AN ACT CONCERNING THE HEALTHFIRST CONNECTICUT INITIATIVE.

This bill expands access to public health insurance by making a number of changes in the HUSKY, Medicaid, and State-Administered General Assistance (SAGA) programs. Among other changes it:

1. raises the income limit for HUSKY A (Medicaid) coverage for caretaker relatives and pregnant women;

2. restores continuous eligibility for children enrolled in HUSKY A or B and adds it for adults;

3. requires (a) the Department of Social Services (DSS) to establish a dental provider fee schedule for services to anyone enrolled in HUSKY or Medicaid and (b) all Medicaid providers to be reimbursed for services at the same rate Medicare pays; and

4. requires DSS to increase the income limit for the SAGA medical assistance program and seek a federal waiver to convert the program from a fully state-funded program to a Medicaid-funded one.

The bill extends, from age 23 to 30, the age to which group comprehensive and individual health insurance policies that cover dependent children must do so, and it requires employers to offer employees a chance to pay their health insurance premiums with pre-tax dollars (section 125 plans). It creates a panel to study ways to provide health coverage to un- and under-insured state residents. It requires DSS and the Department of Public Health (DPH) to inventory public and private disease management program.

It designates a nonprofit corporation as the state's electronic health information exchange, requires DPH to develop an electronic license renewal system for certain professions, and requires the healthcare advocate to create a consumer health information website.

Finally, it appropriates funds for various school- and community-based health center operations.

EFFECTIVE DATE: July 1, 2007, except for the provisions concerning (a) on-line license renewal, DSS and DPH disease management inventories, the health care panel, and extension of the school-based health center committee, which are effective upon passage, and (b) the consumer health information website and section 125 plans, which are effective October 1, 2007.

Increase Income Limit for HUSKY A Coverage for Adult Caretaker Relatives; Eliminate Cost Sharing in HUSKY A (§ 2)

The bill increases, from 150% to 185% of the federal poverty level (FPL, from $ 25,755 to $ 31,764 annually for a family of three in 2007) the income limit for HUSKY A adult caretaker coverage. This higher limit already applies to children applying for or enrolled in the HUSKY A program.

The bill requires the DSS commissioner, when individuals or families apply for Medicaid coverage, to advise them of the (1) effect that having income over the limit has on program eligibility and (2) availability of HUSKY B for those ineligible for HUSKY A. (HUSKY B provides virtually identical subsidized medical coverage to children in families whose income is between 185% and 300% of the FPL. )

The bill repeals a never-implemented requirement that DSS make HUSKY A caretaker relatives with incomes above 100% of the FPL pay cost sharing, including premiums and co-payments, as allowed by federal law or waivers.

The bill provides that any child determined eligible for HUSKY A or B, and any adult caretaker eligible for HUSKY A, must remain eligible for 12 months from the initial eligibility determination date, unless they are no longer state residents, or, in the case of the child, the child turns 19. During this period of continuous eligibility, the family must comply with federal requirements concerning the reporting of information to DSS, including change of address information. Currently, families must report changes in financial circumstances within the 12-month period, which can render the child, adult, or both ineligible for assistance. Federal law does not appear to allow adults to be continuously eligible for Medicaid without a waiver. The bill's passage could affect the state's eligibility for federal matching funds.

The bill makes a corollary change by repealing a separate provision that prohibits adults enrolled in HUSKY A from being guaranteed eligibility for six months without regard to changes in circumstances that would otherwise render them ineligible. Federal law allows states to guarantee continuous enrollment of adults in Medicaid managed care for the first six months they are enrolled in a plan.

Although, under the bill, children remain continuously eligible for HUSKY, the bill requires DSS within 10, instead of 12, months from its HUSKY eligibility determination to determine if the child will continue to qualify once the 12-month period ends. It requires DSS, if a HUSKY beneficiary requests, to send renewal applications electronically instead of automatically mailing a renewal form, which the law continues to require if no request is made.

The bill requires DSS to increase the income limit for HUSKY A coverage for pregnant women from 185% to 300% of the FPL ($ 3,422 per month for two-person household). It requires DSS to seek a federal Health Insurance Flexibility and Accountability demonstration waiver to cover these women. The waiver must specify that the expanded coverage will be provided through a re-allocation of the state's unspent State Children's Health Insurance Program (SCHIP) block grant funds. (Federal Medicaid funds match the state's payments for the coverage for women with incomes under 185% of the FPL. )

The bill requires the DSS commissioner to establish a fee schedule for dental services provided to all individuals eligible for HUSKY A, other Medicaid programs, or HUSKY B. The schedule, applicable for each dental service other than orthodontia provided on and after July 1, 2007, must provide for a fee equal to the 70^th percentile of normal and customary private provider fees, as defined by the National Dental Advisory Service Comprehensive Fee Report. The schedule must provide for a fee for orthodontic services, which can be less than the 70^th percentile.

The commissioner must evaluate whether the schedule results in improved access to oral health care for “medical assistance recipients under the age of 19” (presumably, children enrolled in HUSKY or other Medicaid). The evaluation must look at (1) the current number of providers registered to provide Medicaid dental services and children served (2) any increase in the number of providers and children served, and (3) the number of children receiving services from newly registered providers. By December 31, 2009, the commissioner must submit the evaluation and any recommendations to the Human Services and Public Health committees.

Under current practice, DSS maintains a pediatric dental fee schedule, but it is not used because children in HUSKY receive all medical services through the managed care organizations (MCO) that contract with DSS. The MCOs subcontract with dental providers, including managed care plans, for these services and these plans set the reimbursement rates that the dental providers receive. DSS' current pediatric dental fees fall well below the 70^th percentile.

DSS Requirements. The bill requires DSS, in consultation with the Children's Health Council (defunct), the Medicaid Managed Care Council, and 2-1-1 Infoline, to develop ways to increase outreach and maximize enrollment of children and adults in HUSKY. Under current law, they must develop outreach. The mechanisms must include developing and implementing an on-line application. Current law requires, and DSS already has, a mail-in application.

The bill adds the Mental Health and Addiction Services, Mental Retardation, Education, and Motor Vehicles departments to the list of agencies with which DSS must collaborate to disseminate outreach materials. It eliminates a requirement that the commissioner include in the outreach efforts information on the Medicaid program for purposes of maximizing the enrollment of eligible children and the use of federal funds.

By law, the DSS commissioner, within available appropriations, must contract with severe need schools (poor schools located in priority or former priority districts) and community-based organizations for purposes of public education, outreach, and recruitment of HUSKY-eligible children. The bill extends this to include also HUSKY-eligible adults.

Current law requires DSS to report annually to the governor on its community-based outreach program. Starting January 1, 2008, this report must also go to the Human Services, Public Health, and Appropriations committees, and it must be on all outreach efforts, not just community-based ones.

School District Requirements. The bill requires each local or regional board of education or similar body governing a nonpublic school to provide HUSKY eligibility outreach materials to parents and guardians of students at the beginning of each school year. DSS must develop these materials and disseminate them to the schools.

Multi-Year, Statewide Information Campaign. The bill requires DSS, in consultation with DPH, to create a joint, public-private program to establish and implement a multi-year, statewide public information campaign to promote HUSKY enrollment.

The bill requires DSS to consult with DPH and solicit bids from private organizations to design and operate the campaign, regardless of any contrary provision in the personal service agreement law (see BACKGROUND). The bids must be solicited by sending notice to prospective bidders and posting notice on public bulletin boards within the departments. The bids must be opened publicly at the time the solicitation states. The departments' acceptance of a bid must be based on standard specifications they adopt. The bill allows DSS to accept gifts, donations, bequests, grants, or funds from public or private agencies for the campaign.

Starting January 1, 2008, DSS must annually report to the Human Services, Public Health, and Appropriations committees on the campaign's status.

The bill requires DSS, in consultation with the servicer (enrollment broker with which DSS contacts, currently ACS, Inc. ), to establish a centralized unit to be responsible for processing all HUSKY applications. DSS, through its contract, must ensure that a child determined eligible for HUSKY has uninterrupted coverage for as long as the parent or guardian elects to enroll or re-enroll the child.

The bill requires DSS in consultation with the servicer, instead of the servicer alone, to jointly market the HUSKY A and B as one program. And it requires the servicer to electronically send HUSKY A, as well as HUSKY B, enrollment and disenrollment data to DSS.

The bill makes it clear that the servicer sends DSS all HUSKY applications, not just those for children with family income of 185% of FPL or less.

The bill requires the DSS commissioner to file a Medicaid State Plan amendment to allow him to raise the income limit for aged, blind, and disabled individuals applying for and receiving coverage under the Medicaid medically needy coverage group. He must establish a special income disregard, which when applied, will have the effect of raising the income limit to the same limit that applies to HUSKY A caretaker relatives (150% of FPL currently but raised to 185% under the bill). Currently, the medically needy income limit for one person is $ 476 per month. Under the bill, it would effectively rise to $ 1,574 per month at the 185% of FPL level.

The bill requires the DSS commissioner to increase the income limit for SAGA medical assistance recipients from the Medicaid medically needy income limit (currently $ 476 per month for a single resident living in most parts of the state) to the FPL (presumably 100% of the FPL, or $ 850 per month for this person). It requires DSS, by January 1, 2008, instead of March 1, 2004, to seek a federal Medicaid waiver to get Medicaid coverage for the SAGA medical assistance program.

The bill removes obsolete language pertaining to town-administered General Assistance medical assistance.

It eliminates the deadline (August 20, 2003) by which federally qualified health centers (FQHC) participating in the SAGA medical assistance program must enroll in the federal Office of Pharmacy Affairs Section 340B drug discount program.

The bill requires the DSS commissioner to reimburse all Medicaid providers for services at the same rate the Medicare program pays. The HUSKY A program is part of Medicaid, but providers are not paid by DSS but the MCOs. It is not clear whether DSS would be required to amend the MCO contracts to ensure these rates are paid. (The bill also establishes a dental fee schedule for medical assistance programs, including Medicaid. But since Medicare does not pay for dental services, this provision would not appear to conflict with the earlier one. )

The bill requires the DSS commissioner to amend the Medicaid state plan to include foreign language interpreters as a covered service for Medicaid beneficiaries with limited English proficiency.

The bill extends, from age 23 to 30, the age to which group comprehensive and individual health insurance policies that cover children must do so. Current law requires coverage for unmarried, dependent children until they turn 19, or 23 if the child is a full-time student at an accredited school. The bill eliminates the requirement that children be dependent and limits continuing coverage to those who live in Connecticut.

1. individual health insurance policies delivered, issued, amended, or renewed after September 30, 2007 that cover (a) basic hospital and medical surgical expenses, (b) major medical expenses, (c) accidents, (d) limited benefits, and (e) hospital or medical services; and

2. group comprehensive health care plans and plans continuing coverage after an employee's layoff, reduction of hours, leave of absence, or termination.

This coverage extension for these plans appears to apply beginning July 1, 2007.

The bill requires every employer that deducts health insurance premiums from its employees' pay to give the employees the opportunity to make these payments with pre-tax dollars as permitted under IRS Code section 125.

The bill creates a 12-member health care panel to evaluate alternatives for providing health insurance for un- and underinsured state residents such as premium assistance, individual and employer coverage mandates, and a single-payer system. The panel must report its recommended strategies by January 1, 2009 to the Public Health, Human Services, and Insurance committees. It can also collect data on, and promote, wellness, nutrition, disease prevention, and exercise among state residents.

Legislative leaders and the governor appoint 10 members some of whom must represent specific interests as Table 1 shows. The DPH and DSS commissioners are also panel members.

*Appointing Authority* *Appointments*	*Appointee*
Governor (2)	• Health quality or patient safety advocate • Unspecified
Senate president pro tempore (2)	• Managed care organizations representative • Unspecified
House speaker (2)	• Health care provider • Unspecified
Senate majority leader (1)	Representative of businesses with fewer than 50 employees
House majority leader (1)	Health insurers representative
Senate minority leader (1)	Person with community health experience
House minority leader (1)	Representative of businesses with 50 or more employees

All appointments must be made within 30 days after the bill is enacted. The appointing authority fills vacancies. The speaker and president pro tempore choose the chairpersons who must schedule the first panel's meeting no more than 60 day's after the bill's enactment.

By January 1, 2008, the bill requires DSS and DPH to inventory public and private disease management initiatives implemented as of the date the bill passes. DSS must inventory initiatives in the HUSKY, SAGA medical assistance, and other Medicaid programs. DPH must inventory all other public and private programs. For each initiative and program, the report must include a summary, total spent, and number of people served. The DPH report must also include recommendations about best practices and ways to replicate them statewide. DSS must report to the Human Services and Public Health committees, DPH just to the Public Health Committee.

The bill designates eHealth Connecticut, a nonprofit corporation, as the state's lead health information exchange organization from July 1, 2007 to July 1, 2012. It requires the DPH commissioner to contract with eHealth to develop a statewide health information technology plan that includes standards, protocols, and pilot programs for health information exchange.

The bill requires the Healthcare Advocate's Office, within available appropriations, to create and maintain a website for consumer health care information. At a minimum, the website must contain (1) information about wellness programs, such as disease prevention and health promotion, available in various regions; (2) hospital quality and experience data; and (3) a link to the Insurance Department's managed care consumer report card.

The bill requires DPH, by October 1, 2007, to implement a secure, on-line license renewal system for physicians; dentists; and registered, advance practice registered, and licensed practical nurses. The system must provide for electronic funds transfer or credit card payment. It permits DPH to charge up to $ 5 for on-line payments.

The bill appropriates $ 2. 5 million in FY 08 for DPH to fund expansion and operating costs of school-based health centers (SBHCs) in priority school districts and federally designated health professional shortage or medically underserved areas or those designated as having medically underserved populations. It makes permanent the ad hoc committee established in 2006 to advise DPH on SBHCs. It requires the committee to meet at least quarterly and annually report recommendations to the Public Health and Education committees for statutory and regulatory changes to improve health care access through SBHCs.

The bill requires any SBHC constructed on or after October 1, 2007 that is located in, or attached to, a school building, to have an entrance separate from the school.

The bill appropriates to DPH in FY 08 (1) $ 2 million for infrastructure grants to community-based health centers, including health information technology and (2) $ 500,000 for grants to these centers to transport patients to medical appointments. In making the latter grants, DPH must give priority to Federally Qualified Health Centers in areas with limited public transportation options.

The federal Civil Rights Act prohibits discrimination based on race, color, or national origin. The courts and the U. S. Department of Health and Human Services have applied this law to the protection of national origin minorities who do not speak English well. The Office of Civil Rights has issued guidance on this law that essentially says health care providers caring for Medicaid clients must take reasonable steps to ensure meaningful access to care.

Federal Medicaid regulations allow states to establish separate income disregards for subgroups of their medically needy populations (e. g. , aged, blind, and disabled). In Connecticut, this would be added to the existing unearned income disregard (currently $ 227 per month), and have the effect of raising the income limit.

In general, whenever a state agency wishes to hire a person, firm, or corporation to provide services on a contractual basis, a PSA must be executed, which defines the services the contractor must perform. For PSAs costing up to $ 20,000, the contract should, but does not have to, be competitively bid. PSAs costing more than $ 20,000 must be competitively bid, unless the agency purchasing the services (1) determines that a sole source is necessary, (2) applies to the Office of Policy and Management secretary for a waiver, and (3) the secretary grants it. The secretary must approve any PSA costing more than $ 50,000, regardless of whether a waiver is requested (CGS § 4-212, et. seq. ).

The IRS Code (§ 125) permits employers to offer their employees a choice between cash salary and a variety of qualified, nontaxable benefits. Payments for a qualified benefit, which includes health care, vision and dental care, and group term-life and disability insurance, are excludable from an employee's gross income.

eHealth Connecticut is a nonprofit corporation whose goal is to create a secure, statewide system that enables the electronic exchange of health information among health care providers and payers. Its board comprises representatives of physicians, other health care providers, insurers, academics, and state agencies.

Several committees have favorably reported bills broadly addressing health care access that contain provisions similar to those in sSB 1. They are:

1. sHB 6976, reported favorably by the Public Health and Human Services committees, requires DPH and the Office of Policy and Management to develop a five-year strategic plan for a statewide chronic disease management system.

2. sHB 7111 (file 370) requires DPH to establish, by July 1, 2008, a secure on-line license renewal system for physicians, surgeons, dentists, and nurses.

3. sHB 7366, favorably reported by the Public Health Committee, and sHB 6515, favorably reported by the Children's and Public Health committees, appropriates funds for school- and community-based health centers. sHB 7366 also extends the life of the ad hoc SBHC committee.

4. sHB 6839, favorably reported by the Public Health Committee, establishes a Health Information Technology Office in DPH and requires it to develop a plan to establish a statewide health information exchange.

5. sHB 7069, favorably reported by the Public Health Committee, requires DSS to adopt a dental provider fee schedule like the one in sSB 1, but limited to pediatric services.

6. sSB 1181, reported favorably by the GAE committee, changes the PSA reporting requirements.

*Bill Number*	*File Number*	*Committee*
sSB 3	345	Human Services
sSB 70	106	Insurance
sSB 1127		Human Services
sSB 1371	233	Insurance
sHB 6158	6158	Children
sHB 6652	7314	Insurance
sHB 7314	264	Labor
sHB 7375	296	Human Services