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Pensions and Benefits
School Employees' Health Benefits Commission
Meeting Minutes 2010
* START TIME IS 1:00 P.M.
** MEETING WILL BE HELD AT THOMAS EDISON STATE COLLEGE, PRUDENCE HALL, TRENTON, NJ.

Special School Employees’ Health Benefits Commission
Minutes, Meeting No. 17
January 14, 2010; 10:00 AM

Adequate notice of this special meeting was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 11, 2010.

The special meeting of the School Employees Health Benefits Commission (Commission) was called to order at 10:06 AM, Thursday, January 14, 2010. 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:

Wendell Steinhauer, Commissioner
Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner – Via Telephone
R. David Rousseau, State Treasurer
James Geiger, Commissioner
Neil Jasey, Commissioner Department of Banking & Insurance – Via Telephone
Richard Quinn, Commissioner – Via Telephone
Joseph Del Grosso, Commissioner – Via Telephone

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
Jean Williamson, Acting Secretary
Barbara Scherer, Health Benefits Program

Resolution B was read in its entirety.

State Treasurer Rousseau advised the Commission the only business before the Commission today was the nomination of three individuals to be forwarded to the Governor for appointment. 

Commissioner Steinhauer made a motion to open the nominations.  State Treasurer Rousseau seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to recommend David E. Earling, Dennis Testa and Rosemary Graziano as the three nominations. Commissioner Steinhauer made a motion to close the nominations.  State Treasurer Rousseau seconded the motion. All voted in favor.

Commissioner Geiger seconded the motion. Approved (Vote 7:1:0 Commissioner Jahn voted nay).

There being no further business, Commissioner Steinhauer made a motion to adjourn, Commissioner Geiger seconded it and all voted in favor.  The meeting adjourned at 10:11am.

  Respectfully submitted,
 

 

 

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

School Employees’ Health Benefits Commission
Minutes, Meeting No. 18
January 27, 2010; 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:08 AM, Wednesday, January 27, 2010. 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:

Wendell Steinhauer, Commissioner
Cynthia Jahn, Commissioner
Thomas Gallagher, representing Acting Commissioner Thomas B. Considine, Department of Banking & Insurance
David Earling, Chairperson
Kevin Kelleher, Commissioner
James Geiger, Commissioner

ABSENT:

Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff
Richard Quinn, Commissioner
Joseph Del Grosso, Commissioner

ALSO PRESENT:

Rubin Weiner, Deputy Attorney General
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, Pensions and Benefits
Horizon Representatives

A motion to approve the meeting minutes of June 24, 2009, was made by Commissioner Steinhauer, seconded by Commissioner Gallagher. Approved (5:0:1 Commissioner Earling abstained).

A motion to approve the meeting minutes of December 23, 2009, was made by Commissioner Steinhauer, seconded by Commissioner Gallagher. Approved (5:0:1 Commissioner Earling abstained).

A motion to approve the meeting minutes of January 14, 2010, was made by Commissioner Steinhauer, seconded by Commissioner Gallagher. Approved (5:0:1 Commissioner Earling abstained).

ISSUES

A. Carrier Updates

David Pointer advised the Commission that Medco’s transition is moving along relatively smoothly with a few bumps in the road.

A two page document concerning the NJ DIRECT Managed Network Update was given to the Commissioners. This was in response to Commissioner Kelleher’s request for the status of the Horizon managed network.

B. Employer Updates

Jean Williamson advised the Commission that she would email the employer updates.

David Pointer advised the Commission the second phase of the Dependent Eligibility Verification Audit (DEVA) has begun. Certifying Officer letters were sent to the SHBP Participating Local Government Employers and the SEHBP Participating Local Education Employers on January 25, 2010 outlining the correspondence employees can expect to receive from Aon and due dates for submission of documentation to Aon. Initial Audit Packets for these members will start being mailed to the home addresses February 10, 2010.

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.

Case #SE011001 – (Attorney Present as well as deceased member’s daughter and son) This Horizon NJ DIRECT10 appeal concerned a denial of benefits for expenses for care rendered at JKF Hartwyck at Oak Tree. The member’s attorney gave an overview of his appeal. Medical Director Ebben Smith said the wound care that she required could have been done in a different environment. Commissioner Kelleher made a motion to go into Executive Session under Resolution B. Commissioner Jahn seconded the motion. All voted in favor. Upon return from Executive Session, Commissioner Earling made a motion to postpone the decision of the appeal until March 24, 2010’s meeting and asked that Horizon appoint a person to review all claims in connection with this case. Commissioner Kelleher seconded the motion. Motion Passed (Vote 6: 0: 0).

Case #SE011002 (Member present) This Horizon NJ DIRECT10 appeal concerned a denial of benefits for expenses for 24 hour private duty nursing (PDN) care for a disabled dependent. The Member advised the Commission prior to her employer joining the School Employees’ Health Benefits Program her disabled son had 24 hour private duty nursing coverage, seven days a week. Horizon reduced the time to 20 hours and she is presently paying for four hours per day of the PDN. On January 21st the PDN was reduced by another four hours. The member said she can pay for four hours but cannot afford eight hours. Medical Director Ebben Smith from Horizon stated some of the care provided is custodial care. The plan does not include PDN for an extended period of time even if it is medically necessary. Commissioner Steinhauer asked how long her son has been receiving PDN 24 hours a day 7 days a week. Member responded for 19 years. Commissioner Kelleher made a motion to approve this appeal based on the records in front of the Commission today. Commissioner Jahn made a motion to go into Executive session under Resolution B. Commissioner Geiger seconded the motion. All voted in favor. Upon return from Executive Session, Commissioner Kelleher withdrew his motion. Commissioner Steinhauer made a motion to approve 24 hour PDN care because such care is medically necessary and home is the most appropriate setting for such care. Commissioner Kelleher seconded the motion. Approved (Vote 6:0:0). Commissioner Geiger made a motion to schedule a meeting in the future to provide Horizon with guidance as how to handle future PDN claims processing. Commissioner Steinhauer seconded the motion. All voted in favor.

Case #SE011003 (Member and attorney present). This Division appeal concerned the denial of coverage for a member’s stepchildren. The member’s attorney stated that the stepchildren should be eligible for coverage as defined under NJAC 17:9-3.1. David Pointer advised the Commission that the children do not live with the member and the member is not financially responsible for the children. It was confirmed that there is a court order for the member’s spouse to provide medical coverage for his children. It was also established that coverage for the children is available through the employer of the member’s spouse. Commissioner Geiger made a motion to go into Executive Session under Resolution B. Commissioner Jahn seconded the motion. All voted in favor. Upon return from Executive Session, Commissioner Jahn made a motion to deny this appeal based on the fact that the children are not substantially dependent upon the member for support and maintenance and the fact that they reside out of state with the natural mother. Commissioner Geiger seconded the motion. Motion Passed (Vote 6:0:0).

Case #SE011004 - A settlement offer was before the Commission for claims paid ($1,300) that the Division determined should not have been paid because they were work related. The settlement offer was for $1,000. Commissioner Geiger made a motion to accept the settlement proposal. Commissioner Steinhauer seconded the motion. Approved (Vote 6:0:0).

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

Susanne Culliton advised the Commission that due to a recent Executive Order, the Regulations are being held for three months.

Commissioner Kelleher made a motion that the Step Therapy Program to be implemented on February 1, 2010 by Medco be put on hold indefinitely.

Commissioner Steinhauer seconded the motion. After some discussion, a vote was taken. Motion failed. (Vote 3:3:0, Commissioner Jahn, Gallagher and Earling voted nay).

There being no further business to transact, a motion was made to adjourn by Commissioner Gallagher, seconded by Commissioner Jahn. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 1:15 PM.

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

School Employees’ Health Benefits Commission
Minutes, Meeting No.20
July 14, 2010; 1:00 PM

Adequate notice of this meeting was provided through the annual notice of the schedule of regular meetings of the Commission filed with and prominently posted in the offices of the Secretary of State.  The 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and was amended on June 1, 2010.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 1:08 PM, Tuesday, July 14, 2010.  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:

Wendell Steinhauer, Commissioner
Cynthia Jahn, Commissioner
Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff
Thomas Gallagher, representing Commissioner Thomas B. Considine, Department of Banking & Insurance (Left after the 1st appeal)
David Earling, Chairperson
Kevin Kelleher, Commissioner
Joseph Del Grosso, Commissioner (Attended by telephone)

ALSO PRESENT:

Rubin Weiner, Deputy Attorney General
Florence J. Sheppard, Acting Director, Pensions and Benefits
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, Health Benefits Program
Edward Fox, Aon Consulting
James Christ, Aon Consulting
Susan Marsh, Aon Consulting
Wendy Burns, Horizon Representative
Rosemary Middlebrook, Horizon Representative

ISSUES

Edward Fox, Aon Consulting, gave an introduction and made general remarks.  Susan Marsh, Aon Consulting, gave an overview of the 2011 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, 2010 Meeting

School Employees’ Health Benefits Program (SEHBP)
Recommended Plan Year 2011
Active Employee and Retiree
Medical/Rx Rate Renewal Recommendation


For Plan Year 2011, Aon is recommending premium rate changes that – in the aggregate – represent an overall increase of 5.7% for SEHBP Active Employees and Retirees:

 
Employees
Early
Retirees
Medicare
Retirees
NJ DIRECT10 8.5% 3.0% 0.0%
NJ DIRECT15 8.5% 3.0% 0.0%
Aetna HMO 12.0% 3.0% 0.0%
CIGNA HMO 11.5%  3.0% 0.0%
Rx Card Plan  4.0% NA NA
       
Average Change 8.6% 3.0%  0.0%
  • This recommended rate 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 selection of Medco as the Program’s Prescription Benefit Manager (PBM), effective 1/1/10, will result in a 9% reduction in Rx claim costs in Plan Years 2010 and 2011.  In Plan Year 2011, this translates into  $41 million in savings as a result of deeper discounts and larger rebates than were available through the previous PBMs;
    • The Dependent Eligibility Verification Audit is projected to generate Plan Year 2011 SEHBP claim savings of $35 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.  Specific to Health Care Reform, the SEHBP will be impacted by:

        • Coverage of Dependent Children to Age 26 (which increases costs $6 million)

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

        • Early Retiree Reinsurance Program
    • SEHBP Active Employee enrollment will decrease 5% in Plan Year 2011, and
    • SEHBP Early Retiree enrollment will increase 1% in Plan Year 2011 and Medicare Retiree enrollment will not change.
  • 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 in Plan Years 2010 and 2011.
    • HMO 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 2011.
  • Factors contributing to the overall recommended rate actions include:

    • 9% trend from Plan Year 2010 to Plan Year 2011, which is slightly better than industry trends;

    • Mandated benefit enhancements, including New Jersey and federal mandates (including Health Care Reform), which add 2% to the increases;

    • 1% margin added to the Plan Year 2011 premium rates in order to increase the Active Employee Claim Stabilization Reserve to a more appropriate level;

    • Retiree premium rates were reduced to reflect a reduction in the Retiree Claim Stabilization Reserve, and

    • 4% savings from the Dependent Eligibility Verification Audit and the transition to Medco.

  • Plan Year 2011 projected costs for the SEHBP are $1.89 billion ($1.13 billion for Actives and $.76 billion for Retirees).  Plan Year 2011 renewal premiums are set 1% higher than projected costs for Actives and 3% lower than projected costs for Retirees.  This results in a projected $10.3 million gain for Actives and a projected $45.6 million loss for Retirees in Plan Year 2011. 
  • The 12/31/11 Claim Stabilization Reserve level for Actives is projected at 1.6 months of projected plan costs, 20% 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 6% loss, the Retiree Claim Stabilization Reserve is projected at 3.2 months as of 12/31/11.

Chairperson Earling recessed the meeting for fifteen minutes.

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

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

Case #SE071001 - (Attorney and deceased member’s daughter and son present). This tabled Horizon NJ DIRECT10 appeal concerned a denial of benefits for expenses for care rendered at JKF Hartwyck at Oak Tree to allow Horizon to review all claims in connection with this case. The member’s attorney gave a recap of his overview presented at the January 27, 2010 Commission meeting.  He said upon requesting a written policy that stated the benefit days have a limit of 120 and run concurrently with the Medicare days from Horizon he was told it was an informal policy of theirs.  Chairperson Earling asked Horizon to explain their policy.  Wendy Burns said Fact Sheet #23, “Your Retired Health Benefits and Medicare Part A & B”, published by the Division of Pensions and Benefits, explains this benefit.  A brief discussion took place between Horizon and the Commission and it was determined the member’s spouse was advised the days run concurrent with Medicare by a Horizon representative. Chairperson Earling made a motion to go into Executive Session under Resolution B.  Commissioner Kelleher seconded the motion.  All voted in favor.  Upon return from Executive Session, Commissioner Kelleher made a motion to deny this appeal based on the fact the member’s spouse was advised of the policy by telephone, and the policy is included in the member handbook and Fact Sheet #23.  Commissioner Jahn seconded the motion.  All voted in favor.

Case #SE071002 -  This Division appeal concerned a denial to fill a prescription for Vaniqa cream.  The Division denied the request on the basis that the drug was used primarily for cosmetic purposes and was therefore specifically excluded from the Prescription Drug plan. Commissioner Kelleher asked if anyone from Medco was here for the meeting.  Commissioner Kelleher made a motion that a representative from Medco be present for all appeals pertaining to the Employee Prescription Drug Plan.  Commissioner Steinhauer seconded the motion.  All voted in favor.  Commissioner Steinhauer made a motion to table the remaining three prescription drug appeals until a Medco representative was in attendance.   Commissioner Kelleher seconded the motion.  All voted in favor.  [Note:  the next appeal, Case #SE071003 was heard before this appeal/motion was made because the Member was present.]

Case #SE071003 – (Member and dependent child present) This Division appeal concerned a denial to fill prescriptions for Rogaine and Propecia.  The Division denied the request on the basis that Rogaine is available over the counter and Propecia is primarily used for cosmetic reasons.  Member advised the Commission his son’s condition was a result of treatments he received for an illness he had as a young child.  Commissioner Jahn made a motion to deny this appeal.  Chairperson Earling seconded the motion.  Approved. Vote (5:0:1, Commissioner Kelleher voted nay).

Case #SE071004 -This Division appeal concerned a denial to fill prescription for Meclizine on the basis that the drug is available over the counter and therefore specifically excluded from the Employee Prescription Drug plan. (Appeal Tabled per motion in Case #SE071002 above)

Case #SE071005 -This Division appeal concerned a denial to fill prescription for Polyethyene Glycol on the basis that the drug is available over the counter and therefore specifically excluded from the Prescription Drug plan. (Appeal Tabled per motion in Case #SE071002 above)

Mr. Pointer advised the Commission there were no carrier updates and gave a brief update on the Dependent Eligibility Verification Audit (DEVA).

There being no further business to transact, a motion was made to adjourn by Commissioner Steinhauer, seconded by Commissioner Jahn. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 3:38 PM.

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


School Employees’ Health Benefits Commission
Minutes, Meeting No 21
July 21, 2010, 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and was amended on June 1, 2010.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:20 AM, Wednesday, July 21, 2010.  The meeting was held at the Thomas Edison State College, Prudence Hall, 101 West State Street, Trenton, New Jersey.

ROLL CALL

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

Wendell Steinhauer, Commissioner
Cynthia Jahn, Commissioner
Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff
Thomas Gallagher, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
David Earling, Chairperson (attended by telephone)
Kevin Kelleher, Commissioner
James Geiger, Commissioner

ABSENT:

Joseph Del Grosso, Commissioner

ALSO PRESENT: 
Rubin Weiner, Deputy Attorney General
Florence Sheppard, Acting Director
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary

A motion to approve the meeting minutes of May 26, 2010 was made by Commissioner Steinhauer, seconded by Commissioner Kelleher. Approved (6:0:0).

Rate Renewals for 2011

Edward Fox, Aon Consulting, introduced the Aon team and turned the meeting over to Susan Marsh also of Aon Consulting.  Ms. Marsh gave an overview of her memo to Florence Sheppard dated July 19, 2010 which responded to questions that were raised at the meeting on July 14, 2010 concerning the recommendations for the 2011 Rate Renewals.  Commissioner Peden asked if adverse selection had been studied.  Mr. Fox said no; but it is considered as part of the analysis of each renewal.  Commission Jahn made a motion to go into Executive Session under Resolution B.  Commissioner Peden seconded the motion and all voted in favor.  Upon return from Executive Session, Commissioner Steinhauer made a motion to approve the rate renewals.  Commissioner Kelleher seconded the motion and all voted in favor.

Commissioner Peden handed out a chart that was from OMB staff and reviewed it with the Commission.

Commissioner Kelleher asked Aon representatives about the pros and cons of going back to a fiscal year that would match up with the boards’ of education fiscal year.  Mr. Fox responded the issue rests with the Division of Pensions and Benefits.  Ms. Marsh mentioned the out-of-pocket maximum and benefit changes may be a challenge.  Mr. Pointer said the 125 plans are also an issue.  Mr. Fox agreed to look into the issue.

There being no further business, Commissioner Steinhauer made a motion to adjourn which was seconded by Commissioner Kelleher.  All voted in favor.  The School Employees’ Health Benefits Commission meeting was adjourned at 11:30 PM.

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

 


School Employees’ Health Benefits Commission
Minutes, Meeting No. 22
September 22, 2010; 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and was amended on June 1, 2010.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:08 AM, on Wednesday, September 22 2010.  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:

Wendell Steinhauer, Commissioner
Cynthia Jahn, Commissioner
Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff
Thomas Gallagher, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Kevin Kelleher, Commissioner

Absent:

David Earling, Chairperson

Also present: 

Rubin Weiner, Deputy Attorney General
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, Health Benefits Program
Horizon Representatives
Magellan Representative
Medco Representatives

Commissioner Steinhauer nominated Commissioner Peden as Interim Chairman for today’s meeting, seconded by Commissioner Gallagher. All voted in favor.

A motion to approve the meeting minutes of July 14, 2010 was made by Commissioner Steinhauer and seconded by Commissioner Gallagher. Approved (5:0:0).

A motion to approve the meeting minutes of July 21, 2010 was made by Commissioner Steinhauer and seconded by Commissioner Gallagher. Approved (5:0:0).

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. 

Case #SE091001 – This tabled Medco appeal concerned a denial of a request to fill a prescription for Vaniqa cream.  Commissioner Peden made a motion to deny this appeal because the drug is used for cosmetic purposes and is, therefore, excluded under the plan. Commissioner Jahn seconded the motion. All voted in favor. (Vote 5: 0: 0)  
 
Case #SE091002 - This tabled Medco appeal concerned a denial of a request to fill a prescription for Meclizine.  Commissioner Gallagher made a motion to deny this appeal because the drug is available over the counter and is, therefore, excluded under the plan. Chairperson Peden seconded the motion.  Approved (Vote 5: 0: 0)  
 
Case #SE091003 - This tabled Medco appeal concerned a denial of a request to fill a prescription for Polyethylene Glycol.  Chairperson Peden made a motion to deny this appeal because the drug is available over the counter and is, therefore, excluded under the plan. Commissioner Gallagher seconded the motion.  Approved (Vote 5: 0: 0)  

Case #SE091004 – (Member present) - This Horizon-NJ DIRECT10 appeal concerned the denial of reimbursement for services rendered on behalf of the Member’s son. The Member’s son’s suffered an accidental injury involving his teeth on September 18, 2000. At that time the member was covered under a Horizon corporate plan. A review of Horizon’s records indicates that the Member’s coverage under NJ PLUS became effective on July 1, 2004 when her employer joined the State Health Benefits Program (SHBP) and terminated July 1, 2007 when the employer left the SHBP. The Member’s employer joined the School Employees’ Health Benefits Program (SEHBP) on July 1, 2008 and the member has been covered under NJ DIRECT since that time.  The member asserted that all of the treatment the child received could not be completed until he was grown.  A claim for $7,000 was submitted to Horizon NJ DIRECT by the provider on January 7, 2009. A discussion took place in which Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ) explained that NJ DIRECT may provide coverage for accidental injuries to teeth but the member must be covered by NJ DIRECT at the time the injury occurred.  Furthermore, the treatment and replacement must occur within 12 months of the accident.  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 Chairperson Peden requested that Horizon BCBSNJ obtain a copy of the original Horizon corporate contract and review it to determine whether the plan in effect for the member when the accident occurred covered the claim. Commissioner Gallagher made a motion to table this appeal Chairperson Peden seconded the motion. All voted in favor.     
  
Case #SE091005 – (Member and attorney present) - This Horizon NJ DIRECT/Magellan appeal concerned a request to treat the Member’s dependent child’s eating disorder diagnosis as a biologically based mental illness (BBMI).  NJ DIRECT provides benefits for non-biologically based mental health conditions under the Mental Health benefits contract.  These benefits are subject to mental health maximums.  Services rendered for biologically based mental health conditions are treated like any other illness and are not subject to the mental health maximums.  Horizon was directed by the Division to continue to pay the claims until the Commission hearing today without application of the mental health maximums, however they requested that Magellan continue to request and review medical records during this interim.  The Member and his attorney presented their case and Horizon BCBSNJ Representatives answered questions from the Commissioners.  Commissioner Kelleher made a motion to go into Executive Session under Resolution B.  Commissioner Jahn seconded the motion.  All voted in favor. Upon return from Executive Session, Commissioner Steinhauer made a motion to table this appeal and instructed Horizon and the Division to provide the Commission and the attorney with additional information prior to the November 17th meeting.  Until then all medically necessary payments will continue. Commissioner Jahn seconded the motion.  All voted in favor. 

Case #SE091006 – (Member’s son and Healthcare Advocate Kevin Flynn present via telephone) This Horizon NJ DIRECT10/Magellan appeal concerned a denial of benefits for expenses for continued residential treatment received by Member’s son at Alina Lodge. Healthcare Advocate, Kevin Flynn gave a history of the son’s condition and treatment plans that lead up to this appeal. Member’s son spoke briefly of his past history of treatment.  Commissioner Kelleher made a motion to go into Executive Session under Resolution B.  The motion was seconded by Commissioner Steinhauer.  All voted in favor.  Upon returning to closed session, Commissioner Kelleher made a motion to deny the appeal, but to pay the member for the amount that would have been due had the member received the appropriate level of care for the appropriate number of days, as determined by Magellan.  Commissioner Steinhauer seconded the motion. All voted in favor.

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

ISSUES

  1. Carrier Updates

David Pointer indicated there was a NJ DIRECT Network Update included in the Commission binders this month.  He also gave an update on the 2009 access project reimbursement to members who met the out-of-pocket maximum ($400) as follows:  to date approximately 3,000 members requested reimbursement for out-of-pocket expenses and approximately $1.2 million was paid out. Horizon BSBCNJ had estimated 13,000 people were eligible for the reimbursement with a total cost of approximately $1.8 million.  Requests for reimbursement are still being received.

  1. Dependent Eligibility Verification Audit DEVA - FYI

David Pointer advised the Commission that the appeal process has ended.  As of August 9, 2010 there were 4,000 dependents that declared themselves ineligible, there were another 4,000 that did not respond and approximately 4,700 sent incomplete information. The Division is still in the process of reinstating members that Aon confirmed were eligible.

  1. Employer Updates – FYI

A list of new employers who enrolled in and employers who terminated from the SEHBP was provided to the Commission.

Mr. Pointer said, as far as Healthcare Reform, the State’s application for the early retiree reinsurance was accepted by the federal government and it’s now a matter of submitting claims.

Finally, Mr. Pointer stated the age 26 eligibility mailing went out last week to retirees.  Employees will be notified through the usual open enrollment period.

There being no further business to transact, a motion was made to adjourn by Chairman Peden, seconded by Commissioner Kelleher. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 1:45 PM.

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

School Employees’ Health Benefits Commission
Minutes, Meeting No 23
November 17, 2010; 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009 and was amended on June 1, 2010.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:11 AM, Wednesday, November 17, 2010.  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:

Wendell Steinhauer, Commissioner
Cynthia Jahn, Commissioner
Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff
Thomas Gallagher, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
Kevin Kelleher, Commissioner

ABSENT:

David Earling, Chairman

ALSO PRESENT: 

Rubin Weiner, Deputy Attorney General
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, Health Benefits Program
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ)
Rosemary Middlebrook, Horizon BCBSNJ
David Perry, Horizon BCBSNJ
Dr. Candice Saldarini, Medical Director, Magellan
Michelle Zurawski, Magellan
Dr. John O’Donnell, Magellan
Katherine Impellizzeri, Aetna
Dr. Thomas Howe, Aetna
Sharon Cannon, Aetna
Patrick Currie, Aetna
Michael North, Aetna
Angela Pierson, Medco Health Solutions
Bhavesh B Modi, RPh, Medco Health Solutions

Commissioner Steinhauer nominated Commissioner Gallagher as Interim Chairman in Chairman Earling’s absence.  It was seconded by Commissioner Jahn. All voted in favor.

A motion to approve the meeting minutes of September 22, 2010 was made by Commissioner Steinhauer, seconded by Commissioner Gallagher. 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 Jahn made a motion to go into closed session under Resolution A.  Commissioner Kelleher seconded the motion.  All voted in favor. 

Case #SE111001 – (Member Present) - This tabled Horizon dental appeal concerned a denial of reimbursement for expenses for a dental procedure for the member’s dependent son.  Following an overview of what was discussed at the previous Commission meeting, and review of the Horizon contract that the member was covered by at the time of the accident, it was determined that implants would not be covered under either plan. Commissioner Peden made a motion to deny this appeal since implants are not a covered benefit. Commissioner Jahn seconded the motion. All voted in favor. (Vote 5: 0: 0)  
 
Case #SE111002 - This Medco appeal concerned a denial of a request to fill a prescription for Lac-Hydrin 12% lotion.  Commissioner Kelleher made a motion to deny this appeal because over-the-counter drugs are excluded from coverage under the prescription drug plan.  Commissioner Steinhauer seconded the motion.  Approved (Vote 5: 0: 0)

The Commission asked if the member is given the name of the over-the-counter (OTC) medication in Medco’s denial letter.  Medco will review their letter to the member and see if the member can be told the name of the OTC drug.  Medco’s representatives stated the member can ask the retail pharmacist or they can call the Medco pharmacist.    

Case #SE111003 - This Medco appeal concerned a denial of a request to fill a prescription for Imodium. Commissioner Kelleher made a motion to deny this appeal because over-the-counter drugs are not covered by the plan.   Commissioner Steinhauer seconded the motion.  Approved (Vote 5: 0: 0) 

Case #SE111004 – This Medco appeal concerned a denial of a request to fill a prescription for Glycolax.  Commissioner Gallagher made a motion to deny this appeal because over-the-counter drugs are excluded from coverage under the prescription drug plan.  Commissioner Steinhauer seconded the motion.  Approved (Vote 5: 0: 0)

Case #SE111005 – This Division appeal concerned a request to add an overage dependent to coverage. The dependent was denied enrollment because the divorce decree states the father is responsible for the child’s health benefits. A brief discussion took place regarding the appeal. Commissioner Steinhauer made a motion to go into Executive Session under Resolution B. Commissioner Gallagher seconded the motion. All voted favor.  Upon return from Executive Session, Commissioner Steinhauer made a motion to approve this appeal because the dependent is under the care of the mother. Enrollment is contingent on a medical review to determine whether or not the overage child  is disabled  and therefore eligible for coverage under the plan.  Commissioner Kelleher seconded the motion. Approved (Vote 4: 1: 0, Commissioner Peden voted nay).
 
Case #SE111006 – This Medco appeal concerned a denial of a request to fill a prescription for Lac-Hydrin 12% lotion.  Commissioner Gallagher made a motion to deny this appeal because over-the-counter drugs are excluded from coverage under the prescription drug plan.  Commissioner Steinhauer seconded the motion.  Approved (Vote 5: 0: 0)

Case #SE111007 – This Medco appeal concerned a denial of a request to fill a prescription for Ranitine 150mg. Commissioner Gallagher made a motion to deny this appeal because over-the-counter drugs are not covered by the plan.   Commissioner Peden seconded the motion.  Approved (Vote 5: 0: 0)

Case #SE111008 – This Aetna appeal concerned the denial of benefits for a total discectomy and two level artificial disc replacements performed in Germany without prior authorization.  Dr. Thomas Howe, Aetna Medical Director, gave an overview of the requests for the procedure and the level of appeals. The Member’s first and second level of appeal were both denied as the procedure performed did not meet the definition of emergency services as outlined in the Aetna member handbook. Also, the safety and efficacy of two level artificial disc replacements has not been proven and therefore not an approved procedure in the United States. Therefore, it is considered experimental and investigational. Commissioner Jahn made a motion to deny this appeal because:  1) elective surgery is not covered out of the country; and 2) the procedure is considered investigational.  Commissioner Kelleher seconded the motion. Approved (Vote 5: 0: 0)

Case #SE111009 – (Member Present) – This Horizon NJ DIRECT15/Magellan appeal concerns a denial of benefits for residential treatment at the Caron Foundation for the member’s dependent son.  The member said he was aware the Caron Foundation was an out-of-network facility but the member thought they would only be responsible for a portion of the claims.  Commissioner Gallagher made a motion to go into Executive Session under Resolution B. Commissioner Jahn seconded the motion. All voted favor.  Upon return from Executive Session, Commissioner Kelleher made a motion to deny this appeal, but to reimburse the member for two weeks at the 2.5 level of care and two weeks at the 2.1 level of care.  Commissioner Jahn seconded the motion. Approved (Vote 5: 0: 0) Commissioner Gallagher also requested the division staff contact the member and Horizon to help with the additional care the member is seeking for this dependent.   

Case #SE111010 – This Medco appeal concerned a denial of a request to fill a prescription for Meclizine 25mg. Commissioner Kelleher made a motion to deny this appeal because over-the-counter drugs are not covered by the plan.   Commissioner Peden seconded the motion.  Approved (Vote 5: 0: 0)

Case #SE111011 – This Medco appeal concerned a denial of a request to fill a prescription for Miralax.  Commissioner Kelleher made a motion to deny this appeal because over-the-counter drugs are not covered by the plan.   Commissioner Gallagher seconded the motion.  Approved (Vote 5: 0: 0)

Case #SE111012 – This Medco appeal concerned a denial of a request to fill a prescription for Meclizine 25mg. Commissioner Kelleher made a motion to deny this appeal because over-the-counter drugs are not covered by the plan.   Commissioner Gallagher seconded the motion.  Approved (Vote 5: 0: 0)

Case #SE111013 - This Medco appeal concerned a denial of a request to fill a prescription for Glycolax.  Commissioner Kelleher made a motion to deny this appeal because over-the-counter drugs are excluded from coverage under the prescription drug plan. Commissioner Jahn seconded the motion.  Approved (Vote 5: 0: 0)

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

ISSUES

  1. Carrier Updates

Aetna’s Medicare Advantage Plan

Katherine Impellizeri, Aetna, advised the Commission due to Federal regulations, the Aetna Medicare Open Plan is being replaced by the Aetna Medicare Plan (HMO) as of January 1, 2011.  Sharon Cannon, Aetna, gave an overview of the plan differences.

Medco

David Pointer said the Medco’s Pharmacy Benefits Program 1H 2010 Performance Review was included in the binders for the Commission’s information. 

B.
2011 Calendar - Jean Williamson requested approval for the meeting schedule for 2011.  The meetings are scheduled to begin at 10:00 a.m.  Commissioner Steinhauer made a motion to approve the 2011 bi-monthly meeting dates which will be posted on the Division’s website. Commissioner Gallagher seconded the motion. All voted in favor.
 
C.
Employer Updates - David Pointer said that a list of the current Employers participating in the SEHBP as of November 1, 2010 was included in this month’s binders. The employers’ choice of a prescription drug plan was added to the list. Updates will be provided on a quarterly basis.

There being no further business to transact, a motion was made to adjourn by Commissioner Steinhauer, seconded by Commissioner Gallagher. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 12:37 PM.

  Respectfully submitted,
 

 

 

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

School Employees’ Health Benefits Commission
Minutes, Meeting No 19
May 26, 2010, 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 2010 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 23, 2009.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:08 AM, Wednesday, May 26, 2010. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey.

Jean Williamson announced that Richard Quinn resigned from the Commission.

ROLL CALL

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

Wendell Steinhauer, Commissioner
Cynthia Jahn, Commissioner (attended by telephone)
Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff
Thomas Gallagher, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
David Earling, Chairperson
Kevin Kelleher, Commissioner
James Geiger, Commissioner

ABSENT:

Richard Quinn, Commissioner
Joseph Del Grosso, Commissioner

ALSO PRESENT: 

Rubin Weiner, Deputy Attorney General
Jean Williamson, Acting Secretary
David Pointer, Manager, Policy, Planning and Operations
Barbara Scherer, Pensions and Benefits
Horizon Representatives

A motion to approve the meeting minutes of January 27, 2010 was made by Commissioner Steinhauer, seconded by Commissioner Gallagher. Approved (6:0:0).

ISSUES

David Pointer gave an update on Health Care Reform and the changes that will affect the program. Effective January 1, 2011, coverage will be extended to dependent children to the age of 26.  Members will be notified in the fall in time for open enrollment. The definition of a dependent child in the regulations will need to change to conform with the legislation’s criteria for a dependent child.  Up until 2014, coverage will be denied for dependents if they are eligible for coverage under another employer. Thereafter, dependents cannot be denied because they are eligible for other employer coverage. The legislation also eliminates certain benefit maximums beginning in 2011. The mental health maximums are under review. The Early Retiree Reinsurance Program will reimburse eligible employers’ claim costs incurred above $15,000 and below $90,000 for early retirees. Early retirees are defined as those retirees between the ages of 55 and 65 (non-Medicare retirees). Five billion dollars are available for the program which is offered on a first-come, first-served basis. Aon Consulting is assisting the Division on the application and claims submission process.

Governor Christie signed into law Chapter 2, P.L. 2010 that makes numerous changes to the School Employees’ Health Benefits Program (SEHBP) and State Health Benefits Program (SHBP).  There is an FAQ for employers and employees on the Division’s website. An eligible individual may only enroll in the SHBP/SEHBP as an employee, retiree, or dependent. Multiple coverage under the SHBP and/or SEHBP is not permitted.  The Division is currently working to identify individuals with multiple coverage. Letters are expected to go out at the end of summer.     

  1. Carrier Updates

Horizon BCBSNJ has established an acupuncture network; 90 to 100 acupuncturists have joined. Horizon BCBSNJ has documented that NJ DIRECT members have access to a licensed acupuncturist or professional who performs acupuncture using a standard of one provider within 45 miles.  Effective July 1, 2010, Horizon BCBSNJ will begin processing all acupuncture services performed by a non-participating provider according to the out-of-network benefit provisions of the contract.  Members who have received these services within the last 6 months will be advised of the change.

  1. Dependent Eligibility Verification Audit DEVA - FYI

David Pointer advised the Commission that the audit closed two weeks ago.  Aon has finished reviewing the documents.  The SEHBP has over 20,000 dependents subject to termination effective July 1, 2010.  Approximately 11,000 of those terminations are the result of incomplete documentation; approximately 9,000 were due to no response to the audit.  On June 9, 2010, members will be notified of the appeal process and a list of acceptable documents will be included.  Aon will be handling the appeal process.  Commissioner Kelleher asked if a member is appealing a termination will the dependent or dependents stay on the coverage.  Mr. Pointer said no, they will be termed 7/1/2010 and if proper documentation is received they will be reinstated retroactively back to July 1, 2010.   There were 4,000 dependents that were self-identified as ineligible.     

  1. Employer Updates – FYI

A list of new employers who enrolled in and employers who terminated from the SEHBP was provided to the Commission.

David Pointer stated the Consultant RFP is being handled by the Division of Purchase and Property and was released on May 4, 2010.  A Mandatory Bid Conference was held on May 17, 2010.  Proposals are due on June 25, 2010.

  1. Revised time and location change of July 21, 2010 scheduled meeting.

Commissioner Steinhauer made a motion to approve the time and location changes (The meeting will begin at 10 a.m. and will be located at Thomas Edison State College, Prudence Hall). Commissioner Kelleher seconded the motion. 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 Geiger made a motion to go into closed session under Resolution A.  Commissioner Steinhauer seconded the motion.  All voted in favor. 

Case #SE051001 – This Division appeal concerned a denial of a request to fill a prescription for Diphenhydramine.  Commissioner Gallagher made a motion to deny this appeal because the drug is available over the counter and is, therefore, excluded under the plan. Chairperson Earling seconded the motion.  Approved (Vote 6: 1: 0, Commissioner Geiger voted nay).  
 
Case #SE051002  - This Division appeal concerned a denial for Latisse which is a drug deemed to be used for cosmetic purposes. There was a brief discussion that took place between the Division and the Commission regarding additional medical information on this medication.  Commissioner Steinhauer made a motion to table this appeal to obtain more medical information from the Division.  Commissioner Peden amended the motion asking the Division to request clinical evidence be provided that the member’s condition can cause or lead to the cornea abrasions. Commissioner Steinhauer accepted the altered motion. Chairperson Earling seconded the motion. Approved (Vote 7:0:0).  Commissioner Kelleher requested the claim records of when the patient was treated for cornea abrasions be provided.

Case #SE051003 - This Horizon-NJ DIRECT10 appeal concerned the denial of benefits above the reasonable and customary allowance for surgery. Wendy Burns of Horizon stated the only issue for this appeal was the reasonable and customary amount allowed.  Claims were paid on the fee schedule utilized for out-of-network providers for these types of surgeries.  Horizon’s Medical Director did review the appeal and determined the claims were processed correctly. Commissioner Geiger made a motion to deny this appeal. Commissioner Peden 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 Gallagher seconded it. All   voted in favor.

Commissioner Jahn, who was attending by telephone, left the meeting at this point.

Commissioner Kelleher asked about an appeal that had been tabled in January pending additional medical documentation.  Jean Williamson responded that Horizon reviewed the additional information and all of the claims were paid except for the month of December 2008.  Ms. Williamson stated the attorney for the family said they would like to pursue the appeal for the claims incurred in December 2008, and that she anticipated the appeal would be scheduled for the July meeting.

Commissioner Kelleher then asked the status of Commissioner Geiger’s motion at the January meeting to schedule a meeting to provide guidance to Horizon on how to handle future private duty nursing claims processing.  Ms. Williamson indicated the issue could be placed on a future agenda.

Finally, Commissioner Kelleher asked if the regulations are still on hold.  David Pointer stated that staff would get him an update on the status of the regulations.

There being no further business to transact, a motion was made to adjourn by Commissioner Steinhauer, seconded by Commissioner Kelleher. All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 10:55 AM.

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