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Pensions and Benefits
School Employees' Health Benefits Commission
Meeting Minutes 2014
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.

School Employees’ Health Benefits Commission
Minutes, Meeting No 46
March 7, 2014

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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 31, 2014.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:02 AM, Friday, March 7, 2014.  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 (via telephone)
Robert Peden, Commissioner

ALSO PRESENT: 

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

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

ISSUES

Local Employer Updates-  Acting Secretary Kierney Corliss distributed a summary of 2013 Local Education Employer new employers and terminations. There were approximately 6,900 terminated subscribers and approximately 3,700 new employees.

Carrier Updates- Ms. Corliss distributed a memo summarizing the 2014 changes to the Preferred Drug Step Therapy (PDST) Program.

Ms. Corliss advised the Commission that Kennedy Hospital, which had previously terminated from Aetna’s network as of June 1, 2013, rejoined Aetna’s network effective February 18, 2014.

2014 Meeting Dates- Commissioner Kelleher made a motion to approve the meeting dates presented for 2014. Commissioner Gallagher seconded the motion. All voted in favor.

Minutes- Commissioner Kelleher made a motion to approve the minutes from July 10, 2013. Commissioner Peden seconded the motion. Motion passed (6: 0: 1, Commissioner Gallagher abstained).

Commissioner Kelleher made a motion to approve the minutes from July 18, 2013. Commissioner Peden seconded the motion. Motion passed (6: 0: 1, Commissioner Gallagher abstained).

Commissioner Kelleher made a motion to approve the minutes from September 6, 2013. Commissioner Gallagher seconded the motion. Motion passed (6: 0: 1, Commissioner Peden abstained).

Commissioner Kelleher made a motion to approve the minutes from September 25, 2013. Commissioner Gallagher seconded the motion. Motion passed (6: 0: 1, Commissioner Peden abstained).

Surcharge Rate for Non-Participating Boards of Education- Ms. Corliss distributed a memo from State Treasurer Andrew Sidamon-Eristoff regarding the surcharge rate for non-participating Boards of Education. The 2014 rate is 2.6 percent.

PBM Contract Extension- Commissioner Gallagher made a motion to go into Executive Session to discuss this item. Commissioner Kelleher seconded the motion. All voted in favor. There was no further discussion of this item upon return from Executive Session.

Phillip Yucht vs. SEHBC—This Appellate Court decision concerned the payment of out-of-network behavioral health claims. Commissioner Kelleher made a motion to apply the court decision back to the date of the change of the payment structure—May 2009—and reimburse payment of behavioral health claims incurred since that date using the Reasonable and Customary allowance set forth in the national database of charges; and if the Deputy Attorney General believes it is necessary, to require that the member provide proof of loss. Commissioner Steinhauer seconded the motion. Motion passed (4: 3: 0, Commissioners Gallagher, Jahn, and Peden voted nay).

Commissioner Gallagher made a motion to go into Closed Session to consider member appeals. Commissioner Del Grosso seconded the motion. All voted in favor.

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

Case #SE031401 (member present) — This appeal concerned a denial of coverage for an overage disabled dependent. The member’s employment contract stated that her employer would contribute to the cost of family coverage effective July 1, 2013. Prior to that date, the employer would only contribute to the cost of single coverage. The employer joined the SEHBP on September 1, 2014, and coverage for the dependent was denied because he was not on the member’s coverage prior to the local education employer joining the SEHBP. Commissioner Kelleher made a motion to table the appeal and ask the member to obtain a determination from her prior plan regarding her son’s eligibility for the time period July 1, 2013 through September 1, 2013. Commissioner Peden seconded the motion. All voted in favor.

Case # SE031402 — This tabled case concerned a denial to add a subscriber’s dependent children to coverage outside of the open enrollment period. Commissioner Kelleher made a motion to deny the appeal but to allow the member to apply for coverage for her children effective January 1, 2014. Commissioner Steinhauer seconded the motion. Motion passed (6: 0: 1, Commissioner Del Grosso abstained).

Case # SE031403 — This tabled case concerned the eligibility for post-retirement medical benefits for an active member. The case had been tabled pending advice from the Deputy Attorney General. Commissioner Gallagher made a motion to go into Executive Session. Commissioner Kelleher seconded the motion. (6: 0: 1, Commissioner Del Grosso abstained).

Upon return from Executive Session, Commissioner Gallagher made a motion to deny the appeal as the Commission does not give advisory opinions. Commissioner Peden seconded the motion. Motion passed (6: 0: 1, Commissioner Del Grosso abstained).

Case # SE031404—This tabled case concerned a denial of coverage for a dependent child. The member had not submitted an enrollment application with birth certificate within 60 days of the child’s date of birth. The case was tabled in order for the member to provide information as to why there was a delay. Ms. Corliss advised the Commission that the member had not responded to repeated requests for information. Commissioner Gallagher made a motion to deny the appeal. Commissioner Peden seconded the motion. Motion passed (6: 0: 1, Commissioner Del Grosso abstained).

Commissioner Kelleher made a motion to return to Public Session. Commissioner Gallagher seconded the motion. All voted in favor.

Cases # SE031405, SE031406, SE031407, SE031408, SE031409, SE031410, SE031411, 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. All voted in favor.

Case # SE031412 Commissioner Kelleher made a motion to approve the settlement proposal for 21st Century American. Commissioner Peden seconded the motion. All voted in favor.  

Commissioner Gallagher made a motion to adjourn. Commissioner Steinhauer seconded the motion. All voted in favor. The School Employees’ Health Benefits Commission Meeting was adjourned at 11:25 AM.

 

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
School Employees’ Health Benefits Commission

 


School Employees’ Health Benefits Commission
Minutes, Meeting No 47
March 26, 2014

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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 31, 2014.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:10 AM, Wednesday, March 26, 2014.  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
Cynthia Jahn, Commissioner (via telephone)
Wendell Steinhauer, Commissioner
Susanne Culliton, Representing State Treasurer Andrew P. Sidamon-Eristoff

ABSENT:

David Earling, Chairman

ALSO PRESENT: 

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

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

Commissioner Steinhauer made a motion to go into Closed Session to consider member appeals. Commissioner Gallagher seconded the motion. All voted in favor.

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

Case #SE051401 (member present)—This appeal concerned a denial of coverage for expenses related to an automobile accident. The member’s car insurance had lapsed at the time of the accident. The member, who was a pedestrian, had signed a settlement agreement with the driver’s insurance provider.  Commissioner Kelleher made a motion to go into Executive Session. Commissioner Culliton seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Gallagher made a motion to deny the appeal based on plan provisions that exclude coverage for automobile accidents. Commissioner Steinhauer seconded the motion. All voted in favor.

Case # SE051402—This case concerned a denial of coverage for expenses for reading therapy. The member requested that the case be sent to the Office of Administrative Law as a contested case. Commissioner Culliton made a motion to approve the request to send the case to the OAL. She then withdrew the motion. Commissioner Culliton made a motion to deny the appeal and authorize the Commission secretary to prepare a Final Administrative Determination for review by the Commission. Commissioner Steinhauer seconded the motion. All voted in favor.

Commissioner Kelleher made a motion to return to Public Session. Commissioner Gallagher seconded the motion. All voted in favor.

Case # SE051403- Commissioner Culliton made a motion to authorize settlement as detailed in the proposal dated February 14, 2014. Commissioner Kelleher seconded the motion. All voted in favor.

Case # SE051404—Commissioner Gallagher made a motion to authorize settlement as detailed in the proposal dated November 4, 2013. Commissioner Steinhauer seconded the motion. All voted in favor.

Case # SE051405—Commissioner Steinhauer made a motion to authorize settlement as detailed in the proposal dated February 27, 2014. Commissioner Kelleher seconded the motion. All voted in favor.

Case # SE051406-- Commissioner Steinhauer made a motion to authorize settlement as detailed in the proposal dated February 25, 2014. Commissioner Kelleher seconded the motion. All voted in favor.

Case # SE051407-- Commissioner Steinhauer made a motion to authorize settlement as detailed in the proposal dated October 21, 2013. Commissioner Kelleher seconded the motion. All voted in favor.

Commissioner Gallagher made a motion to adjourn. Commissioner Del Grosso seconded the motion. All voted in favor. The School Employees’ Health Benefits Commission Meeting was adjourned at 10:45 AM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
School Employees’ Health Benefits Commission

 


School Employees’ Health Benefits Commission
Minutes, Meeting No 48
May 28, 2014

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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 31, 2014.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:10 AM, Wednesday, May 24, 2014.  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 Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner
Wendell Steinhauer, Commissioner
Robert Peden, Representing State Treasurer Andrew P. Sidamon-Eristoff
Serena DiMaso, Commissioner

Absent:

Carmen Gonzalez-Gannon, Commissioner

Also present: 

Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Douglas Martucci, Division of Pensions and Benefits
Mark Cipriano, Division of Pensions and Benefits

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

Issues

NJ WELL- Douglas Martucci, Division of Pensions and Benefits, gave a brief presentation on NJ WELL, the incentive-based Wellness Program for active SEHBP members.

Commissioner Jahn made a motion to go into Closed Session to consider member appeals. Commissioner Steinhauer seconded the motion. All voted in favor.

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

Case #SE051401 (member present)— This case concerned the eligibility for post-retirement medical benefits for an active member. The case was before the Commission for reconsideration. The member’s spouse, an attorney, stated that he disagreed with the Commission’s prior determination that this was an advisory opinion because the member was currently paying towards a purchase of service credit.

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

Upon return from Executive Session, Commissioner Jahn made a mtion to reaffirm the prior determination that the Commission is not in a position to make a ruling at the present time. Commissioner Peden seconded the motion. Motion passed (7: 1: 0; Commissioner Kelleher voted no).

Case # SE051402 — This NJ DIRECT case concerned the denial of additional nutritional counseling visits. The plan allows three visits per year for nutritional counseling that is medically needed and at the appropriate level of care. Commissioner Gallagher made a motion to deny the appeal in accordance with plan limitations. Commissioner Jahn seconded the motion. All voted in favor.

Case # SE051403 — This NJ DIRECT appeal concerned the denial of benefits for expenses above the reasonable and customary allowance. Commissioner Peden made a motion to deny the appeal. Commissioner Jahn seconded the motion. All voted in favor.

Case # SE051404 — Final Administrative Determination (FAD)- Commissioner Kelleher made a motion to accept the FAD draft concerning the denial of approval of expenses for reading therapy. Commissioner Jahn seconded the motion. Motion passed (7: 0: 1; Commissioner DiMaso abstained)

Case # SE051405 — This NJ DIRECT case concerned a denial of expenses for bronchial thermoplasty for the treatment of asthma. The appeal had been denied by Horizon and by an Independent Review Organization (IRO) as experimental and investigational. Commissioner Jahn made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner DiMaso seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Kelleher made a motion to deny the appeal. Commissioner Steinhauer seconded the motion. Commissioner Kelleher amended the motion to deny the appeal and direct the Division to issue a FAD. Commissioner Gallagher seconded the amendment. All voted in favor.

Case # SE051406— This NJ DIRECT case concerned a denial of expenses for phrenic nerve grafting. The Appeal had been denied by Horizon and by an IRO as experimental and investigational. Commissioner Kelleher made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner Gallagher seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Kelleher made a motion to deny the appeal and direct the Division to draft a FAD. Commissioner DiMaso seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to return to Public Session. Commissioner DiMaso seconded the motion. All voted in favor.

Cases # SE051407, SE051408, SE051409, SE051410 – Commissioner Steinhauer made a motion to accept the settlement proposals as proposed. Commissioner Kelleher seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to adjourn. Commissioner Gallagher seconded the motion. All voted in favor. The School Employees’ Health Benefits Commission Meeting was adjourned at 12:05 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
School Employees’ Health Benefits Commission



School Employees’ Health Benefits Commission
Minutes, Meeting No 49
July 9, 2014

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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 31, 2014.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:10 AM, Wednesday, July 9, 2014.  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
Joseph Del Grosso, Commissioner (via telephone)
Thomas Gallagher, representing Commissioner Kenneth E Kobylowski, Department of Banking & Insurance (Appeal portion)
Carmen Gonzalez-Gannon, Commissioner
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner
Felix Schirripa, representing Commissioner Kenneth E Kobylowski, Department of Banking & Insurance (Rate Renewal portion)
Wendell Steinhauer, Commissioner
Robert Peden, Representing State Treasurer Andrew P. Sidamon-Eristoff
Serena DiMaso, Commissioner

Also present: 

Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
David Pointer, Assistant Director, NJ Public Employees’ Health Benefits Programs
Mark Cipriano, Division of Pensions and Benefits
Ed Fox, Aon Hewitt
Susan Marsh, Aon Hewitt
Jeffrey Chanin, Aon Hewitt
Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey

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

Issues

2015 Rate Renewal Reports-- Ed Fox, Aon-Hewitt Consulting, introduced Susan Marsh and Jeffrey Chanin. Mr. Fox gave an overview of the 2015 proposed rates. Mr. Chanin reviewed the 2015 Rate Renewal Recommendations for Medical/Rx for the School Employees’ Health Benefits Program (SHBP). The following is a summary of the presentation:

  • For Plan Year 2015, Aon Hewitt is recommending SEHBP overall premium rate changes of 10.3% for Active Employees, 9.3% for Early Retirees, and 6.8% for Medicare Retirees. In the aggregate, the recommended rate actions represent an overall increase for the SEHBP of 9.4%. Following are our recommended premium rate changes by plan type:

                                    Early              Medicare         Employees
                                    Retirees           Retirees                      
Medical PPO                     10.9%             8.5%              2.8%
Medical HMO                    10.7%            11.5%              6.0%
Prescription Drug PPO          5.3%            11.0%            10.0%
Prescription Drug HMO         5.3%            16.0%            15.0%
Total                              10.3%             9.3%              6.8%

  • This recommended Plan Year 2015 rate renewal assumes:
    • The Retiree Rx copays and Out-Of-Pocket Maximum limits for SEHBP PPOs and HMOs will increase based on formulas as specified by regulation (these changes are projected to decrease prescription drug costs by 1.6%);
    • No change in benefit landscape for Plan Year 2015, with Horizon and Aetna providing the PPO, HMO, and HDHP options and Express Scripts continuing as the SEHBP’s PBM;
    • SEHBP Medicare Prescription Drug Integration will continue as EGWP Plus Wrap;
    • Local Education employer groups experienced increases in employee contributions on July 1, 2014, as a result of Chapter 78. Therefore, we are projecting a small increase in the percentage of Employees enrolling in the lower-cost plan options for Plan Year 2015, although the actual numbers of Employees/Retirees enrolled are expected to remain very small percentages of overall SEHBP enrollment, with only 2% of Employees and 1% of Retirees enrolling in the new plans.
    • NJWELL is projected to increase Plan Year 2015 net costs $7 million, with savings anticipated for future years.
    • The New Jersey State Breast Evaluation and Other Medically-Necessary Testing mandate is projected to increase medical costs by 0.5%.
    • 2.0% decrease in projected prescription drug trends as a result of better pricing terms anticipated in the ESI contract extension.
    • Overall, Plan Year 2015 SEHBP Active Employee enrollment is projected to increase approximately 2% in Plan Year 2015, while Retiree enrollment is projected to increase approximately 5%.
    • The following components of Federal Health Care Reform impact the SHBP in Plan Year 2015:
      • In-Network Out-Of-Pocket Maximum – It is expected that the In-Network medical and prescription drugs will have a combined out-of-pocket maximum of $6,600 Single and $13,200 Family as allowed by Federal Health Care Reform. The impact of changing the maximum limits is expected to have an insignificant cost impact on the SEHBP.
      • The Transitional Reinsurance Fee ($44 per Non-Medicare member), assessed to employer group health plans such as the SEHBP to help stabilize the cost of individual and small-group coverage through the state health insurance exchanges that were implemented in 2014, is projected to add $13 million to the SEHBP plan costs for Plan Year 2015, and
      • The Comparative Effectiveness Fee estimated at $2.25 per member per year in Plan Year 2015 is projected to increase costs by $0.9 million.
  • The renewal report summarizes, in Exhibit 8, a number of possible benefit plan design changes, each of which could further reduce plan costs in Plan Year 2015 and beyond.
  • Differences in the rate changes among Actives and Retirees benefit plans and coverage tiers 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 2014 and 2015. The Medicare Retiree medical trend has been lowered from 5.0% to 4.5%. The low trend combined with favorable experience, results in very low medical premium increases for Plan Year 2015.
    • Rx trends are expected to increase to 10.5% for retirees and to 9.0% for active employees. The higher Rx trends assumptions are due to increasing frequency of high-cost compound drugs and new high-cost specialty drugs.
    • The Retiree HMO Rx recommended premium increases are greater than the PPO Rx recommended premium increases based on experience. The Retiree HMO Rx loss ratio is 27% higher than PPO Rx loss ratios. This is due to the Legacy HMO plan which has lower copays than the Legacy PPO plans and also lower premiums (typically richer plan designs have higher premiums).
    • New Federal regulations have reduced the projected 2014 and 2015 EGWP credits, although EGWP still provides significant savings with projected credits of $181 million for Plan Year 2015.
    • 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 is recommended to increase from 65% of the Single coverage rate to 75%. This will increase Plan Year premiums for Employee+Child(ren) coverage an additional 6% and Family coverage an additional 4%. (See Attachment A for premium increases by coverage tier). This adjustment will make the Employee + Child(ren) rate more consistent with actual experience, which shows that Child(ren) coverage claim costs are 87% of the cost of Employee coverage, an increase from the pre-Health Care Reform level of 72%.
  • Plan Year 2015 projected costs for the SEHBP are $2.83 billion ($1.76 billion for Actives and $1.07 billion for Retirees). Plan Year 2015 renewal premiums are projected to produce a $28 million gain for Actives and no loss or gain for Retirees.
  • The 12/31/15 Claim Stabilization Reserve level for Actives is projected at 1.1 months of projected Plan costs, well below the recommended level of 2.0 months, so the projected $28 million gain will help restore the Active reserve toward the target level.
  • Since the State is responsible for approximately 90% of Local Education Retiree claim payments, Plan Year 2015 premiums do not include any margin to rebuild Retiree reserve levels.

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

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

Case #SE071401 (member present)— Chairperson Earling made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner Jahn seconded the motion. All voted in favor.

This Horizon appeal concerned a denial of intravenous antibiotic treatment for Lyme Disease. The claim was denied by Horizon because medical necessity criteria were not met. The member subsequently appealed to an Independent Review Organization (IRO) and the denial was upheld because the IRO concluded that there was no objective evidence that the member suffered from Lyme Disease. Wendy Burns, Horizon Blue Cross Blue Shield of New Jersey, gave a summary of the IRO process.

Commissioner Steinhauer made a motion to go into Executive Session to see advice 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 postpone the Commission’s decision on the IRO report. Commissioner Kelleher seconded the motion. All voted in favor. Chairperson Earling requested that prior to the case being heard again, the member provide information from physicians that specifies how the member meets each of the criteria in the medical policy.

Commissioner Steinhauer made a motion to return to Public Session. Commissioner Kelleher seconded the motion. All voted in favor.

Cases # SE071402, SE021403, SE071404, SE071405 – Commissioner Steinhauer made a motion to accept the settlement proposals as proposed. Commissioner Kelleher seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to adjourn. Commissioner Gallagher seconded the motion. All voted in favor. The School Employees’ Health Benefits Commission Meeting was adjourned at 12:05 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
School Employees’ Health Benefits Commission


School Employees’ Health Benefits Commission
Minutes, Meeting No 50
July 17, 2014

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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 31, 2014.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:10 AM, Wednesday, July 17, 2014.

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)
Carmen Gonzalez-Gannon, Commissioner
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner
Felix Schirripa, representing Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Wendell Steinhauer, Commissioner
Robert Peden, Representing State Treasurer Andrew P. Sidamon-Eristoff
Serena DiMaso, Commissioner

Also present: 

Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
David Pointer, Assistant Director, NJ Public Employees’ Health Benefits Programs
Mark Cipriano, Division of Pensions and Benefits
Ed Fox, Aon Hewitt
Susan Marsh, Aon Hewitt
Jeffrey Chanin, Aon Hewitt
Dave Perry, Horizon Blue Cross Blue Shield of New Jersey

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

Issues

Local Employer Update—Acting Secretary Kierney Corliss distributed a year-to-date report of new and terminating SEHBP local employers. There were no questions or discussion.

2015 Rate Renewal Recommendations—Commissioner Kelleher made a motion to approve the rate renewal recommendations with the following modifications to retiree copayments:

 

PPO 10/15

HMO 10

PPO/HMO 1525

PPO/HMO 2030

Retail Generic

$10

$6

$7

$3

Retail Preferred Brand

$22

$14

$18

$20

Retail Non-Preferred Brand

$44

$27

$37

$50

Mail Generic

$5

$5

$5

$5

Mail Preferred Brand

$33

$20

$43

$38

Mail Non-Preferred Brand

$54

$32

$95

$99

Commissioner Steinhauer seconded the motion.

Commissioner Peden made a motion to go into Executive Session to seek advice from the Deputy Attorney General. Commissioner Jahn seconded the motion. All voted in favor.

Upon return from Executive Session, the Commission voted on the motion. Motion failed (4: 5: 0; Commissioners Schirripa, DiMaso, Peden, Jahn, and Earling voted no).

Commissioner Peden made a motion to accept the Rate Renewal Recommendations as proposed. Commissioner Jahn seconded the motion. Motion passed (5: 4: 0; Commissioners Del Grosso, Steinhauer, Kelleher, and Gonzalez-Gannon voted no). 

Case #SE071406— Commissioner Steinhauer made a motion to accept the settlement proposal as proposed. Commissioner DiMaso seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to have an update on the Commission’s regulations at the next meeting. Commissioner Kelleher seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to adjourn. Commissioner Schirripa seconded the motion. All voted in favor. The School Employees’ Health Benefits Commission Meeting was adjourned at 11:10 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
School Employees’ Health Benefits Commission

School Employees’ Health Benefits Commission
Minutes, Meeting No 51
September 24, 2014

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 2014 annual meeting schedule was mailed to the Secretary of State, Star Ledger and the Trenton Times on January 31, 2014.

The meeting of the School Employees’ Health Benefits Commission (Commission) was called to order at 10:15 AM, Wednesday, September 24, 2014.  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)
Carmen Gonzalez-Gannon, Commissioner
Kevin Kelleher, Commissioner
Cynthia Jahn, Commissioner (via telephone)
Thomas Gallagher, representing Commissioner Kenneth E Kobylowski, Department of Banking & Insurance
Wendell Steinhauer, Commissioner
Robert Peden, Representing State Treasurer Andrew P. Sidamon-Eristoff
Serena DiMaso, Commissioner

Also present: 

Danielle Schimmel, Deputy Attorney General
Kierney Corliss, Acting Secretary
Mark Cipriano, Division of Pensions and Benefits
Paul Anzano, Pringle, Quinn, and Anzano
Michael O’Connell, Pringle, Quinn and Anzano
Bart Gerber, Express Scripts
Chris Smith, Express Scripts
Katherine Impellizzeri, Aetna
Dr. Andrew Baskin, Medical Director, Aetna
Wendy Burns, Horizon
Donna Ruotola, Horizon

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

Minutes, Meeting No. 46, March 7, 2014: Commissioner Steinhauer made a motion to accept the minutes. Commissioner Gallagher seconded the motion. Motion passed (7: 0: 1, Commissioner DiMaso abstained)

Minutes, Meeting No. 47, March 26, 2014: Commissioner Steinhauer made a motion to accept the minutes. Commissioner Gallagher seconded the motion. Motion passed (7: 0: 1, Commissioner DiMaso abstained)

Commissioner Steinhauer made a motion to approve the agenda with flexibility. Commissioner Kelleher seconded the motion. All voted in favor.

Commissioner Gallagher made a motion to go into Closed Session. Commissioner Steinhauer seconded the motion. All voted in favor.

Case #SE091401— This Aetna appeal concerned the denial of expenses for a rowing machine and a recumbent cross-trainer. Dr. Andrew Baskin, Aetna, stated that the medical necessity of the equipment was not in dispute, however, the equipment does not meet the definition of Durable Medical Equipment and is not a covered benefit under the plan.

Commissioner Kelleher made a motion to go into Executive Session. Chairperson Earling seconded the motion. All voted in favor.

Upon return from Executive Session, Commissioner Gallagher made a motion to deny the appeal because the equipment does not meet the definition of Durable Medical Equipment. Commissioner Peden seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to return to Open Session. Commissioner Peden seconded the motion. All voted in favor.

Issues

Express Scripts Pharmacy Payments— Paul Anzano and Michael O’Connell from the law firm of Pringle, Quinn, and Anzano spoke on behalf of the Independent Pharmacy Alliance (IPA). Mr. Anzano stated that members of the IPA have noticed that it is taking longer to receive payments from Express Scripts.

Bart Gerber, Express Scripts, stated that the pharmacy in question contracts with a third party Pharmacy Services Administrative Organization (PSAO). Express Scripts sends the payment to the PSAO, and the PSAO in turn pays the pharmacy. Express Scripts reviewed a sample of claims and determined that they were in compliance with contractual terms that require them to make payment within an average of 30 days.

Chris Smith, outside counsel for Express Scripts, indicated that he has had no response to correspondence sent to the law firm of Pringle, Quinn, and Anzano. Mr. Anzano stated that Express Scripts had not advised him that outside counsel was retained.

Commissioner Steinhauer requested that both sides make another effort to resolve the issues between themselves and to have at least three meetings before returning to the Commission. Both sides agreed.

Commissioner Steinhauer made a motion to go into Closed Session to hear member appeals. Commissioner Kelleher seconded the motion. All voted in favor.

Case #SE091402— This Horizon appeal concerned a denial of expenses above the Reasonable and Customary allowance. The member had several procedures done by an out-of-network provider. Horizon had incorrectly advised the provider’s office that the initial procedure would be paid at 100%; as a result, the initial claim was reprocessed to be paid in full. Subsequent procedures were paid according to plan provisions. Commissioner Steinhauer made a motion to postpone the decision on this case until the next meeting pending information from Horizon regarding when the member received an Explanation of Benefits to notify him of his financial responsibility. Commissioner Kelleher seconded the motion. All voted in favor.

Case #SE091403— Commissioner Steinhauer made a motion to go into Executive Session to discuss ongoing litigation. Commissioner Gallagher seconded the motion. All voted in favor.

There was no futher discussion regarding this case upon return from Executive Session.

Case #SE091404— This Division appeal concerned the denial of coverage for an over-age disabled dependent. An application for continuance was not received by the Division prior to the deadline of January 31, 2014. Commissioner Gallagher made a motion to deny the appeal. Commissioner Peden seconded the motion. All voted in favor.

Case #SE091405— This Division appeal concerned the denial of coverage for an over-age disabled dependent. Coverage was denied because the dependent was married. Commissioner Kelleher made a motion to deny the appeal. Commissioner Steinhauer seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to return to Open Session. Commissioner Kelleher seconded the motion. All voted in favor.

Cases #SE091406 and #SE091407— Commissioner Steinhauer made a motion to accept the Final Administrative Determinations as presented. Commissioner Gallagher seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to go into Executive Session. Commissioner Kelleher seconded the motion. All voted in favor.

Cases #SE091408 and #SE091409— Upon return from Executive Session, Commissioner Gallagher made a motion to approve both Worker’s Compensation Settlements as proposed. Commissioner Kelleher seconded the motion. All voted in favor.

Chairperson Earling advised the Commission that he was resigning, effective immediately, due to a business conflict. Commissioner Steinhauer made a motion to acknowledge the great chairmanship of David Earling. Commissioner Peden seconded the motion. All voted in favor.

Commissioner Steinhauer made a motion to adjourn. Commissioner Peden seconded the motion. All voted in favor. The School Employees’ Health Benefits Commission Meeting was adjourned at 1:05 PM.

  Respectfully submitted,
 

 

 

  Kierney Corliss
Acting Secretary
School Employees’ Health Benefits Commission

 

 

 

 
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