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Pensions and Benefits
School Employees' Health Benefits Commission
Meeting Minutes 2012
Unless otherwise noted, meetings are held at 10:00 a.m. at the Office of the Division of Pensions and Benefits, 50 West State Street, Trenton, NJ.
*RATE RENEWAL MEETING

Special School Employees’ Health Benefits Commission
Minutes, Meeting No 32
January 11, 2012, 10:00 AM

Adequate notice of this Special meeting has been provided and prominently posted in the offices of the Secretary of State.  The notice was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 9, 2012.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:10 AM, Wednesday, January 11, 2012. 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:

David Earling, Chairman (via telephone)
Joseph Del Grosso, Commissioner (via telephone)
Cynthia Jahn, Commissioner (via telephone)
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff (via telephone)
Gale Simon, representing Commissioner Thomas B Considine, Department of Banking & Insurance
Wendell Steinhauer, Commissioner

Also present: 

Eileen Den Bleyker, Senior Deputy Attorney General
Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director Division of Pension and Benefits
Janice F. Nelson, Deputy Director Division of Pension and Benefits
Jean Williamson, Acting Secretary

Resolution B was read in its entirety and roll call was taken.

The Medical RFP was the only issue on the agenda.  Chairman Earling stated the RFP draft is currently available for review with the Division of Purchase and Property (DPP) and asked several questions. Florence Sheppard responded to the questions.  Chairman Earling solicited questions from the rest of the Commissioners.  Commissioner Kelleher expressed some concerns about the short timeframe given to the Commission to make a decision and mentioned issues with previous bids.  Commissioner Steinhauer made a motion to postpone approval of the RFP and Commissioner Del Grosso seconded the motion.  There ensued a long discussion.  Commissioner Simon asked if some of the questions could be answered today.  SDAG Den Bleyker answered some of the questions that were raised.  She said the Division of Purchase and Property would award the contract and that the RFP is consistent with the current plans which were approved by the Plan Design Committees.  The Commission action needed is to authorize the RFP be issued jointly on behalf of the SEHBC and SHBC through the DPP. 

There were some questions about the Evaluation Committee such as who is represented on the Committee and the amount of time dedicated by Committee members.  Ms. Sheppard said that a representative from the Commission could be appointed to the Evaluation Committee.  SDAG Den Bleyker discussed the confidentiality of the RFP.  After considerable discussion, Ms. Sheppard asked SDAG Den Bleyker if the Commission can take action in two steps:  review the document and vote at next meeting [January 25, 2012].  SDAG Den Bleyker said the Commission’s regulations would allow it; it would be subject to the Division of Purchase and Property’s approval. 

Commissioner Steinhauer withdrew his motion.  He said on legal advice, he was making a motion to participate in the procurement, subject to review of the RFP and to vote at the next meeting on January 25th whether to authorize the DPP to proceed.  Commissioner Del Grosso seconded the motion.  There was a brief discussion concerning where the RFP could be reviewed and how questions could be submitted.  A vote was taken and the motion was approved unanimously. 

There being no further business, Commissioner Steinhauer made a motion to adjourn, Chairman Earling seconded the motion.  All voted in favor. 

The School Employees’ Health Benefits Commission meeting was adjourned at 12:02 PM.

                                

  Respectfully submitted,
 

 

 

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

 


School Employees’ Health Benefits Commission
Minutes, Meeting No 33
January 25, 2012, 10:00 AM

Adequate notice of this meeting has been 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 2011 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and revised notice was sent January 9, 2012.  

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:08 AM, Wednesday, January 25, 2012.  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
Susanne Culliton, representing State Treasurer Andrew P. Sidamon-Eristoff
Thomas Gallagher, representing Commissioner Thomas B. Considine, Department of Banking & Insurance
David Earling, Chairman (via telephone)
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner
Joseph Del Grosso, Commissioner (via telephone)

Also present: 

Diane Weeden, Deputy Attorney General
Kellie Pushko, Deputy Attorney General
Florence J. Sheppard, Acting Director (Open Session only)
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Barbara Scherer, School Employees’ Health Benefits Program
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ)
Rosemary Middlebrook, Horizon BCBSNJ
Dr. Claudia Hanson, Medical Director Horizon BCBSNJ
Sue Rizzni, Magellan Health Services
Dr. Lou Parrott, Medical Director, Magellan Health Services

A motion to approve the meeting minutes of November 16, 2011 was made by Commissioner Steinhauer, seconded by Commissioner Del Grosso. Motion Approved (Vote 6:0:1, Commissioner Culliton abstained).

ISSUES

  1. Medical Plans Request for Proposals (RFP) – David Pointer stated that Commissioners Kelleher and Steinhauer had the opportunity to review the RFP last week. Commissioner Steinhauer said the whole process was very educational and thanked everyone.  Commissioner Steinhauer made a motion to authorize the Division of Purchase and Property to release the RFP. Commissioner Gallagher seconded the motion. A discussion ensued regarding the Commission’s inability to review the Evaluation Team’s selections prior to awarding the contract because the Division of Purchase and Property awards the contract.  There is still an option to have a member from the Commission be on the Evaluation Committee. There was a brief discussion about the Commission’s right to contract directly.  Commissioner Steinhauer amended his motion to authorize the Division of Purchase and Property to release a RFP with an appointed member from the Commission to sit on the Evaluation Committee. Commissioner Gallagher seconded the motion. Motion passed.  (Vote 7: 0: 0). The Commission decided it would appoint a Commissioner to the Evaluation Committee during a subsequent Executive Session.
     
  2. Carrier Updates: David Pointer advised the Commission there were no carrier updates.
     
  3. Employer Updates: Mr. Pointer said the 2012 year-to-date report for New Education Employers and Termination of Education Employers was in the Commission books for their information.  Commissioner Kelleher asked if the Division gets the new employers’ loss ratios. Mr. Pointer responded no.  Commissioner Steinhauer asked how many employers participate in the School Employees’ Health Benefits Program (SEHBP). David Pointer said he didn’t have the total with him but he would e-mail it to the Commissioners following the meeting.

The following cases, due to HIPAA regulations, are heard 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 Del Grosso seconded the motion.  All voted in favor

Case #SE011208(Representative attended on behalf of Member) This Horizon NJ DIRECT10/Magellan Health Services appeal concerned a denial of additional reimbursement for an out-of-network provider. The representative gave an overview of the appeal. Chairman Earling asked the Division to provide an explanation.  Chairman Earling 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 postpone the decision on this appeal to the next meeting scheduled for March 28, 2012 to allow the Commission to review documentation from a public session of the State Health Benefits Commission that the Commission utilized when it adopted the tiering of payments for mental health providers in accordance with the provider’s licensing. Chairman Earling seconded the motion.  All voted in favor. Approved (Vote 7: 0: 0).

Case #SE011205 (Member and Attorney Present ) - This Horizon NJ DIRECT10/Magellan appeal concerned a denial of residential substance abuse treatment at Hazelden Center for Youth and Families (Hazelden). The member’s attorney was present; however the member provided an overview of the appeal.  The member said her son was admitted to Hazelden on July 16, 2011 and coverage was provided until July 18, 2011.  She paid out-of-pocket for a 30 day stay at Hazelden.  She said she was told that Hazelden was an in-network facility. Sue Rizzni, Magellan Health Services said the son was in a facility in Florida on July 8, 2011.  She said Magellan was not called prior to the son being admitted into Hazelden.  Ms. Rizzni also added the member was advised this facility was not an in-network facility on July 8, 2011.  Dr. Lou Parrott, Medical Director, Magellan Health Services, stated that Magellan’s physician advisor determined on July 19, 2011 that continued residential treatment was not medically necessary based on the American Society of Addiction Medicine (ASAM) criteria.  An intensive outpatient program (IOP) was recommended as an appropriate level of care. The member told the Commission in order for someone to be accepted into a half way house they must successfully complete 30 days of residential treatment.  Chairman Earling asked how much Magellan would have paid if the member’s son was in an intensive outpatient program.  Magellan provided a range of costs based on local provider charges and a brief discussion ensued.  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 deny this appeal based on the ASAM criteria.  His motion also included a provision that Horizon BCBSNJ reimburse the member an amount of $4,000.00 which was in the range of costs paid for IOP.  Commissioner Kelleher seconded the motion.  Motion passed (Vote 7: 0: 0).

A brief discussion took place concerning the need to make members aware that Magellan conducts a review of medical necessity every few days.  Commissioner Gallagher made a motion for Horizon BCBSNJ to work with Magellan to facilitate educating and informing the member that a reevaluation of medical necessity is conducted every 3-4 days.  The results of the reevaluation determine whether the level of treatment is approved to continue.  Commissioner Steinhauer seconded the motion.  Motion Passed (Vote 7: 0: 0).

Commissioner Culliton asked the Chairman for a fifteen minute break before hearing the next appeal.  Chairman Earling agreed.  The break began at 12:15 PM. Commissioner Jahn and Mr. Pointer left the meeting at that point. The Commission resumed Closed Session at 12:35 PM.

Case #SE011207 (Member and Attorney Present) -This Division appeal concerned a break in family level of coverage which was a result of the Dependent Eligibility Verification Audit. The member’s attorney gave an overview of the appeal.  The member had moved three times from January 2010 through July 2010 and he did not receive notification of the termination.  The Member said his wife sent in the required documents and he assumed everything was okay.  Commissioner Steinhauer made a motion to go into Executive Session under Resolution B.  Commissioner Del Grosso seconded the motion. All voted in favor.  Upon return from Executive Session Commissioner Steinhauer made a motion to approve this appeal and reinstate family coverage for the time period of July 1, 2010 through October 31, 2010 based on miscommunications and the letter of June 9, 2010 being sent to the wrong address.  Commissioner Kelleher seconded the motion.  Motion passed. (Vote 5: 1: 0, Commissioner Culliton voted nay).

Case #SE011202(Member and Attorney Present )- This appeal concerns a dispute in the reimbursement amount that will be due to the SEHBP in the event the Commission’s denial is upheld in the member’s pending appeal at the Office of Administrative Law (OAL). The OAL matter concerns whether the member’s daughter’s eating disorder is a Biologically Based Mental Illness (BBMI).  At the Commission meeting of August 18, 2011, emergency relief was granted to the member on behalf of his daughter. At the meeting the member verbally agreed to reimburse the SEHBP in full for his daughter’s eating disorder treatment if his pending appeal at the OAL is denied. Following the meeting, the member was sent a written agreement for his signature.  The member was advised by his attorney not to sign the agreement. A discussion took place to clarify the agreement.  Chairman Earling said the coverage is undisputed up to day 50.  According to the terms of the plan the SEHBP would not be paying for day 51 onwards.  The member would have to go to an in-network facility and the SEHBP would continue to pay whatever the normal reimbursement would be for that inpatient facility.  But because of the problems associated with moving the member, the decision was to continue to pay for day 51 and beyond.  However, if the OAL upholds the Commission’s initial denial to treat an eating disorder as a BBMI, then the member agreed to reimburse the SEHBP for the extra cost of days 51 onwards at the out-of network facility versus what would have been paid by the plan  had she gone to an in-network facility.  Chairman Earling made a motion to have Deputy Attorney General (DAG) Weeden revise the original agreement for signature by the beneficiary to state that the expectation of the Commission and the SEHBP is that the family and the beneficiary would reimburse the plan for the incremental cost over and above in-network treatments that the plan incurred if the pending OAL appeal is denied. Commissioner Kelleher seconded the motion.  Commissioner Steinhauer requested the revised agreement be provided to the Commission for review prior to sending it to the member. Motion passed. (Vote 5: 0: 1, Commissioner Culliton abstained).   The member thanked the Commission and advised them he might not be able to make a payment in one lump sum; he might have to pay the reimbursement over time. The Commission agreed a repayment schedule could be made, however the payment schedule was not discussed.  

Case #SE011203(Member and Attorney Present)- The member sent a letter dated November 21, 2011 to Horizon BCBSNJ which concerned an issue related to the member’s OAL appeal of whether his daughter’s eating disorder is a BBMI.  Horizon BCBSNJ forwarded the letter to the Division. The Division recommended that the member’s letter be forwarded to the OAL and be consolidated with the original appeal currently pending in the OAL. Commissioner Steinhauer made a motion to forward the member’s letter of November 21, 2011 to the OAL to be consolidated with the original appeal currently pending in OAL. Commissioner Del Grosso seconded the motion. Motion passed (Vote 5: 0: 1, Commissioner Culliton abstained).

Case #SE011204(Member and Attorney Present) -This Horizon-NJ DIRECT10 appeal concerned precertification for “meal support” for the member’s daughter. An overview of the appeal was presented by the member’s attorney.  The Member asked the Commission to consider the meal support as therapy. Wendy Burns, Horizon BCBSNJ said NJ DIRECT allows for three visits per calendar year for in-network nutritional counseling that is medically needed and at the appropriate level of care.  In this case, the provider is out-of-network. Dr. Lou Parrott, Medical Director, Magellan Health Services said an alternative to this therapy is an Intensive Out-Patient (IOP) program.  This would provide a higher level of care, including meal support, along with other therapies all bundled together.  Commissioner Culliton asked if this type of treatment would require her going someplace else. Dr. Parrott responded yes. Commissioner Steinhauer asked the member if he would be willing to have his daughter participate in the alternative treatment.  The Member declined.  Commissioner Del Grosso 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 Chairman Earling made a motion to deny this appeal because the provider is not covered or certified by the plan and Magellan has provided an alternative treatment which the member has declined.  Commissioner Gallagher seconded the motion.  Motion passed. (Vote 6: 0: 0).  The member’s attorney asked if this appeal could also be forwarded to the OAL.  The Commission determined this appeal’s issues were a separate matter and the request to have the appeal forwarded to OAL needed to be in writing.

Chairman Earling left the meeting at 2:00.

Case #SE011201 – At the November 16, 2011 meeting the Commission asked Horizon BCBSNJ to provide updates on the Caregivers training progress. A memo dated January 29, 2012 from Wendy Burns of Horizon BCBSNJ was distributed.  Ms. Burns provided the Commission with an overview of the caregiver’s training.  She said Horizon BCBSNJ has encountered many obstacles in their attempts to coordinate and schedule caregiver training by Preferred Home Health. She also reported the member has not given permission for a different agency to come into his home to provide the training.Horizon BCBSNJ recommended an approval of a two week extension for training.  Following the discussion, Commissioner Steinhauer made a motion to extend the 24 hour/7 day a week Private Duty Nursing Care for an additional 4 weeks.  This will provide the Caregiver more time to coordinate and receive training from Preferred Home Health to care for the member in a safe and effective manner. The Commission expects to see significant training by Preferred Home Care during the first week and through February 21, 2012.  If the training is incomplete as of February 21, 2012, Horizon BCBSNJ will utilize Bayada Nurses for the training services beginning February 22 through February 29, 2012.  Commissioner Kelleher seconded the motion.  Motion passed. (Vote 5: 0: 0).        

Case #SE011106 –This Horizon NJ DIRECT10 appeal concerned a denial of benefits for expenses above the reasonable and customary allowance.  The Commission asked Horizon BCBSNJ representatives if the reasonable and customary amount is based on the geographical area where services were rendered.  Horizon BCBSNJ replied they are.  Commissioner Gallagher made a motion to deny this appeal based on the plans reasonable and customary amount allowed. Commissioner Steinhauer seconded the motion.  All voted in favor. Approved (Vote 5: 0: 0).

There being no further appeals, Commissioner Steinhauer made a motion to return to open session, which was seconded by Commissioner Del Grosso.  All voted in favor. There being no further business, Commissioner Steinhauer made a motion to adjourn, which was seconded by Commissioner Gallagher.  All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 2:18 PM.

  Respectfully submitted,
 

 

 

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

School Employees’ Health Benefits Commission
Minutes, Meeting No 34
March 28, 2012; 10:00 AM

Adequate notice of this meeting has been 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 2011 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and revised notice was sent January 9, 2012. 

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:37 AM, Wednesday, March 28, 2012.  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:

David Earling, Chairman (via telephone)
Joseph Del Grosso, Commissioner (via telephone)
Thomas Gallagher, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff
Wendell Steinhauer, Commissioner

ALSO PRESENT: 

Kellie Pushko, Deputy Attorney General
David Pointer, Manager, Policy, Planning and Operations
Jean Williamson, Acting Secretary
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ)
Rosemary Middlebrook, Horizon BCBSNJ
Dr. Claudia Hanson, Medical Director, Horizon BCBSNJ
Sue Rizzni, Magellan Health Services
Dr. Lou Parrott, Medical Director, Magellan Health Services

NOTE:  The meeting start time was delayed because of a miscommunication with the court reporter agency and the need to wait for a court reporter to arrive.

A motion to approve the meeting minutes of January 11, 2012 and January 25, 2012 was made by Commissioner Steinhauer, seconded by Commissioner Gallagher. Motion Approved (Vote 6:0:1, Commissioner Jahn abstained).

ISSUES

  1. Medco Off-patent Strategy:  Angela Pearson, Medco Health Solutions, Inc. handed out a FAQ and presented an overview of the Generics Rx Advantage Plan and off-patent copay waiver program.
     
  2. Carrier Updates:  David Pointer announced that Aetna is still in negotiations with Cooper Hospital University Medical Center and Centra State Medical Center.  The termination dates have been extended to May 1, 2012 and May 15, 2012, respectively.

  3. Revised 2012 Meeting Schedule:  Commissioner Steinhauer made a motion to accept the changes to the 2012 meeting schedule:  cancelling the July 11 and July 18 meetings; scheduling a regular meeting on July 25, 2012 and a rate renewal meeting on August 16, 2012.  Commissioner Del Grosso seconded the motion and all voted in favor.

  4. Local Employers:  Commissioner Steinhauer asked how many local employers participate in the SEHBP.  Mr. Pointer responded approximately 300-350.  Commissioner Steinhauer also asked for an explanation of the loss ratio.  Mr. Pointer explained the loss ratio is the claims experience for those groups.  He said if the ratio is under one hundred it’s good and if it’s over a hundred it’s poor experience.   

The following cases, due to HIPAA regulations, are heard 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 Peden seconded the motion.  All voted in favor

Case #SE031201(Representative attended on behalf of Member) – This tabled Horizon BCBSNJ/Magellan Health Services NJ DIRECT10 appeal concerned a denial for additional reimbursement for an out-of-network provider. The Member’s representative gave a brief overview of the appeal.  Commissioner Kelleher made a motion to go into Executive Session under Resolution B.  Commissioner Steinhauer seconded the motion and all voted in favor.  Upon return from Executive Session, Commissioner Peden asked to hear from the Magellan representative, Susan Rizzni.  Ms. Rizzni explained that claims are paid based on licensure, geographic location and the actual procedures being performed.  A discussion ensued concerning the statute and the tiering policy in general.  Cheryl Eagan, Horizon BCBSNJ provided explanations of the charge based schedule and the rationale used for the tiering of reimbursements.  Commissioner Gallagher made a motion to deny the appeal to be consistent with the policy of the plan as used by both Commissions.  Commissioner Jahn seconded the motion.  Approved (4: 3: 0, Commissioners Del Grosso, Kelleher and Steinhauer voted nay).

Case #SE031202 – This $13,688.91 NJ DIRECT10 appeal (Magellan Health Services) concerns a denial of residential substance abuse treatment at Hazelden Center City because the medical necessity criteria was not met.  Ms. Rizzni, Magellan Health Services, gave an overview of the case.  A transcript of a telephone call between the member and Magellan was distributed to the Commission.  A discussion ensued concerning the appeal and the fact that Magellan was unable to substantiate that the member was told that his in-patient stay would be reviewed every few days for medical necessity.  Ms. Rizzni stated Magellan has changed the procedure for the customer service representatives as part of the benefit quoting mechanism to educate the members the first time they call regarding the fact that treatment at a residential facility is reviewed every few days and they may be stepped down as a result. She said Magellan encourages the member to stay in NJ for this reason. Commissioner Kelleher made a motion to approve the appeal because when the member called Magellan he was promised benefits and not told about the precertification of benefits based on the telephone call transcript of March 22, 2011.  Commissioner Steinhauer seconded the motion.  Commissioner Gallagher expressed concern about setting a bad precedent and also asked if Magellan should be held liable for the charge.  He made a motion to go into Executive Session under Resolution B.  Commissioner Jahn seconded the motion and all voted in favor.  Upon return from Executive Session, the motion was restated and voted upon.  Approved (5: 1: 0; Commissioner Gallagher voted nay and Commission Peden was absent).  Commissioner Kelleher made a motion directing the Division to recoup the payment.  The motion was withdrawn.  Chairperson Earling made a motion directing the Division to pursue restitution in the amount of $13,688.91 from Magellan due to: 1) failure to provide the necessary transcripts substantiating their claim, and, 2) for what seems to be in evidence of misinformation provided to the subscriber with respect to the level of benefits and the restrictions under the benefits.   Commissioner Kelleher seconded the motion.  Approved (6: 0: 0  Commissioner Peden was absent).

Case #SE031203 (Personal Appearance) – This NJ DIRECT10 appeal concerned a denial of a request for precertification for oocyte retrieval.  The member gave an overview of her appeal.  Dr. Hanson, Medical Director, Horizon BCBSNJ, provided an overview of the reasons the oocyte retrieval and cryopreservation was not covered.  She said that coverage is provided to treat infertility rather than to preserve fertility.  The member clarified that she is not asking for the cryopreservation to be covered.  Chairman Earling made a motion to go into Executive Session under Resolution B.  Commissioner Kelleher seconded the motion and all voted in favor.  Upon return from Executive Session, Commissioner Peden made a motion to deny the appeal because the diagnosis of infertility had not been established.  Commissioner Jahn seconded the motion.  Approved (7: 0; 0).

Case #SE031204 – A request that an appeal be forwarded to the Office of Administrative Law (OAL) concerning the precertification of meal support for a non-participating provider was received from the member.  Chairman Earling made a motion to forward the appeal to the OAL.  A discussion ensued clarifying the reasons for sending an appeal to the OAL.  The Division was asked to add its recommendation to the cover sheet for future requests.  The motion was withdrawn.  Commissioner Gallagher made a motion for the Division to draft a Final Administrative Determination (FAD).  Commissioner Steinhauer seconded the motion.  Approved (7: 0: 0).

Case #SE031205 – Commissioner Steinhauer made a motion to go into Executive Session under Resolution B to hear a workers’ compensation settlement proposal.  Commissioner Del Grosso seconded the motion and all voted in favor.  Upon return from Executive Session, Commissioner Kelleher made a motion to accept the workers’ compensation settlement proposal.  Commissioner Steinhauer seconded the motion.  Approved (7: 0: 0).

There being no further appeals or business, a motion was made to return to open session and to adjourn by Commissioner Steinhauer and seconded by Commissioner Gallagher. All voted in favor.

The School Employees’ Health Benefits Commission meeting was adjourned at 12:55 PM.

  Respectfully submitted,
 

 

 

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

School Employees’ Health Benefits Commission
Minutes, Meeting No 35
May 23, 2012; 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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and revised notice was sent January 9, 2012.  

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:03 AM, Wednesday, May 23, 2012.  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 (via telephone)
David Earling, Chairman (via telephone)
Thomas Gallagher, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Wendell Steinhauer, Commissioner

ABSENT:

Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff
Cynthia Jahn, Commissioner

ALSO PRESENT: 

Diane Weeden, Deputy Attorney General
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Jean Williamson, Acting Secretary
Barb Scherer, School Employees’ Health Benefits Program
Wendy Burns, Horizon Blue Cross Blue Shield New Jersey
Rosemary Middlebrook, Horizon Blue Cross Blue Shield New Jersey
Cheryl Eagan, Horizon Blue Cross Blue Shield New Jersey
Dr. Claudia Hanson, Medical Director Horizon Blue Cross Blue Shield New Jersey

A motion to approve the meeting minutes of March 28, 2012 was made by Commissioner Steinhauer, seconded by Commissioner Gallagher. All voted in favor.

Issues

A. Carrier Updates

Aetna – David Pointer said that UMDNJ terminated its contract with Aetna effective May 1, 2012.  Centra State Medical Center is still in negotiations with Aetna and a determination should be made in June.   

B. Local Employer – The 2012 year-to-date report for New Education Employers and Termination of Education Employers was provided to the Commission. 

The following cases, due to HIPAA regulations, are heard 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 #SE051202 - (Member Present) - This Horizon/NJ DIRECT10 appeal concerned a denial of benefits for expenses for PhotoFacial Treatment by Pulsed Dye Laser. The member gave an overview of the appeal. She explained she has tried numerous treatments for her condition and this is the only valid treatment for her condition. She also stated that the wrong treatment was being reviewed; she was receiving the PhotoFacial Treatment by Intense Pulsed Light (IPL) and not the PhotoFacial Treatment by Pulsed Dye Laser.  Furthermore, Horizon BCBSNJ authorized her to receive these treatments in 2005 and has been paying for one treatment every year.  Dr. Hanson, Medical Director, Horizon BCBSNJ, presented an overview of the case and also explained Horizon BCBSNJ’s policy which considers PhotoFacial Treatment experimental and investigational. Since 2005 the medical evidence has not been definitive.  In 2010 the policy was reviewed again and the treatment was considered experimental and investigational.  Dr. Hanson said the member was sent a letter on May 17, 2011 informing her that the claim for the procedure in 2010 would be paid but any requests for further authorizations would not be considered.  The member said she never received the letter and was unaware of this until December 2011, after she had already received another treatment. 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 deny this appeal based on the treatment being considered experimental and investigational and therefore not covered under the plan. However, due to miscommunication the Commission authorized Horizon BCBSNJ to process and pay the claim for the treatment the member received in July 2011.  Commissioner Kelleher seconded the motion. All voted in favor. After the vote Commissioner Steinhauer informed the member that in the future Horizon BCBSNJ will not pay for this treatment.  If the member wants to continue this type of treatment it will be at her expense.

Case #SE051201 – The Commission previously requested the Attorney General’s office to draft a reimbursement agreement for the member in connection with an application for emergency relief that was approved by the Commission at its August 2011 meeting. Commissioner Steinhauer made a motion to send the Reimbursement Agreement to the member’s attorney. Commissioner Gallagher seconded the motion.  All voted in favor. 

Case #SE051203 – Final Administrative Determination (FAD) – Commissioner Kelleher made a motion to accept the FAD draft concerning the denial of approval for precertification for “meal support”. Commissioner Steinhauer seconded the motion.  All voted in favor.

Case #SE051204 – The Member had requested that the Commission’s denial of additional reimbursement for an out-of-network provider be forwarded to the Office of Administrative Law (OAL) for a hearing. Commissioner Kelleher stated there may be a difference in the facts for this case with regard to the reimbursement level at the 90th percentile which is in the Statutes.  Deputy Attorney General Diane Weeden said it is a question of the law, not a dispute about the facts. There is a Statute that says the Commission has the authority to make adjustments to the plan to avoid unnecessary utilization. There is a similar appeal at the Appellate Division currently. Mr. Pointer added there is no reimbursement amount specific to these Practitioners. They have less education than psychiatrists who are in the database. DAG Weeden advised the Commission to remain consistent with its previous SHBC decision on the matter. Commissioner Gallagher made a motion to deny this request for a hearing at the OAL and to issue a FAD.  Commissioner Steinhauer seconded the motion. All voted in favor.

Mr. Pointer advised the Commission that in December 2011, Medco Health Solutions (Medco) provided the State Health Benefits Commission (SHBC) a clinical update for the use of Cialis.  On October 6, 2011, the Federal Drug Administration (FDA) approved a new indication for Cialis as a once a day medication for the treatment of men who have both erectile dysfunction (ED) and the signs and symptoms of benign prostatic hyperplasia (BPH). The daily doses available for treating ED and BPH are 5 mg and 2.5 mg and will require a Prior Authorization. The SHBC approved the daily use of Cialis for these conditions providing Medco performs a coverage review.  Since other erectile dysfunction drugs did not file with the FDA, those drugs will continue to be limited to the four-pill a month dispensing limit. 

There being no further appeals or further business to transact, a motion was made to return to open session and adjourn by Commissioner Gallagher.  It was seconded by Commissioner Steinhauer. The School Employees’ Health Benefits Commission meeting was adjourned at 10:52 AM.

  Respectfully submitted,
 

 

 

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

Meeting No. 524
Minutes
June 13, 2012
10:00 AM
Joint Meeting of the
State Health Benefits Commission (Regularly scheduled meeting) and the
Special School Employees’ Health Benefits Commission

Adequate notice of this meeting has been provided through the annual notice of the schedule of regular meetings of the State Health Benefits Commission filed with and prominently posted in the offices of the Secretary of State.  The 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and was revised on April 10, 2012.  In addition, notice of the special joint meeting of the School Employees’ Health Benefits Commission with the regularly scheduled State Health Benefits Commission of June 13, 2012 was provided to the Secretary of State, Star Ledger and the Trenton Times on May 15, 2012.

The Joint meeting of the State Health Benefits Commission (SHBC) and the School Employees’ Health Benefits Commission (SEHBC) of New Jersey was called to order on Wednesday, June 13, 2012 at 10:12 AM.  The meeting was held at the Division of Pensions and Benefits, 50 West State Street, 1st floor Conference Room, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff:

ROLL CALL

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

State Health Benefits Commission (SHBC)

Susanne Culliton, Chairperson, representing State Treasurer Andrew P. Sidamon-Eristoff
Sylvia Allen-Ware, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Robert M Czech, Chair, Civil Service Commission (Left at 11:53)
Dudley Burdge, Representative for Local Government Employees
Patrick Nowlan, Representative for State Government Employees (Arrived After Roll Call)

School Employees’ Health Benefits Commission (SEHBC)

Joseph Del Grosso, Commissioner (via telephone)
Thomas Gallagher, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Cynthia Jahn, Commissioner (via telephone)
Kevin Kelleher, Commissioner
Wendell Steinhauer, Commissioner

ABSENT:

Robert Peden, SEHBC, representing State Treasurer Andrew P. Sidamon-Eristoff
David Earling, Chairman, SEHBC

ALSO PRESENT: 

Jean Pierce, School Employees’ Health Benefits Program Plan Design Committee
Diane Weeden, Deputy Attorney General
Jean Williamson, Acting Secretary
Barb Scherer, State Health Benefits Program
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey (Horizon BCBSNJ)
Linda Schwimmer, Director of Strategic Relationships & External Affairs, Horizon Healthcare Innovations
Dr. Steven Peskin, MD, MBA, FACP, Senior Medical Director of Clinical Innovations, Horizon Healthcare Innovations

Issues:  Patient Centered Medical Homes and Accountable Care Organizations

A presentation was given by Dave Perry, Horizon Blue Cross Blue Shield of New Jersey (Horizon) and Dr. Steven Peskin and Linda Schwimmer from Horizon Healthcare Innovations on Patient-Centered Medical Homes (PCMH) and Accountable Care Organizations (ACO).  Horizon distributed a handout to the Commissions concerning transforming health care delivery in New Jersey with PCMHs and ACOs.  Mr. Perry gave an overview of the PCMH and ACO health care models. Afterward, he introduced Dr. Steven Peskin and Linda Schwimmer who discussed how the PCMH and ACO models afford better care at lower costs.   Currently, there are over 21,700 members in PCMHs and the number is expected to grow to 180,000 by January 2013. The presentation was interactive and the Commissioners were able to ask and receive answers to their questions.  The Joint Meeting of the State Health Benefits Commission and the School Employees’ Health Benefits Commission was adjourned at 12:10 PM. 

  Respectfully submitted,
 

 

 

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

 


School Employees’ Health Benefits Commission
Minutes, Meeting No 37
August 16, 2012; 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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and revised notice was sent April 10, 2012. 

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:07 AM, Thursday, August 16, 2012.  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:

Robert Peden, Commissioner
David Earling, Chairman (via telephone)
Felix Schirripa, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner

Absent:

Wendell Steinhauer, Commissioner
Joseph Del Grosso, Commissioner

Also present: 

Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Jean Williamson, Acting Assistant Chief of Policy and Planning, Division of Pensions and Benefits
Susan Barrett, Acting Secretary
Barb Scherer, School Employees’ Health Benefits Program
Edward W. Fox, Aon Hewitt Consultants
Susan Marsh, Aon Hewitt Consultants
James Christ, Aon Hewitt Consultants

David Pointer advised the Commission the Medical RFP had been awarded to Horizon Blue Cross and Blue Shield of New Jersey (Horizon) and Aetna. The following benefit plans will be offered in Plan Year 2013: NJ DIRECT1O, Aetna PPO1O, NJ DIRECT15, Aetna PPO15, NJ DIRECT1525, Aetna PP01525, NJ DIRECT2O3O, Aetna PP02030, legacy HMO plan, HM01525, HM02030, HD4000, and HD1500. Active employees will continue with their current Prescription Drug Plans: Local Employers can select the Prescription Drug Card Plan available under the SEHBP, which is administered by Express Scripts, the Pharmacy Benefit Manager (PBM), or prescription drug coverage under the medical plan (which is also administered by Express Scripts), or purchase prescription drug coverage from an outside vendor.

Issues

Edward Fox, Aon-Hewitt Consulting, gave an introduction and made general remarks concerning the 2013 proposed rates.  Susan Marsh, Aon-Hewitt Consulting, gave an overview of the 2013 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-Hewitt Consulting was James Christ. The following is a summary:

Recommended Plan Year 2013
Active Employee and Retiree
Medical Rx Rate Renewal Recommendation


For Plan Year 2013, Aon Hewitt is recommending SEHBP premium rate changes of 14.7% for Active Employees, 21.9% for Early Retirees, and 11.4% for Medicare Retirees.  In the aggregate, the recommended rate actions represent an overall increase for the SEHBP of 14.8%:


                                               Early       Medicare
                     Employees  Retirees   Retirees

Medical                         15.6%          22.4%         13.2%
Prescription Drug              7.5%          19.9%         10.0%
Total                            14.7%          21.9%         11.4%

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

  • The overall renewal increase is larger than SEHBP trends (which are about 9%) because of higher than anticipated trends in Plan Year 2011, which are largely due to the increase in the number of dependents resulting from Federal Health Care Reform, which mandates coverage of adult children to age 26.  The Early Retiree renewal increase is 10% greater than the Medicare Retiree renewal increase due to:
    • 7% from the decrease in the Early Retiree Reinsurance Program credit for Plan Year 2013, as compared to Plan Year 2012, and

    • 3% from the change in the renewal loss ratio target.  Plan Year 2013 renewal rates are set equal to costs, while the Plan Year 2012 renewal rates were set 3% below expected costs in order to spend down the Claim Stabilization Reserve.
  • This recommended rate renewal assumes:
    • The Retiree Rx copays and Out-Of-Pocket Maximum for SEHBP PPOs and HMOs will be frozen at Plan Year 2012 levels;

    • A new benefit landscape for Plan Year 2013, resulting from the recently-concluded Medical RFP, with Horizon and Aetna providing the PPO, HMO, and HDHP options and Express Scripts (formerly known as Medco) continuing as the PBM.

    • The revised Employee contribution schedule that went into effect in 2011 had little impact on Employee enrollment for the Plan Year 2012, since the 1.5% of salary floor exceeded contributions generated by the new schedule for all Employees in the first year of the new schedule.  In fact, only about 140 Employees/Retirees enrolled in the new plan options for Plan Year 2012.  In the second year of the Chapter 78 contribution schedule, many Employees will experience increased contributions and will experience another increase in contributions in the third year of the schedule’s phase-in.  As a result, we are projecting a significant increase in the percentage of employees enrolling in the “new” plan options for Plan Year 2013, although the actual numbers of Employees/Retirees enrolled will still be a very small percentage of overall SEHBP enrollment.  Additionally, the Plan Year 2013 renewal projections assume that a small number of Employees will drop coverage, which is more than offset by new employers joining the SEHBP. 

    • 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 was effective January 1, 2011 and increases costs $14 million);

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

      • Early Retiree Reinsurance Program (which reduces costs by $9 million);

      • Coverage of certain additional preventive care services for women (which increases costs by $7 million), and

      • The Comparative Effectiveness Fee of $2 per member per year in Plan Year 2013 (which increases costs by $0.8 million).

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

      • SEHBP Active Employee and Retiree enrollment will increase 6% in Plan Year 2013.

  • Aggregate differences in the rate changes for different benefit plans and coverage tiers, and between Actives and Retirees, reflect the impact of:

    • Medicare Retiree medical trends have been well below industry norms for the past few years and we are projecting that the low trend levels will continue into Plan Years 2012 and 2013.

    • HMO claim trends had averaged about 3% higher than Horizon trends for a number of years.  However, they appear to be moderating and we are therefore projecting that HMOs will trend at a rate less than the PPO plans in Plan Year 2013.

    • Projected Retiree costs have been reduced $55 million due to projected savings from the change to EGWP Plus Wrap and from the Early Retiree Reinsurance Program.

    • For Active premiums, increases vary by coverage tier, since the differences in costs by coverage tier have been revised based on actual SEHBP experience.  Specifically, the Employee + Child(ren) coverage tier will receive approximately an additional  5% increase for Plan Year 2013, which will change its cost relative to Single coverage from 148% to 156%.  This adjustment will make the Employee + Child(ren) rate more consistent with actual experience, which shows that Child(ren) coverage claim costs are 80% of the cost of Employee coverage, an increase from the pre-Health Care Reform level of 72%.

  • Factors contributing to the overall recommended rate actions include:

    • 8.9% average trend from Plan Year 2012 to Plan Year 2013, which is consistent  with industry trends;

    • Higher trends for Early Retirees, which are partially offset by the Early Retiree Reinsurance Program credit;

    • EGWP Plus Wrap savings which reduce Medicare Retiree projected costs, and


    • 2% margin added to the Plan Year 2013 Active premium rates in order to build up the Active Employee Claim Stabilization Reserve.

  • Plan Year 2013 projected costs for the SEHBP are $2.57 billion ($1.60 billion for Actives and $.97 billion for Retirees).  Plan Year 2013 renewal premiums are projected to produce a $32 million gain for Actives and no loss/no gain for Retirees. 

  • The 12/31/13 Claim Stabilization Reserve level for Actives is projected at 0.8 months of projected Plan costs, well below the recommended level of 2.0 months, so the projected $32 million gain will help restore the Active reserve to a more adequate level.

  • Since the State is responsible for approximately 90% of Local Education Retiree claim payments, Plan Year 2013 premiums do not include any margin to rebuild Retiree reserve levels.

Attachment A

School Employees’ Health Benefits Program
Plan Year 2013 Rate Renewal Recommendations

0


Aon-Hewitt Consultants answered questions that were asked by the Commission concerning the comparisons of plans co-pays compared to market co-pays and the Claims Stabilization Fund. 

Commissioner Kelleher asked if the Division was capable of producing a report that shows the number of employees enrolled in each plan by employer.  David Pointer will look into Commissioners Kelleher’s request and advise if such a report is possible. 

Mr. Pointer noted that any additional questions following the meeting should be emailed to him by the end of business day Friday, August 17, 2012, in order to allow Aon-Hewitt’s consultants time to respond. 

Susan Barrett announced that the next scheduled meeting would be held Tuesday, August 21, 2012 at 10:00 AM. 

There being no further business, Commissioner Schirripa 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 11:02 AM.

  Respectfully submitted,
 

 

 

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

 


School Employees’ Health Benefits Commission
Minutes, Meeting No 38
August 21, 2012; 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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and revised notice was sent August 16, 2012. 

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:07 AM, Tuesday, August 21, 2012.  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 (via telephone)
David Earling, Chairman (via telephone)
Cynthia Jahn, Commissioner
Kevin Kelleher, Commissioner
Robert Peden, Commissioner
Felix Schirripa, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Wendell Steinhauer, Commissioner

Also present: 

Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Jean Williamson, Acting Assistant Chief of Policy and Planning, Division of Pensions and Benefits
Susan Barrett, Acting Secretary
Barb Scherer, School Employees’ Health Benefits Program
Edward W. Fox, Aon Hewitt Consultants
Susan Marsh, Aon Hewitt Consultants
James Christ, Aon Hewitt Consultants

Mr. Pointer announced that the Division had received questions regarding the rate renewals from Commission members, which had been forwarded to Aon Hewitt for reply. Aon’s replies were made available the day prior and Aon representatives were present at the meeting to answer any additional questions.

Commissioner Kelleher asked for clarification regarding the Claim Stabilization Reserve. Ms. Marsh confirmed that the reserve is in place to smooth the renewal increases over time. She explained that the rates were deliberately set three percent lower last year in order to spend down the reserve gradually.

Commissioner Steinhauer asked if the high deductible plans were put in a separate risk pool. Ms. Marsh explained that there were three steps involved in Aon Hewitt’s renewal process. First, they pooled large claims across all carriers and all programs. They then looked at Horizon experience and determined a Horizon increase. They combined Aetna and Cigna experience to determine an increase necessary for the HMO plans. They looked at prescription drugs separately. The second step was to look at the new plans introduced for 2013. Based on their RFP analysis for the new plans, she said there is a one percent premium differential between Aetna and Horizon. The third step was to freeze the HDHP rates to encourage enrollment. Commissioner Steinhauer questioned the last step, because he believed it was the Plan Design Committee’s intention to keep everybody in the same risk pool. There was a lengthy discussion as to whether or not the HDHP plan risk was pooled separately and whether this was against the intentions of the Plan Design Committee. Commissioner Kelleher made a motion to go into Executive Session. Commissioner Steinhauer seconded, all were in favor.

Upon returning to Public Session, Commissioner Kelleher questioned the reasoning behind the parent/child relative value increase from 1.40 to 1.73 by plan year 2015. Ms. Marsh responded that the increase was done because the current rate does not support the child experience. Also, there is a contribution anomaly created by Chapter 78, P.L. 2011. Due to the legislation, in some salary tiers rates would be created wherein parent/child coverage would be less expensive than single coverage, if the factor was not increased. Commissioner Kelleher commented that numbers have to be moved around in order to compensate for a piece of legislation that has a premium sharing chart over which the Commission has no control. There was further discussion regarding the relative value increases and Aon-Hewitt’s rationale behind the increases. Commissioner Kelleher made a motion to go into Executive Session, seconded by Commissioner Steinhauer. All were in favor.

Upon returning to Public Session, Commissioner Steinhauer made a motion to approve the rates as presented. Commissioner Jahn seconded, and there was discussion. Commissioner Steinhauer explained that he wished to make modifications. He made a motion to amend the rate indexing for 2013 for the single relative value to stay at 1.00, parent/child would change from 1.48 to 1.52, member/spouse would stay at 2.00, and family would go to 2.52. There was further discussion. Commissioner Schirripa suggested modifying those rate indexes to 1.00 for single, 1.56 for parent/child, 2.00 for member/spouse, and 2.56 for family. Commissioner Steinhauer accepted Commissioner Schirripa’s modifications to his motion. Commissioner Peden seconded the motion, all voted in favor.

Commissioner Steinhauer made a second motion amending the original rate approval motion. He moved to include the HDHP plan in the regular pooling and reflect those rates. Commissioner Kelleher seconded the motion. A vote was taken and all voted in favor.

A vote was then taken on the original motion to approve the rates with the accepted amendments. The motion passed with all in favor.
Commissioner Steinhauer put forth a motion to have the SEHBC rate renewal meeting for plan year 2014 be held after the SEHBP Plan Design Committee recommendation meetings. Commissioner Kelleher econded the motion. All voted in favor.

There being no further business, Commissioner Steinhauer made a motion to adjourn, which was seconded by Commissioner Peden. All voted in favor.

  Respectfully submitted,
 

 

 

  Susan Barrett
Acting Secretary, School Employees’
Health Benefits Commission

 


Special School Employees’ Health Benefits Commission
Minutes, Meeting No 39
August 29, 2012; 3:00 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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and revised notice was sent August 27, 2012. 

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 3:05 PM, Wednesday, August 29, 2012.  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:

Robert Peden, Commissioner(via telephone)
Feliz Schirripa, representing Acting Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner (via telephone)
Cynthia Jahn, Commissioner (via telephone)
Wendell Steinhauer, Commissioner (via telephone)
Joseph Del Grosso, Commissioner (via telephone)

Absent:

David Earling, Commissioner

Also present: 

Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
Jean Williamson, Acting Assistant Chief Health Benefits Program
Doug Martucci, Acting Secretary
Barb Scherer, School Employees’ Health Benefits Program
Edward W. Fox, Aon Hewitt Consultants (via telephone)
Susan Marsh, Aon Hewitt Consultants (via telephone)

Issue:

Rate Renewals for Plan Year 2013 incorporating the Plan Design Committee’s change to the Retiree Prescription Drug Plan for approval – Susan Marsh, Aon Hewitt, advised the Commission the retiree prescription drug renewals include an increase in the co-pay and out-of-pocket maximum which were approved by the Plan Design Committee for the PPO10, PPO15 and HMO10 plans.  The impact of these changes is to reduce projected costs for Plan Year 2013 by $4 million. Commissioner Del Grosso asked why the rates needed to be voted on again. Commissioner Schirripa replied the Plan Design Committee took action to change the retiree prescription drug copays, which affected the rate renewals.  Commissioner Steinhauer made a motion to approve the recommendations.  Commissioner Kelleher seconded the motion.  Commissioner Kelleher suggested the Plan Design Committee meet next year prior to this Commission voting on the 2014 Plan Year Rate Renewal Recommendations. Approved (Vote 5: 1: 0, Commissioner Del Grosso voted nay).

There being no further business, Commissioner Schirripa made a motion to adjourn, which was seconded by Commissioner Steinhauer.  All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 3:12 PM.

  Respectfully submitted,
 

 

 

  Douglas Martucci
Acting Secretary, School Employees’
Health Benefits Commission

 


School Employees’ Health Benefits Commission
Minutes, Meeting No 39
November 28, 2012

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 2012 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 15, 2011 and revised notice was sent September 17, 2012. 

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:25 AM, Wednesday, November 28, 2012.  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 (via telephone)
David Earling, Chairman (via telephone)
Thomas Gallagher, representing Acting Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner (via telephone)
Cynthia Jahn, Commissioner (via telephone)

Absent:

Robert Peden, Commissioner
Wendell Steinhauer, Commissioner

Also present: 

Diane Weeden, Deputy Attorney General
Florence J. Sheppard, Acting Director, Division of Pensions and Benefits
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Susan Barrett, Acting Secretary
Douglas Martucci, Division of Pensions and Benefits
Edward W. Fox, Aon Hewitt Consultants
Susan Marsh, Aon Hewitt Consultants
James Christ, Aon Hewitt Consultants
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey

Resolution A and B were read in their entirety. Ms. Barrett apologized for the delay caused by telephone issues.

A motion to approve the meeting minutes of August 21, 2012 was made by Commissioner Kelleher, seconded by Commissioner Del Grosso. The motion passed (Vote 4:0:1, Commissioner Gallagher abstained).

A motion to approve the meeting minutes of August 29, 2012 was made by Commissioner Kelleher, seconded by Commissioner Del Grosso. The motion passed (Vote 4:0:1, Commissioner Gallagher abstained).

Issues

Carrier Updates- Mr. Pointer advised the Commission that Deborah Heart and Lung Center has agreed to remain an in-network facility with Aetna effective September 1, 2012, causing no member disruption.

Mr. Pointer explained that the SHBC/SEHBC has historically used the Prevailing Health Care Charges System (PHCHS), a database used to determine reasonable and customary (R&C) charges. Effective January 1, 2013, the intention is to move to the use of the FAIR Health database. He then introduced Mr. Perry, who gave an overview of the change.

Mr. Perry explained that, due to a lawsuit by the New York Attorney General settled in 2009, which found the system to be unfair, PHCS is no longer a valid option. Horizon is seeking formal approval to use FAIR Health for the SEHBC beginning in 2013. Commissioner Kelleher made a motion to go into Executive Session to seek legal counsel. Commissioner Jahn seconded the motion; all were in favor. Upon returning to Open Session, Commissioner Gallagher made a motion to approve the use of FAIR Health by Horizon and Aetna for the SEHBC beginning in 2013. Commissioner Del Grosso seconded the motion. The motion passed with all in favor.

Local Employer Updates - The 2012 year-to-date report for New Education Employers and Termination of Education Employers was provided to the Commission. New Employer and Termination Reports for January 2013 were also provided. Commissioner Del Grosso asked for an explanation of the changes in numbers of members related to the number of employers. Mr. Pointer explained that some larger employers left, while some smaller employers joined.

The 2013 Meeting Schedule was provided for consideration. Commissioner Del Grosso made a motion to approve the 2013 meeting dates. Commissioner Gallagher seconded the motion. All voted in favor. The Commissioners requested that the Division send invitations through the Outlook calendar. Ms. Barrett agreed to do so.

Commissioner Gallagher made a motion to go into Closed Session under Resolution A to discuss an OAL case for reconsideration. Commissioner Kelleher seconded the motion. All voted in favor.

The following case, due to HIPAA regulations, was heard in closed session.

Case # SE111201 –OAL Case for Reconsideration– Mr. Pointer gave a brief summary of the case, which was originally denied by Horizon as being not medically necessary. The case went to the OAL, where the DAG litigating the case received additional information which Horizon had not previously reviewed. When Horizon reviewed this new information, they determined that the rehabilitation in question was medically necessary and appropriate. Horizon planned to pay the claim in full. Mr. Pointer asked if the Commission was required to approve the payment. DAG Weeden advised that the Commission should now approve the payment for the record, based on the new information. Commissioner Kelleher made a motion to approve the appeal in light of the new information received from Horizon Blue Cross Blue Shield. Commissioner Del Grosso seconded the motion. The motion passed, with all in favor.
Commissioner Kelleher made a motion to return to Open Session, seconded by Commissioner Gallagher. All were in favor.

Upon returning from Closed Session, Commissioner Kelleher made a motion to go into Executive Session to discuss a Workers’ Compensation Settlement Proposal. Commissioner Del Grosso seconded, all were in favor.

Case # SE111202 - Settlement Proposal
Upon return from Executive Session, Commissioner Gallagher made a motion to authorize the workers’ compensation settlement as recommended in John Fedorko’s memo of September 27, 2012. Commissioner Earling seconded the motion. The motion passed, with all in favor.
There being no further business, Commissioner Del Grosso made a motion to adjourn, which was seconded by Commissioner Gallagher.  All voted in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 10:55 AM.

  Respectfully submitted,
 

 

 

  Susan Barrett
Acting Secretary
School Employees’ Health Benefits Commission

 

 

 

 

 

 

 
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