Increase in Income Limits for Adult Caretaker Relatives, Reduction in Transitional Medicaid Duration, and HUSKY Cost Sharing

Increase in Income Limits for Adult Caretaker Relatives, Reduction in Transitional Medicaid Duration, and HUSKY Cost Sharing

Effective July 1, 2005, the bill increases the income limit for adult coverage in the HUSKY A program from 100% to 150% of the federal poverty level (FPL). HUSKY A (Medicaid) coverage is available to adults who are parents or caretaker relatives of children receiving HUSKY A. The income limit for the children is 185% of the FPL. The current FPL is $ 19,350 for a four-person household.

Under current law, families who lose eligibility for HUSKY A coverage due to employment or child support income are eligible for transitional Medicaid. The bill reduces from two years to one the time that these families can receive this assistance. Federal law requires states to provide one year of transitional Medicaid but allows states to provide an additional year. The bill specifies that only working parents whose income from employment makes them ineligible (i. e. , their income goes above the set limits) can get the transitional assistance.

Under the bill, a family already receiving transitional Medicaid on July 1, 2005 can receive the balance of such benefits, but they may not receive more than 12 additional months of assistance.

As a corollary, the bill repeals PA 05-1, which extends to June 30, 2005 transitional Medicaid for certain individuals with incomes between 100% and 150% of the FPL who lost their eligibility for this coverage on March 31, 2005.

The bill requires the Department of Social Services commissioner, to the extent permitted by federal law or waiver, to impose cost sharing requirements on parents and needy caretaker relatives receiving HUSKY (presumably HUSKY A since HUSKY B is for children only) with income over 100% of the FPL. The cost sharing includes (1) a $ 25 monthly premium and (2) $ 1 co-payment for outpatient medical services. Currently, there are no cost sharing requirements in HUSKY A. If DSS seeks a federal waiver, it must submit a copy of the waiver to the Appropriations and Human Services committees for review, which is required by law for most waiver requests.

The bill permits the commissioner to implement policies and procedures needed to administer the cost sharing while in the process of adopting regulations provided she publishes notice of intent to adopt the regulations in the Connecticut Law Journal within 20 days of implementing the changes. These policies and procedures remain valid until final regulations are adopted.

Federal Medicaid law limits the circumstances under which states may impose cost sharing requirements on Medicaid (HUSKY A is a subset of Medicaid in Connecticut) recipients without a waiver. For example, it allows states to impose premiums on people in the “medically needy” spend-down category, but it prohibits states from imposing premiums on people who are “categorically needy,” such as pregnant women, children, and certain families. Federal regulations also establish maximum cost sharing amounts. For example, a state cannot charge more than $ 1 for services costing between $ 10. 01 and $ 25. 00.

The bill continues the current freeze on cost of living increases for the Temporary Family Assistance (TFA) and the State-Administered General Assistance (SAGA) programs for FY 06 and FY 07.

DSS’s fraud early detection system currently applies to Medicaid, TFA, and the Food Stamp program. The bill specifically adds the child care subsidy program and allows the system to apply more broadly to programs administered by the department, including, but not limited to, those specified. The fraud early detection system identifies and investigates potential fraud in applications before the department grants assistance under these welfare programs.

It requires the DSS commissioner to make quarterly reports to the Appropriations and Human Services committees on the savings realized through the implementation of this program.

REDUCTION IN PHARMACY REIMBURSEMENTS AND APPLICATION OF DISPENSING FEE (§ 4)

The bill lowers what DSS pays pharmacies for prescription drugs for its clients in the Medicaid, SAGA, ConnPACE and Connecticut AIDS Drug Assistance Program by requiring the payment to be the lower of (1) the rate set by the federal Center for Medicare and Medicaid Services as the federal acquisition cost, (2) the average wholesale price (AWP) minus 14% (this is a reduction from the current AWP minus 12% set by regulation), or (3) an equivalent percentage as established under the State Medicaid Plan. Generic drugs are already subject to a different ‘maximum allowable cost” (MAC) reimbursement schedule based on federal upper limits.

This section eliminates payment of the usual ConnPACE and Medicaid pharmacy-dispensing fee when a Medicare Part D plan beneficiary obtains a Medicare Part D prescription drug.

The bill eliminates the DSS commissioner’s authority to rely on income information that HUSKY A and B applicants put on the program renewal application unless she has reason to believe it is inaccurate or incomplete.

The bill delays by six months the effective date for the second and third phases of higher minimum Medicaid rates for inpatient hospital care (target amount per discharge floors). The current target amount is $ 3,750. The $ 4,000 target amount is effective on October 1, 2006 instead of April 1, 2006. And the $ 4, 250 target amount is effective on October 1, 2007 instead of April 1 of that year.

HUSKY B provides subsidized, managed health insurance to children in families with incomes between 185% and 300% of the FPL. Families with incomes between 235% and 300% (Band 2) of the FPL currently pay $ 30 per month in premiums, as well as co-payments on most medical services, with an overall annual cost sharing cap of $ 1,250. Families with lower incomes (Band 1) pay no premiums, but they pay up to $ 650 annually in co-payments.

Current law permits the DSS commissioner to increase the maximum annual cost sharing caps, provided they do not exceed 5% of the family’s gross annual income, and it allows the commissioner to impose premiums on the lower income families. The bill requires the commissioner (1) beginning July 1, 2005, to increase the caps, (2) to impose premiums on families with incomes between 185% and 235% of the FPL, and (3) to increase the premiums for the Band 2 families.

The bill requires DSS to expedite Medicaid eligibility for pregnant women. DSS must ensure that it processes (1) emergency applications, as the commissioner determines, within 24 hours from when it receives all required information from the applicant and (2) all other applications no later than five calendar days after receiving the information.

The bill requires the commissioner to submit reports every two years to the Medicaid Managed Care Council on how it is complying with these deadlines.

Under current law, DSS must perform presumptive eligibility (PE), with an emphasis on pregnant women, in accordance with federal law. In practice, DSS has never implemented PE per se, as authorized by federal law. Instead, it implemented expedited eligibility for these women using standards different from the federal PE ones. Current regulations require DSS to grant PE in appropriate cases (with an emphasis on pregnant women) within one day from when it receives required minimum information (e. g. , proof of identity and citizenship status and income), and requires that the applicants get the required information to DSS within 30 days of applying.

RESTORING PRESUMPTIVE ELIGIBILITY FOR HUSKY A CHILDREN, CONTRACTS FOR SERVICES, CHANGING MANAGED CARE PLANS, AND TECHNICAL CHANGE (§ 9)

The bill requires the DSS commissioner to reinstitute PE for children applying for HUSKY A coverage. PE determinations must be made in accordance with applicable federal law. (In essence, PE enables children to start getting HUSKY A coverage while DSS is in the process of completing the eligibility determination. )

It requires DSS to adopt regulations to establish standards and procedures for designating organizations as “qualified entities” to grant PE. These entities must ensure that at the time they grant PE, a completed Medicaid application is submitted to DSS for a full eligibility determination. In adopting the standards and procedures, DSS must ensure representation of statewide and local organizations that provide services to children.

PA 03-3, June 30 Special Session, eliminated PE for HUSKY A children. Until then, DSS used qualified entities to make PE determinations, using the same requirements as those required in the bill.

By law, DSS must contract with an entity to be a single point of entry “servicer” for HUSKY A and B applicants and enrollees. In addition to providing enrollment assistance, the servicer must do outreach and provide public information about these programs. DSS currently contracts with ACS, Inc.

The bill requires DSS, when its existing contract expires, to develop one or more new contracts for single point of entry services and managed care enrollment brokering. It also allows it to enter into more than one contract, the duration of which cannot exceed seven years. The ACS contract, in place since 1995, expired in December 2004. It has never been formally re-bid.

Any future contract must include performance measures, including (1) time limits for processing applications, (2) parameters establishing requirements for completed and “reviewable” applications, and (3) the percentage of applications forwarded to DSS in a complete and timely fashion. The contracts must also include a process for identifying and correcting noncompliance with performance measures, including sanctions when continued noncompliance occurs.

The bill requires HUSKY A and B beneficiaries to remain enrolled in a managed care plan for 12 months before they can switch to another plan, unless (1) they can demonstrate good cause for switching sooner or (2) the beneficiary no longer mets the program’s eligibility requirements. Under current DSS regulations, HUSKY B enrollees may only switch plans once a year. HUSKY A enrollees can switch more often.

The bill repeals language that requires the services and cost sharing requirements in HUSKY B to be substantially similar to those offered by the largest commercially available health plan offered by a managed care organization to state residents.

Starting April 1, 2007, this bill increases the amount of assets that people in the state-funded side of the Connecticut Home Care Program for Elders (CHCPE) can keep and still be eligible for the program. It does this by tying these limits, respectively, to 150% and 200% of the federally required minimum community spouse protected amount (CSPA) of assets for people entering nursing homes on Medicaid ($ 19,020 for 2005). Currently, these asset limits are 100% of CSPA ($ 19,020) for a single person and 150% for a couple ($ 28,530). For 2005, 150% is $ 28,530 for single people and $ 38,040 for married couples. The federal government adjusts these CSPAs annually for inflation, so it will likely be higher by 2007, when the change takes effect.

The CSPA is the federally set asset amount that a Medicaid-eligible nursing home resident's spouse living in the community can keep. A single person who enters a nursing home and becomes eligible for Medicaid can only keep assets of $ 1,600. But federal and state law allow a spouse still living in community to keep a assets up to the CSPA for his or her own needs. To calculate the protected amount, the couple must go through a “community spousal assessment. ” DSS adds up the couple’s assets (excluding the house and a number of other exclusions) and divides them by two. The CSPA is equal to the spouse’s share up to a maximum of $ 95,100 or a minimum of $ 19,020.

The CHCPE provides home- and community-based care to seniors age 65 and over who would otherwise be at risk of going to a nursing home, meet certain financial requirements, and have incomes too high for regular Medicaid in the community.

• Under the state-funded portion, there is currently no specific income limit; asset limits are $ 19,020 for an individual and $ 28,530 for a couple, regardless of whether one or both are receiving services.

• For the Medicaid-funded portion, the income limit is currently $ 1,737 a month for the individual who receives the services. Assets are limited to $ 1,600 per individual, $ 3,200 per couple if both receive services, and $ 20,620 per couple if only one receives services (the patient’s $ 1,600 plus the $ 19,020 CSPA). These limits can be higher for the Medicaid side if the couple undergoes a “community spousal assessment” as they would when one of them enters a nursing home.

SAGA PILOT PROGRAM FOR YOUNG ADULTS WITH MENTAL DISORDERS AND CHRONIC HEALTH CONDITIONS (§ 11)

The bill requires the DSS commissioner to develop and implement a two-year pilot program for up to 100 people who (1) are age 19 to 21, (2) live with a parent or relative caregiver, (3) have been diagnosed with one or more mental disorders as defined in the most recent edition of the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders (DSM), (4) have a chronic health condition, (5) have a substantial functional impairment as a result of the mental disorder or chronic health condition, and (6) are ineligible for SAGA because their parents’ or relative caregiver’s income is too high.

For the pilot, “mental disorder” does not include mental retardation, learning disorders, motor skill disorders, communication disorders, caffeine related disorders, relational problems, and other conditions that may be a focus of clinical attention that are not otherwise defined as mental disorders in the DSM’s most recent edition.

The bill requires an individual who is eligible for benefits under this pilot program to cooperate in establishing eligibility for Medicaid based on disability.

EXTENDED SUNSET FOR RESIDENTIAL ENERGY CONSERVATION SERVICES PROGRAM (§ 12)

The bill extends the sunset date for the Office of Policy and Management’s (OPM) residential energy conservation program from July 1, 2005 to July 1, 2010.

The bill requires the DSS commissioner or the managed care organization or other entity performing administrative functions for the State-Administered General Assistance (SAGA) to require prior authorization for drug coverage of treatment of erectile dysfunction (presumably in SAGA medical assistance recipients). And it allows them to limit or exclude coverage for these drugs for convicted sex offenders who are required by law to register with the commissioner of public safety.

The bill adds to the list of non-covered drugs and drug products in the ConnPACE program drugs for the treatment of erectile dysfunction for these offenders.

And the bill requires the commissioner, to the extent permitted by federal law, to require prior authorization for Medicaid coverage of these drugs. She may limit or deny coverage for sex offenders or exclude the drugs altogether from coverage for such sex offenders.

Since 1998, federal regulations have required states to provide erectile dysfunction treatments under Medicaid when they are “medically necessary,” without any other distinctions as to who could or could not get the treatment. But recently, the federal Medicaid agency ordered state agencies to take measures to limit payments in these circumstances.

PRIOR AUTHORIZATION (PA) FOR PRESCRIPTION DRUGS IN DSS DRUG ASSISTANCE PROGRAMS AND DESIGNATION OF SPECIFIC DRUG SUPPLIERS (§ 16-17)

The bill changes the duration of PA in DSS’ drug assistance programs. By law, DSS must generally require PA for brand name drugs when a chemically-equivalent substitute is available and for early refills of drugs covered by its drug assistance programs. Under current law, PA is not required for other than the initial prescription for the drug. The PA plan, which DSS developed to carry out PA, applies a more narrow interpretation. It essentially says that PA lasts for the lifetime of the therapy unless another chemically equivalent generic is subsequently approved by the Food and Drug Administration. For non-maintenance drugs, PA is required every six months. Prescriptions for a less than 15-day supply are never subject to PA.

The bill specifies that PA for a brand name drug is valid for one year from the date the prescription is first filled.

The bill also eliminates DSS authority to require PA for drugs costing $ 500 or more for a 30-day supply.

The bill also allows the DSS commissioner to designate specific suppliers of a prescription drug from which a dispensing pharmacy must order the prescription and the supplier bill Medicaid. Currently, the commissioner, to increase cost efficiency or enhance access to a particular drug, must establish a plan under which she can designate such suppliers. She has apparently already developed the plan.

And it requires that any revisions to DSS’ prior authorization plan, the plan for specific suppliers, and the schedule for maximum quantities of oral dosage units under the Medicaid and SAGA medical assistance programs (already permitted by law) made on and after July 1, 2005 are subject to legislative committee review.

Effective Date: Upon passage for the plan changes and July 1, 2005 for implementation of the duration of PA.

The bill allows, rather than requires, DSS to establish preferred drug lists for Medicaid, ConnPACE, and SAGA in consultation with the Medicaid Pharmaceutical and Therapeutics Committee. It specifies that the committee must contain physicians with experience serving recipients of medical assistance, instead of just the Medicaid program. It also removes the word “Medicaid” from the committee’s name to be consistent with its broader responsibilities.

Prescriptions for drugs not on the lists will need prior authorization except for mental health-related and antiretroviral drugs. The law continues to require DSS, after entering into a contract with an entity to provide drug coverage for managed care medical assistance recipients, to expand the preferred drug list for use in the HUSKY A and B programs.

Current law requires DSS, by June 30, 2005, in consultation with the committee, to expand the drug lists to include other classes of drugs (except mental health-related and antiretroviral drugs) in order to achieve savings reflected in DSS’ FY 2005 appropriations for the various program components. .

The bill specifies that nonpreferred drugs in the classes of drugs included on the preferred drug lists must be subject to prior authorization. It makes prior authorization for a drug not on the preferred drug list, if granted, valid for one year from the date the prescription is first filled.

Current law makes mental health-related drugs and antiretroviral drugs exempt from prior authorization and not to be included on the preferred drug lists. The bill specifies that this exemption applies to classes of antiretroviral drugs.

It specifies that DSS may negotiate supplemental rebate agreements with the manufacturers in addition to the rebates required under Medicaid.

The permanent federal Medicare Part D program, which begins January 2006, allows Medicare beneficiaries to voluntarily enroll in Medicare-approved private prescription plans. The plans must provide at least a specified “standard” package of benefits to all Medicare beneficiaries. The standard benefits (for people who are not on ConnPACE or dually eligible for Medicare and Medicaid) consist of at least: (1) 75% coverage of prescription costs up to $ 2,250 with a $ 250 annual deductible; (2) no coverage beyond the $ 2,250 threshold until the beneficiary has spent a total of $ 3,600 in out-of-pocket costs ($ 5,100 in total consumer and Medicare expenditures), known as the “gap in standard coverage” or, informally “the donut hole; ” and (3) “catastrophic coverage” of 95% of all prescription costs above $ 5,100 (the beneficiary pays the greater of 5% of the cost per prescription or $ 2 for generic or preferred drugs and $ 5 for others). The plans may charge a monthly premium that can vary, but is expected to be about $ 37.

Under the federal law, Medicare beneficiaries with low incomes and assets and those who are Medicare-Medicaid dually eligible will receive varying additional subsidies which involve lower deductibles and premiums or none at all, lower copays, and coverage for the “donut hole. ”

Not all prescription drugs are covered, only those designated as “Medicare Part D covered drugs. ” In addition, the private plans can choose which of the Part D covered drugs they will offer on their formularies. Under a federal exception process, people can appeal the plan’s decisions and, if they win, the drugs in question can be treated and paid for as though they were on the formulary.

This bill responds to the federal legislation by modifying state law concerning (1) the Connecticut Pharmaceutical Contract to the Elderly and Disabled (ConnPACE) program and (2) Medicaid prescription coverage for people who are fully eligible for both the Medicare and Medicaid programs (the “dually eligible”). It also makes related changes for Department of Mental Retardation and Department of Mental Health and Addiction Services clients.

The bill coordinates the Medicare Part D benefits with the state’s ConnPACE program so that no ConnPACE beneficiaries will pay more than the current $ 16. 25 per-prescription copayment and the $ 30 annual registration fee for drugs that are (1) preferred drugs on their Part D prescription plan’s formulary or (2) not designated a Part D covered drug. Beneficiaries may pay less than the $ 16. 25 copay if the required Part D copays are lower. When a drug is a Medicare-covered drug but is not a preferred drug on the particular plan’s formulary, the bill allows DSS to pay for it at the lower of several alternative prices and makes the client responsible for paying the difference and the usual ConnPACE copay. DSS generally pays nothing for Part D covered drugs that are not on a plan’s formulary, but under the federal exception procedure, if the client or DSS appeals and wins, drugs not on the formulary could be treated and paid for as though they were on it.

Under the bill, DSS pays the Medicare Part D plan monthly premiums for ConnPACE recipients who are subject to them. It will cover drugs to the same extent as otherwise during the federal deductible period and the gap (“donut hole”) in the standard Medicare Part D plan.

The bill requires ConnPACE participants to (1) enroll in one of the Medicare Part D plans as a condition of receiving ConnPACE benefits; (2) disclose their income and assets to DSS as a means of determining whether they are eligible for federal low-income subsidies; and (3) appoint the DSS commissioner as their authorized representative, who can place them in a plan if they do not choose one in a timely manner.

Under the federal law, Medicare-Medicaid dually eligible beneficiaries will no longer receive their prescription coverage through Medicaid for drugs designated as “Medicare Part D covered drugs. ” Federal law allows them to choose a Medicare Part D plan and provides them with varying levels of extra subsidies compared to the “standard” Part D plan.

The bill makes separate provision for these “dually eligibles. ” They will no longer receive Medicaid benefits for drugs that could be covered under Medicare Part D, even if these covered drugs are not on the chosen plan’s formulary. For the drugs that are on their plan’s formulary, they will have to pay the new federal copays for this specific group, varying from $ 1 to $ 5 depending on their income and the type of drug (generic/preferred or other). Currently, there are no prescription copays under Medicaid in Connecticut. But this group will still receive Medicaid coverage for drugs that are not covered by Part D.

Medicaid Coverage Eliminated For Part D Drugs; Continued For Non-Part D Drugs (§ 19)

Under this section, Medicaid will no longer cover prescription drugs that could be covered under Medicare Part D for Medicaid recipients who are also eligible for Part D coverage, starting when that program begins. It specifies that Medicaid coverage will be provided for prescription drugs that are not Medicare Part D drugs as defined in the new federal law.

The federal law and regulations define “Medicare covered Part D drug” as a prescription drug, a biological product, insulin and related medical supplies, or vaccines, if they are used for a medically accepted indication. It excludes drugs available under Medicare Part A (hospital) or Part B (which has very limited outpatient coverage for a few items such as chemotherapy) and certain drugs such as over-the counter drugs, which may be excluded from or restricted under Medicaid coverage. (42 CFR 423. 100. FR 1/28/05, p. 4534)

The bill defines “assets” as meaning a person’s resources as defined in the federal Medicare Part D law.

It defines “low-income subsidy” as a premium and cost-sharing subsidy for low-income people as defined in the Medicare Part D law.

It defines “Medicare Part D covered prescription drugs” as drugs that are included in the Medicare Part D plan’s formulary or are treated as being included in such a formulary, as defined in the federal law.

It defines “Medicare Part D plan” as such a plan as defined in the federal law.

It defines “gap in standard Medicare Part D coverage” as a drug obtained after a Medicare Part D beneficiary exceeds the initial coverage limit but before he meets the annual out-of-pocket threshold as defined in the federal law (the “donut hole”).

The bill generally continues the current ConnPACE required maximum copayment of $ 16. 25 per prescription, but subjects replacement prescriptions to the copay.

The bill specifies that ConnPACE income limits apply to current annual income at the time of application or redetermination. The federal Medicare Part D program requires eligibility to be determined according to current income information. Currently, applicants can use their prior year income or, if that does not qualify them for the program, their current year income. The bill also specifically allows people who have Medicare Part D coverage to participate in ConnPACE and deletes obsolete language (§ 22(a)).

Generally, ConnPACE does not pay for a prescription if other insurance or assistance is available at the time of dispensing. The bill makes an exception for the Part D program and requires the pharmacy to make reasonable efforts to ascertain whether the customer has Medicare Part D benefits (§ 22(b)(1)).

The bill makes a Part D beneficiary responsible for paying Part D copayments, coinsurance, and deductible requirements for Part D covered prescription drugs, to the extent they do not exceed the ConnPACE copayment requirements. It also requires DSS to pay Medicare Part D monthly premiums for the beneficiary. If the Part D beneficiary’s out-of-pocket copayment, coinsurance, or deductible requirements are more than the ConnPACE copayment requirements, the bill requires DSS to pay the pharmacy to cover costs above the ConnPACE copayment amount. It makes DSS responsible for payment of a Medicare Part D covered drug obtained during the gap in the standard coverage.

To the extent allowed by federal law, the bill allows DSS to pay for the prescription at (1) the lowest price established by the Part D plan for a preferred drug in the same therapeutic class and category that is dispensed by a preferred pharmacy, with the beneficiary responsible for paying the cost differential beyond DSS’s payment; (2) the lower of the price that would be paid under ConnPACE or the negotiated price established by the plan; or (3) in consultation with the Office of Policy and Management secretary, at the price that ConnPACE would pay. DSS generally pays nothing for Part D covered drugs that are not on the plan’s formulary or treated as being on the formulary. But for prescription drugs that are not “Medicare Part D covered drugs,” the bill requires DSS to pay under the ConnPACE program and makes the client responsible only for the usual $ 16. 25 ConnPACE copay (§ 22(b)(2)).

The bill eliminates the current exemption from the ConnPACE copayment for replacement prescriptions (§ 22(b)(3)).

The bill makes the law concerning the temporary two-year Medicare drug discount cards effective only until the new Medicare Part D program begins (§ 22(d)).

It requires people eligible for the Medicare Part D program to enroll in it as a condition of eligibility for ConnPACE. It requires ConnPACE to cover the financial costs of Part D participation for ConnPACE recipients in accordance with this bill. In addition, starting July 1, 2005, a ConnPACE applicant or recipient must, as a condition of eligibility, provide information about his assets and income (and his spouse’s if they live in the same household), as DSS requires to determine the extent of federal benefits for which they may be eligible under Medicare Part D (§ 22(e)).

The bill also requires a ConnPACE applicant or recipient, as a condition of eligibility, to appoint the DSS commissioner as his authorized representative for the purpose of applying to the Social Security Administration to obtain the Part D low-income subsidy. It allows the commissioner, as the authorized representative for this purpose, to sign required forms and enroll the ConnPACE applicant or recipient in a Medicare Part D plan.

The commissioner must give the individual an opportunity to choose a plan and must notify him of this opportunity. If the person does not choose a plan within a reasonable time, as determined by the commissioner, DSS must enroll him in a plan the commissioner designates. The bill also requires the applicant or recipient to appoint the commissioner as his authorized representative for the purpose of appealing any denial of Medicare Part B benefits and for any other purpose the federal law allows if the commissioner deems it necessary (§ 22(f)).

DMR and DMHAS Commissioners as Authorized Representatives for Their Clients (§§ 28-29)

The bill allows the Department of Mental Retardation (DMR) and Department of Mental Health and Addiction Services (DMHAS) to be their clients’ authorized representatives for the purpose of applying to the Social Security Administration to obtain the Medicare Part D low income subsidy for their clients, for appealing Medicare Part D denials, and for other purposes related to that law the commissioners consider necessary. The bill gives these clients an opportunity to choose a plan and if they do not, requires the departments to enroll them in a plan the respective commissioner designates.

The bill requires the DSS commissioner to submit an interim status report by January 1, 2007 on the implementation of the new Medicare Part D program to the Public Health, Human Services, and Appropriations committees.

MANDATORY ENROLLMENT IN DEPARTMENT OF MENTAL RETARDATION MEDICAID WAIVERS (§ 31)

The bill requires anyone receiving or applying for residential placement through the DMR or receiving service or support from it to enroll in Medicaid and the department’s Medicaid waiver programs, if they meet Medicaid eligibility criteria. It makes enrollment a condition for continuing an individual’s placement, support, or services and eligibility for placement. It allows the DMR commissioner to provide services, within available appropriations, for individuals who are ineligible for Medicaid or a waiver program but who must receive services under state or federal law or a court order.

The bill applies to people (1) currently living in a DMR residential placement (e. g. , Southbury Training School, a regional center, or a community living arrangement) and those seeking placement and (2) receiving any DMR support or service included in or covered by any federal program administered and operated by DMR and DSS (e. g. , Medicaid).

Under the bill, anyone whose excess income or assets make him ineligible for Medicaid can remain in his placement or continue to receive DMR supports and services while “spending down” that income and assets until he qualifies.

The bill requires the DMHAS commissioner to provide for up to 500 additional units of affordable, supportive housing for people with mental illness. These units are a second, “Next Steps,” phase of the Supportive Housing Initiative. The first phase, the Supportive Housing Pilots Initiative, was instituted in 2001 to create 650 units.

Like the pilot initiative, the Next Steps Initiative is funded through mortgages, tax credits, and grants from the Connecticut Housing Finance Authority (CHFA) and the Department of Economic and Community Development (DECD); DSS rent subsidies; and grants from various state agencies for support services. The bill permits the state to pay debt service on tax-exempt bonds CHFA issues for the program.

1. people or families affected by psychiatric disabilities, chemical dependency, or both who are homeless or at risk of homelessness (including people living on the streets or in shelters or unsafe, abusive, or overcrowded environments; paying more than 50% of their income for rent; leaving homeless programs or transitional housing with no permanent housing; or needing supportive services to maintain permanent housing);

2. families who are eligible for temporary family assistance;

3. 18- to 23-year olds who are homeless or at risk of homelessness because they are transitioning out of foster care or other residential programs; and

4. community-supervised offenders with serious mental health needs who are under the jurisdiction of the Judicial Branch or the Correction Department.

All of the units developed under the bill must be permanent and can house individuals and families with or without special needs.

The bill requires the DMHAS commissioner and OPM secretary to enter into an MOU with the department of Children and Families (DCF), DSS, and DECD, and CHFA by October 1, 2005. That memorandum must provide for:

1. submission of a collaborative plan and timetables for creating up to 500 supported units;

2. an option for DSS to provide subsidies, including project-based rent subsidies during the term of any mortgage;

3. CHFA and DECD to offer viable financing through grants, mortgages, or tax credits, including capitalized operating reserves;

4. the treasurer and OPM secretary’s ability to enter into an agreement, after January 1, 2006, to pay debt service on any tax-exempt bonds CHFA issues for the units;

5. DMHAS, DSS, and DCF to provide annual grants for supportive services during the term of any mortgage; and

6. a plan for private and federal predevelopment financing and for grants and loans from nonstate sources generated by federal and state tax credits and federal project-based rent subsidies.

The bill requires CHFA, by January 1, 2006, to issue a request for proposals for participation in the initiative. It also requires CHFA to review and underwrite projects developed under both the pilot and Next Steps initiatives.

The bill permits the treasurer and OPM secretary, on behalf of the state, to contract with CHFA to pay principal and interest and reasonable operating and replacement reserves on CHFA mortgages issued under both phases of the Supportive Housing Initiative. The contract must contain provisions they find (1) needed to assure the initiative is put into effect, (2) appropriate for repaying the state when CHFA receives mortgage payments from federal or other sources, and (3) in the state’s best interests by allowing direct payment to the bond trustee or paying agent.

The bill makes any contract provision for the state’s paying an amount equal to the annual debt service a state contract with bondholders, appropriates all amounts needed to pay promptly, and requires the treasurer to make payments when due. It allows CHFA to pledge the state’s payment as security for the bonds. And it allows CHFA to issue refunding bonds at any time.

The bill allows the DSS commissioner to set aside some of its rent assistance certificates for tenant- and project-based supportive housing units. Tenant-based certificates go to individuals who secure private housing; project-based certificates go to property owners who participate in government housing development programs. The bill requires, to the extent practicable, that the tenant’s share of rent under a certificate for supportive housing be calculated based on federal Housing Choice Voucher Program regulations. These call for a tenant to pay 30% of the family’s adjusted monthly income for a unit that rents for up to the fair market price set by the Department of Housing and Urban Development.

The bill adds DCF and DSS to the list of agencies (DMHAS, DECD, CHFA) that must submit an interim status report to various legislative committees on the Supportive Housing Initiative and extends the deadline for this report to January 1, 2006. It also extends the deadline for the final report by one year to January 1, 2007.

The bill requires DMR to contract, within available resources, for a unit cost study for its Birth-to-Three program. The study must look at operating costs for those services for which the state contracts, including salaries, benefits, contract costs, administrative support, rent, vehicles and equipment, travel, materials and supplies, utilities, insurance, and training. DMR’s contract for the study must permit current service providers to provide input. The commissioner must report to the governor and the Appropriations and Public Health committees by January 1, 2006.

The bill requires the Insurance and Real Estate Committee to study the possible implementation of a “Nutmeg Health Partnership Insurance Plan,” a joint public-private initiative. The committee must study ways, and develop a plan, to (1) increase the number of residents with health insurance, (2) provide broader health care access, and (3) make health care more affordable. By February 1, 2006, the committee must submit a report to the General Assembly that details the plan and considers legislation to implement it.

The bill approves the settlement agreement reached in Emily J. v Rell, a class action that involves the state’s provision of mental health services to children in detention. The law requires the attorney general to submit agreements that call for spending $ 2. 5 million or more for approval by the General Assembly. The attorney general submitted the Emily J agreement to the General Assembly on June 7, 2005. It calls for DCF and the Judicial Department to provide a variety of services to class members, including therapeutic foster care, substance abuse treatment, group home placement, multisystemic therapy, therapeutic mentors, and staff training.

The bill continues the current freeze on benefits for the State Supplement Program for FYs 06 and 07.

By law, DSS, within available appropriations, must provide security deposit guarantees of up to two months’ rent, and can also offer a limited number of security deposit grants, to people residing in emergency shelters or other emergency housing, as well as to people who cannot remain in permanent housing due to circumstances beyond their control. Currently, people can receive subsequent guarantees without DSS’ approval if they are requested or provided at least 18 months after the guarantee. The bill permits the DSS commissioner to deny eligibility for the program to an applicant who has made more than two claims in a five-year period.

By law, the commissioner can establish priorities for giving out guarantees or deposits. The bill specifies that the purpose for such prioritization is to keep the program within the available appropriation.

By law, the DSS commissioner must impose a penalty period (period of Medicaid ineligibility) on a person who transfers assets for less than fair market value within 36 months of applying for long-term care Medicaid in order to qualify for such assistance. The bill restores, with minor revisions, a provision that permits the commissioner to waive the penalty period when the person transferring the asset (1) suffers from dementia when she applies for Medicaid and cannot explain such transfers, (2) suffered from dementia at the time of the transfer, or (3) was exploited into making the transfer due to dementia. This waiver authority was eliminated in sHB 6688, passed by both chambers.

By law, when such transfers occur and result in a penalty period, they create a debt that either the person transferring the asset or the person receiving it must pay. The bill specifies that the above transfers will still be subject to the debt creation even though they do not result in a penalty period.

The bill adds an exception to the current nursing home certificate of need (CON) moratorium for a request for up to 20 beds associated with a freestanding hospice facility for the terminally ill operated by an organization that the Department of Public Health previously authorized to provide hospice services.

The bill requires the DSS commissioner, by January 1, 2006, to report to the Public Health, Human Services, and Appropriations committees on the feasibility and costs of establishing a program to purchase and continue health insurance policies for people with HIV or AIDS that would use the same eligibility criteria DSS uses for its AIDS drug assistance program.

DSS’ Connecticut AIDS Drug Assistance Program is for people with HIV or AIDS. DSS pays the costs of drugs needed to treat the illness for people with incomes up to 400% of the FPL ($ 38,280 annually for one person).

The bill also allows DCF-licensed congregate residential settings to house youth until they reach 21 years of age if (1) the youth was placed in this type of facility prior to his 18^th birthday and (2) is attending school or a state accredited job training program on a full-time basis. The current cutoff is age 18.

TREATMENT OF PROCEEDS OF DISCRIMINATION SUITS AND SETTLEMENTS IN WELFARE PROGRAMS (§§ 44-45)

The bill prohibits the state from claiming or applying a lien against a settlement or award in a housing or employment discrimination case received by a beneficiary of certain state assistance. The programs affected include the State Supplement Program, Medicaid, the former AFDC program, TFA, or SAGA. In these programs, the state can recover assistance it has provided to participants or former participants if they later receive money or it can place liens on their property and recover from their estates when they die.

It also exempts payments people receive as a result of a human rights complaint under state or federal antidiscrimination law, either as a claim settlement or an award in a judicial or administrative proceeding from being considered as income, resources, or assets for determining eligibility or assistance amounts for certain state assistance programs during the month it is received or in the following three months. After this time period, any remaining funds must be counted for purposes of these programs. The programs affected include State Supplement, Medicaid or other medical assistance programs, TFA, TANF, SAGA and the individual development account program.

The bill requires the DSS commissioner to establish PA procedures in the Medicaid program for home health services when these include more than two weekly skilled nursing visits.

Medicaid providers are not required to submit PA requests more than once a month unless there are revisions to the PA received during the month.

The bill permits the commissioner to contract with an entity to administer any aspect of PA, or it can expand the scope of an existing contract with an entity that performs utilization review services on DSS’ behalf.

DSS can implement policies and procedures needed to administer the PA while in the process of adopting them in regulations, provided she publishes notice of intent to adopt the regulations in the Connecticut Law Journal within 20 days of implementing them.

The bill makes numerous, mostly technical, changes in the nursing facility user fee, established in sHB 6940 of the 2005 session, as passed by the House and Senate.

The law specifies that the nursing home rate increases scheduled for July 1, 2005 remain in effect unless (1) federal matching funds are no longer available or (2) the user fee is no longer in effect.

It specifies that the day a nursing home resident dies is considered a resident day for purposes of calculating the fee.

The bill eliminates the requirement in sHB 6940 that residential care homes receive a 4% State Supplement increase for their residents who qualify for State Supplement. Instead, it requires that these facilities receive a rate that is determined in accordance with applicable law and subject to appropriations.

It also eliminates a requirement that at least 85% of a nursing home’s net revenue gain be applied to increased employee wage rates and benefits, as well as additional direct and indirect component staffing, along with a related requirement that DSS verify that this has occurred and penalize homes that have not complied.

Under sHB 6940, homes are prohibited from applying any net revenue gain to wage and salary increases provided to administrators, owners, or related party employees. This bill permits the DSS commissioner to verify whether homes have met this requirement by comparing their wage expenditures in 2005 with those in 2006. It allows her to recover any amounts improperly applied using the same methods currently applied to violations of the 85% rule.

The bill establishes a Department on Aging, headed by a commissioner on aging appointed by the governor. It requires the commissioner to serve full-time and be knowledgeable and experienced in the conditions and needs of the elderly. He must administer all laws under the department’s jurisdiction and use the most efficient and practical means to provide care for and protection of elderly persons. The bill requires the commissioner to:

1. administer, coordinate, and direct department operations;

2. adopt and enforce regulations;

3. establish rules for the department’s internal operation and administration;

4. plan for, establish, and develop programs, administer services, and enter into contracts to achieve the department’s purposes;

5. advocate for additional needed comprehensive and coordinated programs for the elderly;

6. assist and advise all appropriate state, federal, local, and area planning agencies for the elderly in the performance of their functions and duties under federal law;

7. coordinate outreach activities by public and private agencies serving the elderly; and

8. consult and cooperate with area and private planning agencies.

The bill transfers the functions, powers, duties, and personnel of the DSS Division of Elderly Services to the Department on Aging. (This DSS division was recently merged into a larger Bureau of Aging, Community, and Social Work Services. ) It continues in force relevant DSS and Commission on Aging orders and regulations in effect on January 1, 2007, until they are amended, repealed, or superseded.

The bill establishes a 23-member task force to study reestablishment of the Department on Aging. The task force must study this bill’s provisions and make recommendations on further revising the statutes and other changes needed or advisable to implement the bill. It consists of the chairmen, vice chairmen, and ranking members of the Aging Committee; the Office of Policy and Management secretary or his designee; and the DSS, DPH, DMHAS, DMR, DECD, transportation, and insurance commissioners or their designees. Appointed members include one member each appointed by the House speaker, Senate president pro tempore, and House and Senate majority and minority leaders. The legislative appointments may be legislators. The governor appoints two members. All appointments must be made by July 31, 2005. If the legislative leaders fail to make the appointments, the bill authorizes the Aging Committee’s chairmen and ranking members to do so. Vacancies must be filled by the appointing authority. The House speaker and Senate president pro tempore together must select the task force co-chairmen from among its members, and the co-chairmen must schedule the first meeting by August 29, 2005. The bill designates the Aging Committee’s administrative staff as staff for the task force. The task force also (1) must report on its findings by February 15, 2006 to the Aging Committee and (2) terminates on the earlier of the date it submits the report or January 1, 2007.

THE ESTABLISHMENT OF INDEPENDENT TRANSPORTATION NETWORKS TO SERVE THE ELDERLY (§ 55)

The bill requires the Department of Social Services (DSS) commissioner, within existing budgetary resources, to provide $ 100,000 for grants of $ 25,000 each for FY 06 to up to four towns with populations of at least 25,000 or nonprofit organizations located in them.

The grants must be used to develop and plan financially self-sustaining, community-based regional transportation systems that, through a combination of private donations and user fees, provide transportation to elderly persons. Before receiving the grant, a municipality selected to receive it must demonstrate to the DSS commissioner’s satisfaction that it has secured at least $ 25,000 in matching private funds for this purpose. Under the bill, a municipality selected to receive the grant must, to the extent practicable, model its community-based regional transportation system on the ITNAmerica model. This model uses a combination of volunteers and paid drivers to provide on-demand transportation to seniors in passenger automobiles. The recipient town must also work cooperatively with the regional planning agency of which it is a member to develop the network.

The bill requires local zoning regulations to treat as single family homes community residences housing six or fewer people receiving mental health or addiction services and necessary staff. To receive this treatment, DMHAS must pay for or provide the services and staff and the home must be licensed licensed by DPH, if licensure is required. The bill permits any resident of a town hosting such a home to petition the DMHAS commissioner to withdraw the residence’s funding on the grounds that it is not complying with the statutes or regulations governing its operation. The town’s legislative body must approve the resident’s action.

The bill includes “critical access hospital “ under the category of “health care institution” for DPH regulatory purposes and defines it as a facility used intermittently, deployed at the discretion of the governor, or her designee, for training purposes in the event of a public health or other emergency for isolation purposes or triage and treatment during a mass casualty event.

The bill establishes a board of directors to advise DPH on the operations of the critical access hospital. The board includes the commissioners of public health, emergency management and homeland services, and social services or their designees, the OPM secretary or his designee, the adjutant general or his designee, one representative of a hospital with over 500 licensed beds and one from a hospital with 500 or fewer beds, both appointed by the health commissioner. The DPH commissioner is the board’s chairperson. The board must adopt bylaws and meet as specified by the bylaws and as deemed necessary by the DPH commissioner. The board must advise DPH on operating policies and procedures; facility deployment and operation; appropriate facility utilization; clinical programs and delivery of patient services; staffing patterns and ratios; human resources; standards and accreditation guidelines; staff credentialing; patient admission, transfer and discharge policies; quality assurance and performance improvement; patient rates and billing and reimbursement mechanisms; staff education and training; and alternative facility uses.

The bill exempts a critical access hospital from the state’s certificate of need (CON) law as administered by the Office of Health Care Access. Also, any additional critical access hospital beds and related equipment obtained to enhance the state’s bed surge capacity or providing isolation care under the state’s health preparedness planning activities is exempt from CON (§ 37-38).

The bill establishes a critical access hospital account as a separate, nonlapsing account within the general fund. The money in the account must be used by DSS to fund the operations of the critical access hospital in the event of activation. The account contains all funds required by law to be deposited in it. The sum of $ 1 is appropriated to DSS from the general Fund for FY 06 for deposit into the account and $ 1 for FY 07.

The bill requires all individual and group health insurance policies delivered, issued for delivery, renewed, amended or continued in the state as of July 1, 2005 to provide benefits for isolation care and emergency services provided by the state’s critical access hospital. The benefits are subject to any policy provisions which apply to other services covered by the policy. The rates paid by individual and group policies under this provision must be equal to the rates paid under Medicaid as determined by DSS.

The bill requires DSS to provide coverage for isolation care and emergency services provided by the critical access hospitals to persons participating in the HUSKY Plan Part A and B programs and fee for service Medicaid programs. The DSS commissioner must adopt regulations to implement critical access hospital policies and procedures for isolation care and emergency services.

The bill requires the public health commissioner, in conjunction with the Public Health Committee chairpersons, to convene a working group to study whether the state should contract for development of a prescription drug purchasing program or enter into an existing program, that allows Connecticut residents to purchase drugs through pharmacies in Canada or other countries. Theworking group’s membership includes the commissioner or his designee, the health committee chairpersons or their designees, the Attorney General or his designee, an OPM representative, and any other person the health commissioner and chairpersons deem necessary.

The study must evaluate any new or existing prescription drug program that would allow Connecticut residents to purchase drugs through Canadian pharmacies or those in other countries to assess (1) whether it would meet all of the current levels of safety and quality assurance afforded Connecticut residents concerning prescription drug purchasing and whether it would provide state residents who enroll access to more affordable drugs and (2) whether Connecticut residents would be required to compromise any legal rights as condition of program participation. The study must also examine and make recommendations concerning the parameters of a request for proposal to solicit the implementation of a program in Connecticut. DPH can enter into contracts with consultants to assist with the study.

The health commissioner must report by January 1, 2006 to the Public Health and Appropriations committees on the study results.

This bill establishes a licensure requirement for perfusionists, administered by the Department of Public Health (DPH). Perfusionists operate circulation equipment during medical situations when it is necessary to temporarily and artificially replace the patient’s circulatory or respiratory functions. A perfusionist is part of the surgical team for operations, such as open-heart surgery.

The bill defines “perfusion” as the functions necessary for the support, treatment, measurement or supplementation of the cardiovascular, circulatory, or respiratory system or other organs, and to ensure the safe management of physiologic functions by monitoring and analyzing the parameters of the systems under an order and supervision of a licensed physician. It includes:

1. the use of “extracorporeal circulation” (diversion of a patient’s blood through a heart-lung machine or similar device that assumes the functions of the patient’s heart, lungs, kidney, liver or other organs), long-term cardiopulmonary support techniques including extracorporeal carbon-dioxide removal and extracorporeal membrane oxygenation and associated therapeutic and diagnostic technologies;

2. counterpulsation, ventricular assistance, autotransfusion, blood conservation techniques, myocardial and organ preservation, extracorporeal life support and isolated limb perfusion; and

3. the use of techniques involving blood management, advance life support and other related functions.

It also includes (1) the administration of pharmacological and therapeutic agents, or blood products or anesthetic agents through the extracorporeal circuit or through an intravenous line as ordered by a physician; (2) the performance and use of anticoagulation monitoring and analysis, physiologic monitoring and analysis, blood gas and chemistry monitoring and analysis, hematologic monitoring and analysis, hypothermia, hyperthermia, hemoconcentration and hemodilution, or modified extracorporeal circulatory hemodialysis; or (3) the observation of signs and symptoms related to perfusion services, determination of whether the signs and symptoms exhibit abnormal characteristics, and implementation of appropriate reporting, perfusion protocols, or changes in or the initiation of emergency procedures.

Applicants for licensure must pay a $ 250 application fee and provide satisfactory evidence of successful completion of (1) a perfusion education program with standards established by the Accreditation Committee for Perfusion Education and approved by the Commission on Accreditation of Allied Health Education Programs, or a program approved by DPH with substantially equivalent standards, (2) at least 50 cases after graduating from a perfusion education program and (3) after completing (1) and (2) above, the certification examination offered by the American Board of Cardiovascular Perfusion, or its successor, or a substantially equivalent examination approved by DPH.

Between October 1, 2005 to December 31, 2006, the bill allows DPH to license a person without examination if the applicant provides satisfactory evidence that he has (1) actively practiced perfusion in Connecticut since October 1, 2005 or earlier and (2) been operating a cardiopulmonary bypass system during cardiac surgical procedures in a licensed health care facility as part of his primary duties since October 1, 2005. The applicant must pay a $ 250 fee.

The bill also specifies that the licensure requirements do not apply to the activities and work of a person (1) who has successfully completed a perfusion education program, is gaining the experience necessary to meet the minimum case requirement for licensure and the work is done under direct supervision, and is designated as an intern or trainee or other title indicating their training status or (2) enrolled in an accredited education program and performing such work as incidential to the course of study. “Direct supervision” means a supervising physician is physically present in the location where the perfusionist trainee is performing routine perfusion functions.

The bill prohibits DPH from issuing a license to an applicant facing pending disciplinary action or who is the subject of an unresolved complaint in any state or territory. It also specifies that practicing perfusion is not considered the practice of medicine.

The bill prohibits an individual from using the title “perfusionist” or using any title, words, letters, or abbreviations that may be reasonably confused with licensure as a perfusionist unless the person has a valid license from DPH.

A license can be renewed annually for $ 250. The individual must apply for renewal annually during the month of his birth, providing his full name, residence, business address, and other information DPH requires.

EFFECTIVE DATE: October 1, 2005, except that secs. 52, 54 and 56 are effective on the later of October 1, 2000, or the date notice is published by the DPH commissioner in the Connecticut Law Journal that the licensing of athletic trainers and physical therapist assistants is being implemented.

The bill subjects perfusionists to the same disciplinary actions DPH can currently take against other licensed health care practitioners for (1) failure to conform to accepted practice standards; (2) felony conviction; (3) fraud or deceit in obtaining or reinstating a license; (4) fraud or deceit in practice; (5) negligent, incompetent, or wrongful conduct in professional activities; (6) physical, mental or emotional illness or disorder resulting in an inability to conform to accepted practice standards; (7) alcohol or substance abuse; (8) willful falsification of entries in any medical records; or (9) violation of any of the perfusionist licensure provisions.

By law, DPH can order a licensee to undergo a reasonable physical or mental examination if the physical or mental capacity of the licensee to practice safely is under investigation.

The possible disciplinary actions DPH can take include (1) suspending or revoking a license, (2) issuing a letter of reprimand to or censuring the licensee, (3) placing him on probation, (4) assessing a civil penalty up to $ 10,000, or (5) taking summary action against the licensee if he is found guilty of a state or federal felony or subject to disciplinary action in another jurisdiction.

DPH can petition the Hartford Superior Court to enforce any order or action taken above. DPH must give the practitioner notice and an opportunity for a hearing.

The bill eliminates the requirement that Cedarcrest Hospital be an independent facility in DMHAS and permits DMHAS to create an acute care division of Connecticut Valley Hospital. It eliminates (1) a requirement that DMHAS consist of separate mental health and substance abuse divisions and (2) obsolete references to several substance abuse and child-serving facilities in the statutory definition of “state-operated” mental health and substance abuse facilities.

The bill states that if Cedarcrest and CVH consolidate operation functions, each still constitutes separate hospitals for purposes of the law governing the transfer of both committed and voluntary patients. Both hospitals must continue to designate an administrator authorized to make final decisions on patient complaints and grievances.

The bill requires the Commission on Medicolegal Investigations to set the deputy chief medical examiner’s salary. Under current law, the commission recommends a salary to the administrative services commissioner. The commission continues to recommend salaries for associate and assistant medical examiners and other professional staff.

The bill requires the DMHAS commissioner, by June 30, 2006, to begin to develop, implement, promote, and maintaining a website that provides timely access to mental health care information and assistance for children, adolescents, and adults.

1. directory information on available federal, state, regional, and local assistance, programs, services, and providers;

2. current mental health diagnosis and treatment options;

3. links to national and state advocacy organizations, including legal assistance;

4. summaries of state and federal mental health laws, including those concerning private insurance; and

5. an optional, secure personal folder for people to manage information about their own mental health care and assistance.

The bill requires the DSS commissioner, by December 31, 2006 and in consultation with the DMHAS commissioner and the Community Mental Health Strategy Board, to amend the state’s Medicaid plan to include assertive community treatment teams and community support services in the definition of optional adult rehabilitation services, thereby making them eligible for federal reimbursement. Under the bill, these teams provide intensive, integrated multidisciplinary services to adults with severe psychiatric disabilities, including people who: are homeless; diverted or discharged from hospitals and nursing homes; or diverted or released from, or at risk of going to, prison. They must provide intensive community care management through case managers, nurses, and physicians and must include vocational, peer, and substance abuse specialists.

The bill requires the DSS and DMHAS commissioners to enter into an memorandum of understanding delegating DMHAS to clinically manage the adult rehabilitation services the agency provides to its clients. Under the bill, “clinical management” is the process of evaluating and determining appropriate use of mental health services and providing assistance to clinicians or beneficiaries to ensure the appropriate use of resources. Assistance can include prior authorization, concurrent and retrospective review, discharge review, quality management, and provider certification and performance enhancement.

The bill requires the DSS commissioner to adopt regulations to establish the teams and the community support services. She may implement policies and procedures that establish these services while in the process of adopting the regulations. She must print notice of her intent to adopt regulations in the Connecticut Law Journal within 20 days after implementing the policies and procedures. The interim measures remain valid until the regulations take effect.

The bill allows the agencies’ commissioners jointly to adopt clinical management policies and procedures. It allows the DSS Commissioner to implement these, which can include changes to existing policies and procedures governing utilization management, while in the process of adopting them as regulations following the process described above.

The bill requires the DSS and DMHAS commissioners to convene a task force by July 1, 2005 to develop a feasibility plan to obtain a federal waiver to create a Medicaid-financed home and community-based pilot program to help adults with severe and persistent psychiatric disabilities who are diverted or discharged from nursing homes. The program can include housing assistance.

The task force consists of the DSS and DMHAS commissioners and the OPM secretary, or their designees; the co-chairmen and ranking members of the Public Health and Human Services committees; and three members designated by the Community Mental Health Strategy Board. It must report to the governor and General Assembly by January 1, 2006.

The bill permits the DMHAS commissioner, within available appropriations, to expand services for young adults with psychiatric disabilities to cover additional catchment areas. It requires him to identify service gaps for this population and report by January 1, 2007 to the Public Health and Human Services committees on the need to expand services and services that should be added.

The bill requires the DCF commissioner, within available appropriations and in consultation with the DMHAS commissioner, to maintain the availability of flexible emergency funds for children with psychiatric disabilities who are not under DCF supervision.

The bill permits the DMHAS commissioner, before January 1, 2006 and within available appropriations, to provide additional supportive or supervised housing for adults with severe and persistent psychiatric disabilities.

The bill requires the managed care ombudsman, by October 1, 2005 and in consultation with the Strategy Board, to establish a process for mental health care providers, patients, business organizations, and managed care organizations to communicate about and ensure:

1. compliance with state insurance laws governing (a) compliance with federal law on guaranteed availability and renewability of coverage, mental health parity, and discrimination based on health status, (b) standards concerning psychotropic drug coverage, (c) mental health parity, and (d) coverage continuation for children with mental disabilities;

2. best practices in mental health treatment and recovery (presumably to assure that these practices are followed); and

3. the relative costs and benefits of providing effective mental health coverage to employees and their families (it is not clear what is to be assured by this provision).

The ombudsman must report annually to the Public Health and Insurance committees, beginning January 1, 2006, on his implementing this requirement.

The bill requires the DSS commissioner, in consultation with the DMHAS commissioner and OPM secretary, to determine the feasibility of creating enhanced care clinics for adults by July 1, 2006. These clinics could include those based in hospitals. The commissioner must report to the governor and General Assembly by January 1, 2006.

The bill requires the Office of Health Care Access (OHCA) commissioner to establish a committee to study whether there are enough inpatient psychiatric beds for children in the state and make recommendations to expand capacity. The committee consists of the DSS and DCF commissioners or their designees, the child advocate or her designee, and representatives of private children’s hospitals and children’s mental health advocacy groups. The OHCA commissioner must report the committee’s findings and recommendations to the General Assembly by January 1, 2006.

The bill establishes a Behavioral Health Partnership between DCF and DSS to develop and implement an integrated behavioral health system for children and families receiving services under HUSKY A and B; children enrolled in DCF’s voluntary services program; and, at the DCF commissioner’s discretion, other children and families the department serves. The Connecticut Community KidCare program, through which these agencies serve HUSKY A and B and voluntary services program participants, remains in place.

The partnership is to increase access to quality behavioral health services through (1) expanding individualized, family centered, community-based services and reducing unnecessary institutional and residential service use; (2) maximizing federal revenue and capturing and reinvesting any such revenue derived from reducing residential and increasing community-based services; (3) improving administrative oversight and efficiency; and (4) monitoring overall performance, individual outcomes, and provider performance (in the latter case taking client acuity mix into consideration).

The bill also requires the agencies to follow specific financial requirements concerning converting from grant-funded to rate-based services (see Rate Setting, below).

The bill requires the DSS and DCF commissioners to designate a partnership director in each agency. The director coordinates his or her agency’s responsibilities for planning, developing, administering, and evaluating the activities the agency undertakes to meet the system’s goal of increasing access to services.

The departments must jointly direct the administrative services organization (ASO, see below) they select to develop a community system of care to (1) alleviate hospital emergency room overcrowding, (2) reduce unnecessary admissions to hospitals and residential treatment facilities and the length of time people stay there, and (3) increase the availability of outpatient services.

Current law governing the KidCare program permits the DSS commissioner to delegate to DCF responsibility for the clinical management portion of the agencies’ contract with the ASO pertaining to children. The bill removes the limitation that DCF’s responsibility is solely for children, apparently giving DCF clinical management responsibility for any adults the partnership serves. It also allows DSS to contract with an ASO to develop a provider network.

The law governing the KidCare program requires the DSS and DCF commissioners jointly to develop clinical management policies and procedures for implementation by the ASO. It permits the agencies to implement these while in the process of adopting them as regulations. The interim measures were to remain valid until the regulations took effect or December 1, 2003, whichever happened first. The bill extends this deadline to the earlier of December 31, 2006 or the regulations’ effective date.

The bill creates a 38-member Behavioral Health Partnership Oversight Council to advise DSS and DCF on planning and implementing the partnership. The council must make recommendations on partnership planning and implementation matters including its review of (1) the agencies’ contract with the ASO to assure that its decisions are based solely on the clinical management criteria developed by the committee the bill establishes (see section 74, below); (2) behavioral health services provided under HUSKY A and HUSKY B to assure that federal fund revenues are being maximized; (3) periodic reports on program activities, finances, and outcomes, including reports from the partnership director on achieving the system’s goals; (4) consumer grievance procedures (see section 75, below), and (5) proposed provider-specific rates for certain services (see section 78, below).

The council can conduct an external, independent evaluation of the partnership or can have one done. Beginning by March 1, 2006, it must report annually on its activities and progress to the Appropriations, Human Services, and Public Health committees.

The council consists of 29 voting and nine nonvoting members. The voting members are (1) the chairmen and ranking members of the Appropriations, Human Services, and Public Health committees; (2) a member of the Community Mental Health Strategy Board, selected by the board; the DMHAS commissioner or his designee, and (4) 16 people selected as follows by the chairmen of the Medicaid Managed Care Advisory Council:

1. two general or psychiatric hospital representatives,

2. two parents of children with behavioral health problems or who have received child protection or juvenile justice services from DCF,

3. one adult with a psychiatric disability,

4. one advocate for adults with psychiatric disabilities and one for children with behavioral health disorders,

5. one person with expertise in health policy and evaluation,

6. a primary care provider and a psychiatrist serving HUSKY children,

7. an adult with a substance abuse disorder or an advocate for such adults,

8. a representative of school-based health clinics,

9. one adult and one children’s community-based behavioral health services provider,

10. a children’s residential treatment service provider, and

11. a member of the Medicaid Managed Care Advisory Council.

1. one each appointed by the DCF, DSS, and DMHAS commissioners and the Office of Policy and Management secretary to represent their respective agencies;

2. one ASO representative-; and

3. a representative of each Medicaid managed care organization (there are currently four).

All appointments must be made by July 1, 2005. The Medicaid Managed Care Advisory Council chairmen select the partnership advisory council chairmen who must convene the first meeting by August 1, 2005. The council must meet at least monthly. The Legislative Management Committee must provide the chairmen with administrative support and help in convening the council’s meetings. The initial appointing authority fills membership vacancies.

The bill establishes a seven-member committee to develop clinical management guidelines the partnership and the ASO must use. The committee consists of two members each from DCF, DSS, and the oversight council and one member selected by the DMHAS commissioner. Their respective commissioners select the agency representatives; the council selects its representatives. All members must be expert or experienced in behavioral health services.

The bill requires DCF and DSS to develop consumer grievance procedures. They must establish time frames, including an expedited review in emergencies, for people to appeal the ASO’s decisions. The procedure must require hearing appeals with 30 days after they are filed and deciding on them within 45 days of filing. The oversight council must review and comment on the proposed procedures.

The bill requires DCF and DSS to evaluate the partnership annually beginning October 1, 2006. The evaluation must examine the partnership’s provision of services, including the status of the ASO implementation and collaboration between the departments, the services provided, the number of people served, and program outcomes and spending for children and adults. They must submit the report to the Appropriations, Human Services, and Public Health committees.

The bill also requires DCF to monitor the implementation of the partnership and report annually on any estimated cost savings that result from it. The report goes to the above committees.

Current law requires the agencies, within available appropriations, to conduct a five-year, independent longitudinal evaluation of the KidCare program’s effectiveness.

The bill permits DSS and DCF to establish provider specific rates for inpatient, partial hospitalization, intensive outpatient, and other intensive services. If they do this before January 1, 2006, each provider’s initial rates must at least equal its blend of rates under HUSKY A and B as of July 1, 2005. If they implement these rates after January 1, 2006, the initial rates must at least equal the blend of each provider’s rates in effect 60 days before the date the partnership is implemented (which date the agencies apparently determine). The departments may provide grants, where necessary, to address the financial effects this new system may have on provides. The initial rate changes and the grants must be made within available appropriations.

The departments can establish uniform outpatient rates that contain a differential payment for adult and child services. These cannot exceed the rates Medicare pays for these services.

The bill rate setting provisions supersede other laws governing DSS rate setting for hospitals, residential mental health and substance abuse facilities, and free-standing detoxification centers.

Before the partnership can convert any grant-funded services (the method DCF currently uses to pay service providers) to a rate-based, fee-for-service payment system, the bill requires DCF and DSS to submit documentation to the Oversight Council verifying that the proposed rates seek to cover the reasonable cost of providing the services.

The bill requires the departments to submit initial rates, rate reductions, and changes in the methodology they use to establish rates to the Oversight Council for its review. If the council does not accept the rates or methodology changes, it can send its recommendations to the Appropriations, Human Services, and Public Health committees. These committees must hold a public hearing on the subject of the proposed rates (but not on rate-setting methodology) to learn the partnership’s reasons for the changes. They must make recommendations to the departments within 90 days after they submitted the changes to the council. The departments must make every effort to incorporate the council’s and the committees’ recommendations when setting rates.

The bill requires DCF and DSS to contract jointly with one ASO to perform the following functions: eligibility verification; utilization, intensive care, and quality management; coordination of medical and behavioral health services; provider network development and management; recipient and provider services; and reporting. The contract must call for the ASO to begin performing these functions by October 1, 2005.

The bill prohibits the ASO from having any financial incentive to approve, deny, or reduce services. It requires the ASO to base its decisions to authorize services solely on the clinical management guidelines set by the clinical management committee the bill establishes (see section 74, above). But, it allows the ASO to make exceptions to the guidelines when a member, a member’s legal guardian, or a service provider asks and the ASO determines making an exception is in the member’s best interest. The ASO must ensure that service providers and people seeking services have timely (1) access to program information and (2) responses to inquiries, including those concerning clinical guidelines. DSS and DCF make decisions concerning guideline interpretation.