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Pensions and Benefits
School Employees' Health Benefits Commission
Meeting Minutes 2013
The School Employees' Health Benefits Commission meetings are scheduled to start at 10:00 a.m. at Division of Pensions and Benefits, 50 West State Street, 1st Floor, Trenton, NJ 08625.
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

School Employees’ Health Benefits Commission
Minutes, Meeting No 39
January 23, 2013

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 7, 2012.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:10 AM, Wednesday, January 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)
Thomas Gallagher, representing Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Robert Peden, Commissioner
Wendell Steinhauer, Commissioner

Absent:

David Earling, Chairman
Cynthia Jahn, Commissioner

Also present: 

Danielle Schimmel, Deputy Attorney General
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Susan Barrett, Acting Secretary
Douglas Martucci, Division of Pensions and Benefits

Resolution A (Closed Session) and B (Executive Session) were read in their entirety.

A motion to approve the meeting minutes of November 28, 2012 was made by Commissioner Kelleher, seconded by Commissioner Del Grosso. The motion passed (Vote 4:0:1, Commissioner Steinhauer abstained).

Issues

Carrier Updates- Mr. Pointer advised the Commission that Kennedy Memorial Hospital, with locations in Cherry Hill, Stratford, and Turnersville, will terminate from the network effective February 1, 2013. Negotiations are ongoing. Aetna’s negotiations with Barnabus Health Center have been settled, with them remaining in the network.

Commissioner Gallagher made a motion to go into Executive Session to discuss Workers’ Compensation settlement proposals. Commissioner Steinhauer seconded the motion. All were in favor, at which time the meeting convened in Executive Session to discuss the dollar amounts of the case. After this discussion, the meeting convened in Closed Session. Commissioner Steinhauer made a motion to appoint Robert Peden as acting chair for the meeting. Commissioner Gallagher seconded. All were in favor.

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

Case # SE011301 - Settlement Proposal recommended in John Fedorko’s memo of September 13, 2012.

Case # SE011302 – Settlement Proposal recommended in John Fedorko’s memo of December 31, 2012.

Upon return from Executive Session, Commissioner Steinhauer made a motion to authorize both Workers’ Compensation settlements as recommended in John Fedorko’s memos. Commissioner Kelleher seconded the motion. The motion passed, with all in favor.

Commissioner Steinhauer made a motion to return to Public Session. Commissioner Gallagher seconded the motion. 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 10:25 AM.

  Respectfully submitted,
 

 

 

  Susan Barrett
Acting Secretary, School Employees’
School Employees’ Health Benefits Commission


School Employees’ Health Benefits Commission
Minutes, Meeting No 40
March 27, 2013

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 7, 2012.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:07 AM, Wednesday, March 27, 2013.  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)
Thomas Gallagher, representing Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Susanne Culliton, representing State Treasurer Andrew P. Sidamon-Eristoff
Cynthia Jahn, Commissioner (via telephone)

Absent:

David Earling, Chairman
Wendell Steinhauer, Commissioner

Also present: 
Danielle Schimmel, Deputy Attorney General
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Susan Barrett, Acting Secretary
Douglas Martucci, Division of Pensions and Benefits

Resolution A (Closed Session) and B (Executive Session) were read in their entirety.

A motion to approve the meeting minutes of January 23, 2013 was made by Commissioner Kelleher, seconded by Commissioner Del Grosso. The motion passed (Vote 3:0:2, Commissioners Jahn and Culliton abstained).

ISSUES

Carrier Updates- Mr. Pointer advised that there were no carrier updates at this time.

PBM RFP – Mr. Pointer advised that the current Pharmacy Benefit Management (PBM) contract expires on December 31, 2014. He asked the Commission for approval for the Division of Purchase and Property to develop and distribute a Request for Proposal (RFP) for the PBM services now performed by Express Scripts.

Commissioner Kelleher made a motion to make Commissioner Gallagher the Acting Chair of the Commission, in Commissioner Earling’s absence. Commissioner Culliton seconded the motion, all were in favor.

Commissioner Jahn made a motion to approve the Division’s request to proceed with the developing the PBM RFP through the Division of Purchase and Property. Commissioner Culliton seconded the motion. Commissioner Gallagher asked if Purchase and Property would do the bid, the Director of Purchase and Property would make the award, and the Commission would be notified in the end. Mr. Pointer confirmed that that is the process. Commissioner Kelleher asked if the Commission would have an opportunity to review the RFP and if someone from the Commission could sit on the RFP evaluation committee. Mr. Pointer confirmed that the Commissioners would have the opportunity to review the RFP at Division offices before it is finalized. It is also acceptable to have a Commissioner on the evaluation committee, if they wish, as was done with the medical RFP. Commissioner Jahn amended her motion to add that the RFP comes back to the Commission before releasing it to bidders. Commissioner Culliton seconded the amended motion. All voted in favor.

Commissioner Kelleher made a motion to go into closed session to discuss a member appeal. Commissioner Gallagher seconded the motion. All voted in favor.

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

Case # 032701 – This case involves a member appealing the denial to allow her disabled adult child to enroll under her plan. Dependent children are eligible to remain on their parent’s coverage until the end of the year in which they turn twenty-six. A child may remain on the coverage if proof that the child qualifies as a disabled dependent is provided. One of the six criteria to be eligible as a disabled dependent is to submit a Continuance for Dependent with Disabilities form, no later than thirty-one days after the date of coverage for over age children would normally end. The daughter turned twenty-six on February 8, 2011 and was terminated as a dependent effective January 1, 2012. The member did not submit this form by the deadline, January 31, 2012.
At that time, the member was awaiting approval of her daughter’s application for Social Security Disability Insurance (SSDI) benefits. She claims that she believed the SSDI approval had to be completed before she could apply for the daughter to be under the member’s employer-paid coverage as a disabled dependent. In the meantime, the member applied for her daughter to be covered under the provisions of Chapter 375, P.L. 2005, which provides coverage for children under the age of thirty-one. There is a monthly premium charge for such coverage, which she was paying.

Commissioner Kelleher made a motion to allow the mother to apply for disabled dependent coverage, as long as she meets the other five criteria, the deadline criterion would be waived, and coverage would be retroactive to January 1, 2012. Commissioner Del Grosso seconded the motion. In discussing the motion, Commissioner Kelleher stated that he felt that the member was attempting to do the right thing, but applied for the wrong coverage. The motion failed (2:3:0, Commissioners Gallagher, Jahn, and Culliton voted nay).

Commissioner Kelleher made a motion to allow the daughter to be covered retroactive to September 24, 2012, as long as she meets the other five criteria to be eligible as a disabled dependent, the sixth criterion being waived. Commissioner Del Grosso seconded the motion. September 24, 2012 was the date that the member first contacted the Division regarding the disabled dependent coverage. The motion passed (4:1:0, Commissioner Culliton voted nay).

There being no further business, Commissioner Gallagher made a motion to go back into Public Session and adjourn. Commissioner Culliton seconded the motion, all were in favor.

  Respectfully submitted,
 

 

 

  Susan Barrett
Acting Secretary, School Employees’
School Employees’ Health Benefits Commission

 


School Employees’ Health Benefits Commission
Minutes, Meeting No 41
May 22, 2013

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 7, 2012.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:04 AM, Wednesday, May 22, 2013.  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, left at 10:55 AM)
Thomas Gallagher, representing Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Robert Peden, representing State Treasurer Andrew P. Sidamon-Eristoff
Cynthia Jahn, Commissioner (via telephone)
Wendell Steinhauer, Commissioner

Absent:

Joseph Del Grosso, Commissioner

Also present: 

Danielle Schimmel, Deputy Attorney General
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Susan Barrett, Acting Secretary
Douglas Martucci, Division of Pensions and Benefits
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Dr. Louis Parrott, Medical Director, Magellan Behavioral Health of New Jersey
Susan Rizzni, Magellan Behavioral Health of New Jersey

Resolution A (Closed Session) and B (Executive Session) were read in their entirety.

Ms. Barrett advised that the minutes from the January 23, 2013 meeting were not yet available and would be provided before the next scheduled meeting.

ISSUES

Carrier Updates- Mr. Pointer provided an updated list of medications that are included in the Prescription Drug Step Therapy (PDST) Program. He advised that additions and deletions occur due to changes in the prescription marketplace. Updates will be provided in the future as necessary.

Commissioner Kelleher made a motion to go into closed session to discuss a member appeal. Commissioner Gallagher seconded the motion. All voted in favor.

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

Case # 052201(subscriber present) This appeal involved the denial of benefits for residential substance use disorder treatment at The Caron Foundation (Caron), an out-of-network facility located in Pennsylvania. The member’s mother, the subscriber, gave an overview of the appeal and distributed a letter from her son’s current treatment provider, detailing his progress. She explained that her son is dually diagnosed with depression and addiction. She said that he was sent to Caron on December 26, 2011, as it appeared to be the best option. On December 27, 2011, Caron contacted Magellan Behavioral Health of New Jersey, LLC (Magellan), which is contracted by Horizon Blue Cross Blue Shield of New Jersey (Horizon) to manage the behavioral health benefits for all NJ Direct members. The care manager at Magellan did not feel that the member met the American Society of Addiction Medicine (ASAM) criteria for medical necessity and referred the request for admission to a physician advisor for review. The physician advisor also determined that admission to residential substance use disorders treatment was not medically necessary based on ASAM criteria. Due to the denial, Caron’s bill was paid out-of-pocket by the member’s family. Dr. Parrott acknowledged that he reviewed the case in March 2013 and overturned the initial decision, authorizing what he believed would have been a reasonable level of care. There was a discussion about the member’s transition to aftercare following residential treatment.

Commissioner Steinhauer made a motion to go into Executive Session to seek guidance from the Deputy Attorney General. Commissioner Kelleher seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Steinhauer made a motion to deny the appeal, but to authorize Horizon to pay residential treatment from December 26, 2011 through February 7, 2012, seven days partial hospitalization, eight weeks of intensive outpatient, then the remainder of time through May 1, 2012, according to the chart from Dr. Parrott’s letter of March 12, 2013. Commissioner Kelleher seconded the motion. Commissioner Gallagher moved to amend the motion to include that the authorized payment would be subject to all deductibles and co-pays and the amendment was seconded by Commissioner Steinhauer. The motion passed (5:0:0, Commissioner Earling left during Executive Session).

Commissioner Steinhauer made a motion to go into Executive Session to discuss the six Workers’ Compensation cases. Commissioner Jahn seconded the motion and all voted in favor.

Case #s 052202, 052203, 052204, 052205, 052206, 052207 - Upon return to Public Session, Commissioner Steinhauer made a motion to approve all six of the Workers’ Compensation settlement proposals as recommended by Socrates. Commissioner Kelleher seconded the motion. Approved (5:0:0)

There being no further business, Commissioner Steinhauer made a motion to adjourn. Commissioner Gallagher seconded the motion, all were in favor.

An individual then came forward, claiming to have a case on the agenda. Commissioner Steinhauer made a motion to rescind the adjournment. Commissioner Kelleher seconded the motion and all were in favor. Commissioner Steinhauer apologized for the scheduling confusion between the individual and the Division and offered to have the appeal rescheduled for July 18, 2013, assuring that the appeal would be the first item on the agenda. The individual accepted this offer to reschedule.

Commissioner Steinhauer made a motion to adjourn. Commissioner Kelleher seconded the motion, with all in favor. The School Employees’ Health Benefits Commission meeting was adjourned at 11:11 AM.

  Respectfully submitted,
 

 

 

  Susan Barrett
Acting Secretary, School Employees’
School Employees’ Health Benefits Commission

School Employees’ Health Benefits Commission
Minutes, Meeting No 42
July 10, 2013

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 7, 2012.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:00 AM, Wednesday, July 10, 2013.  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
Felix Schirripa, representing Commissioner Kenneth E. Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner
Robert Peden, Commissioner

ABSENT:

Wendell Steinhauer

ALSO PRESENT: 

Danielle Schimmel, Deputy Attorney General
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Susan Barrett, Acting Secretary
Douglas Martucci, Division of Pensions and Benefits
Edward Fox, Aon Hewitt
Susan Marsh, Aon Hewitt
James Christ, Aon Hewitt
Alex Jaloway, Aon Hewitt

Resolution A (Closed Session) and B (Executive Session) were read in their entirety.

Commissioner Kelleher made a motion to approve the minutes of March 27, 2013 and May 22, 2013. Commissioner Del Grosso seconded the motion. Minutes approved (5:0:1, Commissioner Schirripa abstained). Commissioner Kelleher asked that the minutes be provided at least two days in advance of the meetings. Ms. Barrett responded that she would comply with this request.

Case #s SE071001, SE071002, SE071003, SE071004

Commissioner Kelleher made a motion to allow the SEHBP to negotiate settlements within the ranges recommended in the memos from Socrates of the three cases before the Commission for Workers’ Compensation. He amended the motion to clarify that there were four cases before them. Chairman Earling seconded the motion. Approved (6:0:0)

Carrier Updates

Mr. Pointer advised that there were no carrier updates.

Nomination for Prescription Benefit Management Request for Proposals Evaluation Committee (PBM RFP)

Mr. Pointer advised that, earlier in the year, the Commission moved to review the PBM RFP before it was available to bidders and that a Commissioner be nominated for the Evaluation Committee. He explained the process and time commitment involved. Chairman Earling made a motion to table the vote until the next meeting. Commissioner Peden seconded the motion; all were in favor.

Rate Renewals for 2014

Mr. Fox gave an introduction and made general remarks. Ms. Marsh, gave an overview of the 2014 Rate Recommendations for Medical and Prescription Drugs for the Active Employees and Retirees of the School Employees’ Health Benefits Program (SEHBP). The following is a summary: 

School Employees’ Health Benefits Program (SEHBP)
Recommended Plan Year 2014
Active Employee and Retiree
Medical/Rx Rate Renewal Recommendation

  • For Plan Year 2014, Aon Hewitt is recommending SEHBP premium rate changes of 5.4% for Active Employees, 8.5% for Early Retirees, and 3.8% for Medicare Retirees.  In the aggregate, the recommended rate actions represent an overall increase for the SEHBP of 5.6%:

                                                                                              Early              Medicare
                                                            Employees              Retirees             Retirees

Medical PPO                                  4.6%                    7.6%                   7.6%
Medical HMO                                 4.2%                    9.6%                   9.6%
Prescription Drug PPO                    13.7%                   11.0%                   0.0%
Prescription Drug HMO                   13.7%                   13.0%                   2.0%
Total                                           5.4%                     8.5%                   3.8%     

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

  • This recommended rate renewal assumes:
    • The Retiree Rx copays and Out-Of-Pocket Maximum for SEHBP PPOs and HMOs will increase based on experience trends;
    • No change in benefit landscape for Plan Year 2014, with Horizon and Aetna providing the PPO, HMO, and HDHP options and Express Scripts continuing as the SEHBP’s PBM;
    • SEHBP Medicare Integration will continue as EGWP Plus Wrap;
    • Local Education employer groups will experience increases in employee contributions as a result of Chapter 78. As a result, Aon is projecting an increase in the percentage of employees enrolling in the lower-cost plan options for Plan Year 2014, although the actual numbers of Employees/Retirees enrolled will still be a very small percentage of overall SEHBP enrollment, with 99% of Employees and virtually 100% of Retirees remaining in the legacy plans.
    • 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 $45 million);
        • Elimination of Benefit Maximums (which increases costs $10 million);
        • Coverage of certain additional preventive care services for women (which increases costs by $7 million);
        • The Transitional Reinsurance Fee, assessed to employer group health plans like the SEHBP to help stabilize the cost of individual and small-group coverage through the health insurance exchanges that will be implemented in 2014, which adds $18 million to the SEHBP plan costs for Plan Year 2014, 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 enrollment will remain unchanged from Plan Year 2013 to 2014, while Retiree enrollment will increase 3%.
    • The health insurance exchanges mandated by federal health care reform will be effective in 2014, but should have minimal impact on enrollment or cost levels in the SEHBP.

  • 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 2013 and 2014.
    • HMOs have trended higher than NJ DIRECT for a number of years.  However, they appear to have moderated somewhat and we are therefore projecting that HMOs will trend at a rate less than the PPO plans in Plan Year 2014.
    • Projected Retiree costs have been reduced $65 million due to projected savings from the change to EGWP Plus Wrap.
    • 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 load for Child(ren) coverage will increase from 56% of the Single coverage rate to 65%.  This will increase Plan Year 2014 premiums for Employee + Child(ren) coverage an additional 6% and Family coverage an additional 4%.  (See Attachment A for total premium increases by coverage tier).  This change will make the load for Child(ren) coverage  more consistent with actual experience, which shows that Child(ren) coverage claim costs are 81% 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:

    • 8.4% average annual trend increase over the two most recent years of experience, which is consistent  with industry trends;
    • Loss of the ERRP credit for Early Retirees;
    • EGWP Plus Wrap savings which reduce Medicare Retiree projected costs, and
    • 2% margin added to the Plan Year 2014 Active premium rates in order to build up the Active Employee Claim Stabilization Reserve to the recommended level of 2.0 months of plan costs.

  • Plan Year 2014 projected costs for the SEHBP are $2.75 billion ($1.78 billion for Actives and $.97 billion for Retirees).  Plan Year 2014 renewal premiums are projected to produce a $37 million gain for Actives and no loss/no gain for Retirees. 
  • The 12/31/14 Claim Stabilization Reserve level for Actives is projected at 1.6 months of projected Plan costs, well below the recommended level of 2.0 months, so the projected $37 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 2014 premiums do not include any margin to rebuild Retiree reserve levels.

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

  • none

There being no further business, Chairman Earling made a motion to adjourn. Commissioner Jahn seconded the motion, with all in favor. The meeting adjourned at 11:33 AM.

  Respectfully submitted,
 

 

 

  Susan Barrett
Acting Secretary, School Employees’
School Employees’ Health Benefits Commission

 

School Employees’ Health Benefits Commission
Minutes, Meeting No 43
July 18, 2013

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 7, 2012.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 9:10 AM, Thursday, July 18, 2013.  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
Felix Schirripa, representing Commissioner Kenneth  E. Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner
Robert Peden, Commissioner
Wendell Steinhauer, Commissioner

Also present: 

Danielle Schimmel, Deputy Attorney General
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Susan Barrett, Acting Secretary
Kierney Corliss, Division of Pensions and Benefits
Edward Fox, Aon Hewitt
Susan Marsh, Aon Hewitt
James Christ, Aon Hewitt
Alex Jalloway, Aon Hewitt

Resolution A (Closed Session) and B (Executive Session) were read in their entirety.

Ms. Barrett asked permission from the Chair to go out of order on the agenda, which was allowed.

Rate Renewals

Ms. Marsh went over a memorandum which provided answers to follow-up questions from the Commission. It had been forwarded to the commissioners for review prior to the meeting. There was discussion regarding the Claim Stabilization Reserve (CSR), retiree prescription drug indexing history, coverage tier ratios, Mental Health Parity, employee cost-sharing, and emergency room utilization. Chairman Earling made a motion to go into Executive Session. Commissioner Steinhauer seconded the motion, and all were in favor. Upon return to Public Session, Commissioner Peden made a motion to accept the rate renewal recommendations as presented by Aon Hewitt on July 10, 2013. Approved (4:3:0, Commissioners Del Grosso, Kelleher, Steinhauer voted nay).

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 to hear appeals.

Case # SE071801 - Division appeal regarding eligibility for State-paid health coverage in retirement. The member was scheduled to attend, but canceled just prior to the meeting. Commissioner Steinhauer made a motion to postpone the appeal until the September meeting. Commissioner Peden seconded the motion, with all in favor.

Case # SE071802 – (Member present via telephone) Horizon appeal regarding the denial of reimbursement for copayments exceeding the $400.00 individual maximum for calendar year 2011. The member presented his case. He claimed that Horizon had informed him by mail and phone that he was entitled to $357.06 that he had paid beyond the plan out-of-pocket maximum. Horizon admitted that he was misinformed, but that the misinformation was given a year after the services were rendered. There were not services rendered as a result of the miscommunication. Commissioner Schirripa made a motion to go into Executive Session, seconded by Commissioner Peden. All were in favor. Upon return from Executive Session, Commissioner Steinhauer made a motion to deny the appeal, but to have payment of $357.60 made to the claimant as coordinated by Horizon and the Division. Commissioner Kelleher seconded the motion. Commissioner Steinhauer modified the motion to add that it should be paid by Horizon. Chairman Earling seconded the motion. Motion approved (7:0:0).

Case # SE071803 – Division appeal to add a dependent child. The application was not filed within the required sixty days. Chairman Earling made a motion to table the appeal until the next meeting. The Division was instructed to contact the member and request that she attend in person or telephonically for more clarification on the progression of events with respect to the birth certificate.  Commissioner Peden seconded the motion. Appeal tabled (7:0:0)

Commissioner Steinhauer made a motion to come out of Closed Session. Commissioner Del Grosso seconded, with all in favor. Commissioner Steinhauer made a motion to go into Executive Session. Commissioner Kelleher seconded, with all in favor.

Nomination for Prescription Benefit Management Request for Proposals Evaluation Committee (PBM RFP)

The commissioners had discussed the name of the commissioner that they wished to nominate for the PBM RFP Evaluation Committee during Executive Session. The meeting re-convened in Public Session. Commissioner Steinhauer made a motion to reaffirm the nomination of that commissioner through a Public Session vote. Commissioner Del Grosso seconded the motion. The nominated commissioner was approved (7:0:0).
 
There being no further business, Commissioner Steinhauer made a motion to adjourn. Commissioner Kelleher seconded the motion, with all in favor. The meeting adjourned at 11:30 AM.

  Respectfully submitted,
 

 

 

  Susan Barrett
Acting Secretary, School Employees’
School Employees’ Health Benefits Commission

School Employees’ Health Benefits Commission
Minutes, Meeting No 44
September 6, 2013

Adequate notice of this meeting was provided through the annual notice of the schedule of regular meetings of the Commission filed with and prominently posted in the offices of the Secretary of State.  The 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012, and revised notice was sent August 28, 2013.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:03 AM, Friday, September 6, 2013.  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 Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner (via telephone)
Wendell Steinhauer, Commissioner

Absent:

Robert Peden

Also present: 

Kellie Pushko, Deputy Attorney General
Douglas Martucci, Acting Secretary
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Florence Sheppard, Acting Director, Division of Pensions and Benefits

Resolution to go into Executive Session was read in its entirety.

Mr. Martucci advised that the only agenda item was the approval of rates for the new 2035 PPO and HMO plans. Mr. Pointer advised that the rates for all of the other plans were previously approved.

Commissioner Steinhauer made a motion to approve the rates for the new 2035 PPO and HMO plans. Commissioner Kelleher seconded the motion. Commissioner Kelleher shared that the Plan Design Committee met and developed these new plans as well as other changes for Plan Year 2014, including a wellness program, mental health parity, and a change to the prescription co-pays. Mr. Martucci added that the other actions do not affect the rates. The only item requiring approval by the Commission is the rates for the new plans. Mr. Pointer noted that the new plans are for active employees only, not retirees. Motion approved (6:0:0).

There being no further business, Commissioner Kelleher made a motion to adjourn. Commissioner Steinhauer seconded the motion, with all were in favor. The meeting adjourned at 10:10 AM.

  Respectfully submitted,
 

 

 

  Douglas Martucci,
Acting Secretary,
School Employees’
Health Benefits Commission

School Employees’ Health Benefits Commission
Minutes, Meeting No 45
September 25, 2013

Adequate notice of this meeting was provided through the annual notice of the schedule of regular meetings of the Commission filed with and prominently posted in the offices of the Secretary of State.  The 2013 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on December 7, 2012.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:05 AM, Wednesday, September 25, 2013.  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, left at 12:05 PM)
Thomas Gallagher, representing Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner
Wendell Steinhauer, Commissioner (via telephone)

Absent:

Robert Peden

Also present: 

Danielle Schimmel, Deputy Attorney General
David Pointer, Assistant Director NJ Public Employees’ Health Benefits Program
Susan Barrett, Acting Secretary
Douglas Martucci, Division of Pensions and Benefits
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey (Horizon)
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Dr. Steven Wolinsky, Horizon Blue Cross Blue Shield of New Jersey
Dr. Louis Parrott, Medical Director, Magellan Behavioral Health of New Jersey
Gerald Jones, Magellan Behavioral Health
Thomas Hower, Deputy Attorney General

Resolution A (Closed Session) and B (Executive Session) were read in their entirety.

Commissioner Gallagher made a motion to go into Closed Session to discuss appeals. Commissioner Kelleher seconded the motion, with all in favor.

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

Case # SE091301 (member and attorney present) This appeal was a previously tabled case regarding eligibility for State-paid health coverage in retirement. Commissioner Jahn made a motion to go into Executive Session to consult with legal counsel. Commissioner Gallagher seconded the motion, with all in favor. Upon return to Closed Session, Commissioner Kelleher made a motion to table the case, pending legal advice as to whether the SEHBC is the correct venue for the appeal. Commissioner Jahn seconded the motion. The motion passed (6:0:0).

Case # SE091302 (subscriber present) This was a Horizon appeal regarding denied coverage for dyslexia treatment. The subscriber described her son’s need for a reading program to treat his dyslexia. Ms. Burns explained that there is an exclusion under NJ Direct for educational services and supplies, including reading therapy. In addition, the teacher providing the services does not qualify as an eligible provider under the SEHBP. She added that dyslexia is considered a developmental disability under the Autism and Development Disabilities Mandate. However, allowable treatment would include physical, occupational or speech therapies, but not reading therapy. Commissioner Kelleher made a motion to go into Executive Session to seek legal counsel. Commissioner Jahn seconded the motion, with all in favor. Upon return from Executive Session, Commissioner Earling made a motion to deny the appeal based on the fact that the services of reading therapy or educational services or testing or instruction skills are not to be covered under NJ Direct. Commissioner Gallagher seconded the motion. The motion passed (6:0:0).

Case # SE091303 (subscriber present) This was a Horizon appeal regarding the denial of substance use treatment. The subscriber explained that his son was receiving substance use disorders treatment at Caron Renaissance (Caron). Prior to October 1, 2011, the subscriber had a different insurance benefit through his employer, which was also through Horizon/Magellan, under which his son’s treatment had been authorized. Once his employer joined the SEHBP on October 1, 2011, the subscriber failed to get prior authorization to continue treatment under NJ Direct.

Chairman Earling left the meeting. Commissioner Kelleher made a motion to nominate Commissioner Gallagher as Acting Chair. Commissioner Jahn seconded the motion, with all in favor.

Commissioner Kelleher made a motion to go into Executive Session to seek advice from counsel. Commissioner Jahn seconded the motion, with all in favor.

Upon return from Executive Session, Commissioner Gallagher made a motion to deny the appeal, but to authorize Horizon to pay for the dates of service using the Current Procedural Terminology (CPT) codes as presented by Magellan to the Commission at the meeting, but with modifications to the start and end dates. Commissioner Jahn seconded the motion. The motion passed, (5:0:0).

Case # SE091304 (member present) The member was appealing his health benefits termination for failure to enroll in the full Medicare program. The member had enrolled in Medicare Part A effective December 1, 2012, but neglected to enroll in Medicare Part B, as is required by the SEHBP. Horizon stopped paying claims under the plan effective August 1, 2013, due to an audit. The member subsequently contacted the Centers for Medicare and Medicaid Services (CMS), applied for Medicare Part B, and requested an effective date retroactive to December 2012. The member was led to believe that this request would be approved, although there might be a lengthy wait for processing time. Commissioner Gallagher made a motion to table the case until the Medicare Part B effective date is determined. Commissioner Kelleher seconded the motion. The motion passed (5:0:0).  The member was advised to advise Ms. Barrett of the decision of his appeal with CMS, regardless of the outcome.

Case # SE091305 (member present) This was a Division appeal to reinstate the member’s spouse to his plan retroactively. The spouse was removed from coverage effective July 1, 2010 due to the Dependent Eligibility Verification Audit (DEVA). She was later reinstated, effective July 1, 2012, once the Division received the proper documentation for eligible dependents. The dependent was in an automobile accident in October 2011, and the member requested that related claims be paid, as he was unaware that she had been removed from the policy. Commissioner Kelleher made a motion to go into Executive Session to seek legal advice. Commissioner Jahn seconded the motion, with all in favor.

Upon return to Closed Session, Commissioner Kelleher made a motion to approve the appeal, with these three conditions: a marriage certificate must be provided to the Division; the Division must verify that the member is entitled to State-paid retired health benefits; the claims are processed based on medical necessity. Commissioner Gallagher seconded the motion. The motion passed (5:0:0).

Case # SE091306 Commissioner Gallagher made a motion to go into Executive Session to discuss this case pending before the Office of Administrative Law (OAL) regarding eating disorder treatment. Commissioner Kelleher seconded the motion, with all in favor.
Upon return to Public Session, Commissioner Gallagher made a motion to authorize the Attorney General’s office to propose a settlement as outlined in DAG Hower’s memorandum of September 25, 2013. Commissioner Jahn seconded the motion.  The motion passed (5:0:0).

Case # SE091307 This was a tabled Division appeal to add a dependent child to coverage. The Division had received the member’s application to add her newborn to her coverage beyond the 60-day requirement. The case was on the agenda of the July 18, 2013 meeting, but the case was tabled because the Commissioners wanted to be sure that the member was notified of the postponement of the case. On July 19, 2013, the Division sent the member notification that she was on the agenda today, through regular mail, with no response from the member. Commissioner Jahn made a motion to table the case until the Commission is certain that the member received the notice that her appeal was scheduled to be heard, through certified mail. Commissioner Kelleher seconded the motion. The motion passed (5:0:0)

Case # SE091308 This was a Division appeal to add dependent children. In her appeal letter, the member requested to add two children to her plan that had previously been covered by their father, who had recently left the country. Mr. Pointer explained that, had the member provided a HIPAA notice indicating that the children lost coverage within 60 days prior to the date the Division received the member’s application, it would be processed with no need to appeal. Ms. Barrett added that she had attempted to phone the member, with no response. Commissioner Gallagher made a motion to table the case pending valid documentation. If the documentation is provided, the Division shall process the request. If the member does not provide proof, the case will return to the Commission. Commissioner Kelleher seconded the motion. The motion passed (5:0:0).

Commissioner Gallagher made a motion to return to Open Session to vote on the Workers’ Compensation settlement cases. Commissioner Kelleher seconded the motion, with all in favor.

Case # SE091309, SE091310, SE091311, SE091312, SE091313, SE091314, SE091315, Commissioner Gallagher made a motion to authorize all of the settlement proposals for Workers’ Compensation cases listed on the agenda, as outlined in their respective memorandums from John Fedorko of Socrates. Commissioner Kelleher seconded the motion. The motion passed (5:0:0).

Case # SE091316 DAG Schimmel advised that this case was on the agenda for informational purposes. It had been an SEHBC case which was recently reversed by the appellate court.  Mr. Pointer advised that the Division would provide a copy of the Appellate Division decision to the  Commissioners through email. DAG Schimmel would notify the Commission at the next meeting whether or not it had been appealed to the Supreme Court.

Commissioner Jahn made a motion to return to Executive Session for further legal advice  regarding Case # SE091301. Commissioner Kelleher seconded the motion, with all in favor. Upon return to Open Session, with there being no further business, Commissioner Jahn made a motion to adjourn. Commissioner Del Grosso seconded the motion, with all in favor. The meeting adjourned at 1:30 PM.

  Respectfully submitted,
 

 

 

  Susan Barrett
Acting Secretary, School Employees’
School Employees’ Health Benefits Commission

 

 

 

 
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