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Health
Benefit Commission Meeting Minutes
The 449th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:10 AM Wednesday, January 11, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Caroline Ehrlich,
representing State Treasurer, John E. McCormac Frederick Beaver,
Director, Division of Pensions & Benefits 1. Minutes - Meeting No. 448. Brian Volz made a motion to accept the minutes and Richard Dougherty seconded the motion. Four voted in favor. Michael Malloy abstained.
The following
cases due to HIPPA regulations are seen in closed session, with
the motions and voting done in open session. Case # 010601: (Member present) This Division appeal concerns a request for assurance from the State Health Benefits Program (SHBP) that if their adult child should lose her present State Health Benefits Program coverage, she will be eligible for State Health Benefits coverage in the future since she is considered disabled. The adult child was covered as an overage disabled dependent. Since she is employed, has her own SHBP coverage and is not residing at home, the Division terminated her from her parent's coverage. Caroline Ehrlich made a motion to deny the appeal and uphold the termination of coverage. Michael Malloy seconded the motion. All voted in favor. Case # 010602: This Division appeal concerns a request for retired State Health Benefits Program coverage. Dudley Burdge made a motion to approve the appeal on an exception basis. Brian Volz seconded the motion. Three opposed. The motion fails. Caroline Ehrlich made a motion to deny the appeal. Michael Malloy seconded the motion. Three voted in favor. Two opposed. The motion carries. Case # 010603: (Member present) This $175 NJ PLUS appeal concerns a denial of continued occupational therapy services for the member's son. Caroline Ehrlich made a motion to deny the appeal. Richard Dougherty seconded the motion. Four voted in favor; Dudley Burdge opposed. The motion carries. Case # 010604: (Member present) This tabled $30,712.50 Traditional Plan appeal concerns the denial of benefits for expenses for speech therapy. Richard Dougherty made a motion to deny the appeal. Caroline Ehrlich seconded the motion. Four voted in favor; Dudley Burdge opposed. The motion carries. Case # 010605: The Commission voted to approve a draft of a Final Administrative Determination (FAD) for an appeal concerning the denial of orthodontic treatment, periodic oral exams and x-rays for a dependent child. At its meeting of December 20, 2005 the Commission determined that no issue of material fact exists and therefore, denied the request for an OAL hearing. Caroline Ehrlich made a motion to approve the FAD. Richard Dougherty seconded the motion. Four voted in favor and Dudley Burdge abstained. The motion carries. There being
no further business to transact, a motion to adjourn was made by
Caroline Ehrlich and seconded by Brian Volz. All voted in favor.
The State Health Benefits Commission meeting was adjourned at 11:34
AM. Jean M. Williamson The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:15 AM, Wednesday, February 8, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: Roll Call Robert Smartt,
representing Acting State Treasurer, Bradley I. Abelow Frederick Beaver,
Director, Division of Pensions & Benefits Issues The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. Brian Volz made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor. Case #020601 - This $550 Traditional Plan appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for surgery. Michael Malloy made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor. Case #020602 - (Member was represented by Marianne Farber and Dr. Jay Cohen) - This Aetna Plan appeal concerned a request for payment of in-patient mental health care for subscriber's dependent. Robert Smartt made a motion to deny the appeal and Michael Malloy seconded the motion. Three opposed the motion; it did not carry. Eric Richard made a motion to approve payment of the in-patient mental health care claims. Brian Volz seconded the motion. Three voted in favor (Eric Richard, Brian Volz and Richard Dougherty) and two opposed (Robert Smartt and Michael Malloy). The motion carried. Case #020603 - (Member was present) - This Aetna Dental Expense appeal concerned a denial of benefits for dental implants. Richard Dougherty made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor. Case #020604 - (Member was present) - This tabled Traditional Plan appeal concerned a denial of benefits for Viagra beyond four Viagra pills per month/twelve pills in a 90-day period for rehabilitative purposes. Richard Dougherty made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor. There being no further business to transact, a motion to adjourn was made by Richard Dougherty and seconded by Eric Richard. The State Health Benefits Commission meeting was adjourned at 11:45 am. Respectfully Submitted, Jean M. Williamson Meeting No. 451 The 451st meeting of the State Health Benefits Commission of New Jersey was called to order at 10:20 AM, Wednesday, March 8, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL David Ridolfino, representing State
Treasurer, Bradley I. Abelow Also present: Florence Sheppard, Deputy Director,
Division of Pensions & Benefits ISSUES 1. Minutes - Meeting No. 450. David Ridolfino made a motion to approve the Minutes and Richard Dougherty seconded the motion. All voted in favor. The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. David Ridolfino made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor. Case #030601: This Traditional Plan appeal concerns a denial of benefits for expenses for Viagra beyond four Viagra pills per month/twelve pills in a 90-day period. Richard Dougherty made a motion to deny this appeal. Motion seconded by David Ridolfino. All voted in favor. Case #030602: This Traditional Plan appeal concerns a denial of benefits for expenses for Viagra beyond four Viagra pills per month/twelve pills in a 90-day period. Richard Dougherty made a motion to deny this appeal. Motion seconded by David Ridolfino. All voted in favor. Case #030603: (Member was present) - This $982 Oxford appeal concerns a denial of benefits for expenses for an out-of-network provider treating a dependent child. David Ridolfino made a motion for the Commission to go into Executive Session to consult with counsel. Richard Dougherty seconded the motion. All voted in favor. Richard Dougherty made a motion to go back to Closed Session. Motion seconded by Michael Malloy. All voted in favor. Richard Dougherty made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor. Case #030604: (Member was present) - This NJ PLUS appeal concerns a denial of continued speech therapy services and a denial of pre-authorization for occupational therapy services for a dependent child. David Ridolfino made a motion for the Commission to go into Executive Session to consult with counsel. Richard Dougherty seconded the motion. All voted in favor. Motion made by David Ridolfino to go back into Closed Session. Motioned seconded by Richard Dougherty. All voted in favor. Richard Dougherty made a motion to deny this appeal. Motion seconded by David Ridolfino. Three voted in favor and one opposed. Richard Dougherty made a motion to expedite a Final Administrative Determination. Motion seconded by David Ridolfino . Three voted in favor and one abstained. Case #030605: The ALJ requested that the Commission reconsider additional information submitted by subscriber regarding a disabled dependent. Additional information was reviewed by Horizon's Medical Director and there were no significant changes. Richard Dougherty made a motion for the Commission to maintain denial of prior decision. Motion seconded by Michael Malloy. All voted in favor. There being no further business to transact, a motion to adjourn was made by Richard Dougherty and seconded by David Ridolfino. The State Health Benefits Commission meeting was adjourned at 12:45 am. Respectfully submitted, Jean M. Williamson Meeting No. 452 This special meeting of the State Health Benefits Commission of New Jersey was called to order at 3:00 PM, Wednesday, March 22, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Michael Malloy, representing Acting
Commissioner, Donald Bryan, Department of Banking and Insurance
(Via telephone) Also present: Florence Sheppard, Deputy Director,
Division of Pensions & Benefits ISSUES The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. Case #000001: This appellate case concerning private duty nursing services was remanded to the Commission. An overview of the options available was given by DAG David Dembe. Richard Dougherty made a motion to go into executive session to consult with counsel. Michael Malloy seconded the motion and all voted in favor. Richard Dougherty made a motion to return to closed session. Michael Malloy seconded the motion and all voted in favor. A motion was made by Richard Dougherty to pursue a settlement. Michael Malloy seconded the motion. All voted in favor. There being no further business to transact, a motion to adjourn was made by Richard Dougherty and seconded by Michael Malloy. The State Health Benefits Commission meeting was adjourned at 3:45 pm. Respectfully submitted, Jean M. Williamson Meeting No. 453 The 453rd meeting of the State Health Benefits Commission of New Jersey was called to order at 10:30 AM, Wednesday, April 12, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Joseph Reilly, representing State Treasurer,
Bradley I. Abelow Also present: Frederick Beaver, Director, Division
of Pensions and Benefits ISSUES 1. Minutes - Meeting No. 451: Richard Dougherty made a motion to approve the Minutes and Brian Volz seconded the motion. Four voted in favor and one abstained. 2. Minutes - Meeting No. 452: Richard Dougherty made a motion to approve the Minutes and Eric Richard seconded the motion. Three vote in favor and two abstained. 3. Aetna Medicare Advantage - Len Leto presented a proposal for a new plan which would be an option for retirees who are eligible for Medicare. Representatives from Aetna were also present. Joseph Reilly made a motion to approve the plan subject to the understanding that the rate would need to be approved. The motion was subsequently withdrawn. Gale Simon requested more time to review the proposal. Eric Richard wanted to wait to hear about the projected cost savings referenced in a memo from AON. In addition, the Commission would like to have a finalized rate for the plan. Richard Dougherty made a motion to review the proposal and Joseph Reilly seconded the motion. All voted in favor. Joseph Reilly made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor. The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. Case #040601: This $9,802.34 Traditional Plan appeal concerns a request for dental services to be considered eligible under the Traditional Plan. Richard Dougherty made a motion to deny this dental appeal. Gale Simon seconded the motion. Three voted in favor and two abstained. Case #040602: This $5,485 Traditional Plan appeal concerns a denial of benefits for expenses for a routine colonoscopy. Gale Simon made a motion to deny this appeal. Joseph Reilly seconded the motion. All voted in favor. Case #040603: This $8,785 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery. Richard Dougherty made a motion to deny this appeal. Joseph Reilly seconded the motion. All in favor. Case #040604: (Member was present) - This $1,400 Traditional Plan appeal concerns a denial of benefits for weight loss classes attended from October 18, 2004 through October 27, 2005. Joseph Reilly made a motion to deny this appeal based on the exclusion in the Traditional Handbook. Richard Dougherty seconded the motion. Four voted in favor and one recuse from the vote. Case #040605: (Member was represented by an attorney) This $8,755 Traditional Plan appeal concerns a denial for an ineligible mental health provider and the denial of benefits for expenses for mental health care above the mental health lifetime maximum. Gale Simon made a motion to pay up to the lifetime maximum, approximately $7,000. Brian Volz seconded the motion. Four voted in favor and one voted against. Case #040606: (Member was present) This Traditional Plan appeal concerns a denial of benefits for proposed Vagus Nerve Stimulation (VNS) for the treatment of depression. Joseph Reilly made a motion to deny this appeal because the procedure is considered investigational. Richard Dougherty seconded the motion. All voted in favor. Case #040607: The Commission agreed to refer case to OAL for decision. Gale Simon made a motion to send to OAL to determine apportionment of covered and noncovered care. Richard Dougherty seconded the motion. All voted in favor. Case #040608: The Commission approved a Final Administrative Determination concerning (a) continued speech therapy and (b) a pre-authorization for occupational therapy services for a dependent child. Joseph Reilly made a motion to approve the Final Administrative Determination. Richard Dougherty seconded the motion. All voted in favor. There being no further business to transact, a motion to adjourn was made by Gale Simon, seconded by Joseph Reilly and all voted in favor. The State Health Benefits Commission meeting was adjourned at 12:20 pm. Respectfully submitted, Jean M. Williamson Meeting No. 454 The 454th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:20 AM, Wednesday, May 10, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Joseph Reilly, representing State Treasurer, Bradley I. Abelow Also present: Frederick Beaver, Director, Division of Pensions & Benefits ISSUES 1. Minutes - Meeting No. 453: Joseph Reilly made a motion to approve the Minutes and Richard Dougherty seconded the motion. All voted in favor. Joseph Reilly made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor. The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. Case #050601: (Member was present) This $14,098.50 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery. Because of the unique injury and no recognized reasonable and customary data available, Gale Simon made a motion to treat the actual charges for the following three CPT Codes as reasonable and customary: CPT Codes 27766, 28445 and 28555; and that CPT Code 27766 be treated as primary. In addition, denial of payment of benefits is upheld for the following three CPT codes: CPT Code 27848-51 in the amount of $4,000, CPT Code 64708-51 in the amount of $4,400 and CPT Code 99283 in the amount of $275. Joseph Reilly seconded the motion. All voted in favor. Case #050602: (Member was present) This $591.20 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery. Dudley Burdge made a motion to approve this appeal. Gale Simon seconded the motion. All voted in favor. Case #050603: This $1,470 Traditional Plan appeal concerns a denial of benefits for electrolysis treatment, corrective acne treatment and treatment creams and lotions. Richard Dougherty made motion to deny this appeal. Joseph Reilly seconded the motion. All voted in favor. Case #050604: This NJ PLUS Plan appeal concerns a denial of benefits for hearing aids. Richard Dougherty made a motion to deny this appeal based on the fact that hearing aids are an excluded benefit as indicated in the NJ PLUS Handbook. Gail Simon seconded the motion. All voted in favor. Case #050605: The Commission received a request to forward appeal concerning weight loss classes to the Office of Administrative Law. Joseph Reilly made a motion to reject the request to have the appeal forwarded to the Office of Administrative Law. Richard Dougherty seconded the motion. All voted in favor. A final administrative determination will be drafted for review and approval at the June meeting. There being no further business to transact, a motion to adjourn was made by Richard Dougherty, seconded by Joseph Reilly and all voted in favor. The State Health Benefits Commission meeting was adjourned at 11:35 pm. Respectfully Submitted, Jean M. Williamson Meeting No. 455 The 455th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:13 AM, Wednesday, June 14, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Joseph Reilly, representing State Treasurer, Bradley I. Abelow Also Present: Frederick Beaver, Director, Division of Pensions & Benefits ISSUES
Richard Dougherty made a motion to go into Closed Session and Joseph Reilly seconded the motion. All voted in favor. The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. Case #060601 (Member was present): This $1,995.56 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for emergency room services. Michael Malloy made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor. Case #060602 (Member was present): This Division appeal concerns a request for retroactive health benefit coverage for claims for spouse who did not enroll in Medicare Part B. Joseph Reilly made a motion to go into Executive Session to consult with counsel. Richard Dougherty seconded the motion. All voted in favor. Upon returning the closed session, Joseph Reilly made a motion to table this appeal in order for member to obtain and provide medical documentation of his spouse’s diminished capacity. Member will provide medical documentation to the Social Security Administration for reconsideration of enrollment of his spouse in Medicare Part B. Once a determination is made by the Social Security Administration, the appeal will be brought back before the Commission. Richard Dougherty seconded the motion. All voted in favor. Case #06603 (Member was present): This $24,550 Traditional appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for emergency room services. Joseph Reilly made a motion to deny this appeal recognizing an adjustment of the amount that the Traditional plan will pay for a total of $12,269.00. Dudley Burge seconded the motion. All voted in favor. Case #060604 (Member was present): This NJ PLUS appeal is for the denial of benefits for expenses for In-Vitro Fertilization procedures performed for spouse beyond the three attempts limit. Joseph Reilly made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor. Case #060605: The Commission approved a Final Administrative Determination concerning the denial of payment for weight loss classes. Richard Dougherty made a motion to approve the Final Administrative Determination. Joseph Reilly seconded the motion. All voted in favor. Case #060606: The Commission agreed to forward this appeal for expenses for an out-of-network provider treating a dependent child. Joseph Reilly made a motion to send the appeal to the OAL for a hearing. Richard Dougherty seconded the motion. All voted in favor. Case #060607: This is a request for an OAL hearing on an appeal concerning Vagus Nerve Stimulation for the treatment of depression which is considered investigational. Joseph Reilly made a motion to do a Final Administrative Determination. Richard Dougherty seconded the motion. All voted in favor. Case #060608: The Deputy Attorney General representing this OAL case requested the Commission authorize a settlement offering in a case involving private duty nursing services. Richard Dougherty made a motion to authorize a settlement offering. Joseph Reilly seconded the motion. All voted in favor. Case #060609: The Commission approved a settlement proposal from Upper Freehold Regional Board of Education. Dudley Burge seconded the motion. All voted in favor. There being no further business to transact, a motion to adjourn was made by Richard Dougherty, seconded by Joseph Reilly and all voted in favor. The State Health Benefits Commission meeting was adjourned at 1:00 pm. Respectfully Submitted, Jean M. Williamson Meeting No. 456 The 456th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:05 AM, Wednesday, July 12, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Joseph Reilly, representing State Treasurer, Bradley I. Abelow Also present: Frederick Beaver, Director, Division of Pensions & Benefits ISSUES 1. Minutes – Meeting No. 455: Michael Malloy made a motion to approve the Minutes and Richard Dougherty seconded the motion. Three voted in favor, Eric Richard and Brian Volz abstained. The Commission approved the final adoption of NJAC 17:9-6.1 and 17:9-65.3. Joseph Reilly made a motion to approve the proposed amendment. Richard Dougherty seconded the motion. All voted in favor. Brian Volz made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor. The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. Case #070601: This $3,025.00 NJ PLUS appeal is for the denial of benefits for expenses for psychological testing services provided to a dependent child. Joseph Reilly made a motion to table this appeal pending additional information from the provider. Richard Dougherty seconded the motion. All voted in favor. Case #070602: This $2,918.40 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for emergency room services. Michael Malloy made a motion to deny this appeal. Joseph Reilly seconded the motion. All voted in favor. Case #070603: This $358.58 Traditional Plan appeal concerns a denial of benefits for a Hepatitis B Vaccine administered to a dialysis patient. Joseph Reilly made a motion to deny this appeal because vaccinations are not covered by the Traditional Plan. Richard Dougherty seconded the motion. Four voted in favor. Michael Malloy voted against. Case #070604: (Member was present) This $7,030.20 Traditional Plan appeal concerns a denial of benefits for an eight week weight loss program at Duke University Medical Center Diet and Fitness Center. Eric Richard made a motion to go into executive session. Joseph Reilly seconded the motion. All voted in favor. Richard Dougherty made motion to go back into Closed Session. Eric Richard seconded the motion. All voted in favor. Joseph Reilly made a motion to deny this appeal based on the facts presented in Horizon’s letter of May 11, 2006. Richard Dougherty seconded the motion. All voted in favor. Case #070605: This $3,787.00 Traditional Plan appeal concerns a denial of benefits for expenses for a routine colonoscopy. Richard Dougherty made a motion to deny this appeal because the Traditional Plan does not cover preventive care/routine screening services. Joseph Reilly seconded the motion. All voted in favor. Case #070606: This $9,000.00 Traditional Plan appeal concerns the denial of benefits for expenses for pre and post operative orthodontic treatment. Michael Malloy made a motion to deny this appeal. Joseph Reilly seconded the motion. All voted in favor. Case #060707: This $3,715.00 Traditional Plan appeal is for the denial of benefits for expenses for speech therapy. Michael Malloy made a motion to table this appeal because the member called late in the morning of the meeting indicating she could not be present until 1:00, after the meeting would end. Brian Volz seconded the motion. All voted in favor. Case #060708: The Commission approved a Final Administrative Determination concerning Vagus Nerve Stimulation for the treatment of depression. Joseph Reilly made a motion to approve the Final Administrative Determination with a change to include additional medical information. Richard Dougherty seconded the motion. All voted in favor. There being no further business to transact, a motion to adjourn was made by Joseph Reilly, seconded by Michael Malloy and all voted in favor. The State Health Benefits Commission meeting was adjourned at 11:10 am. Respectfully Submitted, Jean M. Williamson Meeting No. 457 The 457th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:15 AM, Wednesday, August 9, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Robert Smartt, representing State Treasurer, Bradley I. Abelow Also Present: Susanne Culliton, Deputy Attorney General ISSUES
Brian Volz made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor. The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. Case #080601: This $980 Traditional Plan appeal concerned a denial of benefits for expenses above the reasonable and customary allowance for emergency room services for a dependent child. Michael Malloy made a motion to deny this appeal. Richard Dougherty seconded the motion. All voted in favor. Case #080602: This $909 Traditional Plan appeal concerned a denial of benefits for expenses for a routine colonoscopy. Richard Dougherty made a motion to deny this appeal. Robert Smartt seconded the motion. All voted in favor. Case #080603 (Member present): This tabled $3,715 Traditional Plan appeal concerns a denial of benefits for speech therapy for a dependent child. Robert Smartt made a motion to grant this appeal. Brian Volz seconded the motion. Eric Richard voted in favor. Michael Malloy and Richard Dougherty voted no. Case #080604: This member requested authorization from HealthNet to allow a dependent child to visit an out-of-network provider. Michael Malloy made a motion to deny this appeal. Eric Richard seconded the motion. All voted in favor Case #080605: Member requested appeal be referred to OAL for a hearing. Michael Malloy made a motion to forward the case to the OAL. Richard Dougherty seconded the motion. All voted in favor. Eric Richard made a motion to go into Executive Session. Brian Volz seconded the motion. All voted in favor. Eric Richard made a motion for Susanne Cullition to obtain an AG opinion on whether the alternate designee is privy to the same documents as the designee. Susanne Culliton would check with the DAG office and provide an answer when meeting reconvene at 1:00 pm. Eric Richard made a motion to recess until 1:00 pm. Michael Malloy seconded the motion All voted in favor. At 1:00, Brian Volz made a motion to reconvene for the AON Rate Renewal presentation. Richard Dougherty seconded the motion and all voted in favor. Eric Richard made a motion to go into Executive Session for response to his question regarding . Brian Volz seconded the motion. Susanne Culliton indicated that the Rate Renewal Report is confidential until acted upon by the Commission. Brian Volz made a motion to go back into Open Public Session. Richard Dougherty seconded the motion. All in favor. AON Representatives Ed Fox and Susan Marsh presented Rate Renewals for 2007 to the Commission. The following is a summary of the Rate Renewals: Recommended Plan Year 2007 Rate Renewal for Active
Employees and Retirees of the State Group
Recommended Plan Year 2007 Rate Renewal for Active
Employees and Retirees of the Local Employer Group
Recommended Plan Year 2007 HMO Rate Renewal
Eric Richard made a motion to permit public testimony at the rate renewal meeting next week. He left it up to the Division to decide how many people could testify and for how long. Brian Volz seconded the motion, and all voted in favor. There being no further business to transact, a motion to adjourn was made by Robert Smartt, seconded by Richard Dougherty and all voted in favor. The State Health Benefits Commission meeting was adjourned at 3:40 pm. Respectfully Submitted,
Jean M. Williamson Meeting No. 458 The 458th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:05 AM, Tuesday, August 22, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Joseph Reilly, representing State Treasurer, Bradley I. Abelow Also Present: Susanne Culliton, Deputy Attorney General The meeting was an open session to hear comments from the public regarding rate renewals for 2007. Joseph Reilly gave an opening statement concerning some rules to follow. Janice Nelson gave an overview of the proposed rule changes, copayments and change to the out-of-pocket maximum for retirees in the Traditional plan and NJ PLUS. Eric Richard thanked the Administration for providing an opportunity for public comments to be presented. The following eighteen speakers made comments before the Commission:
Joseph Reilly asked if anyone else wished to make comments. There was no response. Joseph Reilly made a motion to adjourn, seconded by Richard Dougherty and all voted in favor. The State Health Benefits Commission meeting was adjourned at 1:30 pm. Respectfully Submitted, Jean M. Williamson Meeting No. 459 The 459th meeting of the State Health Benefits Commission of New Jersey was called to order at 2:15 PM, Tuesday, September 5, 2006. The meeting was held at the State House Annex, Committee Room 4, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Joseph Reilly, representing State Treasurer, Bradley I. Abelow Also Present: Susanne Culliton, Deputy Attorney General The special meeting was held in open session to vote on rate renewals.
Joseph Reilly made a motion to adjourn, Richard Dougherty seconded the motion and all voted in favor. The State Health Benefits Commission meeting was adjourned at 2:45 pm. Respectfully Submitted,
Jean M. Williamson Meeting No. 460 The 460th meeting of the State Health Benefits Commission of New Jersey was called to order at 10:20 AM, Wednesday, September 13, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: ROLL CALL Joseph Reilly, representing State Treasurer, Bradley I. Abelow Also present: Frederick Beaver, Director ISSUES
Joseph Reilly made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor. The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. Case #090601 (Member was present): This Aetna Dental Expense Plan appeal concerns a denial of benefits for replacement crowns in less than a five year period. Michael Malloy made a motion to deny this appeal and subsequently withdrew his motion. Richard Dougherty made a motion to table this case until additional information is provided. Dudley Burdge seconded the motion. Three voted in favor. Joseph Reilly and Brian Volz abstained. Case #090602: This tabled Division appeal concerns a request for retroactive health benefits coverage for claims for a member who did not enroll in Medicare Part B timely. Joseph Reilly made a motion to approve this appeal retroactive to May 1, 2006 for member due to proof of diminished capacity from a physician and the Social Security Administration’s retroactive enrollment of member. Richard Dougherty seconded the motion. All voted in favor. Case #090603 (Member present): This $3,715 Traditional Plan appeal concerns a denial of benefits for speech therapy for a dependent child. Joseph Reilly made a motion to go into Executive Session to consult with counsel in order to reconsider the decision of August 9, 2006. Brian Volz seconded the motion. Joseph Reilly made a motion to go back into Closed Session. Brian Volz seconded the motion. All voted in favor. Joseph Reilly made a motion to deny this appeal on the basis that speech therapy is not restorative and is not covered under the SHBP. Richard Dougherty seconded the motion. Four voted in favor and one opposed. Case #090604: Member requested that case concerning a denial of expenses for a Hepatitis B Vaccine be referred to the OAL for a hearing. Joseph Reilly made a motion to deny this request and to do a Final Administrative Determination. Richard Dougherty seconded the motion. All voted in favor. Case #090605: Member requested that case concerning pre and post operative orthodontic treatment be forwarded to the OAL for a hearing. Joseph Reilly Dougherty made a motion to deny this request and to do a Final Administrative Determination. Richard Dougherty seconded the motion. All voted in favor. There being no further business to transact, a motion to adjourn was made by Richard Dougherty, seconded by Joseph Reilly and all voted in favor. The State Health Benefits Commission meeting was adjourned at 12:45 pm. Respectfully Submitted, Jean M. Williamson Meeting No. 461 The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:30 AM, Wednesday, October 11, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: Roll Call Joseph Reilly, representing State Treasurer, Bradley I. Abelow Also present: Susanne Culliton, Deputy Attorney General Issues
Joseph Reilly made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor. The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in open session. Case #100601– (Member present) This $2,975 NJ PLUS appeal concerns a denial of benefits for expenses for physical therapy for child. Joseph Reilly made a motion to permit physical therapy for the child outside of the Botox injections with the caveat that physical therapy unrelated to Botox injections would continue to be subject to review by Horizon Blue Cross and Blue Shield to ensure that such physical therapy is not determined to be an exclusion under the maintenance and supportive care provision of the plan. Michael Malloy seconded the motion. All voted in favor. Case #100602 – This $3,438.10 Traditional Plan appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for emergency room services. Joseph Reilly made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor. Case #100603 – Joseph Reilly made a motion to issue a Final Administration Determination for denial of benefits for a Hepatitis B vaccine for spouse. Richard Dougherty seconded the motion. All voted in favor. Case #100604 – Joseph Reilly made a motion to approve the Final Administration Determination for denial of benefits for expenses for pre and post operative orthodontic treatment rendered to daughter. Richard Dougherty seconded the motion. All voted in favor. Case #100605 – Joseph Reilly made a motion for the Commission to accept Administrative Law Judge, Bruce M. Gorman’s decision. Richard Dougherty seconded the motion. Joseph Reilly, Michael Malloy and Richard Dougherty voted in favor. Dudley Burdge abstained and Brian Volz voted against the motion. There being no further business to transact, a motion to adjourn was made by Joseph Reilly, seconded by Richard Dougherty and all voted in favor. The State Health Benefits Commission meeting was adjourned at 12:45 pm. Respectfully Submitted, Jean M. Williamson Meeting No. 462 The meeting of the State Health Benefits Commission of New Jersey was called to order at 10:05 AM, Wednesday, December 13, 2006. The meeting was held at the Division of Pensions and Benefits, 50 West State Street, Trenton, New Jersey, and was attended by the following members of the Commission and Division staff: Roll Call Susanne Culliton, representing State Treasurer, Bradley I. Abelow Also present: Eileen Den Bleyker, Deputy Attorney General Issues
Brian Volz made a motion to go into Closed Session and Richard Dougherty seconded the motion. All voted in favor. The following cases due to HIPAA regulations are seen in closed session, with motions and voting done in closed session. Case #120601– (Member present) This Traditional Plan appeal concerns a denial of benefits for expenses for the prescription drug, Butorphanol (Stadol). Richard Dougherty made a motion to deny this appeal. Susanne Culliton seconded the motion. Four voted in favor. Michael Malloy abstained. Case #120602 – (Member present) This $8,600 Traditional Plan appeal concerns a denial of benefits for expenses for a surgical procedure performed that was considered investigational. Susanne Culliton made a motion to table this appeal until the February meeting. Brian Volz seconded the motion. All voted in favor. Case #120603 – This $8,777.20 NJ PLUS appeal concerns a denial of benefits for expenses above the reasonable and customary allowance for surgery. Michael Malloy made a motion to deny this appeal. Susanne Culliton seconded the motion. All voted in favor. Case #120604 – (Member Present) This tabled Aetna Dental Expense Plan appeal concerns a denial of benefits for replacement crowns in less than a five year period. Susanne Culliton made a motion to deny this appeal. Michael Malloy seconded the motion. All voted in favor. Case #120605 – Susanne Culliton made a motion to do a Final Administrative Determination (FAD) and deny the appeal be sent to OAL. Richard Dougherty seconded the motion. Four voted in favor. Dudley Burdge voted against. There being no further business to transact, a motion to adjourn was made by Richard Dougherty, seconded by Susanne Culliton and all voted in favor. The State Health Benefits Commission meeting was adjourned at 12:50 pm. Respectfully Submitted, Jean M. Williamson
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