CHAPTER 319v
MEDICAL ASSISTANCE

      Sec. 17b-222. (Formerly Sec. 17-294). "Humane institution" defined. Daily report. As used in this section and sections 17b-223, 17b-228, 17b-229 and 17b-745, "state humane institution" or "humane institution" means state mental hospitals, community mental health centers, treatment facilities for children and adolescents, or any other facility or program administered by the Departments of Mental Health and Addiction Services, Developmental Services, or Children and Families. The person in charge of each state humane institution shall furnish the Commissioner of Administrative Services with a daily report of changes in the patient roster and the date of formal commitment of each patient.

      (1955, S. 1488d; 1957, P.A. 586, S. 7; 1959, P.A. 201; 1967, P.A. 314, S. 16; 839, S. 1; 1971, P.A. 530, S. 1; P.A. 75-603, S. 12, 15; P.A. 77-614, S. 70, 610; P.A. 87-421, S. 6, 13; P.A. 93-91, S. 1, 2; 93-381, S. 9, 39; P.A. 95-257, S. 30, 58; P.A. 04-257, S. 32; P.A. 07-73, S. 2(a).)

      History: 1959 act required that welfare commissioner be supplied with daily report of changes in patient roster and dates of formal commitment of patients; 1967 acts deleted "tuberculosis facilities in chronic disease hospitals" from the definition and provided that the commissioner of finance and control rather than the welfare commissioner receive the reports of patient rosters; 1971 act included community mental health centers, treatment facilities for children and adolescents and other facilities and programs administered by mental health department in definition of "humane institution"; P.A. 75-603 included reference to programs and facilities administered by children and youth services department; P.A. 77-614 replaced commissioner of finance and control with commissioner of administrative services; P.A. 87-421 included facilities or programs administered by the Connecticut state alcohol and drug abuse commission and by the department of mental retardation in the definition of state human institution and excluded state training schools for mentally retarded persons from the definition; P.A. 93-91 substituted commissioner and department of children and families for commissioner and department of children and youth services, effective July 1, 1993; P.A. 93-381 replaced Connecticut alcohol and drug abuse commission with department of public health and addiction services, effective July 1, 1993; Sec. 17-294 transferred to Sec. 17b-222 in 1995; P.A. 95-257 replaced Department of Mental Health with Department of Mental Health and Addiction Services and deleted reference to the Department of Public Health and Addiction Services, effective July 1, 1995; P.A. 04-257 made technical changes, effective June 14, 2004; pursuant to P.A. 07-73 "Department of Mental Retardation" was changed editorially by the Revisors to "Department of Developmental Services", effective October 1, 2007.

      Sec. 17b-225. (Formerly Sec. 17-295c). Availability of patient information to certain agencies. (a) The Department of Public Safety, the Department of Social Services and the United States Department of Health and Human Services shall be entitled to receive only such information concerning patients in institutions, hospitals and facilities of the Departments of Public Health, Developmental Services and Mental Health and Addiction Services as is required to obtain support and payments for the care of such patients, including submissions of such information to probate courts, agencies and corporations dispensing benefits, or only such information concerning such patients as is required for the purpose of claiming federal reimbursement, or only such information concerning such patients as is required for the review and audit of federally funded programs. Any such information received by said Department of Public Safety, Department of Social Services and United States Department of Health and Human Services shall be confidential and shall be used for the purposes of obtaining support and payments for the care of said patients or for the purpose of claiming federal reimbursement or for the review and audit of federally funded programs.

      (b) The Department of Administrative Services shall be entitled to receive only such information concerning patients in institutions, hospitals and facilities of the Departments of Public Health, Mental Health and Addiction Services and Developmental Services, and state humane institutions, as defined in section 17b-222, as is required to obtain support and payments for the care of such patients, including submissions of such information to probate courts, agencies and corporations dispensing benefits. Any such information received by said Department of Administrative Services shall be confidential and shall be used only for the purposes specified in this subsection.

      (1971, P.A. 263; P.A. 73-248, S. 1, 2; P.A. 74-215, S. 1, 3; P.A. 75-420, S. 4, 6; 75-638, S. 21, 23; P.A. 77-614, S. 71, 323, 587, 608, 610; P.A. 78-303, S. 85, 127, 136; P.A. 79-383; P.A. 93-262, S. 1, 87; 93-381, S. 9, 39; P.A. 95-257, S. 11, 12, 21, 58; P.A. 07-73, S. 2(a).)

      History: P.A. 73-248 entitled welfare department and U.S. Department of Health, Education and Welfare to receive information and included information relevant to claims for federal reimbursement or to review or audit of federally-funded programs; P.A. 74-215 added word "only" with reference to information re federal reimbursement and federal reviews and audits; P.A. 75-420 replaced welfare department with department of social services; P.A. 75-638 included information on patients in facilities of mental retardation department; P.A. 77-614 replaced central collections division of department of finance and control with department of administrative services and, effective January 1, 1979, replaced department of health with department of health services and department of social services with department of income maintenance; P.A. 78-303 entitled department of public safety to information; P.A. 79-383 added Subsec. (b) containing special provisions re information to which administrative services department entitled and removed references to said department in previous provisions, now Subsec. (a); P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; P.A. 93-381 replaced department of health services with department of public health and addiction services, effective July 1, 1993; Sec. 17-295c transferred to Sec. 17b-225 in 1995; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health and replaced Commissioner and Department of Mental Health with Commissioner and Department of Mental Health and Addiction Services, effective July 1, 1995; pursuant to P.A. 07-73 "Department of Mental Retardation" was changed editorially by the Revisors to "Department of Developmental Services", effective October 1, 2007.

      Sec. 17b-239. (Formerly Sec. 17-312). Payments to hospitals. Regulations. (a) The rate to be paid by the state to hospitals receiving appropriations granted by the General Assembly and to freestanding chronic disease hospitals, providing services to persons aided or cared for by the state for routine services furnished to state patients, shall be based upon reasonable cost to such hospital, or the charge to the general public for ward services or the lowest charge for semiprivate services if the hospital has no ward facilities, imposed by such hospital, whichever is lowest, except to the extent, if any, that the commissioner determines that a greater amount is appropriate in the case of hospitals serving a disproportionate share of indigent patients. Such rate shall be promulgated annually by the Commissioner of Social Services. Nothing contained in this section shall authorize a payment by the state for such services to any such hospital in excess of the charges made by such hospital for comparable services to the general public. Notwithstanding the provisions of this section, for the rate period beginning July 1, 2000, rates paid to freestanding chronic disease hospitals and freestanding psychiatric hospitals shall be increased by three per cent. For the rate period beginning July 1, 2001, a freestanding chronic disease hospital or freestanding psychiatric hospital shall receive a rate that is two and one-half per cent more than the rate it received in the prior fiscal year and such rate shall remain effective until December 31, 2002. Effective January 1, 2003, a freestanding chronic disease hospital or freestanding psychiatric hospital shall receive a rate that is two per cent more than the rate it received in the prior fiscal year. Notwithstanding the provisions of this subsection, for the period commencing July 1, 2001, and ending June 30, 2003, the commissioner may pay an additional total of no more than three hundred thousand dollars annually for services provided to long-term ventilator patients. For purposes of this subsection, "long-term ventilator patient" means any patient at a freestanding chronic disease hospital on a ventilator for a total of sixty days or more in any consecutive twelve-month period. Effective July 1, 2007, each freestanding chronic disease hospital shall receive a rate that is four per cent more than the rate it received in the prior fiscal year.

      (b) Effective October 1, 1991, the rate to be paid by the state for the cost of special services rendered by such hospitals shall be established annually by the commissioner for each such hospital based on the reasonable cost to each hospital of such services furnished to state patients. Nothing contained herein shall authorize a payment by the state for such services to any such hospital in excess of the charges made by such hospital for comparable services to the general public.

      (c) The term "reasonable cost" as used in this section means the cost of care furnished such patients by an efficient and economically operated facility, computed in accordance with accepted principles of hospital cost reimbursement. The commissioner may adjust the rate of payment established under the provisions of this section for the year during which services are furnished to reflect fluctuations in hospital costs. Such adjustment may be made prospectively to cover anticipated fluctuations or may be made retroactive to any date subsequent to the date of the initial rate determination for such year or in such other manner as may be determined by the commissioner. In determining "reasonable cost" the commissioner may give due consideration to allowances for fully or partially unpaid bills, reasonable costs mandated by collective bargaining agreements with certified collective bargaining agents or other agreements between the employer and employees, provided "employees" shall not include persons employed as managers or chief administrators, requirements for working capital and cost of development of new services, including additions to and replacement of facilities and equipment. The commissioner shall not give consideration to amounts paid by the facilities to employees as salary, or to attorneys or consultants as fees, where the responsibility of the employees, attorneys or consultants is to persuade or seek to persuade the other employees of the facility to support or oppose unionization. Nothing in this subsection shall prohibit the commissioner from considering amounts paid for legal counsel related to the negotiation of collective bargaining agreements, the settlement of grievances or normal administration of labor relations.

      (d) The state shall also pay to such hospitals for each outpatient clinic and emergency room visit a reasonable rate to be established annually by the commissioner for each hospital, such rate to be determined by the reasonable cost of such services. The emergency room visit rates in effect June 30, 1991, shall remain in effect through June 30, 1993, except those which would have been decreased effective July 1, 1991, or July 1, 1992, shall be decreased. Nothing contained herein shall authorize a payment by the state for such services to any hospital in excess of the charges made by such hospital for comparable services to the general public. For those outpatient hospital services paid on the basis of a ratio of cost to charges, the ratios in effect June 30, 1991, shall be reduced effective July 1, 1991, by the most recent annual increase in the consumer price index for medical care. For those outpatient hospital services paid on the basis of a ratio of cost to charges, the ratios computed to be effective July 1, 1994, shall be reduced by the most recent annual increase in the consumer price index for medical care. The emergency room visit rates in effect June 30, 1994, shall remain in effect through December 31, 1994. The Commissioner of Social Services shall establish a fee schedule for outpatient hospital services to be effective on and after January 1, 1995. Except with respect to the rate periods beginning July 1, 1999, and July 1, 2000, such fee schedule shall be adjusted annually beginning July 1, 1996, to reflect necessary increases in the cost of services. Notwithstanding the provisions of this subsection, the fee schedule for the rate period beginning July 1, 2000, shall be increased by ten and one-half per cent, effective June 1, 2001. Notwithstanding the provisions of this subsection, outpatient rates in effect as of June 30, 2003, shall remain in effect through June 30, 2005. Effective July 1, 2006, subject to available appropriations, the commissioner shall increase outpatient service fees for services that may include clinic, emergency room, magnetic resonance imaging, and computerized axial tomography. Not later than October 1, 2006, the commissioner shall submit a report, in accordance with section 11-4a, to the joint standing committees of the General Assembly having cognizance of matters relating to public health, human services and appropriations and the budgets of state agencies, identifying such fee increases and the associated cost increase estimates.

      (e) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, establishing criteria for defining emergency and nonemergency visits to hospital emergency rooms. All nonemergency visits to hospital emergency rooms shall be paid at the hospital's outpatient clinic services rate. Nothing contained in this subsection or the regulations adopted hereunder shall authorize a payment by the state for such services to any hospital in excess of the charges made by such hospital for comparable services to the general public.

      (f) On and after October 1, 1984, the state shall pay to an acute care general hospital for the inpatient care of a patient who no longer requires acute care a rate determined by the following schedule: For the first seven days following certification that the patient no longer requires acute care the state shall pay the hospital at a rate of fifty per cent of the hospital's actual cost; for the second seven-day period following certification that the patient no longer requires acute care the state shall pay seventy-five per cent of the hospital's actual cost; for the third seven-day period following certification that the patient no longer requires acute care and for any period of time thereafter, the state shall pay the hospital at a rate of one hundred per cent of the hospital's actual cost. On and after July 1, 1995, no payment shall be made by the state to an acute care general hospital for the inpatient care of a patient who no longer requires acute care and is eligible for Medicare unless the hospital does not obtain reimbursement from Medicare for that stay.

      (g) Effective June 1, 2001, the commissioner shall establish inpatient hospital rates in accordance with the method specified in regulations adopted pursuant to this section and applied for the rate period beginning October 1, 2000, except that the commissioner shall update each hospital's target amount per discharge to the actual allowable cost per discharge based upon the 1999 cost report filing multiplied by sixty-two and one-half per cent if such amount is higher than the target amount per discharge for the rate period beginning October 1, 2000, as adjusted for the ten per cent incentive identified in Section 4005 of Public Law 101-508. If a hospital's rate is increased pursuant to this subsection, the hospital shall not receive the ten per cent incentive identified in Section 4005 of Public Law 101-508. For rate periods beginning October 1, 2001, through September 30, 2006, the commissioner shall not apply an annual adjustment factor to the target amount per discharge. Effective April 1, 2005, the revised target amount per discharge for each hospital with a target amount per discharge less than three thousand seven hundred fifty dollars shall be three thousand seven hundred fifty dollars. Effective October 1, 2007, the commissioner, in consultation with the Secretary of the Office of Policy and Management, shall establish, within available appropriations, an increased target amount per discharge of not less than four thousand two hundred fifty dollars for each hospital with a target amount per discharge less than four thousand two hundred fifty dollars for the rate period ending September 30, 2007, and the commissioner may apply an annual adjustment factor to the target amount per discharge for hospitals that are not increased as a result of this adjustment. Not later than October 1, 2008, the commissioner shall submit a report to the joint standing committees of the General Assembly having cognizance of matters relating to public health, human services and appropriations and the budgets of state agencies identifying any increased target amount per discharge established or annual adjustment factor applied on or after October 1, 2006, and the associated cost increase estimates related to such actions.

      (1949, 1953, S. 1586d; 1961, P.A. 474, S. 2; 1967, P.A. 726, S. 1; 1969, P.A. 339, S. 1; P.A. 73-117, S. 23, 31; P.A. 77-574, S. 4, 6; P.A. 79-560, S. 26, 39; P.A. 81-472, S. 111, 159; P.A. 84-367, S. 1, 3; P.A. 85-482, S. 1, 2; P.A. 87-27, S. 1; 87-516, S. 1, 5; P.A. 88-156, S. 19; P.A. 89-296, S. 6, 9; June Sp. Sess. P.A. 91-8, S. 13, 43, 63; May Sp. Sess. P.A. 92-16, S. 25, 89; P.A. 93-262, S. 1, 87; May Sp. Sess. P.A. 94-5, S. 2, 30; P.A. 95-160, S. 25, 69; 95-306, S. 1, 7; 95-351, S. 28, 30; P.A. 96-139, S. 12, 13; P.A. 98-131, S. 1, 2; P.A. 99-279, S. 13, 14, 45; June Sp. Sess. P.A. 00-2, S. 15, 53; June Sp. Sess. P.A. 01-2, S. 11, 66, 69; June Sp. Sess. P.A. 01-3, S. 1, 2, 6; June Sp. Sess. P.A. 01-9, S. 119, 120, 121, 129, 131; May 9 Sp. Sess. P.A. 02-7, S. 57; June 30 Sp. Sess. P.A. 03-3, S. 67, 68; P.A. 04-258, S. 1, 3; May Sp. Sess. P.A. 04-2, S. 34; P.A. 05-280, S. 6; P.A. 06-188, S. 21; June Sp. Sess. P.A. 07-2, S. 27.)

      History: 1961 act changed technical language, added standard of comparable charges to Subsec. (a), deleted requirement of Subsec. (b) that special services be professional and added Subsec. (c); 1967 act changed term "welfare" to "state" patients, restricted standard of comparable charges in Subsec. (a), made allowances for unpaid bills, working capital requirements and services development costs in determination of "actual cost" in Subsec. (c) and added Subsec. (d); 1969 act allowed alternative rates in Subsec. (a) based on charges for ward or semiprivate facilities and placed limit on rate for outpatient clinic visit in Subsec. (d); P.A. 73-117 replaced hospital cost commission with committee established in accordance with Sec. 17-311; P.A. 77-574 included allowances for costs associated with collective bargaining agreements in Subsec. (c); P.A. 79-560 replaced committee with commissioner of income maintenance; P.A. 81-472 made technical changes; P.A. 84-367 changed the basis of the rate from "actual" to "reasonable" cost and added Subsec. (e) setting rates for the inpatient care of patients who no longer require acute care; P.A. 85-482 amended Subsec. (d) by substituting 116% for 150% of combined average fee of general practitioner and specialist for office visit as maximum rate for an outpatient clinic visit; P.A. 87-27 amended Subsec. (c) to exclude from "reasonable cost" amounts paid to employees, attorneys or consultants due to unionization disputes; P.A. 87-516 allowed the commissioner to establish a rate cap if he receives approval for a disproportionate share exemption pursuant to federal regulations; P.A. 88-156 added freestanding chronic disease hospitals providing services to persons aided or cared for by the state for routine services furnished to state patients and gave the commissioner the discretion to set a higher rate for hospitals serving a disproportionate share of indigent patients; P.A. 89-296 amended Subsec. (d) to prohibit the state from paying a hospital for services in excess of the charges made by the hospital for comparable services to the public, added a new Subsec. (e) requiring the commissioner to adopt regulations establishing criteria for defining emergency and nonemergency visits to hospital emergency rooms and relettered former Subsec. (e) as Subsec. (f); June Sp. Sess. P.A. 91-8 amended Subsec. (b) to add a provision re payment by the state of charges in excess of charges made when comparable service is rendered to the general public and amended Subsec. (d) re rates paid by the state for outpatient clinic, services, emergency room visits and outpatient hospital services paid on the basis of a ratio of cost to charges; May Sp. Sess. P.A. 92-16 amended Subsec. (d) by providing that emergency room visit rates in effect on June 30, 1991, shall remain in effect through June 30, 1993, except that those which would decrease on July 1, 1992, shall decrease; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; May Sp. Sess. P.A. 94-5 amended Subsec. (d) to add a formula concerning outpatient hospital services paid on the basis of a ratio of cost to charges and required the commissioner to establish a fee schedule for outpatient hospital services, effective July 1, 1994; Sec. 17-312 transferred to Sec. 17b-239 in 1995; P.A. 95-160 amended Subsec. (a) by adding a provision for rates to be paid to freestanding chronic disease hospitals, effective July 1, 1995; P.A. 95-306 amended Subsec. (f) by prohibiting payment to an acute care general hospital for inpatient care of a patient if such patient is no longer in need of such care and is eligible for Medicare, unless Medicare reimbursement is not received for such care, effective July 1, 1995; P.A. 95-351 amended Subsec. (a) by providing that the commissioner use the "actual charge based on utilized service" instead of the "cost of service" when determining rates paid to freestanding chronic disease hospitals, effective July 1, 1995; P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; P.A. 98-131 added new Subsec. (g) requiring commissioner to establish hospital inpatient rates, effective July 1, 1998; P.A. 99-279 amended Subsec. (d) to eliminate annual increases in the fee schedule for outpatient hospital services for the rate periods beginning July 1, 1999, and July 1, 2000, and amended Subsec. (g) to provide an exception for the rate period beginning October 1, 1998, from the application of the 3% annual adjustment factor to the target amount per discharge, to prohibit the commissioner from applying an annual adjustment factor for succeeding rate periods, and to make a technical change, effective July 1, 1999; June Sp. Sess. P.A. 00-2 amended Subsec. (a) by deleting provisions re rates paid to freestanding chronic disease hospitals on and after July 1, 1995, and inserting provisions re rates paid to freestanding chronic disease hospitals and freestanding psychiatric hospitals, beginning July 1, 2000, and thereafter, effective July 1, 2000; June Sp. Sess. P.A. 01-2 amended Subsec. (a) to make a technical change for the purpose of gender neutrality, to require commissioner to use the rate of the highest-paid freestanding chronic disease hospital for any freestanding chronic disease hospital having more than an average of 15% of its inpatient days utilized as long-term ventilator patient days beginning for the rate period ending in 2001, in lieu of rate paid for period when determining rates paid on and after July 1, 2001, notwithstanding provisions of subsection, and to define term "long-term ventilator patient", effective July 1, 2001, and further amended Subsec. (a) to remove discretion of commissioner re determination of appropriate amount in the case of hospitals serving a disproportionate number share of indigent patients and to replace provisions re rates paid to freestanding chronic disease hospitals and freestanding psychiatric hospitals for rate period beginning July 1, 2001, effective July 2, 2001; June Sp. Sess. P.A. 01-3 amended Subsec. (d) by deleting provisions re rate for outpatient clinic visit and rate cap for outpatient clinics upon approval of disproportionate share exemption and adding provision re increase of fee schedule for rate period beginning July 1, 2001, and amended Subsec. (g) by deleting former provisions and adding provisions re establishment of inpatient hospital rates, effective July 1, 2001; June Sp. Sess. P.A. 01-9 amended Subsec. (d) to make 10.5% increase applicable to rate period beginning July 1, 2000, and effective June 1, 2001, and amended Subsec. (g) to make June 1, 2001, the date by which the commissioner is to establish inpatient hospital rates, effective July 1, 2001, and revised effective date of June Sp. Sess. P.A. 01-2 but without affecting this section; May 9 Sp. Sess. P.A. 02-7 amended Subsec. (a) by delaying from July 1, 2002, to January 1, 2003, a 2% rate increase to a free standing chronic disease hospital and a free standing psychiatric hospital and maintaining effectiveness of existing rate until December 31, 2002, effective August 15, 2002; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (d) to provide that outpatient rates in effect as of June 30, 2003, shall remain in effect through June 30, 2005, and amended Subsec. (g) by replacing "and October 1, 2002," with" through September 30, 2005," re period of time during which commissioner shall not apply an annual adjustment factor to target amount per discharge, effective August 20, 2003; P.A. 04-258 amended Subsec. (a) by providing that each freestanding chronic disease hospital shall receive a rate that is 2% more than the rate it received in the prior fiscal year and amended Subsec. (g) by substituting September 30, 2004, for September 30, 2005, re time period during which the commissioner shall not apply an annual adjustment factor to the target amount per discharge and adding provisions re revised target amount per discharge for the periods commencing April 1, 2005, April 1, 2006, and April 1, 2007, effective July 1, 2004; May Sp. Sess. P.A. 04-2 amended Subsec. (g) by substituting March 31, 2008, for September 30, 2004, effective July 1, 2004; P.A. 05-280 amended Subsec. (g) by changing effective date for the $4,000 revised target amount per discharge from April 1, 2006, to October 1, 2006, and changing effective date for the $4,250 revised target amount per discharge from April 1, 2007, to October 1, 2007, effective July 1, 2005; P.A. 06-188 amended Subsec. (a) to make a technical change, amended Subsec. (d) to allow commissioner, within available appropriations, to increase outpatient service fees for services that include clinic, emergency room, magnetic resonance imaging and computerized axial tomography and thereafter report to the General Assembly on such fee increases and the associated cost increase estimates, and amended Subsec. (g) to substitute "September 30, 2006" for "March 31, 2008" re time period during which commissioner shall not apply annual adjustment factor to target amount per discharge, and to substitute former provisions re target amount per discharge that were to take effect October 1, 2006, and October 1, 2007, with new language re target amount per discharge to take effect on October 1, 2006, and reporting requirement on cost estimates for new target amount per discharge, effective July 1, 2006; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by replacing "July 1, 2004" with "July 1, 2007" and "two" with "four" re percentage increase in the rate provided to freestanding chronic disease hospitals over the rate provided in prior fiscal year and amended Subsec. (g) by replacing provisions re increased target amount per discharge effective October 1, 2006, with provisions requiring commissioner to establish increased target amount per discharge effective October 1, 2007, and to report to the General Assembly on the costs associated with such action, effective July 1, 2007.

      Sec. 17b-244. (Formerly Sec. 17-313b). Payments to private facilities providing functional or vocational services for severely handicapped persons and payments for residential care. Establishment of rate. Regulations. (a) The room and board component of the rates to be paid by the state to private facilities and facilities operated by regional education service centers which are licensed to provide residential care pursuant to section 17a-227, but not certified to participate in the Title XIX Medicaid program as intermediate care facilities for persons with mental retardation, shall be determined annually by the Commissioner of Social Services, except that rates effective April 30, 1989, shall remain in effect through October 31, 1989. Any facility with real property other than land placed in service prior to July 1, 1991, shall, for the fiscal year ending June 30, 1995, receive a rate of return on real property equal to the average of the rates of return applied to real property other than land placed in service for the five years preceding July 1, 1993. For the fiscal year ending June 30, 1996, and any succeeding fiscal year, the rate of return on real property for property items shall be revised every five years. The commissioner shall, upon submission of a request by such facility, allow actual debt service, comprised of principal and interest, on the loan or loans in lieu of property costs allowed pursuant to section 17-313b-5 of the regulations of Connecticut state agencies, whether actual debt service is higher or lower than such allowed property costs, provided such debt service terms and amounts are reasonable in relation to the useful life and the base value of the property. In the case of facilities financed through the Connecticut Housing Finance Authority, the commissioner shall allow actual debt service, comprised of principal, interest and a reasonable repair and replacement reserve on the loan or loans in lieu of property costs allowed pursuant to section 17-313b-5 of the regulations of Connecticut state agencies, whether actual debt service is higher or lower than such allowed property costs, provided such debt service terms and amounts are determined by the commissioner at the time the loan is entered into to be reasonable in relation to the useful life and base value of the property. The commissioner may allow fees associated with mortgage refinancing provided such refinancing will result in state reimbursement savings, after comparing costs over the terms of the existing proposed loans. For the fiscal year ending June 30, 1992, the inflation factor used to determine rates shall be one-half of the gross national product percentage increase for the period between the midpoint of the cost year through the midpoint of the rate year. For fiscal year ending June 30, 1993, the inflation factor used to determine rates shall be two-thirds of the gross national product percentage increase from the midpoint of the cost year to the midpoint of the rate year. For the fiscal years ending June 30, 1996, and June 30, 1997, no inflation factor shall be applied in determining rates. The Commissioner of Social Services shall prescribe uniform forms on which such facilities shall report their costs. Such rates shall be determined on the basis of a reasonable payment for necessary services. Any increase in grants, gifts, fund-raising or endowment income used for the payment of operating costs by a private facility in the fiscal year ending June 30, 1992, shall be excluded by the commissioner from the income of the facility in determining the rates to be paid to the facility for the fiscal year ending June 30, 1993, provided any operating costs funded by such increase shall not obligate the state to increase expenditures in subsequent fiscal years. Nothing contained in this section shall authorize a payment by the state to any such facility in excess of the charges made by the facility for comparable services to the general public. The service component of the rates to be paid by the state to private facilities and facilities operated by regional education service centers which are licensed to provide residential care pursuant to section 17a-227, but not certified to participate in the Title XIX Medicaid programs as intermediate care facilities for persons with mental retardation, shall be determined annually by the Commissioner of Developmental Services in accordance with section 17b-244a. For the fiscal year ending June 30, 2008, no facility shall receive a rate that is more than two per cent greater than the rate in effect for the facility on June 30, 2007, except any facility that would have been issued a lower rate effective July 1, 2007, due to interim rate status or agreement with the department, shall be issued such lower rate effective July 1, 2007. For the fiscal year ending June 30, 2009, no facility shall receive a rate that is more than two per cent greater than the rate in effect for the facility on June 30, 2008, except any facility that would have been issued a lower rate effective July 1, 2008, due to interim rate status or agreement with the department, shall be issued such lower rate effective July 1, 2008.

      (b) The Commissioner of Social Services and the Commissioner of Developmental Services shall adopt regulations in accordance with the provisions of chapter 54 to implement the provisions of this section.

      (1971, P.A. 560, S. 1; P.A. 73-117, S. 26, 31; P.A. 79-227; 79-560, S. 28, 39; June Sp. Sess. P.A. 83-39, S. 1, 2, 18; P.A. 84-546, S. 54, 173; P.A. 88-71; P.A. 89-325, S. 14, 26; June Sp. Sess. P.A. 91-8, S. 15, 63; June Sp. Sess. P.A. 91-11, S. 11, 25; May Sp. Sess. P.A. 92-16, S. 28, 89; P.A. 93-262, S. 1, 87; May Sp. Sess. P.A. 94-5, S. 11, 30; P.A. 95-160, S. 65, 69; P.A. 96-139, S. 12, 13; 96-188, S. 1, 2; June 30 Sp. Sess. P.A. 03-3, S. 81; P.A. 05-256, S. 11; P.A. 07-73, S. 2(b); June Sp. Sess. P.A. 07-2, S. 13.)

      History: P.A. 73-117 replaced hospital cost commission with committee established under Sec. 17-311; P.A. 79-227 replaced committee with commissioner of income maintenance, included payments to community residences and changed Association for Retarded Children to Association for Retarded Citizens; P.A. 79-560 deleted reference to Sec. 17-311; June Sp. Sess. P.A. 83-39 provided for payment to private nonprofit facilities providing functional and vocational services for severely handicapped persons and to private facilities operated by regional education service centers providing residential care and added Subsec. (b) re establishment of separate rate (Revisor's note: Subsec. (c) was added editorially by the Revisors); P.A. 84-546 confirmed Revisors' action in editorially adding Subsec. (c) re adoption of regulations; P.A. 88-71 substantially rewrote section to empower commissioner of mental retardation to establish service component of rates where previously commissioner of income maintenance had set all rates and commissioner of mental retardation had performed a consultative role; P.A. 89-325 allowed rates in effect April 30, 1989, to remain in effect through October 31, 1989, and also deleted language re rates to be paid to private nonprofit facilities in Subsec. (a); June Sp. Sess. P.A. 91-8 amended Subsec. (a) re rates paid by the state to private facilities providing functional or vocational services for severely handicapped persons and clients of residential care facilities; June Sp. Sess. P.A. 91-11 amended Subsec. (a) to prohibit the department of income maintenance from considering any grants, gifts, fund-raising or endowment income used during the preceding year for payment of operating costs by a private facility in determining the facility's rates for fiscal year 1992-93; May Sp. Sess. P.A. 92-16 amended Subsec. (a) by providing that for the fiscal year ending June 30, 1993, the inflation factor used to determine rates shall be two-thirds of the gross national product percentage increase from the midpoint of the cost year to the midpoint of the rate year (Revisor's note: In Subsec. (a) in the sentence beginning "For the fiscal year ending June 30, 1992," the words "period between the" were inserted before the word "midpoint" and the words "cost year through the midpoint of the" were inserted before the words "rate year" editorially by the Revisors to reinstate existing language omitted through clerical error); P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; May Sp. Sess. P.A. 94-5 amended Subsec. (a) to establish a formula for rates of return for real property for facilities with real property other than land placed in service prior to July 1, 1991, effective July 1, 1994; Sec. 17-313b transferred to Sec. 17b-244 in 1995; P.A. 95-160 amended Subsec. (a) by adding a provision that for fiscal years ending June 30, 1996, and June 30, 1997, no inflation factor shall be applied in determining rates, effective June 1, 1995; P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; P.A. 96-188 provided that the commissioner shall allow, upon request of a facility, actual debt service whether higher or lower than allowed property costs, provided that, in the case of facilities financed through the Connecticut Housing Finance Authority, the commissioner shall allow actual debt service whether higher or lower than allowed property costs, provided such debt service terms and amounts are determined by the commissioner at the time the loan is entered into to be reasonable in relation to the useful life and base value of the property and made a technical change, effective May 31, 1996; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (a) to add provision re allowance of fees associated with mortgage refinancing provided such refinancing results in state reimbursement savings, effective August 20, 2003; P.A. 05-256 amended Subsec. (a) to include reference to Sec. 17b-244a, effective July 1, 2005; pursuant to P.A. 07-73 "Commissioner of Mental Retardation" was changed editorially by the Revisors to "Commissioner of Developmental Services", effective October 1, 2007; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by providing that for fiscal year ending June 30, 2008, a facility shall receive a rate that is 2% greater than the rate in effect for fiscal year ending June 30, 2007, and that for fiscal year ending June 30, 2009, a facility shall receive a rate that is 2% greater than the rate in effect for fiscal year ending June 30, 2008, except any facility that would have been issued a lower rate due to interim rate status or agreement with the department shall be issued such lower rate, effective July 1, 2007.

      Sec. 17b-244a. Rates for payments to residential facilities for mentally retarded and autistic persons. In determining the service component of the rates to be paid by the state under sections 17b-244 and 17b-246 to private facilities and facilities operated by regional education service centers that are licensed to provide residential care pursuant to section 17a-227, but not certified to participate in the Title XIX Medicaid programs as intermediate care facilities for persons with mental retardation, the Commissioner of Developmental Services shall consider for each facility the actual wage and benefit costs for services and service providers, adjusted for inflation, and said commissioner shall not establish a single fixed amount for wage and benefit costs that is applicable to all such facilities.

      (P.A. 05-256, S. 10; P.A. 07-73, S. 2(b).)

      History: P.A. 05-256 effective July 1, 2005; pursuant to P.A. 07-73 "Commissioner of Mental Retardation" was changed editorially by the Revisors to "Commissioner of Developmental Services", effective October 1, 2007.

      Sec. 17b-245b. Federally qualified health centers. Reimbursement methodology in the Medicaid program. The Commissioner of Social Services shall, consistent with federal law, make changes to the cost-based reimbursement methodology in the Medicaid program for federally qualified health centers. To the extent permitted by federal law, the commissioner may reimburse a federally qualified health center under the Medicaid program for multiple medical, behavioral health or dental services provided to an individual during the course of a calendar day, irrespective of the type of service provided. On or before January 1, 2008, the commissioner shall report to the joint standing committees of the General Assembly having cognizance of matters relating to appropriations and the budgets of state agencies and human services on the status of the changes to the cost-based reimbursement methodology.

      (June 30 Sp. Sess. P.A. 03-3, S. 85; P.A. 07-101, S. 1.)

      History: June 30 Sp. Sess. P.A. 03-3 effective August 20, 2003; P.A. 07-101 allowed commissioner, to extent permitted by federal law, to reimburse a federally qualified health center for multiple medical, behavioral health or dental services provided under Medicaid program to an individual during the course of a calendar day and changed date re commissioner's report on cost-based reimbursement methodology from March 1, 2004, to January 1, 2008, effective July 1, 2007.

      Sec. 17b-261. (Formerly Sec. 17-134b). Medicaid. Eligibility. Assets. Waiver from federal law. (a) Medical assistance shall be provided for any otherwise eligible person whose income, including any available support from legally liable relatives and the income of the person's spouse or dependent child, is not more than one hundred forty-three per cent, pending approval of a federal waiver applied for pursuant to subsection (d) of this section, of the benefit amount paid to a person with no income under the temporary family assistance program in the appropriate region of residence and if such person is an institutionalized individual as defined in Section 1917(c) of the Social Security Act, 42 USC 1396p(c), and has not made an assignment or transfer or other disposition of property for less than fair market value for the purpose of establishing eligibility for benefits or assistance under this section. Any such disposition shall be treated in accordance with Section 1917(c) of the Social Security Act, 42 USC 1396p(c). Any disposition of property made on behalf of an applicant or recipient or the spouse of an applicant or recipient by a guardian, conservator, person authorized to make such disposition pursuant to a power of attorney or other person so authorized by law shall be attributed to such applicant, recipient or spouse. A disposition of property ordered by a court shall be evaluated in accordance with the standards applied to any other such disposition for the purpose of determining eligibility. The commissioner shall establish the standards for eligibility for medical assistance at one hundred forty-three per cent of the benefit amount paid to a family unit of equal size with no income under the temporary family assistance program in the appropriate region of residence. Except as provided in section 17b-277, the medical assistance program shall provide coverage to persons under the age of nineteen with family income up to one hundred eighty-five per cent of the federal proverty level without an asset limit and to persons under the age of nineteen and their parents and needy caretaker relatives, who qualify for coverage under Section 1931 of the Social Security Act, with family income up to one hundred eighty-five per cent of the federal poverty level without an asset limit. Such levels shall be based on the regional differences in such benefit amount, if applicable, unless such levels based on regional differences are not in conformance with federal law. Any income in excess of the applicable amounts shall be applied as may be required by said federal law, and assistance shall be granted for the balance of the cost of authorized medical assistance. All contracts entered into on and after July 1, 1997, pursuant to this section shall include provisions for collaboration of managed care organizations with the Nurturing Families Network established pursuant to section 17a-56. The Commissioner of Social Services shall provide applicants for assistance under this section, at the time of application, with a written statement advising them of (1) the effect of an assignment or transfer or other disposition of property on eligibility for benefits or assistance, (2) the effect that having income that exceeds the limits prescribed in this subsection will have with respect to program eligibility, and (3) the availability of, and eligibility for, services provided by the Nurturing Families Network established pursuant to section 17a-56. Persons who are determined ineligible for assistance pursuant to this section shall be provided a written statement notifying such persons of their ineligibility and advising such persons of the availability of HUSKY Plan, Part B health insurance benefits.

      (b) For the purposes of the Medicaid program, the Commissioner of Social Services shall consider parental income and resources as available to a child under eighteen years of age who is living with his or her parents and is blind or disabled for purposes of the Medicaid program, or to any other child under twenty-one years of age who is living with his or her parents.

      (c) For the purposes of determining eligibility for the Medicaid program, an available asset is one that is actually available to the applicant or one that the applicant has the legal right, authority or power to obtain or to have applied for the applicant's general or medical support. If the terms of a trust provide for the support of an applicant, the refusal of a trustee to make a distribution from the trust does not render the trust an unavailable asset. Notwithstanding the provisions of this subsection, the availability of funds in a trust or similar instrument funded in whole or in part by the applicant or the applicant's spouse shall be determined pursuant to the Omnibus Budget Reconciliation Act of 1993, 42 USC 1396p. The provisions of this subsection shall not apply to special needs trust, as defined in 42 USC 1396p(d)(4)(A).

      (d) The transfer of an asset in exchange for other valuable consideration shall be allowable to the extent the value of the other valuable consideration is equal to or greater than the value of the asset transferred.

      (e) The Commissioner of Social Services shall seek a waiver from federal law to permit federal financial participation for Medicaid expenditures for families with incomes of one hundred forty-three per cent of the temporary family assistance program payment standard.

      (f) To the extent permitted by federal law, Medicaid eligibility shall be extended for one year to a family that becomes ineligible for medical assistance under Section 1931 of the Social Security Act due to income from employment by one of its members who is a caretaker relative or due to receipt of child support income. A family receiving extended benefits on July 1, 2005, shall receive the balance of such extended benefits, provided no such family shall receive more than twelve additional months of such benefits.

      (g) An institutionalized spouse applying for Medicaid and having a spouse living in the community shall be required, to the maximum extent permitted by law, to divert income to such community spouse in order to raise the community spouse's income to the level of the minimum monthly needs allowance, as described in Section 1924 of the Social Security Act. Such diversion of income shall occur before the community spouse is allowed to retain assets in excess of the community spouse protected amount described in Section 1924 of the Social Security Act. The Commissioner of Social Services, pursuant to section 17b-10, may implement the provisions of this subsection while in the process of adopting regulations, provided the commissioner prints notice of intent to adopt the regulations in the Connecticut Law Journal within twenty days of adopting such policy. Such policy shall be valid until the time final regulations are effective.

      (h) Medical assistance shall be provided, in accordance with the provisions of subsection (e) of section 17a-6, to any child under the supervision of the Commissioner of Children and Families who is not receiving Medicaid benefits, has not yet qualified for Medicaid benefits or is otherwise ineligible for such benefits because of institutional status. To the extent practicable, the Commissioner of Children and Families shall apply for, or assist such child in qualifying for, the Medicaid program.

      (i) The Commissioner of Social Services shall provide Early and Periodic Screening, Diagnostic and Treatment program services, as required and defined as of December 31, 2005, by 42 USC 1396a(a)(43), 42 USC 1396d(r) and 42 USC 1396d(a)(4)(B) and applicable federal regulations, to all persons who are under the age of twenty-one and otherwise eligible for medical assistance under this section.

      (1967, P.A. 759, S. 1(b); 1969, P.A. 730, S. 8; P.A. 78-192, S. 4, 7; P.A. 80-50; P.A. 81-214, S. 6; P.A. 85-505, S. 14, 21; 85-527; P.A. 86-363, S. 3; P.A. 87-390, S. 1, 4; P.A. 89-317, S. 1, 2; P.A. 92-233, S. 1; P.A. 93-262, S. 1, 87; 93-289, S. 1-3; 93-435, S. 59, 95; May Sp. Sess. P.A. 94-5, S. 16, 30; P.A. 95-194, S. 30, 33; 95-351, S. 22, 30; P.A. 96-251, S. 9; P.A. 97-288, S. 3, 6; June 18 Sp. Sess. P.A. 97-2, S. 70, 165; October 29 Sp. Sess. P.A. 97-1, S. 19, 23; P.A. 99-279, S. 16, 45; June Sp. Sess. P.A. 00-2, S. 18, 53; June Sp. Sess. P.A. 01-2, S. 3, 69; June Sp. Sess. P.A. 01-9, S. 129, 131; P.A. 03-2, S. 10; 03-28, S. 2; 03-268, S. 7; June 30 Sp. Sess. P.A. 03-3, S. 63; P.A. 04-16, S. 6; P.A. 05-1, S. 1; 05-24, S. 1; 05-43, S. 1; 05-280, S. 1; P.A. 06-164, S. 3; 06-188, S. 49; 06-196, S. 134, 238, 289; P.A. 07-185, S. 3; June Sp. Sess. P.A. 07-2, S. 7.)

      History: 1969 act deleted varying income limits and exclusions dependent upon marital status and number of dependents, referring instead to income limits under federal law; P.A. 78-192 added provisions re increases in eligibility standards; P.A. 80-50 added Subsec. (b); P.A. 81-214 added provisions re effect of transfer of property on eligibility for benefits in Subsec. (a); P.A. 85-505 amended Subsec. (a) to allow the extension of benefits for 6 months for former recipients; P.A. 85-527 amended Subsec. (a) by replacing "the minimum income permissible under federal law" with 120% "of the standard of need"; P.A. 86-363 included children under 18 years of age who are living with their parents and are blind or disabled in group for which parental income shall be considered under Subsec. (b); P.A. 87-390 changed the limit from 120% to 133%, added language on division of property and transfer of the interest in a house between spouses, and added requirement for a written statement advising applicants of the effect of an assignment, transfer or other disposition of property on eligibility; P.A. 89-317 amended Subsec. (a) to require that a person be institutionalized, as defined in the Social Security Act, to be eligible for medical assistance, changed the time from which a transfer of assets will be permitted from 24 months to 30 months prior to the date of application and 30 months prior to the date of institutionalization and to require treatment of any disposition of assets in accordance with Section 1917 (c) of the Social Security Act, 42 U.S.C. 1396p (c); P.A. 92-233 amended Subsec. (a) by adding provisions re attribution of property disposed of on behalf of an applicant or his spouse by a guardian, conservator or authorized representative and disposition of property ordered by a court; P.A. 93-262 and 93-435 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; P.A. 93-289, Sec. 1 required that the medical assistance program provide coverage to persons under the age of 6 and Sec. 2 was added editorially by the Revisors as Subsec. (c) requiring the department of income maintenance to submit a report, effective July 1, 1993; May Sp. Sess. P.A. 94-5 removed the time limit on transfers of assets and extended coverage to children under the age of 19 born after September 30, 1983, rather than children under 6, effective July 1, 1994; Sec. 17-134b transferred to Sec. 17b-261 in 1995; P.A. 95-194 amended Subsec. (a) by changing the eligibility for medical assistance from an income which is not more than 133% of the standard of need established pursuant to Sec. 17b-104 to an income which is not more than 142% of the benefit amount paid to a person with no income under the AFDC program in the appropriate region of residence and by requiring the commissioner to establish the standards for eligibility for medical assistance at 133% of the benefit amount paid to a family unit of equal size with no income under the AFDC program in the appropriate region of residence, added Subdiv. (d) requiring the commissioner to seek a waiver to permit federal financial participation for Medicaid expenditures and made technical changes, effective July 1, 1995; P.A. 95-351 replaced 142% with 143% as the highest allowable percentage of income for the provision of medical assistance and made a technical change, effective July 1, 1995; P.A. 96-251 amended Subsec. (c) by requiring that on and after October 1, 1996, reports be submitted to the legislative committee on human services and to legislators upon request and by adding provisions re submission of report summaries to legislators; P.A. 97-288 amended Subsec. (a) to require that contracts entered into after July 1, 1997, include provisions for collaboration of managed care organizations with the program established under Sec. 17a-56, effective July 1, 1997; June 18 Sp. Sess. P.A. 97-2 amended Subsec. (a) by extending Medicaid coverage, on and after July 1, 1998, from persons under the age of 19 born after September 30, 1983, to persons under the age of 19 born after September 30, 1981, or if possible, within available appropriations, born after June 30, 1980, with family income up to 185% of the federal poverty level without an asset limit, replaced references to aid to families with dependent children with temporary family assistance, and made technical and conforming changes, effective July 1, 1997; Oct. 29 Sp. Sess. P.A. 97-1 amended Subsec. (a) to provide that on and after January 1, 1998, the medical assistance program shall provide coverage to persons under the age of 19 and deleted reference to "born after June 30, 1981, or if possible within available appropriations, born after June 30, 1980", effective October 30, 1997; P.A. 99-279 amended Subsec. (a) to require extension of coverage under the medical assistance program to parents of children enrolled in the HUSKY Plan, Part A and to their needy caretaker relatives who qualify for coverage under Section 1931 of the Social Security Act and made technical changes, effective July 1, 2000; June Sp. Sess. P.A. 00-2 amended Subsec. (a) by deleting "born after September 30, 1981," changing "July 1, 2000," to "January 1, 2001," changing the family income level for eligibility for medical assistance from 185% to 150% of federal poverty level, and adding provision re providing coverage upon the request of a person or upon a redetermination of eligibility, effective July 1, 2000; June Sp. Sess. P.A. 01-2 made technical changes for purposes of gender neutrality in Subsec. (b), added new Subsecs. (c) and (d) re availability and transfer of assets, and redesignated existing Subsecs. (c) and (d) as Subsecs. (e) and (f), effective July 1, 2001; June Sp. Sess. P.A. 01-9 revised effective date of June Sp. Sess. P.A. 01-2 but without affecting this section; P.A. 03-2 amended Subsec. (a) by making a technical change and changing family income eligibility limit for parents and needy caretaker relatives who qualify for medical assistance program coverage under Section 1931 of the Social Security Act from 150% of the federal poverty limit to 100% of the federal poverty limit, and added new Subsec. (g), redesignated by the Revisors as new Subsec. (f), re ineligibility on or after April 1, 2003, of all parent and needy caretaker relatives with incomes exceeding 100% of the federal poverty level, effective February 28, 2003; P.A. 03-28 added new Subsec. (g) re extended Medicaid eligibility; P.A. 03-268 deleted former Subsec. (e) re submission of annual report to General Assembly re children receiving Medicaid services and doctors and dentists participating in state or municipally-funded programs and redesignated existing Subsec. (f) as Subsec. (e); June 30 Sp. Sess. P.A. 03-3 added new Subsec. (h) requiring an institutionalized spouse applying for Medicaid, who has a spouse living in the community, to divert income to the community spouse so as to raise the community spouse's income to the level of the minimum monthly needs allowance described in Section 1924 of the Social Security Act, effective August 20, 2003; P.A. 04-16 amended Subsec. (g) by adding "one of its members who is a caretaker relative is" re extended Medicaid eligibility and making a technical change; P.A. 05-1 added Subsec. (i) which extended transitional Medicaid benefits until June 30, 2005, for certain individuals who were to lose coverage between March 31, 2005, and May 31, 2005, effective March 10, 2005; P.A. 05-24 added new Subsec. (i) re provision of Medicaid coverage to a child under the supervision of the Commissioner of Children and Families, effective July 1, 2005; P.A. 05-43 amended Subsec. (g) by eliminating "or a family with an adult who, within 6 months of becoming ineligible under Section 1931 of the Social Security Act becomes employed", effective July 1, 2005; P.A. 05-280 amended Subsec. (a) by increasing family income limit re eligibility determinations for medical assistance for parents and needy caretakers of persons under the age of 19 from 100% to 150% of federal poverty level, deleted former Subsec. (f) re ineligibility for medical assistance for parents and needy caretaker relatives with incomes exceeding 100% of federal poverty level, redesignated Subsecs. (g) and (h) as Subsecs. (f) and (g), amended redesignated Subsec. (f) to reduce period of transitional medical assistance from 2 years to 1 year, add provision re extension of assistance to family that becomes ineligible "due to income from employment by" one of its members and provide that family receiving extended benefits "shall receive the balance of such extended benefits, provided no such family shall receive more than 12 additional months of such benefits", deleted former Subsec. (i) which had extended transitional medical assistance to June 30, 2005, for certain individuals and added new Subsec. (h) re cost sharing requirements under the HUSKY Plan, effective July 1, 2005; P.A. 06-164 amended Subsec. (a) to substitute "Nurturing Families Network" for "Healthy Families Connecticut Program", insert Subdiv. (1) designator and insert Subdiv. (2) re written statement on services provided by the Nurturing Families Network, effective July 1, 2006; P.A. 06-188 added Subsec. (j) re requirement to provide Early and Periodic Screening, Diagnostic and Treatment program services, as required by federal law, to persons under age 21 who are otherwise eligible for medical assistance, effective July 1, 2006; P.A. 06-196 made a technical change in Subsecs. (a) and (f), effective June 7, 2006, and inserted "and defined as of December 31, 2005," and made a technical change in Subsec. (j), effective July 1, 2006; P.A. 07-185 amended Subsec. (a) by increasing, except as provided in Sec. 17b-277, family income limits used to determine eligibility for medical assistance for parents and needy caretaker relatives of persons under the age of 19 from 150% of federal poverty level to 185% of federal poverty level, by providing that commissioner shall advise applicants in writing of effect that having income in excess of program limits will have with respect to program eligibility and availability of HUSKY Plan, Part B benefits for persons determined not eligible for medical assistance, and by making conforming changes, effective July 1, 2007; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by requiring that medical assistance coverage be provided to persons under 19 with family income up to 185% of federal poverty level without an asset limit, by deleting provision requiring that commissioner, at the time application for assistance is made, provide a written statement re availability of HUSKY Plan, Part B, health insurance benefits to persons not eligible for assistance, and by adding provision requiring that commissioner provide written statement at the time a person is determined ineligible for assistance, deleted former Subsec. (h) re commissioner's authority to impose cost sharing requirements on parents and needy caretakers with incomes in excess of 100% of federal poverty level, and redesignated existing Subsecs. (i) and (j) as Subsecs. (h) and (i), effective July 1, 2007.

      Sec. 17b-261e. Mobile field hospital: HUSKY and Medicaid coverage. The Commissioner of Social Services shall provide coverage for isolation care and emergency services provided by the state's mobile field hospital to persons participating in the HUSKY Plan Part A and Part B and fee for services Medicaid programs under this chapter.

      (P.A. 05-280, S. 66; P.A. 07-252, S. 63.)

      History: P.A. 05-280 effective July 1, 2005; P.A. 07-252 substituted "mobile field hospital" for "critical access hospital", effective July 12, 2007.

      Sec. 17b-261f. Mobile field hospital account. There is established a mobile field hospital account which shall be a separate, nonlapsing account within the General Fund. Moneys in the account shall be used by the Department of Social Services to fund the operations of the mobile field hospital in the event of an activation. The account shall contain all moneys required by law to be deposited in the account.

      (P.A. 05-280, S. 62; P.A. 07-252, S. 64.)

      History: P.A. 05-280 effective July 1, 2005; P.A. 07-252 substituted "mobile field hospital account" for "critical access hospital account" and "mobile field hospital" for "critical access hospital", effective July 12, 2007.

      Sec. 17b-261g. Reimbursement under Medicaid program for certain therapy services provided to children by home health care agencies. To the extent permitted by federal law, the Commissioner of Social Services shall provide reimbursement under the Medicaid program to children for physical therapy, occupational therapy and speech therapy services provided by a home health care agency, as defined in section 19a-490, in the child's home or a substantially equivalent environment. For purposes of such reimbursement, a substantially equivalent environment may include, but not be limited to, facilities that provide child day care services, as defined in subsection (a) of section 19a-77, and after school programs, as defined in section 10-16x.

      (P.A. 06-188, S. 50; June Sp. Sess. P.A. 07-5, S. 25.)

      History: P.A. 06-188 effective July 1, 2006; June Sp. Sess. P.A. 07-5 inserted "To the extent permitted by federal law", substituted "Medicaid" for "HUSKY Plan, Part A", and substituted "physical therapy, occupational therapy and speech therapy services" for "services", effective October 6, 2007.

      Sec. 17b-261h. Enrollment of HUSKY Plan, Part A recipients in available employer-sponsored private health insurance. Waiver from federal law. Regulations. (a) The Commissioner of Social Services shall, if required, seek a waiver from federal law for the purpose of enhancing the enrollment of HUSKY Plan, Part A recipients in available employer-sponsored private health insurance. Such a waiver shall include, but shall not be limited to, provisions that: (1) Require the enrollment of HUSKY Plan, Part A parents, needy caretaker relatives and dependents in any available employer-sponsored health insurance to the maximum extent of available coverage as a condition of eligibility when determined to be cost effective by the Department of Social Services; (2) require a subsidy to be paid directly to the HUSKY Plan, Part A caretaker relative in an amount equal to the premium payment requirements of any available employer-sponsored health insurance paid by way of payroll deduction; and (3) assure HUSKY Plan, Part A coverage requirements for medical assistance not covered by any available employment-sponsored health insurance.

      (b) Notwithstanding any provision of the general statutes or any provision established in a contract between an employer and a health insurance carrier, no HUSKY Plan, Part A recipient, required to enroll in available employer-sponsored health insurance under this section, shall be prohibited from enrollment in employer-sponsored health insurance due to limitations on enrollment of employees in employer-sponsored health insurance to open enrollment periods.

      (c) The Commissioner of Social Services, pursuant to section 17b-10, may implement policies and procedures necessary to administer the provisions of this section while in the process of adopting such policies and procedures as regulation, provided the commissioner prints notice of the intent to adopt the regulation in the Connecticut Law Journal not later than twenty days after the date of implementation. Policies and procedures implemented pursuant to this section shall be valid until the time final regulations are adopted.

      (June Sp. Sess. P.A. 07-2, S. 8.)

      History: June Sp. Sess. P.A. 07-2 effective July 1, 2007.

      Sec. 17b-265. (Formerly Sec. 17-134f). Department subrogated to right of recovery of applicant or recipient. Utilization of personal health insurance. Insurance coverage of medical assistance recipients. Limitations. (a) In accordance with 42 USC 1396k, the Department of Social Services shall be subrogated to any right of recovery or indemnification that an applicant or recipient of medical assistance or any legally liable relative of such applicant or recipient has against an insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, for the cost of all health care items or services furnished to the applicant or recipient, including, but not limited to, hospitalization, pharmaceutical services, physician services, nursing services, behavioral health services, long-term care services and other medical services, not to exceed the amount expended by the department for such care and treatment of the applicant or recipient. In the case of such a recipient who is an enrollee in a managed care organization under a Medicaid managed care contract with the state or a legally liable relative of such an enrollee, the department shall be subrogated to any right of recovery or indemnification which the enrollee or legally liable relative has against such a private insurer or other third party for the medical costs incurred by the managed care organization on behalf of an enrollee.

      (b) An applicant or recipient or legally liable relative, by the act of the applicant or recipient receiving medical assistance, shall be deemed to have made a subrogation assignment and an assignment of claim for benefits to the department. The department shall inform an applicant of such assignments at the time of application. Any entitlements from a contractual agreement with an applicant or recipient, legally liable relative or a state or federal program for such medical services, not to exceed the amount expended by the department, shall be so assigned. Such entitlements shall be directly reimbursable to the department by third party payors. The Department of Social Services may assign its right to subrogation or its entitlement to benefits to a designee or a health care provider participating in the Medicaid program and providing services to an applicant or recipient, in order to assist the provider in obtaining payment for such services. In accordance with subsection (b) of section 38a-472, a provider that has received an assignment from the department shall notify the recipient's health insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, of the assignment upon rendition of services to the applicant or recipient. Failure to so notify the health insurer or other legally liable third party shall render the provider ineligible for payment from the department. The provider shall notify the department of any request by the applicant or recipient or legally liable relative or representative of such applicant or recipient for billing information. This subsection shall not be construed to affect the right of an applicant or recipient to maintain an independent cause of action against such third party tortfeasor.

      (c) Claims for recovery or indemnification submitted by the department, or the department's designee, shall not be denied solely on the basis of the date of the submission of the claim, the type or format of the claim or the failure to present proper documentation at the point-of-service that is the basis of the claim, if (1) the claim is submitted by the state within the three-year period beginning on the date on which the item or service was furnished; and (2) any action by the state to enforce its rights with respect to such claim is commenced within six years of the state's submission of the claim.

      (d) When a recipient of medical assistance has personal health insurance in force covering care or other benefits provided under such program, payment or part-payment of the premium for such insurance may be made when deemed appropriate by the Commissioner of Social Services. Effective January 1, 1992, the commissioner shall limit reimbursement to medical assistance providers, except those providers whose rates are established by the Commissioner of Public Health pursuant to chapter 368d, for coinsurance and deductible payments under Title XVIII of the Social Security Act to assure that the combined Medicare and Medicaid payment to the provider shall not exceed the maximum allowable under the Medicaid program fee schedules.

      (e) Notwithstanding the provisions of subsection (c) of section 38a-553, no self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care plan, or any plan offered or administered by a health care center, pharmacy benefit manager, dental benefit manager or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, shall contain any provision that has the effect of denying or limiting enrollment benefits or excluding coverage because services are rendered to an insured or beneficiary who is eligible for or who received medical assistance under this chapter. No insurer, as defined in section 38a-497a, shall impose requirements on the state Medicaid agency, which has been assigned the rights of an individual eligible for Medicaid and covered for health benefits from an insurer, that differ from requirements applicable to an agent or assignee of another individual so covered.

      (f) The Commissioner of Social Services shall not pay for any services provided under this chapter if the individual eligible for medical assistance has coverage for the services under an accident or health insurance policy.

      (1967, P.A. 759, S. 1(f); P.A. 75-420, S. 4, 6; P.A. 77-614, S. 608, 610; P.A. 83-145; P.A. 84-367, S. 2, 3; P.A. 90-283, S. 1; June Sp. Sess. P.A. 91-8, S. 6, 63; P.A. 93-262, S. 1, 87; 93-381, S. 9, 39; 93-418, S. 32, 41; May Sp. Sess. P.A. 94-5, S. 6, 30; P.A. 95-257, S. 12, 21, 58; 95-305, S. 3, 6; P.A. 99-279, S. 17, 45; June Sp. Sess. P.A. 07-2, S. 20.)

      History: P.A. 75-420 replaced welfare commissioner with commissioner of social services; P.A. 77-614 replaced commissioner of social services with commissioner of income maintenance, effective January 1, 1979; P.A. 83-145 made the existing section Subsec. (b) and added Subsec. (a) dealing with subrogation to any right of recovery, assignment of claim for benefits and entitlements and right of action against third party tortfeasors; P.A. 84-367 added Subsec. (c) prohibiting a provision denying or limiting insurance benefits because services are rendered to an insured who is eligible for or received medical assistance and added Subsec. (d) prohibiting the commissioner from paying for services if the individual has coverage under an accident or health insurance policy; P.A. 90-283 in Subsec. (a) subrogated the department to any right of recovery of a legally liable relative of an applicant or recipient of medical assistance and added provisions whereby the department may assign its right of subrogation; June Sp. Sess. P.A. 91-8 amended Subsec. (b) to require a limitation on reimbursement to medical assistance providers for coinsurance and deductible payments to not exceed the maximum allowable under the Medicaid fee schedules, except for those providers licensed by the department of health services; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; P.A. 93-381 replaced commissioner of health services with commissioner of public health and addiction services, effective July 1, 1993; P.A. 93-418 changed reference to insurer to a private insurer or third party and made other technical changes, effective July 1, 1993; May Sp. Sess. P.A. 94-5 amended Subsec. (c) to prevent insurers from imposing requirements on the department of social services which deny or limit benefits which have been assigned pursuant to this section, effective July 1, 1994; Sec. 17-134f transferred to Sec. 17b-265 in 1995; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health, effective July 1, 1995; P.A. 95-305 amended Subsec. (c) by deleting a provision that an insurer, health care center or issuer of any service plan contract for hospital or medical expense coverage shall not impose requirements on the Department of Social Services which limit or deny benefits and adding a provision prohibiting an insurer from imposing certain requirements on the state Medicaid agency, effective July 1, 1995; P.A. 99-279 amended Subsec. (a) to provide that the department shall be subrogated to any right of recovery or indemnification which an enrollee in a managed care organization under a Medicaid managed care contract or legally liable relative has against a private insurer or other third party for the medical costs incurred by the managed care organization on behalf of an enrollee and made technical changes, effective July 1, 1999; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by dividing existing provisions into Subsecs. (a) and (b), amended redesignated Subsec. (a) by deleting "private", adding "legally liable", delineating entities deemed an insurer or a legally liable third party, adding "legally responsible for payment of a claim for a health care item or service", re responsibilities of third party, providing that health care items or services include behavioral health services and long-term care services and making technical changes, amended redesignated Subsec. (b) by adding "In accordance with subsection (b) of section 38a-472" re provider's notice to department of receipt of an assignment, replacing "private insurer" with "health insurer", adding "legally liable", and delineating entities deemed a health insurer or a legally liable third party, added new Subsec. (c) re time parameters for submission of claims for recovery or indemnification by department, redesignated existing Subsecs. (b) to (d) as Subsecs. (d) to (f), and amended redesignated Subsec. (e) by redefining types of health insurance plans that shall not contain provisions which have effect of denying or limiting enrollment benefits or excluding coverage because services are rendered to individual who is receiving medical assistance and making a technical change, effective July 1, 2007.

      Sec. 17b-265e. Medicare Part D Supplemental Needs Fund. Payment by department for nonformulary prescription drugs. (a) There is established a fund to be known as the "Medicare Part D Supplemental Needs Fund" which shall be an account within the General Fund under the Department of Social Services. Moneys available in said fund shall be utilized by the Department of Social Services to provide assistance to Medicare Part D beneficiaries who are enrolled in the ConnPACE program or who are full benefit dually eligible Medicare Part D beneficiaries, as defined in section 17b-265d, and whose medical needs require that they obtain nonformulary prescription drugs. A beneficiary requesting such assistance from the department shall be required to make a satisfactory showing of the medical necessity of obtaining such nonformulary prescription drug to the department. If the department, in consultation with the prescribing physician, determines that the prescription is medically necessary, the department shall cover the cost of the original prescription and any prescribed refills of the original prescription, less any applicable copayments. The department shall require as a condition of receiving such assistance that a beneficiary establish, to the satisfaction of the department, that the beneficiary has made good faith efforts to: (1) Enroll in a Medicare Part D plan recommended by the commissioner or the commissioner's agent; and (2) utilize the exception process established by the prescription drug plan in which the beneficiary is enrolled. The commissioner shall implement policies and procedures to administer the provisions of this section and to ensure that all requests for, and determinations made concerning assistance available pursuant to this section are expeditiously processed.

      (b) Assistance provided in accordance with the provisions of subsection (a) of this section shall be subject to available funds. All expenditures for prescription drugs under subsection (a) of this section shall be charged to the Medicare Part D Supplemental Needs Fund.

      (c) The Department of Social Services shall, in accordance with the provisions of this section, pay claims for prescription drugs for Medicare Part D beneficiaries, who are also either Medicaid or ConnPACE recipients and who are denied coverage by the Medicare Part D plan in which such beneficiary is enrolled because a prescribed drug is not on the formulary utilized by such Medicare Part D plan. Payment shall initially be made by the department for a thirty-day supply, subject to any applicable copayment. The beneficiary shall appoint the commissioner as such beneficiary's representative for the purpose of appealing any denial of Medicare Part D benefits and for any other purpose allowed under said act and deemed necessary by the commissioner.

      (d) Notwithstanding any provision of the general statutes, not later than July 1, 2006, the Commissioner of Social Services shall implement a plan for pursuing payment under Medicare Part D by Part D plans for prescriptions denied as nonformulary drugs, including remedies available through reconsideration by an independent review entity, review by an administrative law judge, the Medicare Appeals Council or Federal District Court. Reimbursement secured from the Medicare Part D plan shall be returned to the Department of Social Services.

      (e) The Department of Social Services, pursuant to subsection (d) of this section, may authorize appeals beyond the independent review entity. Upon determination by the department that it is not cost-effective to pursue further appeals, the department shall pay for the denied nonformulary drug for the remainder of the calendar year, provided the beneficiary remains enrolled in the Part D plan that denied coverage. Pending the outcome of the appeals process, the department shall continue to pay claims for the nonformulary drug denied by the Part D plan until the earlier of approval of such drug by the Part D plan or for the remainder of the calendar year.

      (Nov. 2 Sp. Sess. P.A. 05-2, S. 2; P.A. 06-188, S. 13; June Sp. Sess. P.A. 07-2, S. 4; June Sp. Sess. P.A. 07-5, S. 26.)

      History: Nov. 2 Sp. Sess. P.A. 05-2 effective December 1, 2005; P.A. 06-188 designated existing provisions as Subsec. (a), added Subsec. (b) re department's authority to pay for nonformulary prescription drugs, added Subsec. (c) re department's authority to contract with an entity for the purpose of pursuing Medicare Part D appeals and added Subsec. (d) re limitations on appeals and payment for nonformulary prescription drugs, effective July 1, 2006; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by deleting provision re designation of moneys to fund by commissioner within available appropriations, by replacing "financial assistance" with "assistance" and "who lack the financial means to obtain medically necessary" with "whose medical needs require that they obtain", by adding provision re department covering cost of original prescription and any prescribed refills, less any applicable copayments, by changing "may" to "shall" re requirements to receive assistance, and by deleting provision re department expeditiously reviewing request for assistance and notifying beneficiary not later than two hours after receiving request, added new Subsec. (b) re assistance provided subject to available funds and not to exceed amounts appropriated in P.A. 06-186, S. 1, redesignated existing Subsecs. (b) to (d) as Subsecs. (c) to (e), amended redesignated Subsec. (d) by deleting provision re department contracting with entity specializing in Medicare appeals and adding "implement a plan" re pursuing payment under Medicare Part D and by making technical changes, and amended redesignated Subsec. (e) by deleting provision re entity contracting with department and by making technical changes, effective July 1, 2007; June Sp. Sess. P.A. 07-5 deleted requirement in Subsec. (b) that expenditures not exceed amount appropriated in P.A. 06-186, S. 1, effective October 6, 2007.

      Sec. 17b-265f. Payment by the department for pharmacy claims. Limitations. Investigation of pharmacy. No pharmacy shall claim payment from the Department of Social Services under a medical assistance program administered by the department or the Medicare Part D Supplemental Needs Fund, established pursuant to section 17b-265e, for prescription drugs dispensed to individuals who have other prescription drug insurance coverage unless such coverage has been exhausted and the individual is otherwise eligible for such a medical assistance program or assistance from the Medicare Part D Supplemental Needs Fund. The department shall recoup from the submitting pharmacy any claims submitted to and paid by the department when other insurance coverage is available. The department shall investigate a pharmacy that consistently submits ineligible claims for payment to determine whether the pharmacy is in violation of its medical assistance provider agreement or is committing fraud or abuse in the program and based on the findings of such investigation, may take action against such pharmacy, in accordance with state and federal law.

      (June Sp. Sess. P.A. 07-2, S. 21.)

      History: June Sp. Sess. P.A. 07-2 effective June 26, 2007.

      Sec. 17b-265g. Health insurer. Duties owed to the state and Commissioner of Social Services. Any health insurer, including a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, and which may or may not be financially at risk for the cost of a health care item or service, shall, as a condition of doing business in the state, be required to: (1) Provide, with respect to an individual who is eligible for, or is provided, medical assistance under the Medicaid state plan, to all third-party administrators, pharmacy benefit managers, dental benefit managers or other entities with which the health insurer has a contract or arrangement to adjudicate claims for a health care item or service, and to the Commissioner of Social Services, or the commissioner's designee, any and all information in a manner and format prescribed by the commissioner, or commissioner's designee, necessary to determine when the individual, his or her spouse or the individual's dependents may be or have been covered by a health insurer and the nature of the coverage that is or was provided by such health insurer including the name, address and identifying number of the plan; (2) accept the state's right of recovery and the assignment to the state of any right of an individual or other entity to payment from the health insurer for an item or service for which payment has been made under the Medicaid state plan; (3) respond to any inquiry by the commissioner, or the commissioner's designee, regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of the provision of the item or service; and (4) agree not to deny a claim submitted by the state solely on the basis of the date of submission of the claim, the type or format of the claim form or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if (A) the claim is submitted by the state or its agent within the three-year period beginning on the date on which the item or service was furnished; and (B) any legal action by the state to enforce its rights with respect to such claim is commenced within six years of the state's submission of such claim.

      (June Sp. Sess. P.A. 07-2, S. 19.)

      History: June Sp. Sess. P.A. 07-2 effective July 1, 2007.

      Sec. 17b-277. (Formerly Sec. 17-134u). Medicaid for needy pregnant women. Expedited eligibility determinations. Presumptive Medicaid eligibility for newborn children. State plan amendment or waiver under federal law. Biannual reports. (a) The Commissioner of Social Services shall provide, in accordance with federal law and regulations, medical assistance under the Medicaid program to needy pregnant women whose families have an income not exceeding two hundred fifty per cent of the federal poverty level.

      (b) The commissioner shall expedite eligibility for appropriate pregnant women applicants for the Medicaid program. The process for making expedited eligibility determinations concerning needy pregnant women shall ensure that emergency applications for assistance, as determined by the commissioner, shall be processed no later than twenty-four hours after receipt of all required information from the applicant, and that nonemergency applications for assistance, as determined by the commissioner, shall be processed no later than five calendar days after the date of receipt of all required information from the applicant.

      (c) On or before September 30, 2007, the Commissioner of Social Services, shall submit a state plan amendment or, if required by the federal government, seek a waiver under federal law to provide health insurance coverage to pregnant women, who do not otherwise have creditable coverage, as defined in 42 USC 300gg(c), and who have income above one hundred eighty-five per cent of the federal poverty level but not in excess of two hundred fifty per cent of the federal poverty level. Following approval of such state plan amendment or approval of such waiver application, the commissioner, on or before January 1, 2008, shall implement the provisions of subsections (a) and (b) of this section.

      (d) Presumptive eligibility for medical assistance shall be implemented for any uninsured newborn child born in a hospital in this state or a border state hospital, provided (1) the parent or caretaker relative of such child resides in this state, and (2) the parent or caretaker relative of such child authorizes enrollment in the program.

      (e) The commissioner shall submit biannual reports to the council, established pursuant to section 17b-28, on the department's compliance with the administrative processing requirements set forth in subsection (b) of this section.

      (P.A. 88-217, S. 1, 2; P.A. 90-134, S. 4, 28; P.A. 93-262, S. 1, 87; June 18 Sp. Sess. P.A. 97-2, S. 72, 165; P.A. 05-280, S. 8; P.A. 07-185, S. 4; June Sp. Sess. P.A. 07-2, S. 9.)

      History: P.A. 90-134 added Subsec. (b) re presumptive eligibility; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; Sec. 17-134u transferred to Sec. 17b-277 in 1995; June 18 Sp. Sess. P.A. 97-2 made technical changes, effective July 1, 1997; P.A. 05-280 amended Subsec. (b) by replacing provisions re presumptive eligibility for pregnant women with respect to Medicaid program with provisions re expedited eligibility and requiring that emergency applications be processed no later than 24 hours after receipt of all required information and that nonemergency applications be processed no later than five calendar days after the date of receipt of all required information, and added new Subsec. (c) requiring commissioner to submit biannual reports to Medicaid managed care council, effective July 1, 2005; P.A. 07-185 amended Subsec. (a) by deleting "children up to one year of age" and replacing up to 185% with not exceeding 250% re federal poverty level, added new Subsec. (c) re presumptive Medicaid eligibility for an uninsured newborn born at an in-state hospital or border state hospital, and redesignated existing Subsec. (c) as Subsec. (d), effective July 1, 2007; June Sp. Sess. P.A. 07-2 added new Subsec. (c) re state plan amendment or waiver from federal law to extend health insurance coverage to pregnant women with income that exceeds 185% of federal poverty level but is not in excess of 250% of federal poverty level, and redesignated existing Subsecs. (c) and (d) as Subsecs. (d) and (e), effective July 1, 2007.

      Sec. 17b-285. (Formerly Sec. 17-134gg). Assignment of spousal support of an institutionalized person or person in need of institutional care. Notwithstanding any provision of the general statutes, an institutionalized person or person in need of institutional care who applies for Medicaid may assign to the Commissioner of Social Services the right of support derived from the assets of the community spouse of such person but only if (1) the assets of the institutionalized person or person in need of institutional care do not exceed the Medicaid program asset limit; and (2) the institutionalized person or person in need of institutional care cannot locate the community spouse; or the community spouse is unable to provide information regarding his or her own assets. If such assignment is made or if the institutionalized person or person in need of institutional care lacks the ability to execute such an assignment due to physical or mental impairment, the commissioner may seek recovery of any medical assistance paid on behalf of the institutionalized person or person in need of institutional care up to the amount of the community spouse's assets that are in excess of the community spouse protected amount as of the initial month of Medicaid eligibility.

      (P.A. 91-396; P.A. 93-262, S. 1; June Sp. Sess. P.A. 07-2, S. 6.)

      History: P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; Sec. 17-134gg transferred to Sec. 17b-285 in 1995; June Sp. Sess. P.A. 07-2 inserted "Notwithstanding any provision of the general statutes", replaced "shall" with "may" re assigning right of support to commissioner, replaced "spouse" with "community Spouse", revised criteria re when person applying for Medicaid may assign to commissioner the right to support derived from assets of a spouse, specified that assignments may be made only if assets of institutionalized person or person in need of institutional care do not exceed Medicaid program asset limit and such person cannot locate the community spouse, or the community spouse is unable to provide information regarding assets, deleted provision re bringing support proceeding against applicant's spouse without assignment and added provision re commissioner's authority to seek recovery of medical assistance paid on behalf of institutionalized person or person in need of institutional care, effective July 1, 2007.

      Sec. 17b-289. Short title: HUSKY and HUSKY Plus Act. HUSKY Plan, Part A and HUSKY Plan, Part B participants. (a) Sections 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session* shall be known as the "HUSKY and HUSKY Plus Act".

      (b) Children, caretaker relatives and pregnant women receiving assistance under section 17b-261 or 17b-277 shall be participants in the HUSKY Plan, Part A and children receiving assistance under sections 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session* shall be participants in the HUSKY Plan, Part B. For purposes of marketing and outreach and enrollment of persons eligible for assistance, both parts shall be known as the HUSKY Plan.

      (October 29 Sp. Sess. P.A. 97-1, S. 1, 23; P.A. 05-44, S. 1; P.A. 07-185, S. 5.)

      *Note: Section 16 of public act 97-1 of the October 29 special session is special in nature and therefore has not been codified but remains in full force and effect according to its terms.

      History: Oct. 29 Sp. Sess. P.A. 97-1 effective October 30, 1997; P.A. 05-44 amended Subsec. (b) to include caretaker relatives and pregnant women receiving assistance under Sec. 17b-261 or Sec. 17b-277 as participants in HUSKY Plan, Part A, effective July 1, 2005; P.A. 07-185 amended Subsec. (b) by adding "and enrollment of persons eligible for assistance" re purposes for which Part A and Part B shall be known as the HUSKY Plan, effective July 1, 2007.

      Sec. 17b-292. HUSKY Plan, Part B. Eligibility. Expedited eligibility under Husky Plan, Part B. Presumptive eligibility under Medicaid. Single point of entry services. Managed care enrollment brokerage services. Managed care enrollment brokerage services. Continued eligibility determinations. Regulations. (a) A child who resides in a household with a family income which exceeds one hundred eighty-five per cent of the federal poverty level and does not exceed three hundred per cent of the federal poverty level may be eligible for subsidized benefits under the HUSKY Plan, Part B.

      (b) A child who resides in a household with a family income over three hundred per cent of the federal poverty level may be eligible for unsubsidized benefits under the HUSKY Plan, Part B.

      (c) Whenever a court or family support magistrate orders a noncustodial parent to provide health insurance for a child, such parent may provide for coverage under the HUSKY Plan, Part B.

      (d) To the extent allowed under federal law, the commissioner shall not pay for services or durable medical equipment under the HUSKY Plan, Part B if the enrollee has other insurance coverage for the services or such equipment.

      (e) A newborn child who otherwise meets the eligibility criteria for the HUSKY Plan, Part B shall be eligible for benefits retroactive to his or her date of birth, provided an application is filed on behalf of the child not later than thirty days after such date. Any uninsured child born in a hospital in this state or in a border state hospital shall be enrolled on an expedited basis in the HUSKY Plan, Part B, provided (1) the parent or caretaker relative of such child resides in this state, and (2) the parent or caretaker relative of such child authorizes enrollment in the program. The commissioner shall pay any premium cost such family would otherwise incur for the first four months of coverage to the managed care organization selected by the parent or caretaker relative to provide coverage for such child.

      (f) The commissioner shall implement presumptive eligibility for children applying for Medicaid. Such presumptive eligibility determinations shall be in accordance with applicable federal law and regulations. The commissioner shall adopt regulations, in accordance with chapter 54, to establish standards and procedures for the designation of organizations as qualified entities to grant presumptive eligibility. Qualified entities shall ensure that, at the time a presumptive eligibility determination is made, a completed application for Medicaid is submitted to the department for a full eligibility determination. In establishing such standards and procedures, the commissioner shall ensure the representation of state-wide and local organizations that provide services to children of all ages in each region of the state.

      (g) The commissioner shall provide for a single point of entry servicer for applicants and enrollees under the HUSKY Plan, Part A and Part B. The commissioner, in consultation with the servicer, shall establish a centralized unit to be responsible for processing all applications for assistance under the HUSKY Plan, Part A and Part B. The department, through its servicer, shall ensure that a child who is determined to be eligible for benefits under the HUSKY Plan, Part A, or the HUSKY Plan, Part B has uninterrupted health insurance coverage for as long as the parent or guardian elects to enroll or re-enroll such child in the HUSKY Plan, Part A or Part B. The commissioner, in consultation with the servicer, and in accordance with the provisions of section 17b-297, shall jointly market both Part A and Part B together as the HUSKY Plan and shall develop and implement public information and outreach activities with community programs. Such servicer shall electronically transmit data with respect to enrollment and disenrollment in the HUSKY Plan, Part A and Part B to the commissioner.

      (h) Upon the expiration of any contractual provisions entered into pursuant to subsection (g) of this section, the commissioner shall develop a new contract for single point of entry services and managed care enrollment brokerage services. The commissioner may enter into one or more contractual arrangements for such services for a contract period not to exceed seven years. Such contracts shall include performance measures, including, but not limited to, specified time limits for the processing of applications, parameters setting forth the requirements for a completed and reviewable application and the percentage of applications forwarded to the department in a complete and timely fashion. Such contracts shall also include a process for identifying and correcting noncompliance with established performance measures, including sanctions applicable for instances of continued noncompliance with performance measures.

      (i) The single point of entry servicer shall send all applications and supporting documents to the commissioner for determination of eligibility. The servicer shall enroll eligible beneficiaries in the applicant's choice of managed care plan. Upon enrollment in a managed care plan, an eligible HUSKY Plan Part A or Part B beneficiary shall remain enrolled in such managed care plan for twelve months from the date of such enrollment unless (1) an eligible beneficiary demonstrates good cause to the satisfaction of the commissioner of the need to enroll in a different managed care plan, or (2) the beneficiary no longer meets program eligibility requirements.

      (j) Not later than ten months after the determination of eligibility for benefits under the HUSKY Plan, Part A and Part B and annually thereafter, the commissioner or the servicer, as the case may be, shall within existing budgetary resources, mail or, upon request of a participant, electronically transmit an application form to each participant in the plan for the purposes of obtaining information to make a determination on continued eligibility beyond the twelve months of initial eligibility. To the extent permitted by federal law, in determining eligibility for benefits under the HUSKY Plan, Part A or Part B with respect to family income, the commissioner or the servicer shall rely upon information provided in such form by the participant unless the commissioner or the servicer has reason to believe that such information is inaccurate or incomplete. The Department of Social Services shall annually review a random sample of cases to confirm that, based on the statistical sample, relying on such information is not resulting in ineligible clients receiving benefits under HUSKY Plan Part A or Part B. The determination of eligibility shall be coordinated with health plan open enrollment periods.

      (k) The commissioner shall implement the HUSKY Plan, Part B while in the process of adopting necessary policies and procedures in regulation form in accordance with the provisions of section 17b-10.

      (l) The commissioner shall adopt regulations, in accordance with chapter 54, to establish residency requirements and income eligibility for participation in the HUSKY Plan, Part B and procedures for a simplified mail-in application process. Notwithstanding the provisions of section 17b-257b, such regulations shall provide that any child adopted from another country by an individual who is a citizen of the United States and a resident of this state shall be eligible for benefits under the HUSKY Plan, Part B upon arrival in this state.

      (October 29 Sp. Sess. P.A. 97-1, S. 4, 23; P.A. 01-137, S. 1, 3, 4, 9; P.A. 03-2, S. 7; June 30 Sp. Sess. P.A. 03-3, S. 56; P.A. 04-16, S. 10; P.A. 05-280, S. 5, 9; P.A. 06-188, S. 16; P.A. 07-185, S. 6; June Sp. Sess. P.A. 07-2, S. 17.)

      History: Oct. 29 Sp. Sess. P.A. 97-1 effective October 30, 1997; P.A. 01-137 amended Subsec. (h) to require servicer to electronically transmit enrollment and disenrollment data re HUSKY Plan, Part B to commissioner who may transmit such data to Children's Health Council and amended Subsec. (k) to require the commissioner or servicer, as the case may be, to determine if a child continues to be eligible for benefits under the HUSKY Plan, Part A or Part B, to mail an application form to each participant in the plan and to rely upon information provided in the application form by the participant in determining eligibility for benefits under the plan with respect to family income unless the commissioner or servicer has reason to believe that such information is inaccurate or incomplete, effective July 1, 2001, and amended Subsec. (m) to require regulations providing that any child adopted from another country by a U.S. citizen and state resident shall be eligible for benefits under the HUSKY Plan, Part B upon arrival in this state, effective June 28, 2001; P.A. 03-2 deleted former Subsec. (d) which provided for 12 months of continuous eligibility under the HUSKY Plan, Part A or Part B, from the date that a child was determined eligible for the program and redesignated existing Subsecs. (e) to (m), inclusive, as Subsecs. (d) to (l), inclusive, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (a) to provide that the services and cost-sharing requirements under HUSKY Plan, Part B shall be substantially similar to those afforded to state residents by the largest commercially available health plan offered by a managed care organization, deleted former Subsecs. (f) and (h) re granting of presumptive eligibility under HUSKY Plan, Part A, redesignated existing Subsec. (g) as Subsec. (f) and deleted reference therein re transmittal of data to Children's Health Council, and redesignated existing Subsecs. (i) to (l) as Subsecs. (g) to (j), effective August 20, 2003; P.A. 04-16 made a technical change in Subsec. (a); P.A. 05-280 amended Subsec. (a) to delete provision that required HUSKY Plan, Part B services and cost-sharing requirements to be substantially similar to those of the largest commercially available health plan offered by a managed care organization, added new Subsec. (f) re implementation of presumptive eligibility for children applying for Medicaid and requiring commissioner to adopt regulations re standards and procedures for the designation of organizations that shall act as qualified entities to grant presumptive eligibility, redesignated existing Subsec. (f) as new Subsec. (g), added new Subsec. (h) re development of new contract for single point of entry services and managed care enrollment brokerage services, redesignated existing Subsecs. (g) to (j), inclusive, as new Subsecs. (i) to (l), inclusive, amended redesignated Subsec. (i) to require HUSKY Plan, Part A or Part B beneficiaries, enrolled in managed care plan, to remain enrolled in such plan for 12 months unless beneficiary demonstrates good cause to enroll in a different plan or no longer meets program eligibility requirements and amended redesignated Subsec. (j) to eliminate mandate that commissioner rely on family income information provided by participant in determining eligibility for benefits under the HUSKY Plan, Part A and Part B, effective July 1, 2005; P.A. 06-188 amended Subsec. (j) to permit commissioner, to the extent permitted by federal law, to rely on self-declared family income when making program eligibility determinations and to require department to review a random sample of cases to confirm that ineligible clients are not receiving program benefits, effective July 1, 2006; P.A. 07-185 amended Subsecs. (a) and (b) by adjusting family income eligibility limits from 300% to 400% of federal poverty level, amended Subsec. (e) by providing that uninsured child born in a hospital in this state or a border state shall be enrolled in HUSKY Plan, Part B with the commissioner to pay any premium costs for the first two months of coverage, provided the parent or caretaker relative of such child authorizes enrollment and resides in this state, amended Subsec. (g) by requiring commissioner, in consultation with servicer, to establish a centralized unit for processing applications for assistance under HUSKY Plan, Part A and Part B, to ensure that a child determined eligible for benefits has uninterrupted health insurance coverage for as long as the parent or guardian elects to enroll the child for coverage and to electronically transmit both Part A and Part B enrollment and disenrollment data to commissioner, amended Subsec. (i) by requiring servicer to transmit "all applications" to commissioner and deleting language re transmittal of applications where child resides in a home with family income not in excess of 185% of federal poverty level, amended Subsec. (j) by changing from 12 to 10 months the time period for commissioner to make continued eligibility determinations and by requiring that, within existing budgetary resources, commissioner, upon the request of a program participant, electronically transmit application information needed to make continued eligibility determinations beyond the 12 months of initial eligibility, effective July 1, 2007; June Sp. Sess. P.A. 07-2 amended Subsecs. (a) and (b) by adjusting family income eligibility limits from 400% to 300% of federal poverty level, amended Subsec. (e) by replacing "two" with "four" re months that commissioner shall pay premium costs for coverage of uninsured newborn children and made conforming changes in Subsecs. (g) and (j), effective July 1, 2007.

      Sec. 17b-295. Cost-sharing requirements under HUSKY Plan, Part B. (a) The commissioner shall impose cost-sharing requirements, including the payment of a premium or copayment, in connection with services provided under the HUSKY Plan, Part B, to the extent permitted by federal law, and in accordance with the following limitations:

      (1) The commissioner may increase the maximum annual aggregate cost-sharing requirements, provided such cost-sharing requirements shall not exceed five per cent of the family's gross annual income. The commissioner may impose a premium requirement on families whose income exceeds two hundred thirty-five per cent of the federal poverty level as a component of the family's cost-sharing responsibility, provided: (A) The family's annual combined premiums and copayments do not exceed the maximum annual aggregate cost-sharing requirement, and (B) premium requirements shall not exceed the sum of thirty dollars per month per child, with a maximum premium of fifty dollars per month per family. The commissioner shall not impose a premium requirement on families whose income exceeds one hundred eighty-five per cent of the federal poverty level but does not exceed two hundred thirty-five per cent of the federal poverty level; and

      (2) The commissioner shall require each managed care plan to monitor copayments and premiums under the provisions of subdivision (1) of this subsection.

      (b) (1) Except as provided in subdivision (2) of this subsection, the commissioner may impose limitations on the amount, duration and scope of benefits under the HUSKY Plan, Part B.

      (2) The limitations adopted by the commissioner pursuant to subdivision (1) of this subsection shall not preclude coverage of any item of durable medical equipment or service that is medically necessary.

      (October 29 Sp. Sess. P.A. 97-1, S. 7, 23; P.A. 98-8, S. 2, 5; June 30 Sp. Sess. P.A. 03-3, S. 55; P.A. 05-280, S. 7; Nov. 2 Sp. Sess. P.A. 05-1, S. 1; P.A. 06-196, S. 135; P.A. 07-185, S. 7; June Sp. Sess. P.A. 07-2, S. 44.)

      History: Oct. 29 Sp. Sess. P.A. 97-1 effective October 30, 1997; P.A. 98-8 amended Subsec. (a)(3) to require each managed care plan, rather than its health care providers, to monitor copayments and premiums, effective April 7, 1998; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (a) to require commissioner to impose cost-sharing requirements in connection with services provided under the HUSKY Plan, Part B to the extent permitted by federal law, to delete "may require" re payment of premiums and copayments, to delete former Subdivs. (1) and (2) re maximum annual cost-sharing for families and add new Subdiv. (1) providing that on and after October 1, 2003, commissioner may increase maximum annual cost-sharing for families in an amount not to exceed 5% of the family's gross annual income, and authorizing commissioner to impose a premium on families with income exceeding 185% of the federal poverty level as a component of the family's cost-sharing responsibility provided family's combined premiums and copayments do not exceed the maximum annual cost-sharing requirement, and to redesignate former Subdiv. (3) redesignated as Subdiv. (2); P.A. 05-280 amended Subsec. (a)(1) by substituting July 1, 2005, for October 1, 2003, and changing "may" to "shall" re commissioner increasing maximum annual cost-sharing requirements, by requiring the commissioner to impose a premium requirement that does not exceed the maximum annual aggregate cost-sharing requirement on families whose income exceeds 185% of the federal poverty level but does not exceed 235% of the federal poverty level and by increasing the premium requirement on families whose income exceeds 235% of the federal poverty level but does not exceed 300% of the federal poverty level, effective July 1, 2005; Nov. 2 Sp. Sess. P.A. 05-1 amended Subsec. (a)(1) by changing "shall" to "may" re commissioner's authority to increase maximum annual cost-sharing requirements, by providing that commissioner shall not impose premium requirements on families whose income exceeds 185% but does not exceed 235% of federal poverty level, by removing provision that required commissioner to increase premium requirements on families whose income exceeds 235% but does not exceed 300% of federal poverty level, and by providing that commissioner may impose premium requirements on families whose income exceeds 235% of federal poverty level, not exceeding $30 per month per child, with a maximum of $50 per month per family, effective November 3, 2005; P.A. 06-196 made technical changes in Subsec. (a), effective June 7, 2006; P.A. 07-185 amended Subsec. (a)(1) by deleting "On and after July 1, 2005, the", by specifying that Subpara. (B) applies to "a family with income that exceeds two hundred thirty-five per cent of the federal poverty level but does not exceed three hundred per cent of the federal poverty level" and by adding new Subpara. (C) specifying that "premium requirements for a family with income that exceeds three hundred per cent of the federal poverty level but does not exceed four hundred per cent of the federal poverty level who does not have any access to employer-sponsored health insurance coverage shall not exceed the sum of fifty dollars per child, with a maximum premium of seventy-five dollars per month", effective July 1, 2007; June Sp. Sess. P.A. 07-2 deleted new language in Subsec. (a)(1)(B) and new Subsec. (a)(1)(C) added by P.A. 07-185, effective July 1, 2007.

      Sec. 17b-297. Outreach programs for HUSKY Plan, Part A and Part B. (a) The commissioner, in consultation with the Children's Health Council, the Medicaid Managed Care Council and the 2-1-1 Infoline program, shall develop mechanisms to increase outreach and maximize enrollment of eligible children and adults in the HUSKY Plan, Part A or Part B, including, but not limited to, development of mail-in applications and appropriate outreach materials through the Department of Revenue Services, the Labor Department, the Department of Social Services, the Department of Public Health, the Department of Children and Families and the Office of Protection and Advocacy for Persons with Disabilities. Such mechanisms shall seek to maximize federal funds where appropriate for such outreach activities.

      (b) The commissioner shall include in such outreach efforts information on the Medicaid program for the purpose of maximizing enrollment of eligible children and the use of federal funds.

      (c) The commissioner shall, within available appropriations, contract with severe need schools and community-based organizations for purposes of public education, outreach and recruitment of eligible children, including the distribution of applications and information regarding enrollment in the HUSKY Plan, Part A and Part B. In awarding such contracts, the commissioner shall consider the marketing, outreach and recruitment efforts of organizations. For the purposes of this subsection, (1) "community-based organizations" shall include, but not be limited to, day care centers, schools, school-based health clinics, community-based diagnostic and treatment centers and hospitals, and (2) "severe need school" means a school in which forty per cent or more of the lunches served are served to students who are eligible for free or reduced price lunches.

      (d) The commissioner, in consultation with the Latino and Puerto Rican Affairs Commission, the African-American Affairs Commission, representatives from minority community-based organizations and any other state and local organizations deemed appropriate by the commissioner, shall develop and implement outreach efforts that target medically underserved children and adults, particularly Latino and other minority children and adults, to increase enrollment of such children and adults in the HUSKY Plan, Part A or Part B. Such efforts shall include, but not be limited to, developing culturally appropriate outreach materials, advertising through Latino media outlets and other minority media outlets, and the public education, outreach and recruitment activities described in subsections (a) to (c), inclusive, of this section.

      (e) All outreach materials shall be approved by the commissioner pursuant to Subtitle J of Public Law 105-33, as amended from time to time.

      (f) Not later than January 1, 2008, and annually thereafter, the commissioner shall submit a report to the Governor and the General Assembly on the implementation of and the results of the community-based outreach programs specified in subsections (a) to (d), inclusive, of this section.

      (October 29 Sp. Sess. P.A. 97-1, S. 9, 23; June 30 Sp. Sess. P.A. 03-3, S. 57; P.A. 07-185, S. 8.)

      History: Oct. 29 Sp. Sess. P.A. 97-1 effective October 30, 1997; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (c) to delete provision that permitted commissioner to contract with "qualified entities authorized to grant presumptive eligibility", effective August 20, 2003; P.A. 07-185 amended Subsec. (a) by substituting "the 2-1-1 Infoline program" for "Infoline of Connecticut", adding that commissioner shall develop mechanisms to increase outreach and maximize enrollment of eligible children and adults in HUSKY Plan, Part A or Part B and specifying that mechanisms shall seek to maximize federal funds where appropriate for outreach activities, added new Subsec. (d) requiring commissioner to develop and implement outreach efforts that target medically underserved children and adults, particularly Latino and other minority children and adults, to increase HUSKY Plan enrollment for such children and adults, redesignated existing Subsecs. (d) and (e) as Subsecs. (e) and (f), amended Subsec. (e) by adding "as amended from time to time" re Public Law 105-33, and amended Subsec. (f) by substituting "2008" for "1999" re submission of annual reports, substituting "programs" for "program" and making a technical change, effective July 1, 2007.

      Sec. 17b-297b. Procedures for sharing information in applications for school lunch program for purpose of determining eligibility under HUSKY Plan. Procedure for application for HUSKY Plan. (a) To the extent permitted by federal law, the Commissioners of Social Services and Education shall jointly establish procedures for the sharing of information contained in applications for free and reduced price meals under the National School Lunch Program for the purpose of determining whether children participating in said program are eligible for coverage under the HUSKY Plan, Part A and Part B. The Commissioner of Social Services shall take all actions necessary to ensure that children identified as eligible for either the HUSKY Plan, Part A or Part B, are enrolled in the appropriate plan.

      (b) The Commissioner of Education shall establish procedures whereby an individual may apply for the HUSKY Plan, Part A or Part B, at the same time such individual applies for the National School Lunch Program.

      (P.A. 01-137, S. 7, 9; P.A. 03-19, S. 43; P.A. 07-185, S. 9.)

      History: P.A. 01-137 effective July 1, 2001; P.A. 03-19 made technical changes in Subsec. (a), effective May 12, 2003; P.A. 07-185 amended Subsec. (a) by providing that commissioner shall ensure that children identified as eligible for either HUSKY Plan, Part A or Part B, are enrolled in the appropriate plan, effective July 1, 2007.

      Sec. 17b-306. Plan for a system of preventive health services for children under the HUSKY Plan, Part A and Part B. (a) The Commissioner of Social Services, in consultation with the Commissioner of Public Health, shall develop and within available appropriations implement a plan for a system of preventive health services for children under the HUSKY Plan, Part A and Part B. The goal of the system shall be to improve health outcomes for all children enrolled in the HUSKY Plan and to reduce racial and ethnic health disparities among children. Such system shall ensure that services under the federal Early and Periodic Screening, Diagnosis and Treatment Program are provided to children enrolled in the HUSKY Plan, Part A.

      (b) The plan shall:

      (1) Establish a coordinated system for preventive health services for HUSKY Plan, Part A and Part B beneficiaries including, but not limited to, services under the federal Early and Periodic Screening, Diagnosis and Treatment Program, ophthalmologic and optometric services, oral health care, care coordination, chronic disease management and periodicity schedules based on standards specified by the American Academy of Pediatrics;

      (2) Require the Department of Social Services to track the utilization of services in the system of preventive health services by HUSKY Plan, Part A and Part B beneficiaries to ensure that such beneficiaries receive all the services available under the system and to track the health outcomes of children; and

      (3) Include payment methodologies to create financial incentives and rewards for health care providers who participate and provide services in the system, such as case management fees, pay for performance, and payment for technical support and data entry associated with patient registries.

      (c) The Commissioner of Social Services shall develop the plan for a system of preventive health services not later than January 1, 2008, and implement the plan not later than July 1, 2008.

      (d) Not later than July 1, 2009, the Commissioner of Social Services shall report, in accordance with the provisions of section 11-4a, to the joint standing committees of the General Assembly having cognizance of matters relating to human services, insurance and public health on the plan for a system of preventive health services. The report shall include information on health outcomes, quality of care and methodologies utilized in the plan to improve the quality of care and health outcomes for children.

      (P.A. 07-185, S. 13; June Sp. Sess. P.A. 07-2, S. 10.)

      History: P.A. 07-185 effective July 1, 2007; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by specifying that implementation of plan shall be "within available appropriations", amended Subsec. (b)(1) by replacing "vision care" with "ophthalmologic and optometric services", amended Subsec. (b)(2) by deleting "electronically" re tracking utilization of services, and amended Subsec. (d) by deleting commissioner's responsibility to report on "the implementation of" plan, effective July 1, 2007.

      Sec. 17b-306a. Child health quality improvement program. Purpose and scope. Annual report. (a) The Commissioner of Social Services, in collaboration with the Commissioners of Public Health and Children and Families, shall establish a child health quality improvement program for the purpose of promoting the implementation of evidence-based strategies by providers participating in the HUSKY Plan, Part A and Part B to improve the delivery of and access to children's health services. Such strategies shall focus on physical, dental and mental health services and shall include, but need not be limited to: (1) Methods for early identification of children with special health care needs; (2) integration of care coordination and care planning into children's health services; (3) implementation of standardized data collection to measure performance improvement; and (4) implementation of family-centered services in patient care, including, but not limited to, the development of parent-provider partnerships. The Commissioner of Social Services shall seek the participation of public and private entities that are dedicated to improving the delivery of health services, including medical, dental and mental health providers, academic professionals with experience in health services research and performance measurement and improvement, and any other entity deemed appropriate by the Commissioner of Social Services, to promote such strategies. The commissioner shall ensure that such strategies reflect new developments and best practices in the field of children's health services. As used in this section, "evidence-based strategies" means policies, procedures and tools that are informed by research and supported by empirical evidence, including, but not limited to, research developed by organizations such as the American Academy of Pediatrics, the American Academy of Family Physicians, the National Association of Pediatric Nurse Practitioners and the Institute of Medicine.

      (b) Not later than July 1, 2008, and annually thereafter, the Commissioner of Social Services shall report, in accordance with section 11-4a, to the joint standing committees of the General Assembly having cognizance of matters relating to human services, public health and appropriations, and to the Medicaid Managed Care Council on (1) the implementation of any strategies developed pursuant to subsection (a) of this section, and (2) the efficacy of such strategies in improving the delivery of and access to health services for children enrolled in the HUSKY Plan.

      (P.A. 07-185, S. 14.)

      History: P.A. 07-185 effective July 1, 2007.

      Sec. 17b-307. Primary care case management pilot program. Notwithstanding any provision of the general statutes, not later than November 1, 2007, the Department of Social Services shall develop a plan to implement a pilot program for the delivery of health care services through a system of primary care case management to not less than one thousand individuals who are otherwise eligible to receive HUSKY Plan, Part A benefits. Such plan shall be submitted to the joint standing committees of the General Assembly having cognizance of matters relating to human services and appropriations and the budgets of state agencies. Not later than thirty days after the date of receipt of such plan, said joint standing committees of the General Assembly shall hold a joint public hearing to review such plan. Said joint standing committees of the General Assembly may advise the commissioner of their approval or denial or modifications, if any, of the plan. Primary care providers participating in the primary care case management system shall provide program beneficiaries with primary care medical services and arrange for specialty care as needed. For purposes of this section, "primary care case management" means a system of care in which the health care services for program beneficiaries are coordinated by a primary care provider chosen by or assigned to the beneficiary. The Commissioner of Social Services shall begin enrollment for the primary care case management system not later than April 1, 2008.

      (June Sp. Sess. P.A. 07-2, S. 16.)

      History: June Sp. Sess. P.A. 07-2 effective July 1, 2007.

      Sec. 17b-311*. Charter Oak Health Plan. (a) There is established the Charter Oak Health Plan for the purpose of providing access to health insurance coverage for state residents who have been uninsured for at least six months and who are ineligible for other publicly funded health insurance plans. The Commissioner of Social Services may enter into contracts for the provision of comprehensive health care for such uninsured state residents. The commissioner shall conduct outreach to facilitate enrollment in the plan.

      (b) The commissioner shall impose cost-sharing requirements in connection with services provided under the Charter Oak Health Plan. Such requirements may include, but not be limited to: (1) A monthly premium; (2) an annual deductible not to exceed one thousand dollars; (3) a coinsurance payment not to exceed twenty per cent after the deductible amount is met; (4) tiered copayments for prescription drugs determined by whether the drug is generic or brand name, formulary or nonformulary and whether purchased through mail order; (5) no fee for emergency visits to hospital emergency rooms; (6) a copayment not to exceed one hundred fifty dollars for nonemergency visits to hospital emergency rooms; and (7) a lifetime benefit not to exceed one million dollars.

      (c) The Commissioner of Social Services shall provide premium assistance to eligible state residents whose gross annual income does not exceed three hundred per cent of the federal poverty level. Such premium assistance shall be limited to: (1) One hundred seventy-five dollars per month for individuals whose gross annual income is below one hundred fifty per cent of the federal poverty level; (2) one hundred fifty dollars per month for individuals whose gross annual income is at or above one hundred fifty per cent of the federal poverty level but not more than one hundred eighty-five per cent of the federal poverty level; (3) seventy-five dollars per month for individuals whose gross annual income is above one hundred eighty-five per cent of the federal poverty level but not more than two hundred thirty-five per cent of the federal poverty level; and (4) fifty dollars per month for individuals whose gross annual income is above two hundred thirty-five per cent of the federal poverty level but not more than three hundred per cent of the federal poverty level. Individuals insured under the Charter Oak Health Plan shall pay their share of payment for coverage in the plan directly to the insurer.

      (d) The Commissioner of Social Services shall determine minimum requirements on the amount, duration and scope of benefits under the Charter Oak Health Plan, except that there shall be no preexisting condition exclusion. Each participating insurer shall provide an internal grievance process by which an insured may request and be provided a review of a denial of coverage under the plan.

      (e) The Commissioner of Social Services may contract with the following entities for the purposes of this section: (1) A health care center subject to the provisions of chapter 698a; (2) a consortium of federally qualified health centers and other community-based providers of health services which are funded by the state; or (3) other consortia of providers of health care services established for the purposes of this section. Providers of comprehensive health care services as described in subdivisions (2) and (3) of this subsection shall not be subject to the provisions of chapter 698a. Any such provider shall be certified by the commissioner to participate in the Charter Oak Health Plan in accordance with criteria established by the commissioner, including, but not limited to, minimum reserve fund requirements.

      (f) The Commissioner of Social Services shall seek proposals from entities described in subsection (e) of this section based on the cost sharing and benefits described in subsections (b) and (c) of this section. The commissioner may approve an alternative plan in order to make coverage options available to those eligible to be insured under the plan.

      (g) The Commissioner of Social Services, pursuant to section 17b-10, may implement policies and procedures to administer the provisions of this section while in the process of adopting such policies and procedures as regulation, provided the commissioner prints notice of the intent to adopt the regulation in the Connecticut Law Journal not later than twenty days after the date of implementation. Such policies shall be valid until the time final regulations are adopted and may include: (1) Exceptions to the requirement that a resident be uninsured for at least six months to be eligible for the Charter Oak Health Plan; and (2) requirements for open enrollment and limitations on the ability of enrollees to change plans between such open enrollment periods.

      (June Sp. Sess. P.A. 07-2, S. 23.)

      *Note: This section is effective July 1, 2008.

      History: June Sp. Sess. P.A. 07-2 effective July 1, 2008.