it is clinically determined the patient is stable and can be transferred, a letter is delivered to patient informing them they can either: (a) be transferred to a participating facility, and their whole hospital stay will be covered as in-network, or (b) remain at non-participating hospital, and the remaining days will be paid out-of-network level.  James Geiger requested quarterly updates on the progress of the pilot plan.

D. New Employers

A list of all education employers that are presently enrolled in the School Employees’ Health Benefits Program was given to the Commission at the start of the meeting.  James Geiger asked if they could get a full listing and put in the order by date of joining. David Pointer offered to send it electronically.

E. Regulations Update

No additional work has been done since the last update.  Any suggestions or comments should be given directly to Jean Williamson. 

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

Joseph Del Grosso made a motion to go into closed session under Resolution A.  Wendell Steinhauer seconded the motion.  All voted in favor.

SE010901 (Member was present) - This Horizon-Traditional/NJ DIRECT10 appeal concerned the denial of expenses for Zaditen tablets. The member gave a brief overview of his appeal.  He advised the Commission that from 1998 until he received a denial in early 2008 the tablets had been covered under the plan. The Member stated that the drug is approved in many countries but does not have FDA approval.  He received a letter dated July 11, 2008 from Horizon that Zaditen tablets are not available in the United States (U.S.).  Ketotifen, the active ingredient in Zaditen, is available under the brand name Zaditor in eye drop form in the U.S. and can be purchased over-the-counter.  The claim submissions for Zaditen obtained on December 10, 2007 and March 31, 2008 were processed by Caremark to allow benefits as an exception.  Future claims for Zaditen (Ketotifen) will not be allowed under the SHBP retiree Prescription Drug Plan. David Perry, Horizon BCBSNJ explained that the policy on foreign claims (member purchased the drugs in Canada) is to try to match up the medication with an equivalent FDA NDC Code.  What happened, in this case, is that the ingredient, Ketotifen, matched up to the ingredient in the eye drops that subsequently became over-the-counter.  Jane Oates made a motion to go into Executive Session under Resolution B.  Kevin Kelleher seconded the motion. All voted in favor.  Upon return from the executive session, James Geiger made a motion to deny this appeal. Cynthia Jahn seconded the motion.  All voted in favor.

There being no further business to transact, a motion was made to adjourn by Wendell Steinhauer, seconded by Joseph Del Grosso. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 12:34 PM.

Respectfully submitted,

 

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


School Employees’ Health Benefits Commission
Minutes, Meeting No. 6
February 25, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The first portion of the meeting is open to the public.  The second portion, in conformity with the Open Public Meetings Act, shall be closed to the public based upon the personal matters exception.  Those matters are confidential unless expressly waived by the individual involved.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:12 AM, Wednesday, February 25, 2009.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

ROLL CALL

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

Jane Oates, Chairperson
Joseph Del Grosso, Commissioner
Thomas Gallagher, representing Commissioner Steven M. Goldman, Department of Banking & Insurance
Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner

Absent:

James Geiger, Commissioner
Richard Quinn, Commissioner

Also present: 

Eileen Den Bleyker, Deputy Attorney General
Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations, Pensions and Benefits
Barbara Scherer, PBS II, Pensions and Benefits

ISSUES

A. Request for Proposal (RFP) for a Prescription Benefits Manager (PBM) – Alice Small, Director, Division of Purchase and Property, addressed the Commission on procedural aspects of the process.  Mary Lou Goho, Deputy Director, Division of Purchase and Property, also attended the meeting.  Ms. Small gave an overview of the way in which a RFP is conducted.  She indicated that neither (Health Benefits) Commission would have direct input in the RFP but that they could pose questions once the RFP is posted on the Purchase and Property website.  Jane Oates spoke highly of Ms. Small and had no doubt of the quality as well as savings the RFP would generate.

B. Memorandum of Understanding (MOU) with the State Health Benefits Commission:  The Commissioners were provided with a MOU with tracked changes as well as the MOU in Final form without the tracked changes.  Kevin Kelleher asked if the December 31, 2012 termination date is because of the contracts. DAG Den Bleyker said yes, at that time if the two Commissions want different things a decision can be made then.  Kevin Kelleher asked if the Commission has enough flexibility retain its copayments even if the State Health Benefits Commission (SHBC) changes their copayments because of negotiations with the unions.  Florence Sheppard said that she did not see that being an issue; it happens now. Joseph Del Grosso made a motion to approve the amended MOU.  Thomas Gallagher seconded the motion.  All voted in favor.

C. Grace’s Law:  David Pointer advised the Commission a hearing aid benefit under “Grace’s Law” was approved by the SHBC.  Effective March 30, 2009, Grace’s Law requires coverage for hearing aid purchase for each ear that are medically necessary and are prescribed by a licensed physician or audiologist up to $1,000.00 per hearing aid every 24 months for members 15 years of age and younger.  The Commission asked where the benefit amount was derived.  Susanne Culliton replied it is in the statute.  David Pointer added that it is the minimum.  Frederick Beaver noted we need to look at the claims experience over time since we don’t know what this is going to cost.  Kevin Kelleher asked if the SHBC has the right to go back and raise the amount if warranted.  David Pointer said yes.  Jane Oates stated that this Commission would like to have the ability to propose to the SHBC an increase in the amount in the future if needed.  She requested an update of the costs to the SEHBC after one year of claims.

D. Carrier Updates

NJ DIRECT:  Effective February 1, 2009, MinuteClinic healthcare centers located at select CVS Pharmacy locations throughout NJ will be considered in-network for all Horizon BCBSNJ products.  MinuteClinic health care center clinicians are board-certified nurse practitioners, supervised by a licensed New Jersey physician, who can diagnose, treat and prescribe medication for common illnesses such as strep throat, sinusitis and bronchitis.  This will provide increased access to members to care for common ailments.

Aetna - Aetna Medicare Advantage – Based on feedback from the SEHBC meeting in December, two benefit levels were enhanced as follows:  1)  Skilled Nursing:  Aetna increased the benefit in the Medicare Open Plan from 100 to 120 days per benefit period. 2)  Psychiatric Hospital – The 190 day lifetime limit for the Medicare Open plan for inpatient services in a psychiatric hospital was removed effective January 1, 2009.  Since implementation, about 200 subscribers opted out of the Aetna Medicare Open plan.

Southern Ocean County Hospital joined Aetna’s network effective February 15, 2009.

E. Regulations Update – Jane Oates requested that at next month’s meeting that more time be allotted to discuss the regulations.  Susanne Culliton advised the Commission the public comments on the proposed SHBP regulations are due on March 6, 2009.  The State Health Benefits Commission will be meeting concerning adoption of the regulations at the end of March.  Jane Oates requested a schedule be set for looking at the regulations at the April meeting.
There being no further business to transact, a motion was made to adjourn by Wendell Steinhauer, seconded by Joseph Del Grosso. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 11:17 AM.

Respectfully submitted,

 

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

 

 

 

 


School Employees’ Health Benefits Commission
Minutes, Meeting No. 7
March 25, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The meeting of the School Employees Health Benefits Commission (Commission) was called to order at 10:06 AM, Wednesday, March 25, 2009.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

ROLL CALL

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

Jane Oates, Chairperson
Joseph Del Grosso, Commissioner
Thomas Gallagher, representing Commissioner Steven M. Goldman, Department of Banking & Insurance
Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner
James Geiger, Commissioner
Richard Quinn, Commissioner

 Also present: 

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations, Pensions and Benefits
Barbara Scherer, PBS II, Pensions and Benefits
Horizon Representatives

Minutes – Meeting No. 5, January 28, 2009.  Chairperson Oates made a motion to accept the minutes. Commissioner Del Grosso seconded the motion. Approved (Vote 7: 0: 1: Commissioner Quinn abstained).

Minutes – Meeting No. 6, February 25, 2009.  Chairperson Oates made a motion to accept the minutes. Commissioner Del Grosso seconded the motion. Approved (Vote 6: 0: 2: Commissioner Quinn and Geiger abstained).

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

Jane Oates made a motion to go into closed session under Resolution A.  Kevin Kelleher seconded the motion.  All voted in favor.

SE030901 – This Horizon NJ DIRECT10 appeal concerned the denial of benefits for expenses for Cialis pills beyond four pills per month/ twelve pills in a 90-day period. Commissioner Geiger questioned the benefit of hearing appeals for what amounts to a $400 case.  Ms. Sheppard asked DAG Weiner to explain the appeal process. DAG Weiner stated the way the procedure is set up is any member that is aggrieved by a decision made by either staff or by Horizon has the authority to appeal before the Commission. Commissioner Geiger stated that he appreciated the due process piece of it, but believed that the persons paid to administer the plans should have wiggle room to resolve disputes without involving the Commission.  Commissioner Del Grosso asked if a study of medical need has been done. Commissioner Geiger asked the background establishing the four pills per month limit. Mr. Pointer replied years ago this was presented to the SHBC and it was determined that four pills a month was the limit. To date the Division has administered that provision.  Mr. Pointer further stated that the Division is unaware of any medical basis that the medicine treats other conditions.  Commissioner Geiger asked how appeals in the past were voted with respect to this limit.  Director Beaver replied they were all denied. Commissioner Quinn asked what it would cost to go from four to eight pills per month.  Director Beaver said that they would have to do a cost analysis. Commissioner Quinn asked if the Commission has the authority to change the amount of pills per month.  DAG Weiner replied that the Commission has limited authority to change the plan, but any discussion of plan changes should be made in open session. Commissioner Oates asked if someone could get four Viagra pills and four Cialis pills in the same month. Dr. Smith from Horizon responded no, the plan permits only one or the other. Commissioner Steinhauer made a motion to deny the appeal based on the fact that the claim exceeded the limit allowed by the plan.  Commissioner Oates seconded the motion. Approved (9:0:0)

There being no other appeals, Commissioner Gallagher made a motion to return to open session. Commissioner Steinhauer seconded the motion.  All voted in favor.

Issues

A. Carrier Updates – FYI
     
Horizon:
    1. Change to Win (CTW)
Dave Perry of Horizon introduced Peggy Johnson, Vice President of Pharmacy at Horizon.  Mr. Perry stated that an entity known as Change to Win is publicly making certain allegations against CVS Caremark that have raised concern among Horizon and its customers.  He stated in great confidence there is no evidence that private information is being compromised by CVS Caremark in their business practices. Mr. Perry read a statement prepared by CVS Caremark that communicated its position to its customers.  Mr. Perry stated that CVS Caremark is subject to the same HIPAA laws as Horizon, and that Horizon is confident that the privacy of Horizon members at Caremark is being protected.  Horizon has not had a single complaint that relates to the potential release of information by Caremark.  Commissioner Kelleher stated that Horizon’s response addressed his concerns.  Commissioner Geiger asked if the Commission should be expecting any appeals or questions regarding privacy violations.  Mr. Perry responded that he wouldn't expect it, but couldn’t definitely say that it's not going to happen.

    2. Dispensing Limits Program for Horizon and CVS Caremark.  Dave Perry from Horizon addressed the Commission on the Dispensing Limits Program (DLP).  CVS/Caremark sent letters to members of the SHBP/SEHBP, notifying them of its intent to expand the DLP.  The DLP establishes limits on the number of units covered by the plan per prescription, per day or within a certain time period for certain medications.  Horizon intends to implement the expanded DLP in five phases, beginning April 1, 2009.  If the member requires a quantity of the drug above the dispensing limit, a DLP review process must be initiated by either the member or the prescribing physician.  Chairperson Oates asked if the cost is the same for drugs that are ten milligrams versus twenty milligrams.  Dave Perry responded the cost to make the drugs would be the same.  Commissioner Geiger asked why the Division would alarm someone who is in the middle of treatment that the drug they are taking may no longer be covered.  Dave Perry replied that they wanted to get the information out with plenty of time for members to see their doctors and discuss this with them.  Commissioner Geiger asked if a member that can’t afford specialty drugs can appeal this to the Commission.  DAG Weiner noted that appeals are only heard once a month.  Commissioner Geiger asked whether there could be appeals that are heard on an expedited basis.  Director Beaver replied there have been no appeals about a specialty drug except for one, which was an abuse case.  Commissioner Del Grosso asked whether this is a change in the plan.  Horizon replied it is only an extension of the DLP program.  Commissioner Kelleher asked when the Division of Pensions and Benefits agreed to send out these letters.  Dave Perry replied the middle part of February.  Commissioner Kelleher asked how many letters went out.  Mr. Perry said 17,000.  Commissioner Kelleher asked if this was presented to the SHBC.  Ms. Sheppard replied no.  Mr. Pointer noted that this was not a change in the plan, but rather an extension of the DLP program.  Chairperson Oates asked if there were there any other comments.

Commissioner Oates made a motion to go into executive session under Resolution B. Commissioner Kelleher seconded the motion.  All voted in favor.

The Commission returned from executive session back into open session Commissioner Oates went to the last issue on the agenda.

B. Regulations

Commissioner Oates asked Ms. Sheppard whether the public comment period was still open until the end of this month, or if it was finished. Ms. Sheppard responded that she believed the public comment period is finished.  She stated that the SHBC is scheduled to adopt the regulations and consider the comments at its special meeting on April 1, 2009.  After that meeting, the Commission would get a copy of the adopted regulations.  Chairperson Oates asked if this version would be the revised version with the comments.  Ms. Sheppard responded yes. Commissioner Jahn asked if the Commission would then be reviewing them for its own adoption.  Ms. Sheppard replied yes, Commissioner Geiger asked that the Commission receive changes that the SHBC made to their regulations. Ms. Sheppard replied that these changes would be sent via email.

There being no further business to transact, a motion was made to adjourn by Commissioner Oates, seconded by Commissioner Del Grosso. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 11:47 AM.

Respectfully submitted,
 
Barbara Scherer
Acting Secretary
School Employees’ Health Benefits Commission

 

 

 

 


School Employees’ Health Benefits Commission
Minutes, Meeting No. 8
April 22, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The meeting of the School Employees Health Benefits Commission (Commission) was called to order at 10:10 AM, Wednesday, April 22, 2009.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

ROLL CALL

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

Jane Oates, Chairperson
Thomas Gallagher, representing Commissioner Steven M. Goldman, Department of Banking & Insurance
Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner
James Geiger, Commissioner
Richard Quinn, Commissioner

Absent:

Joseph Del Grosso, Commissioner

Also present: 

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations, Pensions and Benefits
Jean Williamson, Acting Secretary

Resolution A was not read since there were no appeals to be heard.  Resolution B would be read if needed during the course of the meeting.  A court reporter did not attend the meeting.  Since there were no appeals to be heard and no issues to vote upon (with the exception of meeting dates), everyone agreed to hold the meeting without the court reporter.

Jane Oates indicated that she will be leaving State government to work with the Obama administration at the end of the month.  Therefore, the Commission will be without a Chairperson until a replacement is named.

There were no minutes available from the previous meeting.  They will be available at the May meeting.

ISSUES:  A:  Carrier Updates:

NJ DIRECT:  Network of doctors and hospitals:  Carol Banks, Horizon, Blue Cross Blue Shield of New Jersey (Horizon) gave an overview of a memorandum (see below) that was distributed to the Commissioners at the start of the meeting.  Commissioner Quinn asked for the percentage of the total number of practicing physicians in New Jersey who are in network.  Ms. Banks said she could provide that information but did not have it available with her.  Ms. Banks said Horizon met its goal of recruiting by 2/1/08, 20% of highly utilized physicians who were non-participating providers.  Currently, Horizon has recruited 30% of eligible doctors.  Commissioner Kelleher asked a question on the numbers which was answered and he also asked if the new employers were having an impact.  Ms. Banks said that was not identified as a driver.  Mr. Kelleher inquired if the Tables in the memorandum were available quarterly and if they could be provided to the Commission.  Agreement was made to provide the first Table on a quarterly basis.  Chairwoman Oates thanked Ms. Banks.  There was some discussion regarding information in the memo that was distributed that Horizon claimed was proprietary.  It was agreed that such information would not be attached to the minutes.  Commissioner Geiger asked if the deleted information could be presented in a way that Horizon would not object.  Ms. Banks will review and see if it can be done.

Memorandum for:

New Jersey School Employees’ Health Benefits Commission

Date:

April 22, 2009

Subject:   NJ DIRECT Managed Network Update

In response to Commissioner Kelleher’s request, the following summary of the Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) managed network has been compiled. 

Horizon BCBSNJ Managed Network Summary

Type of Provider

Number of Providers as of March 2008

Number of Providers as of March 2009

Change

Total NJ Providers

22,773

23,321

2.4%

Primary Care Physicians (PCP)

5,207 (22.9%)

5,453 (23.4%)

4.7%

Specialists

13,851 (60.8%)

13,840 (59.3%)

(0.1%)

Ancillary Providers

3,715 (16.3%)

4,028 (17.3%)

8.4%

The Horizon BCBSNJ managed network in New Jersey is a well established and stable network.  Total network growth reported overall from March 2008 to March 2009 was 2.5%.  It should be noted that these figures refer to a unique count of providers, meaning that each provider is counted once, even when the provider has multiple locations or specialties.  In addition to the provider counts shown above, the New Jersey Primary and Specialty Care Network Summaries by County are attached for reference.

NJ DIRECT National Network

Additionally, NJ DIRECT members have access to the BlueCard PPO network for in-network services outside New Jersey.   BlueCard PPO network statistics are summarized below:

BlueCard PPO

Number of Providers

Primary Care Physicians

243,706

Specialists

400,713

Hospitals

4,319

NJ DIRECT Provider Recruitment Summary

As a part of the NJ DIRECT implementation, Horizon BCBSNJ identified a total of 1,578 non participating providers who were highly utilized by State Health Benefits Program Traditional Plan members.  Horizon BCBSNJ made a commitment to contact 75% of these physicians by the end of 2007 and to recruit 20% of the eligible physicians by February 2008.  Outlined below is a summary of this recruitment activity.

 

Number

Percentage

1) Physicians targeted

1,578

 

2) Physicians contacted by year end (2007)

1,306

83%

3) Physicians ineligible for recruitment (due to retirement, death, relocation or did not meet credentialing criteria.)

328

25%

4) Physicians eligible for recruitment

978

75%

5) Eligible physicians recruited by February 2008

195

20%

6) Eligible physicians recruited to date

291

30%

Horizon BCBSNJ continues to manage the network to ensure appropriate access for our members, while providing quality and affordable coverage to the State Health Benefits Program and New Jersey School Employees’ Health Benefits Program participants.

Horizon BCBSNJ Managed Network (NJ)
Primary Care Physician Summary by County
March 2008

County

Family Practice

Internal Medicine

Pediatricians

Total PCPs

REGION I

 

 

 

 

Morris

69

115

73

257

Passaic

44

149

75

268

Sussex

22

29

20

71

Warren

31

33

14

78

Totals

166

326

182

674

REGION II

 

 

 

 

Bergen

67

303

178

548

Hudson

54

139

78

271

Totals

121

442

256

819

REGION III

 

 

 

 

Essex

71

308

162

541

Union

52

124

62

238

Totals

123

432

224

779

REGION IV

 

 

 

 

Hunterdon

71

9

17

97

Mercer

45

142

61

248

Middlesex

104

277

150

531

Somerset

83

59

56

198

Totals

303

487

284

1074

REGION V

 

 

 

 

Burlington

131

61

62

254

Camden

156

140

123

419

Cumberland

33

32

22

87

Gloucester

78

35

30

143

Salem

22

15

3

40

Totals

420

283

240

943

REGION VI

 

 

 

 

Atlantic

49

67

45

161

Cape May

34

10

6

50

Monmouth

75

208

145

428

Ocean

51

160

68

279

Totals

209

445

264

918

Grand Total

1,342

2,415

1,450

5,207

 

Horizon BCBSNJ Managed Network (NJ)
Primary Care Physician Summary by County
 March 2009

County

Family Practice

Internal Medicine

Pediatricians

Total PCPs

REGION I

 

 

 

 

Morris

69

122

79

270

Passaic

49

155

85

289

Sussex

20

25

20

65

Warren

31

34

13

78

Totals

169

336

197

702

REGION II

 

 

 

 

Bergen

76

322

193

591

Hudson

56

142

82

280

Totals

132

464

275

871

REGION III

 

 

 

 

Essex

69

321

165

555

Union

54

124

64

242

Totals

123

445

229

797

REGION IV

 

 

 

 

Hunterdon

66

9

17

92

Mercer

53

156

63

272

Middlesex

113

284

159

556

Somerset

86

66

56

208

Totals

318

515

295

1128

REGION V

 

 

 

 

Burlington

135

82

66

283

Camden

158

147

140

445

Cumberland

32

31

23

86

Gloucester

85

37

32

154

Salem

28

17

3

48

Totals

438

314

264

1016

REGION VI

 

 

 

 

Atlantic

54

66

45

165

Cape May

32

13

8

53

Monmouth

72

217

145

434

Ocean

51

167

69

287

Totals

209

463

267

939

Grand Total

1,389

2,537

1,527

5,453

Specialty Physician Network by County

Horizon BCBSNJ Managed Network (NJ)
Specialists* by County 

County

2008

2009

REGION I

 

 

Morris

971

989

Passaic

594

569

Sussex

130

133

Warren

145

146

Totals

1840

1837

REGION II

 

 

Bergen

1584

1583

Hudson

463

462

Totals

2047

2045

REGION III

 

 

Essex

1684

1647

Union

615

636

Totals

2299

2283

REGION IV

 

 

Hunterdon

162

166

Mercer

712

736

Middlesex

1372

1311

Somerset

447

445

Totals

2693

2658

REGION V

 

 

Burlington

714

703

Camden

1366

1399

Cumberland

168

166

Gloucester

239

235

Salem

79

86

Totals

2566

2589

REGION VI

 

 

Atlantic

544

551

Cape May

91

95

Monmouth

1062

1058

Ocean

709

724

Totals

2406

2428

 

 

 

Grand Total

13,851

13,840

*Specialties include: - Cardiology, Dermatology, Endocrinologist, Immunologist/Allergist, Infectious Disease, General Surgeon, Thoracic Surgeon, Vascular Surgeon, Nephrologist, Neurologist, OB/Gyn, Gynecology, Hematologist, Oncologist, Ophthalmologist, Orthopedic Surgeon, Oral Surgeon, Otolaryngologist, Physiatrist, Pulmonologist, Urologist, Psychiatric Nurse, Psychiatry, Psychology, Other MD/DO

B. New Employers:  There are 25 new boards of education that have joined the SEHBP since January 1, 2009 and no terminations.  Ms. Banks indicated that it is cyclical, depending on the rates.  David Pointer added that flexibility also helped.  Ms. Banks said the direct access product also contributed to the increase in employers joining the plan.

C. Proposed Rate Renewal Meeting Dates:  8/12/09 @ 2:00 and 8/18/09 @ 1:00 and cancellation of the 8/26/09 meeting.  Commissioner Peden asked how many members were needed for a quorum.  DAG Weiner responded five are needed for a quorum and three to carry the vote.  Commissioners who cannot attend in person will have the ability to attend via teleconference.  Commission Quinn asked if the 12th is the earliest they could get the information and also asked about moving the open enrollment a week.  Florence Sheppard and Fred Beaver explained the timing of the process; that due to printing and distribution limitations it is not possible to delay open enrollment.  Wendell Steinhauer made a motion to approve the meeting dates for the rate renewals and to cancel the 8/26/09 meeting.  Jane Oates seconded the motion and all voted in favor.

D. Regulations:  Chairwoman Oates indicated that since she will not be staying she would rather not discuss the regulations today but rather leave that to her successor.  There was discussion on how best to review, perhaps section by section.  Commissioner Peden asked how to reach consensus if they disagree.  DAG Weiner said disagreements should be dealt with at the meeting.  Susanne Culliton, Regulatory Officer for the Division of Pensions and Benefits asked to address the Commission.  She said much of the SHBP regulations are determined by statute which the Commission is bound and case law.  Commissioner Kelleher said he does not have a lot of changes and suggested that the other Commissioners be prepared to go through the entire document at the next meeting.  Florence Sheppard asked the Commissioners to call Jean Williamson if there are any questions.  Jane Oates reminded everyone that they cannot talk among themselves if a quorum is present.

Mr. Kelleher asked if the RFP for a PBM is on target.  David Pointer replied that it is posted on the Purchase and Property website and questions have been submitted.

Thomas Gallagher made a motion to adjourn.  It was seconded by Wendell Steinhauer and all voted in favor.

Respectfully submitted,

 

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

 

 

 

 


School Employees’ Health Benefits Commission
Minutes, Meeting No. 9
May 27, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The meeting of the School Employees Health Benefits Commission (Commission) was called to order at 10:11 AM, Wednesday, May 27, 2009.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

ROLL CALL

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

Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner
James Geiger, Commissioner
Joseph Del Grosso, Commissioner

Absent:

Thomas Gallagher, representing Commissioner Steven M. Goldman, Department of Banking & Insurance
Richard Quinn, Commissioner

Also present: 

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations, Pensions and Benefits
Jean Williamson, Acting Secretary

In light of Jane Oates’ resignation as Chairperson, Commissioner Steinhauer nominated Commissioner Peden as Interim Chairman until a permanent chairperson is named.  Commissioner Del Grosso seconded the motion. Approved (5:0:1 Commissioner Peden abstained).

Resolution A and B were read in their entirety.

A motion to approve the meeting minutes of March 25, 2009 was made by Commissioner Steinhauer, seconded by Commissioner Jahn.  All voted in favor.  A motion to approve the meeting minutes of April 22, 2009 was made by Commissioner Steinhauer and seconded by Commissioner Jahn. Approved (5:0:1 Commissioner Del Grosso abstained).

Fred Beaver asked to go out of order to address the Commission concerning the Governor’s Press Release of May 22, 2009. In the press release, the Governor asked the two health benefits commissions to consider measures that would 1) suspend an employer’s ability to delay premium payments; 2) place a surcharge on employers who enter and leave the program; 3) terminate employers for non-payment of premiums; and 4) identify any new cost saving opportunities.  Mr. Beaver indicated there will likely be a double digit increase in rates for 2010. Aon Consulting is still reviewing and preparing the rates. The rate renewal meetings will be moved up to July so that the rates are available sooner.  The Division had suggested the first three administrative changes. The Governor is looking for the Commission’s ideas for cost savings and the Division can support the Commission as needed.  Commissioner Geiger asked what it would take to implement the first three administrative decisions.  Mr. Beaver indicated the first two would require changes to the Administrative Code. Commissioner Kelleher asked how many employers are behind in their premiums. Mr. Pointer responded there are 21. Commissioner Jahn suggested making changes to the regulations as they review them.  Rubin Weiner said the regulations can be changed as part of the adoption process. Commissioner Jahn made a motion directing staff to provide additional information to the Commission with respect to the Governor’s proposed measures as part of the process of drafting the regulations. Commissioner Geiger seconded the motion and all voted in favor.

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

Commissioner Steinhauer made a motion to go into closed session under Resolution A.  Commissioner Kelleher seconded the motion.  All voted in favor.

SE050901: This Horizon NJ DIRECT10 appeal concerns a denial of benefits for expenses for Cialis pills beyond four pills per month/twelve pills in a 90 day period.  Commissioner Kelleher asked if there was any difference in this case compared to a recent similar appeal.  Commissioner Jahn asked if the drug should be looked at to treat other types of illness.  Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) said a committee reviewed the policy in February 2009 and found that no other indications at this time are supported by medical documentation.  Commissioner Kelleher made a motion to deny this appeal since there is a pill limit.  Commissioner Jahn seconded it.  Approved (5:1:0; Commission Geiger nay).

Commissioner Geiger made a motion to return to public session; Commissioner Kelleher seconded it and all voted in favor.

ISSUES:

  1. Carrier Updates: There were no carrier updates.
  1. New Employers:  There are 45 new employers joining the SEHBP; about 1/3 chose Premium Delay.
  1. Dependent Eligibility Verification Audit (DEVA):  David Pointer gave an update on the DEVA.  The DEVA has begun again for State employees.  The State portion will be done by the end of the summer.  There will be a break due to open-enrollment and the DEVA will start up again for local employers.  Commissioner Kelleher asked if school districts will be involved in the process.  Mr. Pointer indicated that the employers will not be involved; everything is mailed directly to the individual employee/retiree by the Division.
  1. Regulations:  As per Commissioner Kelleher’s e-mail request, David Pointer gave a brief explanation of the following sections of the regulations:

    17:9A-2.12
    17:9A-3.5
    17:9A-3.6 to 17:9A-3.7
    17:9A-5.5
    17:9A-6.1 sections (c) and( g)
    17:9A-6.2 section (a)(3)
    17:9A-6.3 sections (a)(1) and( d)
    17:9A-6.6
    17:9A-7.2(c)(9)
    17:9A-10.5
    17:9A-11

Commissioner Geiger made a motion to adjourn.  It was seconded by Commissioner Steinhauer and all voted in favor.

Respectfully submitted,

 

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

 

 

 

 


School Employees’ Health Benefits Commission
Minutes, Meeting No.10
June 24, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:06 AM, Wednesday, June 24, 2009.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

ROLL CALL

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

Joseph Del Grosso, Commissioner
Thomas Gallagher, representing Commissioner Steven M. Goldman, Department of Banking & Insurance
Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
James Geiger, Commissioner
Wendell Steinhauer, Commissioner

Absent:

Robert Peden, representing State Treasurer R. David Rousseau
Richard Quinn, Commissioner

Also present: 

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations, Pensions and Benefits
Jean Williamson, Acting Secretary
Barbara Scherer, Health Benefits, Pensions and Benefits
Mildred Brown, Health Benefits, Pensions and Benefits

Jean Williamson asked for a motion for an interim chairperson for the meeting. Commissioner Jahn motioned to nominate Commissioner Gallagher as Interim Chairman for the meeting. Commissioner Del Grosso seconded the motion. Approved (5:0:1 Commissioner Gallagher abstained).

Resolutions A and B were read in their entirety.

A motion to approve the meeting minutes of May 27, 2009 was made by Commissioner Steinhauer, seconded by Commissioner Del Grosso. Approved (5:0:1 Commissioner Gallagher abstained).

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

Commissioner Gallagher made a motion to go into closed session under Resolution A.  Commissioner Del Grosso seconded the motion. All voted in favor.

SE060901: (Member present) - This Horizon-NJ DIRECT10 appeal concerned a denial of an authorization for a proposed Magnetic Resonance Imaging (MRI) of the breast. The member gave a brief overview of her appeal. Dr. Smith, Medical Director at Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) gave an overview of the medical policy regarding coverage for MRIs.  Commissioner Kelleher made a motion to approve the appeal for a MRI based on the fact that she had coverage for MRIs in the past prior to transition to NJ DIRECT10. Commissioner Steinhauer seconded the motion. Commissioner Jahn motioned to go into Executive Session under Resolution B. Chairman Gallagher seconded the motion. All voted in favor. Upon return from Executive Session, Commissioner Kelleher withdrew his motion. Commissioner Steinhauer made a motion to approve the appeal based on the testimony and policy number five stated on page 1 of the February 23, 2009 letter to the member from Timothy Sullivan, M.D., Chairperson, Member Appeal Subcommittee, Horizon BCBSNJ that the MRI is medically necessary to detect local tumor recurrence in breast cancer. Commissioner Del Grosso seconded the motion. Approved (Vote: 4: 2: 0; Commissioners Gallagher and Jahn voted nay).

Commissioner Steinhauer made a motion to go into open session. Commissioner Del Grosso seconded. All voted in favor.

Issues

A. Carrier Updates:

David Pointer advised the Commission under NJ DIRECT, East Orange Hospital will no longer be in-network as of June 20, 2009. The final date members can use the hospital as an in-network facility is October 30, 2009.

Horizon – Magellan

David Perry, Horizon BCBSNJ was asked to address the Commission concerning the change in reimbursement rates for out-of-network mental health providers. He explained that the Prevailing Health Care System (PHCS) fee schedule does not make the distinction between behavioral health providers--psychiatrists, psychologists, social workers etc. For instance, a social worker was being reimbursed an allowed amount that was the same as a psychiatrist. He said Horizon recently made a distinction through a methodology that took charge data that existed for those social workers and psychologists and maintained it as a relationship of the psychiatrists' reimbursement. Commissioner Kelleher stated he thinks the law specifically says that the reimbursement level shall be at the PHCS level, at the 90 percentile. Mr. Perry explained PHCS does not have 100% of all codes. He said there are situations where Horizon uses its own methodology by use of conversion factors. He also pointed out a social worker might participate in-network, but not if they know they will be getting reimbursed as much as a psychiatrist if they are out-of-network.

B. New Employers – Mr. Pointer gave a brief update on new employer enrollments in the SEHBP. He noted the Pleasantville Board of Education and Dennis Township Board of Education have also joined the dental plan.

C. Performance Standard Report – As an FYI, Mr. Pointer gave an overview of the Performance Standard Report that was presented to the State Health Benefit Commission at its June 10th meeting.   
D. Regulations Update – Commissioner Steinhauer said he went through the regulations and found ten areas for amendment and moved to approve all existing regulations as proposed with the exception of the 10 areas. Commissioner Jahn said she would like to see what those areas are and wondered if it is possible to circulate comments before the meeting so that they can be reviewed. Chairman Gallagher asked if the changes could be handed out now and then place them on the agenda for the next meeting. DAG Weiner said changes can be provided to the secretary who can distribute them to everybody. Commissioner Steinhauer identified his changes to the regulations and said he would send them to Jean to distribute. There was some discussion about the process. Chairman Gallagher asked that the regulations be on the agenda next month for adoption.

Commissioner Steinhauer made a motion to go into closed session. Commissioner Del Grosso seconded the motion.  All voted in favor.

SE060902: Magellan Health Services (Horizon) NJ DIRECT10-Denial of outpatient therapy in excess of 3 sessions per week. Dr. Saldarini representing Magellan Health Services advised the Commission that the member has been seeing her psychologist since 2005 four sessions per week in forty-five to fifty minute time increments per session. Based on all the facts it was Magellan’s recommendation that the relationship between the member and her doctor be starting to be pared down. Commissioner Geiger made a motion to deny this appeal. Cynthia Jahn seconded the motion. All voted in favor. Approved (Vote 6; 0; 0;).

Commissioner Steinhauer made a motion to resume back into open session.  Commissioner Del Grosso seconded the motion.  All voted in favor. 

Commissioner Kelleher asked Magellan questions concerning handling of calls to their call center. He said he read in one of the appeal letters that the person was on hold for over an hour and asked if that is typical. Dr. Saldarini stated that Magellan looked into that allegation and found that the average speed of answer for those time periods where that member did call in never exceeded seven minutes.

Mr. Pointer noted that everyone received a letter from Marie Bilik of the New Jersey School Board Association for discussion at the next meeting. Commissioner Del Grosso said his organization has similar documents that he'd like to forward to the Commission as well. Chairman Gallagher requested that any additional documents be sent prior to the next meeting.

There was some discussion about the process for the upcoming rate renewal meetings. Mr. Pointer gave a brief overview of the process.

There being no further business to transact, a motion was made to adjourn by Cynthia Jahn, seconded by Joseph Del Grosso. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 12:10 PM.

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

School Employees’ Health Benefits Commission
Minutes, Meeting No.11
July 14, 2009; 1:00 PM

The Special meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 1:08 PM, Tuesday, July 14, 2009. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

Adequate notice of this meeting was provided through a special meeting notice filed with and prominently posted in the offices of the Secretary of State. The special meeting notice was mailed to the Secretary of State, Star Ledger and the Trenton Times on May 29, 2009.

ROLL CALL

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

Joseph Del Grosso, Commissioner
Thomas Gallagher, representing Commissioner Steven M. Goldman, Department of Banking & Insurance
James Geiger, Commissioner (via telephone)
Cynthia Jahn, Commissioner (late 1:12 PM)
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner

Absent:

Richard Quinn, Commissioner

Also present:

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, Health Benefits Program
Mildred Brown, Health Benefits Program
Edward Fox, Aon Consulting
James Christ, Aon Consulting
Susan Marsh, Aon Consulting

Issues

Edward Fox, Aon Consulting, gave an introduction and general overview of the 2010 rates. Susan Marsh, Aon Consulting, gave an overview of the 2010 Rate Recommendations for Medical and Prescription Drugs for the Active Employees and Retirees of the School Employees Health Benefits Program (SEHBP). Also present from Aon Consulting was James Christ. The following is a summary from Aon Consulting:

New Jersey
School Employees’ Health Benefits Commission
July 14, 2009 Meeting

School Employees’ Health Benefits Program
(SEHBP)

Recommended Plan Year 2010
Medical/Rx Rate Renewal Recommendation
for Active Employees and Retirees


  • For Plan Year 2010, Aon is recommending premium rate changes that – in the aggregate – represent an overall increase of 15% for SEHBP Active Employees and Retirees:

 

Active
Employees

Early
Retirees

Medicare Retirees

NJ DIRECT10

25%

11%

1%

NJ DIRECT15

25%

11%

1%

Aetna HMO

24%

19%

6%

CIGNA HMO

24%

19%

6%

Rx Card Plan

7%

NA

NA

Average Change

23%

12%

1%

  • This recommended renewal assumes:
    • For Retiree Rx for NJ DIRECT and HMOs, the brand copays and Out-of-Pocket maximum will receive formula increases based on Retiree Rx experience;
    • The Prescription Benefit Manager (PBM) RFP will result in a new contract, effective 1/1/10 that will reduce Rx costs by a minimum of 2% to 5%.  Premium levels in the renewal report assume a 2% reduction in Rx costs;
    • The Dependent Eligibility Verification Audit will generate Plan Year 2010 SEHBP claim savings of $9 million through the elimination of coverage for ineligible dependents;
    • No other changes in Employee or Retiree benefits, other than those mandated by NJ or federal law, as outlined in the Renewal Report;
    • SEHBP Employee enrollment will increase in August 2009 at half the rate of July 2009 and then remain level from September 2009 through December 2010, and
    • SEHBP Retiree enrollment will continue to increase at about the same rate as in prior years, with a 3% increase in total Retirees (the combination of a 6% increase for Medicare Retirees and a 3% decrease for Early Retirees).
  • Aggregate differences in the rate changes for different benefit plans and between Actives and Retirees reflect the impact of:
    • Medicare Retiree medical trends have been well below industry norms for the past few years and we are projecting that the low trend levels will continue into Plan Years 2009 and 2010.
    • Prior to Plan Year 2009, Early Retiree HMO costs were pooled with Active HMO costs to develop premiums.  Since there are now over 5,000 SEHBP Retirees enrolled in HMOs, the Plan Year 2010 renewal rates were again adjusted to partially reflect the higher level of claim costs attributable to Early Retirees.
    • HMO medical claim trends have averaged about 3% higher than Horizon trends over the past several years, and we are projecting that HMOs will continue to trend at a higher rate than the Horizon plans in Plan Year 2010.
  • Factors contributing to the overall recommended rate actions include:
    • 9% trend from Plan Year 2009 to Plan Year 2010;

    • Higher than previously anticipated trends for Plan Years 2008 and 2009;

    • NJ DIRECT benefit changes approved after the Plan Year 2009 renewal, which add 2% to the increase;

    • Mandated benefit enhancements, which add 1% to the increase;

    • Spend down of the accumulated Claim Stabilization Reserve to reduce Plan Year 2009 premium rates, which adds 6% to the increase;

    • 2% margin added to the Plan Year 2010 premium rates in order to build up the Claim Stabilization Reserve, and

    • 1% decrease in Education Surcharge credits per member, due to the growth of enrollment in the SEHBP.
  • Plan Year 2010 projected costs for the SEHBP are $1.84 billion ($1.10 billion for Actives and $.74 billion for Retirees).  Plan Year 2010 renewal premiums are set 2% higher than projected costs for Actives and 2% lower than projected costs for Retirees.  This results in a projected $18 million gain for Actives and a projected $15 million loss for Retirees in Plan Year 2010. 
  • The 12/31/10 Claim Stabilization Reserve level for Actives is projected at 1.2 months of projected plan costs, significantly below the recommended level of 2.0 months, so the slight gain will help restore the Active reserve to a more adequate level.
  • Despite the projected 2% loss, the Retiree Claim Stabilization Reserve is projected at 3.4 months as of 12/31/10.

Miscellaneous:

Commissioner Kelleher received a letter from a member who is in the appeal process with Horizon Blue Cross Blue Shield of New Jersey; copies of the letter were distributed to the rest of the Commissioners.

Commissioner Jahn distributed copies of a letter from the New Jersey School Board Association to Robert Peden, Interim Chairman for the SEHBC.  

There was a very brief discussion concerning the status of the regulations which will be on the agenda for next week’s regular meeting.

There being no further business to transact, a motion was made to adjourn by Joseph Del Grosso, seconded by Thomas Gallagher. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 2:11 PM.
                          

  Respectfully submitted,
 

 

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



School Employees’ Health Benefits Commission
Minutes, Meeting No. 12
July 22, 2009, 10:00 AM

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:04 PM, Wednesday, July 22, 2009. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

ROLL CALL

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

Joseph Del Grosso, Commissioner
Thomas Gallagher, representing Commissioner Neil N. Jasey, Department of Banking & Insurance
James Geiger, Commissioner
Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner

Absent:

Richard Quinn, Commissioner

Also present:

Rubin Weiner, Deputy Attorney General
Frederick J. Beaver, Director, Pensions and Benefits
Florence J. Sheppard, Deputy Director, Pensions and Benefits
Jean Williamson, Acting Secretary
Barbara Scherer, Health Benefits Program
Mildred Brown, Health Benefits Program
Edward Fox, Aon Consulting
James Christ, Aon Consulting
Susan Marsh, Aon Consulting

Issues:  Rate Renewals

Edward Fox, Aon Consulting, addressed the Commission and made brief statements about the President’s Health Care Reform Act 2010. After introducing the Aon team, he turned it over to Susan Marsh also of Aon Consulting. Ms. Marsh gave an overview of her memo to Florence Sheppard dated July 21, 2009 which addressed follow-ups from questions that were raised at the meeting on July 14, 2009 concerning the recommendations for the 2010 Rate Renewals. Aon answered questions raised by the Commission members.

Ms. Marsh also addressed a couple of questions that were raised on page two in Commissioner Jahn's letter of July 21, 2009 to Commissioner Peden concerning the Claim Stabilization Reserve and a comparison of the projected Claim Stabilization Reserve. Ms. Marsh gave a detailed response to the questions.

Chairman Peden referred to the components of the 23% increase on page 2 of the report and asked if it was safe to conclude that some of the design changes that were intended to save money didn’t save as much as anticipated. Ms. Marsh explained that the increase was due to a 9% trend normalized for the benefit changes.

Chairman Peden asked Commissioner Jahn to summarize some of the key points in her letter. Commissioner Jahn suggested that the Commission seriously consider the recommended changes in the Aon report, and determine the proper responsibility of employees to share in the costs and expense of their health coverage.

DAG Weiner reviewed the changes that were recommended in the Aon report. He stated that a number of the changes were precluded by statute, and therefore would require legislative change. The other recommended changes would require an amendment to the Horizon contract and, under the MOU; this would have to be done in coordination with the State Health Benefits Commission.

Wendell Steinhauer made a motion to approve the 2010 Rate Renewals. Cynthia Jahn seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to recommend that the State Health Benefits Commission not apply for the Mental Health Parity exemption as they have in the past. DAG Weiner explained the reasons the exemption is requested.  Chairman Peden asked for an estimate of how much the cost would increase without the exemption. Susan Marsh replied they project an increase of half-a-percent. Commissioner Kelleher seconded the motion. Approved: Vote (4; 3; 0; Commissioners Jahn, Gallagher and Peden voted nay).

Commissioner Jahn made a motion to seek modification of the Horizon contract to implement changes recommended by Aon. Chairman Peden seconded the motion. There were several questions to clarify the intent of the motion. Motion failed. Vote (3; 4; 0; Commissioner Steinhauer, Kelleher, Geiger and Del Grosso voted nay).

Regulations

Chairman Peden stated that proposed changes to the regulations were received from Commissioner Steinhauer. He asked if Pensions and the DAG’s office looked at these changes and done an analysis of their impact. Director Beaver said an escalator formula was mentioned but that the Division did not have it. Susanne Culliton introduced herself as the Assistant Director and the Regulatory Officer for the Division and spoke briefly about the process for adopting regulations. She asked if there were any other comments on the proposed regulations from the Commissioners. Commissioner Jahn said she has not submitted any comments to date, but would like to do so. DAG Weiner said the Commission should consider changing the provision regarding the number of votes necessary to carry a motion to conform with the statute, and that the Commission should also consider whether they wanted to require appeals to be heard at regular meetings. After a lengthy discussion, Commissioner Steinhauer made a motion to have all comments on the regulations, with exact language of the proposed amendments, submitted by July 31st and to place the regulations on the agenda for the meeting on September 23rd for this Commission to take action. Commissioner Gallagher seconded the motion. All voted in favor.

There being no further business to transact, a motion was made to adjourn by Joseph Del Grosso, seconded by Wendell Steinhauer. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 2:19 PM.

  Respectfully submitted,
 

 

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

School Employees’ Health Benefits Commission
Minutes, Meeting No. 13
September 23, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:08 AM, Wednesday, September 23, 2009.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

Roll Call

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

Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner
James Geiger, Commissioner
Joseph Del Grosso, Commissioner
Thomas Gallagher, representing Commissioner Neil Jasey, Department of Banking & Insurance
Richard Quinn, Commissioner (until 12:30)

Also present: 

Eileen Den Bleyker, Deputy Attorney General
Rubin Weiner, Deputy Attorney General
Florence J. Sheppard, Deputy Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, Health Benefits Program
Mildred Brown, Health Benefits Program
Horizon Blue Cross Blue Shield of New Jersey Representatives

Resolution A and B were read in their entirety.

A motion to approve the meeting minutes of July 14, 2009 with the correction of adding the meeting notice was made by Commissioner Del Grosso, seconded by Commissioner Steinhauer. Approved (7:0:1 Commissioner Quinn abstained).  A motion to approve the meeting minutes of July 22, 2009 was made by Commissioner Del Grosso and seconded by Commissioner Steinhauer.  Approved (7:0:1 Commissioner Quinn abstained).

Issues:

A. Carrier Updates:

Cheryl Eagan from Horizon Blue Cross Blue Shield of New Jersey (Horizon) addressed the Commission on the Coordination of Benefits (COB) between NJ DIRECT10 and NJ DIRECT15.  Horizon had to program the COB into their system.  Members and claims that were covered by both plans had to be identified and retro-processed back to April 1, 2008.  There were approximately 40,000 members impacted. The retro-processing of claims has been completed and COB is a part of the normal process.  Commissioner Kelleher asked if those claims included the Magellan claims. Ms. Eagan replied yes.  Commissioner Kelleher asked if the claims have been processed for the transition from the Traditional plan to the NJ DIRECT10 plan. The process has been completed for 2008 and will begin again for 2009 in early 2010.

David Pointer advised the Commission that implementation of the Pharmacy Benefit Management Contract has begun with Medco Health Solutions, Inc (Medco). Meetings started approximately a month ago and continue on a daily basis.  Mr. Pointer explained that the transfer will be automatic; the member does not need to complete an enrollment application.  In addition open refills will be electronically transferred from Caremark/CVS to Medco.  However, certain prescriptions cannot be transferred electronically because the prescription requires an original prescription which can not be transferred. Commissioner Kelleher requested that a list of the drugs that cannot be transferred be provided to the Commission.  Mr. Pointer agreed to provide one.   

B. Open Enrollment

David Pointer informed the Commission that letters went out to employers last week advising them the Open Enrollment Period for local education employees will begin on October 1, 2009 and end on October 30, 2009.  All changes to coverage made during this open enrollment will be effective on January 1, 2010.  For changes made during this Open Enrollment, completed employer-certified Health Benefit Applications and/orDental Plan Applications should be forwarded to the Health Benefits Bureau as soon as they are received from employees.

C. Dependent Eligibility Verification Audit (DEVA)

David Pointer advised the Commission that DEVA letters will begin going out in January 2010 for education members with dependents.  Commissioner Kelleher asked if the letters are for active and retired members.  Mr. Pointer replied yes.  Commissioner Kelleher then asked if the education members will be provided with a timeframe as the state and local members were.  Mr. Pointer replied yes they will.

D. New Legislation

David Pointer informed the Commission that two pieces of legislation were recently signed into law.  Chapter 113, P.L. 2009 provides a change to the way in which maternity services are reimbursed.  Physicians will be paid in increments over the duration of the pregnancy rather than in a lump sum at the end of it.  Chapter 115, P. L. 2009 provides medically necessary therapies for members with Autism and other developmental disabilities.

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

Commissioner Del Grosso made a motion to go into closed session under Resolution A.  Commissioner Peden seconded the motion.  All voted in favor.

SE090901: This Horizon NJ DIRECT15 appeal concerns a denial of pre-certification for In Vitro Fertilization treatment. Wendy Burns from Horizon provided a summary of this appeal.  Horizon records indicated that the Utilization Management (UM) Department received a request for a pre-certification for an IVF cycle with gestational carrier for the member from the doctor’s office.  The request was received on January 30, 2009. After consideration, the request was denied because the member did not meet criteria for medical necessity; the member had not met the criteria for infertility as required under the State mandated IVF benefit. Ms. Burns advised the Commission that due to miscommunication on Horizon’s part they are willing to reimburse the member 100% for the medical services received pertaining to the IVF that were submitted up until April 9, 2009, not including wages for time missed at work as requested by the member. Commissioner Steinhauer motioned to accept Horizon’s proposal. Commissioner Kelleher seconded the motion.  All voted in favor.  Commissioner Steinhauer made a motion to deny this appeal as the money issue is moot and member did not meet the criteria for infertility.  Commissioner Kelleher seconded the motion.  All voted in favor. 

There being no other appeals, Commissioner Steinhauer made a motion to return to open public session. Commissioner Del Grosso seconded it and all voted in favor.

Eileen Den Bleyker, DAG asked the Commissioners to go into Executive Session to discuss litigation over collective bargaining between the Rockaway Township Education Association and the Rockaway Township Board of Education.  DAG Den Bleyker stated that if any of the Commissioners have been involved with this case, they should recuse themselves.  Commissioner Kelleher recused himself and left the room.  Commissioner Geiger made a motion to go into Executive Session under Resolution B.  Commissioner Gallagher seconded it.  All voted in favor.

E.  Regulations

The Commission returned from executive session back into open session to discuss the Regulations. Susanne Culliton addressed the Commission about the regulations before them.  She explained they would go through page by page and address the comments that were made for each one.
There was discussion about the proposed formula for the escalator for the retiree prescription drug plan on page 40.  A motion was made by Commissioner Kelleher to include the escalator proposed by Commissioner Steinhauer in the version of the regulations to be presented to the Commission for approval.  The motion was seconded by Commissioner Del Grosso. Approved (4:3:0 Commissioners Jahn, Gallagher and Peden voted nay)

There are two sections of the regulations that need to be discussed further: 1) Duplication of benefits 17:9A-2.12 and 2) Local employer payment of charges 17:9A-5.2.

Commissioner Peden made a motion to table the regulations to the next meeting.  Commissioner Jahn seconded it.  Approved (4:3:0 Commissioners Steinhauer, Kelleher and Geiger voted nay)

Commissioner Steinhauer made a motion to adjourn.  It was seconded by Commissioner Geiger and all voted in favor.  The meeting adjourned at 2:10 PM.

  Respectfully submitted,
 

 

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

                     


School Employees’ Health Benefits Commission
Minutes, School Employees’ Health Benefits Commission
Minutes, Meeting No. 14
October 28, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The meeting of the School Employees Health Benefits Commission (Commission) was called to order at 10:24 AM, Wednesday, October 28, 2009.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

Roll Call

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

Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner
James Geiger, Commissioner
Thomas Gallagher, representing Commissioner Neil Jasey, Department of Banking & Insurance
Richard Quinn, Commissioner

Absent
Joseph Del Grosso, Commissioner

Also present: 

Eileen Den Bleyker, Deputy Attorney General
Rubin Weiner, Deputy Attorney General
Florence J. Sheppard, Deputy Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, Health Benefits Program
Mildred Brown, Health Benefits Program
Horizon Blue Cross and Blue Shield of New Jersey Representatives

Resolution A and B were read in their entirety.

A motion to approve the meeting minutes of September 23, 2009 was made by Commissioner Steinhauer, seconded by Commissioner Gallagher. Approved (7:0:0).

Issues

A. Carrier Updates

David Pointer advised the Commission that Horizon Blue Cross Blue Shield of New Jersey and Capital Health reached an agreement that will keep Capital Health’s Mercer Campus in-network and bring the Helen Fuld Campus in-network for all Horizon BCBSNJ members effective October 1, 2009. 

B. Dependent Eligibility Verification Audit (DEVA)

David Pointer advised the Commission delays from the extension of dates for state employees have caused a delay for the audit of local employees.  He anticipates the DEVA will begin at end of January for school employees.

The Commission agreed to go out of order and hear the appeal cases next.

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

Commissioner Steinhauer made a motion to go into closed session under Resolution A.  Commissioner Gallagher seconded the motion.  All voted in favor.

SE100901: This Horizon NJ DIRECT10 appeal concerned a denial of benefits for pre-certification for surgical procedures to be performed on behalf of the member’s spouse. Dr. Smith from Horizon advised the Commission at the time this appeal was presented he believed Horizon denied the appeal correctly.  Under a change to the internal policy made in September, the appeal might be approved if re-reviewed. However, Dr Smith advised the Commission that the spouse went through an alternate surgery which was approved by Horizon.  Commissioner Gallagher made a motion to deny this appeal as the circumstances have changed and do not currently support approval. Commissioner Jahn seconded the motion.  Approved (7:0:0).

SE100902: This Horizon NJ DIRECT10 appeal concerned a denial benefits for Growth Hormone Therapy for dependent daughter. Commissioner Gallagher asked the medical director what the risks are for the tests. Dr. Smith did not have the complete list. Commissioner Gallagher asked if the tests are required to determine deficiency. Dr. Smith responded yes, without the tests you take the risk of treating someone that doesn’t have a growth hormone problem.  Commissioner Quinn asked if the doctor gave a reason why the test was not done.  There was no reason from the doctor or the member. Commissioner Kelleher made a motion to deny this appeal because the criteria for growth hormone treatment had not been met. Commissioner Peden seconded the motion.  Approved (7:0:0).

SE100903: (Member Present) This Horizon NJ DIRECT10 appeal concerned a denial of benefits for expenses for a surgical procedure performed on the member’s spouse.  Member said he was advised by a Horizon representative to pursue the appeal as exceptions can be made.  Wendy Burns confirmed that incorrect information was given to the provider; however, Horizon did tell the member the correct information and member was aware prior to receiving the services that this procedure would not be covered. Commissioner Jahn made a motion to go into Executive Session under Resolution B.  Commissioner Peden seconded the motion.  All voted in favor. Upon return from executive session, Commissioner Peden requested that the Division and Horizon report back to this commission with clarification regarding the policy for exceptions.  Commissioner Geiger made a motion to deny this appeal based on the exclusion from the plan.  Commissioner Jahn seconded the motion. Approved (7:0:0).  Commissioner Peden directed Horizon to provide a written explanation regarding exceptions to the member. 

There being no other appeals, Commissioner Kelleher made a motion to return to open public session. Commissioner Geiger seconded it and all   voted in favor.

Regulations

DAG Den Bleyker explained when it comes to promulgating regulations, the promulgation and establishment of regulations requires a vote of a majority of the full authorized Commission in accordance with the statute which is five members.  Normally a majority of those present would be sufficient.

After discussion about 17:9A-5.2, it was deemed complete and off the list of outstanding issues.

Discussion moved to 17:9A-2.12.  Commissioner Steinhauer raised the issue of supplemental plans and said the regulation reads as though the employer cannot adopt a separate plan and that would conflict with the recent PERC decision.  Mr. Pointer indicated that the Division’s position is that PERC can’t do that.  Commissioner Steinhauer asked about the enforcement of this regulation.  Mr. Pointer said that if the Division is informed of it happening, we tell the employer not to do it.  Commissioner Gallagher made a motion to request legal advice regarding the definition of the word “plan” under the terms of 2.12 .  Commissioner Steinhauer seconded it and all voted in favor.

Other Business

1)  Commissioner Kelleher asked for clarification on how waivers are tracked.  Mr. Pointer explained when a member waives coverage, the member completes an application which is certified by the employer who files it with the Division.

2)  Commissioner Steinhauer brought up a letter from the NJEA asking if the Commission would support a resolution proposed by the NJEA.  DAG Den Bleyker asked if he was advancing it on behalf of the NJEA and he replied “Yes”.  DAG Den Bleyker indicated it would be best to put it on another agenda and explore some of the issues underlying that before it is discussed.  Chairman Peden said to put it on the agenda for next time.

3) Commissioner Kelleher raised the issue of reduced payment to certain groups of mental health providers.  Mr. Beaver indicated the State Health Benefits Commission is addressing the issue at its next meeting.  Commissioner Kelleher asked for an update at the December meeting.

4) There was discussion regarding the procedure for obtaining public comments regarding the regulations.  Commissioner Kelleher asked whether or not he should ask for comments on the regulations to come back to him.  Commissioner Jahn explained that a news article appeared in their publication that gave a summary of what happened at the last Commission meeting, that she is a member, and that anyone who had any issues or questions should be directed to her.  She will forward the article to Mr. Beaver.

There being no further business, Commissioner Steinhauer made a motion to adjourn, Commissioner Gallagher seconded it and all voted in favor.  The meeting adjourned at 12:19 pm.

  Respectfully submitted,
 

 

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


School Employees’ Health Benefits Commission
Minutes, Meeting No. 15
November 18, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The meeting of the School Employees Health Benefits Commission (Commission) was called to order at 10:24 AM, Wednesday, November 18, 2009.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

Roll Call

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

Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner
James Geiger, Commissioner
Thomas Gallagher, representing Commissioner Neil Jasey, Department of Banking & Insurance
Richard Quinn, Commissioner
Joseph Del Grosso, Commissioner

Also present: 

Rubin Weiner, Deputy Attorney General
Janice F. Nelson, Assistant Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, Health Benefits Program
Mildred Brown, Health Benefits Program
Horizon Blue Cross and Blue Shield of New Jersey Representatives

Resolution A and B were read in their entirety.

Issues:

A. Carrier Updates

David Pointer gave an update on the progress of transitioning to a new prescription drug manager, Medco Health Solutions Inc. He stated that an announcement letter was expected to go out to participating employers the following week through EPIC, and that the Division was asking the employers to distribute the letter to their employees. The announcement letter would also be included in the retiree newsletter, The Health Reporter, which was expected to be mailed in early December. COBRA and Chapter 375 participants would receive a direct mailing from Medco which is anticipated to be mailed the following week as well.  Mr. Pointer informed the Commission that Medco's customer service phone number would be activated effective December 1st, 2009 and that its website would also be activated for SHBP/SEHBP members on December 1st, 2009. ID cards and a welcome packet would be mailed to participants by the middle of December, and a letter explaining Medco's formulary would be mailed to members affected by changes some time in December (mostly retirees who have a 3-tier pharmacy benefit). Mr. Pointer noted Medco’s announcement letter will advise members that prescription refills for controlled substances and compound medications will not be transferred, but that there will not be targeted mailings to specific individuals using these medications.  If a member takes one of these medications, he or she would need to obtain a new prescription from his or her doctor.  Mr. Pointer noted that the welcome packets would contain instructions for submitting new prescriptions to the Medco mail order pharmacy.  Commissioner Kelleher asked if the Division could provide the Commissioners with a copy of Medco’s announcement Letter.  Mr. Pointer agreed to e-mail the letter to them. 

B. 2010 Proposed Meeting Dates

David Pointer said there were two schedules proposed for the meeting dates, one a bi-monthly schedule and the other a monthly schedule. Since the Commission averages one to two appeal cases a month, the Division recommended a bi-monthly schedule.  Commissioner Steinhauer made a motion to approve the 2010 bi-monthly meeting dates.  Commissioner Jahn seconded the motion.  Commissioner Kelleher asked if the bi-monthly schedule would delay the finalization of the Regulations.  DAG Weiner replied that the Commission could schedule additional special meetings if necessary.  Commissioner Quinn expressed concern over a member’s appeal waiting an additional month and the effect on the member’s care.  He then asked if a special meeting could be scheduled for a member appeal.  DAG Weiner replied that the regulations could allow for appeals to be heard at special meetings.  Director Beaver added in the past there were a few appeals with extenuating circumstances that required an immediate decision; in those cases a special meeting was set up via teleconference. There still being a motion on the floor, the Commission voted to approve the bi-monthly 2010 meeting dates. Vote (7:0:0).   Commissioner Geiger asked that the 2010 meeting dates be sent electronically to the Commissioners via Outlook.  Jean Williamson agreed to send them electronically. 

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

Commissioner Del Grosso made a motion to go into closed session under Resolution A.  Commissioner Steinhauer seconded the motion.  All voted in favor. 

SE110901: This Horizon NJ DIRECT10 appeal concerned a denial of benefits to purchase Insulin at a retail pharmacy during the summer months but to pay the mail order co-payment applicable to the medication.  David Pointer advised the Commission that the point was moot; the member has not had a loss of any kind.  Anytime there was a problem, Caremark/CVS replaced it the next day.  In addition, a new vendor will be the prescription drug manager.  Commissioner Quinn made a motion to deny this appeal as the member did not suffer a loss. Commissioner Peden seconded the motion.  Approved (Vote 7:0:0).
 
SE110902: This Horizon NJ DIRECT10 appeal concerned a denial of benefits above the Reasonable and Customary allowance for an office visit. Ms. Burns, Horizon BCBSNJ, advised the Commission the member previously had the Traditional Plan.  Under the Traditional Plan, total charges were paid for office visits.  Commissioner Quinn made a motion to deny this appeal. Commissioner Peden seconded the motion. Approved (Vote 7:0:0).

There being no other appeals, Commissioner Del Grosso made a motion to return to open public session. Commissioner Gallagher seconded it. All   voted in favor.

Commissioner Peden asked if there was any other business to discuss.

Commissioner Steinhauer asked for an update on the regulations.  DAG Weiner said their office is researching the definition of the term “plan”.  The regulations will be on next month’s agenda. 

There was also discussion concerning a letter from the NJEA requesting expansion of Horizon’s network.  DAG Weiner said there are ethics issues.  Mr. Beaver said there is a question of who can act on a resolution put forward by the NJEA.  He will contact DAG Den Bleyker and this will be discussed at the next meeting.

Commissioner Kelleher said that several months ago an agreement was made with Horizons BCBSNJ to provide a quarterly summary of Horizon’s Managed Network to the Commission. The summary provided the type and number of Providers in the Managed Network as of March 2008 and March 2009.  Could Horizon provide us with an update on this at the next meeting? Ms. Burns agreed to have an update at the next meeting.

There being no further business Commissioner Del Grosso made a motion to adjourn.  It was seconded by Commissioner Peden.  All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 10:40 AM.
                          
                          

  Respectfully submitted,
 

 

 

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



School Employees’ Health Benefits Commission
Minutes, Meeting No. 16
December 23, 2009; 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 2009 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on November 17, 2008.

The meeting of the School Employees Health Benefits Commission (Commission) was called to order at 10:13 AM, Wednesday, December 23, 2009.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

ROLL CALL

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

Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden representing State Treasurer R. David Rousseau
Wendell Steinhauer, Commissioner
James Geiger, Commissioner
Thomas Gallagher representing Commissioner Neil Jasey, Department of Banking & Insurance
Richard Quinn, Commissioner
Joseph Del Grosso, Commissioner (Via Telephone – Left meeting at 11:30 AM)

Also present: 

Rubin Weiner, Deputy Attorney General
Florence J. Sheppard, Deputy Executive Director, Pensions and Benefits
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, Health Benefits Program
Mildred Brown, Health Benefits Program
Aetna Representatives
Horizon Blue Cross and Blue Shield of New Jersey Representatives

Resolution A and B were read in their entirety.

A motion to approve the meeting minutes of October 28, 2009, was made by Commissioner Steinhauer, seconded by Commissioner Kelleher. Approved (7:0:1 Commissioner Del Grosso abstained).
A motion to approve the meeting minutes of November 18, 2009, was made by Commissioner Steinhauer, seconded by Commissioner Kelleher. Approved (7:0:1 Commissioner Del Grosso abstained).

Issues:

A. Carrier Updates:

David Pointer advised the Commission the implementation of Medco Health Solutions is running smoothly. Commissioner Quinn asked will members be notified of any changes from Caremark/CVS to Medco. Mr. Pointer responded any members currently taking a specialty drug on the new list will receive a letter which was mailed out this past weekend.

B. Employer updates: There was no discussion.  
 
C. Revised 2010 Meeting Schedule: Jean Williamson advised the Commission a revised 2010 meeting schedule was up for approval. A request was made to change the November meeting to the third Thursday, November 17, 2010. Commissioner Gallagher made a motion to approve the revised 2010 meeting schedule. Commissioner Steinhauer seconded the motion. All voted in favor. 

D. Regulations:  It was determined that there was a need to go into Executive Session in order for DAG Weiner to provide answers to questions that were raised during the last meeting. Commissioner Steinhauer made a motion to go into Executive Session under Resolution B. Commissioner Peden seconded the motion. All voted in favor. Upon returning from executive session Commissioner Steinhauer made a motion to approve promulgation of the regulations with changes to pages 39 and 40 of the regulations. Commissioner Peden seconded the motion. Approved (Vote 6:1:1; Commissioner Jahn voted nay and Commissioner Peden abstained). Commissioner Geiger stated for the record that his questions regarding 2.12 stemmed from the simple fact, that the Commission took the wrong position on the Rockaway matter by attempting to vacate the arbitrator's award. He stated his position that joining the School Employees' Health Benefits Plan should not give the employer a shield from any bargaining obligation that they had prior to entering into the School Employees' Health Benefits Plan.  He stated that the Commission's position in Rockaway does exactly that and is inconsistent with the State's policy to accept binding arbitration as the primary form of resolving labor disputes. He stated that the Commission ought to insist in the future that the parties maintain or enforce their collective bargaining agreement at least until such time as a successor agreement has been reached. He also stated that he had asked not just for legal advice as it relates to the definition of the plan, but for a legal opinion, which he presumed would have been forthcoming to this Commission in writing, rather than verbally in Executive Session. He concluded that the narrow construction of an insurance plan versus the broad-based claim of actuarial adverse selection is simply an assertion, and there has been no record of fact that the bargaining agreement in Rockaway had an adverse impact on the plan's costs. 

E. Surcharge
David Pointer told the Commission that pursuant to NJSA 52:14-17.38c, the State Treasurer is required to set an annual surcharge rate for insurers of school districts that do not participate in the School Employees’ Health Benefits Program (SEHBP). The Treasurer set the annual surcharge rate at 2.5 percent for 2010. Commissioner Kelleher requested that the Division advise the Commission where the surcharge is applied and how it is used. David Pointer said he would have that available.     
 
 
The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in closed session.

Commissioner Steinhauer made a motion to go into closed session under Resolution A.  Commissioner Jahn seconded the motion. All voted in favor. 

SE120901: This Aetna Dental appeal concerned a denial of benefits for expenses for the SpeechEasy Device for the member’s dependent daughter. Dr. Rosen, Aetna’s Medical Director advised the Commission this claim was denied in accordance with Aetna’s clinical policy bulletin pertaining to Speech Therapy. Altered auditory feedback devices are considered experimental and investigational for stuttering and all other indications because of a lack of evidence in published literature on the effectiveness of the device. Commissioner Kelleher asked when Aetna’s policy was last reviewed.  Dr. Rosen replied in May 2009 the policy was reviewed and updated. Commissioner Quinn made a motion to deny this appeal. Commissioner Peden seconded the motion. Approved (Vote 7:1:0, Commissioner Kelleher voted nay).
 

SE120902: This Horizon NJ DIRECT10 appeal concerned a denial of benefits for reimbursement for the Zostavax vaccine. Wendy Burns, Horizon BCBSNJ, indicated that the member was informed ten months prior to receiving the vaccine that she had to see an in-network provider in order for the vaccine to be covered. During the telephone conversation, the doctor the member inquired about was an in-network provider. However, the member went to an out-of-network provider doctor who administered the vaccine. The plan does not provide benefits for vaccines administered by an out-of-network provider. Commissioner Jahn made a motion to deny this appeal. Commissioner Peden seconded the motion. Approved (Vote 7:1:0, Commissioner Geiger voted nay).

SE120903: The Member requested that the Commission’s previous denial of an appeal for outpatient therapy in excess of three sessions per week be forwarded to the Office of Administrative Law (OAL) for a hearing. Commissioner Kelleher made a motion to go into Executive Session under Resolution B.  Commissioner Steinhauer seconded the motion. All voted in favor. Upon return from Executive Session, Commissioner Steinhauer made a motion to approve the request for a hearing at the OAL.  Commissioner Kelleher seconded the motion. Approved (Vote 6:0:1, Commissioner Peden abstained; Commissioner DelGrosso had to leave the meeting prior to the vote).

SE120904: The Member requested that the Commission’s previous denial of benefits above the reasonable and customary allowance for an office visit be forwarded to the Office of Administrative Law (OAL) for a hearing. Commissioner Kelleher made a motion to approve this request for a hearing at the OAL. Commissioner Steinhauer seconded the motion. Approved (Vote 7:0:0).

There being no other appeals, Commissioner Steinhauer made a motion to return to open public session. Commissioner Peden seconded it. All voted in favor.

Commissioner Peden asked if there was any other business to discuss.

Commission Kelleher stated Fred Beaver was going to talk about what was discussed at the State Health Benefits Commission meeting regarding mental health. Florence Sheppard replied since Fred is not here, we will put it on the agenda for January 2010. 

There was a brief discussion on the employer updates regarding the outstanding premium delays.   

There being no further business, Commissioner Steinhauer made a motion to adjourn. It was seconded by Commissioner Peden. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 11:45 AM.

  Respectfully submitted,
 

 

 

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