CHAPTER 319v
MEDICAL ASSISTANCE

Table of Contents

Sec. 17b-224. (Formerly Sec. 17-295b). Liability of patient for per capita cost of care.
Sec. 17b-226. (Formerly Sec. 17-295d). Consideration of the costs mandated by collective bargaining agreements.
Sec. 17b-229. (Formerly Sec. 17-299). Liability for prior charges.
Sec. 17b-239. (Formerly Sec. 17-312). Payments to hospitals. Regulations.
Sec. 17b-239c. Interim disproportionate share payments to short-term general hospitals.
Sec. 17b-239d. Payments for outpatient hospital services.
Sec. 17b-239e. Hospital rate plan. Inpatient hospital case rate.
Sec. 17b-240. (Formerly Sec. 17-312a). State payments to hospitals. Rates established by the Office of Health Care Access division of the Department of Public Health.
Sec. 17b-242. (Formerly Sec. 17-313). Payments to home health care agencies and homemaker-home health aide agencies. Appeals. Hearings. Regulations.
Sec. 17b-243. (Formerly Sec. 17-313a). Payments to rehabilitation centers.
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.
Sec. 17b-245. (Formerly Sec. 17-313c). Payments to day care and vocational training programs sponsored by certain associations.
Sec. 17b-256. (Formerly Sec. 17-314m). Prescription drug and insurance assistance program for persons with acquired immunodeficiency syndrome or human immunodeficiency virus. Annual report. Enrollment in Medicare Part D.
Sec. 17b-256d. State medical assistance program. Use of federally-qualified community health centers.
Sec. 17b-256f. Eligibility for Medicare savings programs. Regulations.
Sec. 17b-257b. Alien eligibility for state medical assistance. Regulations.
Sec. 17b-257c. Payments to long-term care facilities for care of illegal immigrants admitted to acute care or psychiatric hospitals. Eligibility. Regulations.
Sec. 17b-260d. Home and community-based services waiver serving persons with acquired immune deficiency syndrome or human immunodeficiency virus.
Sec. 17b-261. (Formerly Sec. 17-134b). Medicaid. Eligibility. Assets. Waiver from federal law.
Sec. 17b-261a. Transfer or assignment of assets resulting in the imposition of a penalty period. Return or partial return of asset. Regulations.
Sec. 17b-261i. Administrative services for Medicaid recipients. Regulations.
Sec. 17b-261k. Protected amount for the community spouse of an institutionalized Medicaid applicant. Regulations.
Sec. 17b-261m. Administrative services organization. Contract for services. Establishment of rates.
Sec. 17b-261n. Coverage for low-income adults under Medicaid program. Amendment to state Medicaid plan to establish alternative benefit package. Regulations.
Sec. 17b-261o. Imposition of penalty period when undue hardship exists. Exception.
Sec. 17b-261p. Notice re determination of penalty period. Filing claim of undue hardship. Nursing home involvement.
Sec. 17b-263. (Formerly Sec. 17-274b). Utilization of outpatient mental health services. Contracts for services. Fee schedule and payment for services.
Sec. 17b-263a. Amendment to state Medicaid plan to include assertive community treatment teams and community support services.
Sec. 17b-263b. Pilot program for individuals ages nineteen to twenty-one with a mental disorder and chronic health condition. Eligibility.
Sec. 17b-263c. Medical homes. Regulations.
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.
Sec. 17b-265e. Medicare Part D Supplemental Needs Fund. Payment by department for nonformulary prescription drugs. Rebates required for pharmaceutical manufacturers. Contracts for supplemental rebates.
Sec. 17b-265f. Payment by the department for pharmacy claims. Limitations. Investigation of pharmacy.
Sec. 17b-272. (Formerly Sec. 17-134m). Personal fund allowance.
Sec. 17b-274. (Formerly Sec. 17-134q). Periodic investigations of pharmacies by Division of Criminal Justice. Brand medically necessary. Procedure for prior approval to dispense brand name drug. Disclosure.
Sec. 17b-274a. Maximum allowable costs for generic prescription drugs. Implementation of maximum allowable cost list.
Sec. 17b-274c. Voluntary mail order option for maintenance prescription drugs and drugs covered under the Medicare Part D program.
Sec. 17b-274d. Pharmaceutical and Therapeutics Committee. Membership. Duties. Preferred drug lists. Supplemental rebates. Administrative hearings.
Sec. 17b-274e. Prescription drugs. Utilization of cost-efficient dosages.
Sec. 17b-276. (Formerly Sec. 17-134s). Competitive bidding process for nonemergency transportation services. Disclosure of payment source. Fee schedules.
Sec. 17b-278a. Coverage for treatment for smoking cessation.
Sec. 17b-278g. Medical assistance for eyeglasses and contact lenses. Regulations.
Sec. 17b-280. (Formerly Sec. 17-134bb). Reimbursement rate for legend drugs. Dispensing fee. Reimbursement for over-the-counter drugs and products. Dispensing fee exception. Enhanced dispensing fee.
Sec. 17b-280a. Payment for over-the-counter drugs under medical assistance program. Exceptions.
Sec. 17b-282d. Commissioner to modify nonemergency dental services. Regulations.
Sec. 17b-290. Definitions.
Sec. 17b-292. HUSKY Plan, Part B. Eligibility. Expedited eligibility under HUSKY Plan, Part B. Presumptive eligibility under Medicaid. Single point of entry services. Continued eligibility determinations. Regulations.
Sec. 17b-295. Cost-sharing requirements under HUSKY Plan, Part B.
Sec. 17b-297. Outreach programs for HUSKY Plan, Part A and Part B.
Sec. 17b-301a. Prohibited acts re medical assistance: Definitions.
Sec. 17b-301b. Prohibited acts re medical assistance. Penalties.
Sec. 17b-301d. Civil action by individual. Consent for withdrawal. Manner of service. Complaint under seal. Intervening in action by Attorney General.
Sec. 17b-301e. Prosecution by Attorney General. Withdrawal. Settlement. Limits on individual's participation. Division of proceeds. Attorneys' fees and costs.
Sec. 17b-301i. Court's jurisdiction over civil actions brought by certain individuals.
Sec. 17b-301k. Discrimination in employment because of acts in furtherance of civil action prohibited. Remedies. Attorneys' fees and costs.
Sec. 17b-301l. Time for bringing civil action. State's intervention in action.
Sec. 17b-306a. Child health quality improvement program. Purpose and scope. Annual reports.
Sec. 17b-311. Charter Oak Health Plan.

      Sec. 17b-224. (Formerly Sec. 17-295b). Liability of patient for per capita cost of care. A patient who is receiving or has received care in a state humane institution, his estate or both shall be liable to reimburse the state for any unpaid portion of per capita cost to the same extent as the liability of a public assistance beneficiary under sections 17b-93 and 17b-95, subject to the same protection of a surviving spouse or dependent child as is provided in section 17b-95 and subject to the same limitations and the same assignment and lien rights as provided in section 17b-94.

      (1969, P.A. 730, S. 13; P.A. 11-44, S. 72.)

      History: Sec. 17-295b transferred to Sec. 17b-224 in 1995; P.A. 11-44 added provision making liability of patient subject to rights and limitations provided in Sec. 17b-94 and made a technical change, effective July 1, 2011.

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      Sec. 17b-226. (Formerly Sec. 17-295d). Consideration of the costs mandated by collective bargaining agreements. The state shall take into consideration the costs mandated by collective bargaining agreements with certified collective bargaining agents or other agreements between employers and employees when making grants to or entering into contracts for services with the following: (1) Nonprofit organizations for mental health services pursuant to section 17a-476; (2) nonprofit organizations concerning services for drug-dependent and alcohol-dependent persons pursuant to section 17a-676; (3) residential and educational services pursuant to subsections (a) and (b) of section 17a-17; (4) psychiatric clinics and community mental health facilities pursuant to section 17a-20; (5) day treatment centers pursuant to section 17a-22; (6) youth service bureaus pursuant to subsection (a) of section 10-19n; (7) programs for the treatment and prevention of child abuse and neglect and for juvenile diversion pursuant to section 17a-49; (8) community-based service programs pursuant to sections 18-101i and 18-101k; (9) programs for children and adults with intellectual disability pursuant to section 17a-217; (10) community-based residential facilities for persons with intellectual disability pursuant to section 17a-218; and (11) vocational training programs for adults with intellectual disability pursuant to section 17a-226.

      (P.A. 87-497, S. 2, 3; P.A. 90-209, S. 22; P.A. 91-406, S. 3, 29; P.A. 93-381, S. 13, 39; P.A. 11-129, S. 7.)

      History: P.A. 90-209 in Subdiv. (2) substituted "alcohol-dependent" for "alcoholic" and Sec. 17-155gg for repealed Sec. 17-226d and made a technical change; P.A. 91-406 deleted former Subdiv. (11) re diagnostic clinics for mentally retarded persons, renumbering former Subsec. (12) accordingly; P.A. 93-381 made technical changes, effective July 1, 1993; Sec. 17-295d transferred to Sec. 17b-226 in 1995; P.A. 11-129 replaced references to "mentally retarded" with references to "intellectual disability".

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      Sec. 17b-229. (Formerly Sec. 17-299). Liability for prior charges. (a) No relative of a patient in a state humane institution, nor the estate of such relative, shall be liable for any portion of the cost of support of any such patient in such institution for any period prior to July 1, 1955, except unpaid charges billed by the Welfare Commissioner.

      (b) The provisions of sections 17a-502, 17b-222, 17b-223, 17b-228, 17b-232, 17b-745, 46b-215 and 53-304 shall not affect or impair the responsibility of any patient or patient's estate for his care in a state humane institution prior to July 1, 1955, and the same may be enforced by any action by which such responsibility would have been enforceable prior to July 1, 1955, but only to the extent of that portion of such estate as is not needed for the support of the spouse, parents and dependent children of such patient.

      (1955, S. 1499d; 1957, P.A. 330, S. 1, 2; February, 1965, P.A. 574, S. 25; P.A. 76-139, S. 11; P.A. 77-614, S. 587, 608, 610; P.A. 78-303, S. 85, 136; P.A. 91-406, S. 4, 29; P.A. 04-257, S. 33; P.A. 11-16, S. 32.)

      History: 1965 act deleted references to Secs. 17-159, 17-168 and 17-323 and added reference to Sec. 17-174a; P.A. 76-139 deleted reference to Secs. 19-122, 19-123 and 19-124 repealed by same act; P.A. 77-614 and P.A. 78-303 would have replaced welfare commissioner with commissioner of income maintenance but for qualifying date reference; P.A. 91-406 made technical changes in Subsec. (b), deleting references to Secs. 17-174a, 17-296 and 17-320 and adding references to Secs. 17a-278 and 46b-215; Sec. 17-299 transferred to Sec. 17b-229 in 1995; P.A. 04-257 made a technical change in Subsec. (b), effective June 14, 2004; P.A. 11-16 deleted reference to repealed Sec. 17a-278, effective May 24, 2011.

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      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, and may annually modify such fee schedule if such modification is needed to ensure that the conversion to an administrative services organization is cost neutral to hospitals in the aggregate and ensures patient access. Utilization shall not be a factor in determining cost neutrality. 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.

      (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; P.A. 11-44, S. 113; 11-61, S. 122.)

      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; P.A. 11-44 amended Subsec. (d) by adding provision allowing commissioner to modify fee schedule for outpatient hospital services and deleting provision re submission of report, effective July 1, 2011; P.A. 11-61 amended Subsec. (d) by adding provision excluding utilization as factor in determining cost neutrality, effective July 1, 2011.

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      Sec. 17b-239c. Interim disproportionate share payments to short-term general hospitals. (a) Notwithstanding any provision of the general statutes, on and after July 1, 2011, the Department of Social Services may, within available appropriations, make interim monthly medical assistance disproportionate share payments to short-term general hospitals. The total amount of interim payments made to such hospitals individually and in the aggregate shall maximize federal matching payments under the medical assistance program as determined by the Department of Social Services, in consultation with the Office of Policy and Management. No payments shall be made under this section to (1) any hospital which, on July 1, 2011, is within the class of hospitals licensed by the Department of Public Health as a children's general hospital, or (2) a short-term acute hospital operated exclusively by the state other than a short-term acute hospital operated by the state as a receiver pursuant to chapter 920. The monthly interim payment amount for each hospital shall be determined by the Commissioner of Social Services based upon the information submitted by the hospital pursuant to Section 1001(d) of Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

      (b) Effective July 1, 2011, interim payments made to hospitals pursuant to this section for the succeeding fifteen months shall be based on 2009 federal fiscal year data and may be adjusted at the commissioner's discretion for accuracy. Effective October 1, 2012, interim payments shall be based on the most recent federal fiscal year data available. For federal fiscal year 2011 and succeeding federal fiscal years, final disproportionate share payment amounts shall be recalculated and reallocated in accordance with Section 1001(d) of Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The commissioner shall prescribe uniform annual hospital data reporting forms. Payments made pursuant to this section shall be in addition to inpatient hospital rates determined pursuant to section 17b-239. The commissioner may withhold payment to a hospital to offset money owed by the hospital to the state.

      (P.A. 11-44, S. 111.)

      History: P.A. 11-44 effective July 1, 2011.

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      Sec. 17b-239d. Payments for outpatient hospital services. The Commissioner of Social Services may establish a fee schedule for the payment of any outpatient hospital services under the Medicaid program.

      (P.A. 11-44, S. 92.)

      History: P.A. 11-44 effective July 1, 2011.

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      Sec. 17b-239e. Hospital rate plan. Inpatient hospital case rate. (a) On or before January 1, 2012, the Commissioner of Social Services, in consultation with the Commissioners of Public Health and Mental Health and Addiction Services and the Secretary of the Office of Policy and Management, shall submit 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 a plan concerning the implementation of a cost neutral acuity-based method for establishing rates to be paid to hospitals that is phased in over a period of time.

      (b) The commissioner may establish a blended in-patient hospital case rate that includes services provided to all Medicaid recipients and may exclude certain diagnoses as determined by the commissioner if the establishment of such rates is needed to ensure that the conversion to an administrative services organization is cost neutral to hospitals in the aggregate and ensures patient access. Utilization shall not be a factor in determining cost neutrality.

      (P.A. 11-44, S. 112; 11-61, S. 121.)

      History: P.A. 11-44 effective July 1, 2011; P.A. 11-61 amended Subsec. (b) by adding provision excluding utilization as a factor in determining cost neutrality, effective July 1, 2011.

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      Sec. 17b-240. (Formerly Sec. 17-312a). State payments to hospitals. Rates established by the Office of Health Care Access division of the Department of Public Health. Section 17b-240 is repealed, effective July 1, 2011.

      (P.A. 78-250, S. 1, 2; P.A. 95-257, S. 39, 58; P.A. 10-179, S. 97; P.A. 11-44, S. 178.)

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      Sec. 17b-242. (Formerly Sec. 17-313). Payments to home health care agencies and homemaker-home health aide agencies. Appeals. Hearings. Regulations. (a) The Department of Social Services shall determine the rates to be paid to home health care agencies and homemaker-home health aide agencies by the state or any town in the state for persons aided or cared for by the state or any such town. For the period from February 1, 1991, to January 31, 1992, inclusive, payment for each service to the state shall be based upon the rate for such service as determined by the Office of Health Care Access, except that for those providers whose Medicaid rates for the year ending January 31, 1991, exceed the median rate, no increase shall be allowed. For those providers whose rates for the year ending January 31, 1991, are below the median rate, increases shall not exceed the lower of the prior rate increased by the most recent annual increase in the consumer price index for urban consumers or the median rate. In no case shall any such rate exceed the eightieth percentile of rates in effect January 31, 1991, nor shall any rate exceed the charge to the general public for similar services. Rates effective February 1, 1992, shall be based upon rates as determined by the Office of Health Care Access, except that increases shall not exceed the prior year's rate increased by the most recent annual increase in the consumer price index for urban consumers and rates effective February 1, 1992, shall remain in effect through June 30, 1993. Rates effective July 1, 1993, shall be based upon rates as determined by the Office of Health Care Access except if the Medicaid rates for any service for the period ending June 30, 1993, exceed the median rate for such service, the increase effective July 1, 1993, shall not exceed one per cent. If the Medicaid rate for any service for the period ending June 30, 1993, is below the median rate, the increase effective July 1, 1993, shall not exceed the lower of the prior rate increased by one and one-half times the most recent annual increase in the consumer price index for urban consumers or the median rate plus one per cent. The Commissioner of Social Services shall establish a fee schedule for home health services to be effective on and after July 1, 1994. The commissioner may annually modify such fee schedule if such modification is needed to ensure that the conversion to an administrative services organization is cost neutral to home health care agencies and homemaker-home health aide agencies in the aggregate and ensures patient access. Utilization shall not be a factor in determining cost neutrality. The commissioner shall increase the fee schedule for home health services provided under the Connecticut home-care program for the elderly established under section 17b-342, effective July 1, 2000, by two per cent over the fee schedule for home health services for the previous year. The commissioner may increase any fee payable to a home health care agency or homemaker-home health aide agency upon the application of such an agency evidencing extraordinary costs related to (1) serving persons with AIDS; (2) high-risk maternal and child health care; (3) escort services; or (4) extended hour services. In no case shall any rate or fee exceed the charge to the general public for similar services. A home health care agency or homemaker-home health aide agency which, due to any material change in circumstances, is aggrieved by a rate determined pursuant to this subsection may, within ten days of receipt of written notice of such rate from the Commissioner of Social Services, request in writing a hearing on all items of aggrievement. The commissioner shall, upon the receipt of all documentation necessary to evaluate the request, determine whether there has been such a change in circumstances and shall conduct a hearing if appropriate. The Commissioner of Social Services shall adopt regulations, in accordance with chapter 54, to implement the provisions of this subsection. The commissioner may implement policies and procedures to carry out the provisions of this subsection while in the process of adopting regulations, provided notice of intent to adopt the regulations is published in the Connecticut Law Journal within twenty days of implementing the policies and procedures. Such policies and procedures shall be valid for not longer than nine months.

      (b) The Department of Social Services shall monitor the rates charged by home health care agencies and homemaker-home health aide agencies. Such agencies shall file annual cost reports and service charge information with the department.

      (c) The home health services fee schedule shall include a fee for the administration of medication, which shall apply when the purpose of a nurse's visit is limited to the administration of medication. Administration of medication may include, but is not limited to, blood pressure checks, glucometer readings, pulse rate checks and similar indicators of health status. The fee for medication administration shall include administration of medications while the nurse is present, the pre-pouring of additional doses that the client will self-administer at a later time and the teaching of self-administration. The department shall not pay for medication administration in addition to any other nursing service at the same visit. The department may establish prior authorization requirements for this service. Before implementing such change, the Commissioner of Social Services shall consult with the chairpersons of the joint standing committees of the General Assembly having cognizance of matters relating to public health and human services.

      (d) The home health services fee schedule established pursuant to subsection (c) of this section shall include rates for psychiatric nurse visits.

      (e) The Department of Social Services, when processing or auditing claims for reimbursement submitted by home health care agencies and homemaker-home health aide agencies shall, in accordance with the provisions of chapter 15, accept electronic records and records bearing the electronic signature of a licensed physician or licensed practitioner of a healthcare profession that has been submitted to the home health care agency or homemaker home-health aide agency.

      (f) If the electronic record or signature that has been transmitted to a home health care agency or homemaker-home health aide agency is illegible or the department is unable to determine the validity of such electronic record or signature, the department shall review additional evidence of the accuracy or validity of the record or signature, including, but not limited to, (1) the original of the record or signature, or (2) a written statement, made under penalty of false statement, from (A) the licensed physician or licensed practitioner of a health care profession who signed such record, or (B) if such licensed physician or licensed practitioner of a health care profession is unavailable, the medical director of the agency verifying the accuracy or validity of such record or signature, and the department shall make a determination whether the electronic record or signature is valid.

      (g) The Department of Social Services, when auditing claims submitted by home health care agencies and homemaker-home health aide agencies, shall consider any signature from a licensed physician or licensed practitioner of a health care profession that may be required on a plan of care for home health services, to have been provided in timely fashion if (1) the document bearing such signature was signed prior to the time when such agency seeks reimbursement from the department for services provided, and (2) verbal or telephone orders from the licensed physician or licensed practitioner of a health care profession were received prior to the commencement of services covered by the plan of care and such orders were subsequently documented. Nothing in this subsection shall be construed as limiting the powers of the Commissioner of Public Health to enforce the provisions of sections 19-13-D73 and 19-13-D74 of the regulations of Connecticut state agencies and 42 CFR 484.18(c).

      (h) For purposes of this section, "licensed practitioner of a healthcare profession" has the same meaning as "licensed practitioner" in section 21a-244a.

      (1957, P.A. 539; P.A. 73-117, S. 24, 31; P.A. 78-264, S. 2, 4; P.A. 91-406, S. 5, 29; June Sp. Sess. P.A. 91-8, S. 20, 63; May Sp. Sess. P.A. 92-16, S. 26, 89; P.A. 93-262, S. 1, 20, 87; 93-418, S. 24, 41; 93-435, S. 59, 95; May Sp. Sess. P.A. 94-5, S. 22, 30; P.A. 95-257, S. 39, 58; 95-351, S. 14, 30; P.A. 96-268, S. 5, 34; P.A. 99-130; June Sp. Sess. P.A. 00-2, S. 16, 53; P.A. 02-101, S. 13; P.A. 03-2, S. 8; June 30 Sp. Sess. P.A. 03-6, S. 197; P.A. 05-118, S. 1; 05-272, S. 44; P.A. 11-44, S. 114; 11-61, S. 123.)

      History: P.A. 73-117 replaced hospital cost commission with committee established under Sec. 17-311; P.A. 78-264 replaced public health nursing agencies with home health care and homemaker-home health aide agencies and replaced previous rate provisions with statement that rate to be determined by commission on hospitals and health care; P.A. 91-406 corrected an internal reference; June Sp. Sess. P.A. 91-8 amended the section by replacing "state" with the specific departments, by specifying the rates paid by the state to home health care agencies and homemaker-home health aide agencies and by adding provisions re the appeal of a rate determination; May Sp. Sess. P.A. 92-16 provided that rates in effect on February 1, 1992, shall remain in effect through June 30, 1993; P.A. 93-262 removed the references to departments of income maintenance, human resources and aging and provided that the department of social services shall determine rates to be charged home health care agencies and homemaker-home health aide agencies, made technical changes and added provisions requiring commissioner to adopt regulations, effective July 1, 1993; P.A. 93-418 added provisions regarding rates effective July 1, 1993, which are determined by the commission on hospitals and health care and authorizing income maintenance commissioner to establish fee schedule on and after July 1, 1994, effective July 1, 1993; P.A. 93-435 authorized the Revisors to substitute social services commissioner for income maintenance commissioner in P.A. 93-418, effective June 28, 1993; May Sp. Sess. P.A. 94-5 allowed the fee schedule to be phased in over a two-year period and allowed the commissioner to increase any fee payable to a home health care agency or homemaker-home health aide agency if there are extraordinary costs, effective July 1, 1994; Sec. 17-313 transferred to Sec. 17b-242 in 1995; P.A. 95-257 replaced Commission on Hospitals and Health Care with Office of Health Care Access, effective July 1, 1995; P.A. 95-351 added Subdiv. (4) allowing the commissioner to increase any fee payable for extraordinary costs relating to extended hour services, effective July 1, 1995 (Revisor's note: In the first sentence the phrase "rates to be charged by home health care agencies and the rates to be paid" was changed editorially by the Revisors to read "rates to be charged by home health care agencies and homemaker-home health aide agencies and the rates to be paid" to correct a clerical error in the preparation of the 1995 General Statutes); P.A. 96-268 added reference to homemaker-home health aide agencies, effective July 1, 1996; P.A. 99-130 designated existing language as Subsec. (a), eliminating the responsibility of the department to determine rates to be charged by home health care agencies and homemaker-home health aide agencies and added Subsec. (b) requiring the department to monitor the rates charged by such agencies, requiring such agencies to file annual cost reports and service charge information with the department, and made technical changes; June Sp. Sess. P.A. 00-2 amended Subsec. (a) by deleting provision re phasing in the fee schedule over a two-year period and inserting provision requiring the commissioner to increase by 2% the fee schedule for home health care services provided under the Connecticut home-care program for the elderly, effective July 1, 2000; P.A. 02-101 amended Subsec. (a) to make a technical change, effective July 1, 2002; P.A. 03-2 added Subsec. (c) re establishment of home health services fee schedule applicable when purpose of nurse's visit is limited to administration of medication, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-6 added Subsec. (d) re rates for psychiatric nurse visits, effective August 20, 2003; P.A. 05-118 added Subsec. (e) allowing for submission of electronic records and records bearing electronic signatures by agencies to department with respect to the processing and auditing of claims for reimbursement and Subsec. (f) re the timely signature of a health care professional on a plan of care for home health services submitted to department; P.A. 05-272 amended Subsec. (e) by requiring department to accept electronic records and signatures of licensed physicians or licensed health care practitioners that have been submitted to an agency, rather than signatures of "an individual duly authorized by any such agency to submit records to the department", added new Subsec. (f) re process for reviewing and validating illegible electronic records or signatures transmitted to home health care agencies or homemaker-home health aide agencies, redesignated existing Subsec. (f) as Subsec. (g), designating provisions therein re document bearing signature as Subdiv. (1) and replacing "provided to such agency" with "signed", added Subsec. (g)(2) re timeliness of signatures from licensed physicians or licensed practitioners of a health care profession in cases involving verbal or telephone orders and re Department of Public Health's powers to enforce specified state and federal regulations concerning patients' care plans and medication administration are not limited by Subsec. (g), and added Subsec. (h) defining "licensed practitioner of a healthcare profession"; P.A. 11-44 amended Subsec. (a) by replacing provision allowing commissioner to increase any fee in fee schedule with provision allowing commissioner to modify fee schedule, effective July 1, 2011; P.A. 11-61 amended Subsec. (a) by adding provision excluding utilization as factor in determining cost neutrality, effective July 1, 2011.

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      Sec. 17b-243. (Formerly Sec. 17-313a). Payments to rehabilitation centers. (a) The rate to be paid by the state to rehabilitation centers, including but not limited to, centers affiliated with the Easter Seal Society of Connecticut, Inc., for services to patients referred by any state agency, except employment opportunities and day services, shall be determined annually by the Commissioner of Social Services who shall prescribe uniform forms on which such rehabilitation centers shall report their costs, except that rates effective April 30, 1989, shall remain in effect through May 31, 1990, and rates in effect February 1, 1991, shall remain in effect through December 31, 1992, except those which would be decreased effective January 1, 1992, shall be decreased. For the rate years beginning January 1, 1993, through December 31, 1995, any rate increase shall not exceed the most recent annual increase in the consumer price index for urban consumers. Such rates shall be determined on the basis of a reasonable payment for necessary services rendered. Nothing contained herein shall authorize a payment by the state to any such rehabilitation center in excess of the charges made by such center for comparable services to the general public. The Commissioner of Social Services shall establish a fee schedule for rehabilitation services to be effective on and after January 1, 1996. The fee schedule may be adjusted annually beginning July 1, 1997, to reflect necessary increases in the cost of services.

      (b) The amount to be paid by the state to rehabilitation centers including but not limited to centers affiliated with the Easter Seal Society of Connecticut, Inc., for employment opportunities and day services to patients referred by any state agency shall be determined annually using a uniform payment system in accordance with the provisions of subsection (a) of section 17a-246.

      (1969, P.A. 346, S. 1; P.A. 73-117, S. 25, 31; P.A. 79-560, S. 27, 39; P.A. 80-483, S. 174, 186; P.A. 89-325, S. 13, 26; June Sp. Sess. P.A. 91-8, S. 14, 63; May Sp. Sess. P.A. 92-16, S. 27, 89; P.A. 93-262, S. 1, 87; 93-418, S. 25, 41; P.A. 95-160, S. 66, 69; P.A. 96-139, S. 12, 13; P.A. 11-16, S. 33.)

      History: P.A. 73-117 replaced hospital cost commission with committee established under Sec. 17-311; P.A. 79-560 replaced the committee with commissioner of income maintenance; P.A. 80-483 deleted "for Crippled Children and Adults" in Easter Seal Society name; P.A. 89-325 amended Subsec. (a) to exclude centers that provide employment opportunities and day services from the rate setting in this section, it also allows rates effective April 30, 1989, to remain in effect through May 31, 1990, and added a new Subsec. (b) re rates for centers providing employment opportunities and day services; June Sp. Sess. P.A. 91-8 amended Subsec. (a) re rates paid by the state for rehabilitation centers; May Sp. Sess. P.A. 92-16 amended Subsec. (a) by providing that for the rate year beginning January 1, 1993, any rate increase shall not exceed the most recent annual increase in the consumer price index for urban consumers. 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. 93-418 amended Subsec. (a) concerning rate increases and the consumer price index to specify applicability for any succeeding rate year after January 1, 1993, effective July 1, 1993; Sec. 17-313a transferred to Sec. 17b-243 in 1995; P.A. 95-160 amended Subsec. (a) by replacing "any succeeding year" with "December 31, 1995" for the period of time after January 1, 1993, which shall not have a rate increase exceeding the most recent annual increase in the consumer price index for urban consumers and by adding a provision requiring the commissioner to establish a fee schedule for rehabilitation services to be effective on and after January 1, 1996, effective June 1, 1995; P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; P.A. 11-16 amended Subsec. (a) to delete "as defined in section 17a-246" re employment opportunities and day services, effective May 24, 2011.

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      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. For the fiscal years ending June 30, 2010, and June 30, 2011, rates in effect for the period ending June 30, 2009, shall remain in effect until June 30, 2011, except that (1) the rate paid to a facility may be higher than the rate paid to the facility for the period ending June 30, 2009, if a capital improvement required by the Commissioner of Developmental Services for the health or safety of the residents was made to the facility during the fiscal years ending June 30, 2010, or June 30, 2011, and (2) any facility that would have been issued a lower rate for the fiscal years ending June 30, 2010, or June 30, 2011, due to interim rate status or agreement with the department, shall be issued such lower rate. For the fiscal years ending June 30, 2012, and June 30, 2013, rates in effect for the period ending June 30, 2011, shall remain in effect until June 30, 2013, except that (1) the rate paid to a facility may be higher than the rate paid to the facility for the period ending June 30, 2011, if a capital improvement required by the Commissioner of Developmental Services for the health or safety of the residents was made to the facility during the fiscal years ending June 30, 2012, or June 30, 2013, and (2) any facility that would have been issued a lower rate for the fiscal years ending June 30, 2012, or June 30, 2013, due to interim rate status or agreement with the department, shall be issued such lower rate.

      (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; Sept. Sp. Sess. P.A. 09-5, S. 42; P.A. 10-179, S. 37; P.A. 11-44, S. 82.)

      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; Sept. Sp. Sess. P.A. 09-5 amended Subsec. (a) by adding provision re rates for fiscal years ending June 30, 2010, and June 30, 2011, effective October 5, 2009; P.A. 10-179 amended Subsec. (a) by adding Subdiv. (1) re exception to rate established for fiscal years ending June 30, 2010, and June 30, 2011, when facility makes required capital improvement and by designating existing exception as Subdiv. (2), effective July 1, 2010; P.A. 11-44 amended Subsec. (a) by adding provisions re rates for fiscal years ending June 30, 2012, and June 30, 2013, effective July 1, 2011.

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      Sec. 17b-245. (Formerly Sec. 17-313c). Payments to day care and vocational training programs sponsored by certain associations. (a) The rates to be paid by the state to the day care and vocational training programs sponsored by the associations affiliated with United Cerebral Palsy of Connecticut, Inc., Epilepsy Foundation of America, Inc., Goodwill Industries of America, Inc. and to any private, nonprofit agency providing such programs for persons with a neurological impairment or autism spectrum disorder, for services to clients referred by any state agency, except employment opportunities and day services, shall be determined annually by the Commissioner of Social Services who shall prescribe uniform forms on which such day care and vocational training programs shall report their costs, except that rates effective April 30, 1989, shall remain in effect through May 31, 1990. Such rates shall be determined on the basis of a reasonable payment for necessary services rendered. Nothing contained herein shall authorize a payment by the state to any such day care or vocational training program in excess of the charges made by such programs for comparable services to the general public.

      (b) The amount to be paid by the state to the day care and vocational training programs sponsored by the associations affiliated with United Cerebral Palsy of Connecticut, Inc., Epilepsy Foundation of America, Inc., Goodwill Industries of America, Inc. and to any private, nonprofit agency providing such programs for autistic or neurologically impaired or severely handicapped persons, for employment opportunities and day services to clients referred by any state agency shall be determined annually using a uniform payment system in accordance with the provisions of subsection (a) of section 17a-246.

      (P.A. 77-371; P.A. 79-560, S. 29, 39; P.A. 89-325, S. 15, 26; P.A. 93-262, S. 1, 87; P.A. 11-16, S. 34.)

      History: P.A. 79-560 replaced committee established under Sec. 17-311 with commissioner of income maintenance; P.A. 89-325 added reference to employment opportunities and day services in Sec. 19a-483d and allowed rates effective April 30, 1989, to remain in effect through May 31, 1990, in Subsec. (a) and added a new Subsec. (b) re rates to day care and vocational training programs; 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. 17-313c transferred to Sec. 17b-245 in 1995; P.A. 11-16 amended Subsec. (a) by substituting "persons with a neurological impairment or autism spectrum disorder" for "autistic or neurologically impaired persons" and deleting "as defined in section 17a-246" re employment opportunities and day services, effective May 24, 2011.

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      Sec. 17b-256. (Formerly Sec. 17-314m). Prescription drug and insurance assistance program for persons with acquired immunodeficiency syndrome or human immunodeficiency virus. Annual report. Enrollment in Medicare Part D. (a) The Commissioner of Social Services may administer, within available appropriations, a program providing payment for the cost of drugs prescribed by a physician for the treatment of acquired immunodeficiency syndrome or human immunodeficiency virus. The commissioner, in consultation with the Commissioner of Public Health, shall determine specific drugs to be covered and may implement a pharmacy lock-in procedure for the program. The Commissioner of Social Services shall adopt regulations, in accordance with the provisions of chapter 54, to carry out the purposes of this section. The Commissioner of Social Services may implement the program while in the process of adopting regulations, provided notice of intent to adopt the regulations is published in the Connecticut Law Journal within twenty days of implementation. The regulations may include eligibility for all persons with acquired immunodeficiency syndrome or human immunodeficiency virus whose income is below four hundred per cent of the federal poverty level. Subject to federal approval, the Commissioner of Social Services may, within available federal resources, maintain insurance policies for eligible clients, including, but not limited to, coverage of costs associated with such policies, that provide a full range of human immunodeficiency virus treatments and access to comprehensive primary care services as determined by the commissioner and as provided by federal law, and may provide payment, determined by the commissioner, for (1) drugs and nutritional supplements prescribed by a physician that prevent or treat opportunistic diseases and conditions associated with acquired immunodeficiency syndrome or human immunodeficiency virus; (2) ancillary supplies related to the administration of such drugs; and (3) laboratory tests ordered by a physician. On and after May 26, 2006, any person who previously received insurance assistance under the program established pursuant to section 17b-255 of the general statutes, revision of 1958, revised to 2005, shall continue to receive such assistance until the expiration of the insurance coverage, provided such person continues to meet program eligibility requirements established in accordance with this subsection. On or before March 1, 2007, 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 the budgets of state agencies on the projected availability of funds for the program established pursuant to this section.

      (b) Applicants for and recipients of benefits under the program established pursuant to subsection (a) of this section shall, if eligible, enroll in Medicare Part D. The Commissioner of Social Services may be the authorized representative of such an applicant or recipient for purposes of enrolling in a Medicare Part D plan or submitting an application to the Social Security Administration to obtain the low income subsidy benefit provided under Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. The applicant or recipient shall have the opportunity to select a Medicare Part D plan and shall be notified of such opportunity by the commissioner. The applicant or recipient, prior to selecting a Medicare Part D plan, shall have the opportunity to consult with the commissioner, or the commissioner's designated agent, concerning the selection of a Medicare Part D plan that best meets the prescription drug needs of such applicant or recipient. In the event that such applicant or recipient does not select a Medicare Part D plan within a reasonable period of time, as determined by the commissioner, the commissioner shall enroll the applicant or recipient in a Medicare Part D plan designated by the commissioner in accordance with said act. The applicant or recipient shall appoint the commissioner as such applicant's or recipient'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. The commissioner may pay the premium and coinsurance costs of Medicare Part D coverage for eligible applicants or recipients.

      (June Sp. Sess. P.A. 91-8, S. 44, 63; P.A. 93-262, S. 1, 87; 93-418, S. 14, 41; P.A. 96-238, S. 16, 25; June Sp. Sess. P.A. 99-2, S. 6, 72; June Sp. Sess. P.A. 01-4, S. 9, 58; May 9 Sp. Sess. P.A. 02-7, S. 49; P.A. 06-188, S. 14; P.A. 10-32, S. 66; P.A. 11-242, S. 26.)

      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; P.A. 93-418 made the program subject to available appropriations, expanded the program to include prescription drugs for the prevention and treatment of AIDS, ARC or HIV, deleting specific reference to AZT and requiring the commissioner to specify the drugs to be covered, required the commissioner to adopt regulations and allowed the commissioner to implement the program while in the process of adopting regulations, effective July 1, 1993; Sec. 17-314m transferred to Sec. 17b-256 in 1995; P.A. 96-238 authorized payment for drugs, nutritional supplements and ancillary supplies and laboratory tests prescribed or ordered by a physician for the prevention or treatment of opportunistic diseases and conditions associated with AIDS or HIV infection, effective July 1, 1996; June Sp. Sess. P.A. 99-2 added provisions allowing regulations to include eligibility for persons with income below 400% of the federal poverty level and allowing commissioner to purchase and maintain insurance policies with specified coverage, effective July 1, 1999; June Sp. Sess. P.A. 01-4 deleted provision re AIDS-related complex (ARC) and made a technical change, effective July 1, 2001; May 9 Sp. Sess. P.A. 02-7 changed "commissioner may, within available appropriations, purchase and maintain insurance polices for eligible clients," to "commissioner shall, within available federal resources, purchase and maintain insurance policies for eligible clients," effective August 15, 2002; P.A. 06-188 designated existing provisions as Subsec. (a) and amended same to add consultative role for Commissioner of Public Health re determination of drugs covered under the program, provide that persons previously receiving insurance assistance pursuant to Sec. 17b-255 shall continue to receive such assistance provided such persons meet program eligibility requirements, add provision requiring Commissioner of Social Services to annually report on the projected availability of funds for the program, and make conforming and technical changes, and added Subsec. (b) requiring eligible program applicants and beneficiaries to enroll in Medicare Part D, effective May 26, 2006; P.A. 10-32 made a technical change in Subsec. (a), effective May 10, 2010; P.A. 11-242 amended Subsec. (a) by substituting "maintain insurance policies for eligible clients" for "maintain existing insurance policies for eligible clients" and by making technical changes.

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      Sec. 17b-256d. State medical assistance program. Use of federally-qualified community health centers. Section 17b-256d is repealed, effective July 1, 2011.

      (June Sp. Sess. P.A. 01-2, S. 20, 69; June Sp. Sess. P.A. 01-9, S. 129, 131; May 9 Sp. Sess. P.A. 02-7, S. 62; June 30 Sp. Sess. P.A. 03-3, S. 97; P.A. 11-44, S. 178.)

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      Sec. 17b-256f. Eligibility for Medicare savings programs. Regulations. Beginning October 1, 2009, and annually thereafter, the Commissioner of Social Services shall increase income disregards used to determine eligibility by the Department of Social Services for the federal Specified Low-Income Medicare Beneficiary, the Qualified Medicare Beneficiary and the Qualifying Individual Programs, administered in accordance with the provisions of 42 USC 1396d(p), by an amount that equalizes the income levels and deductions used to determine eligibility for said programs with income levels and deductions used to determine eligibility for the ConnPACE program under subsection (a) of section 17b-492. The commissioner shall not apply an asset test for eligibility under the Medicare Savings Program. 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 in regulation form, provided the commissioner prints notice of the intent to adopt the regulations in the Connecticut Law Journal not later than twenty days after the date of implementation. Such policies and procedures shall be valid until the time final regulations are adopted.

      (P.A. 09-2, S. 16; Sept. Sp. Sess. P.A. 09-5, S. 70; Sept. Sp. Sess. P.A. 09-7, S. 182; P.A. 11-44, S. 91.)

      History: P.A. 09-2 effective April 1, 2009; Sept. Sp. Sess. P.A. 09-5 changed commencement date from June 30, 2009, to October 1, 2009, and added provision re asset test, effective October 5, 2009; Sept. Sp. Sess. P.A. 09-7 deleted references to fiscal year and inserted "annually", effective October 5, 2009; P.A. 11-44 added provisions requiring commissioner to consider deductions in calculating income disregards used to determine eligibility, effective July 1, 2011.

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      Sec. 17b-257b. Alien eligibility for state medical assistance. Regulations. (a) Qualified aliens, as defined in Section 431 of Public Law 104-193, admitted into the United States on or after August 22, 1996, other lawfully residing immigrant aliens or aliens who formerly held the status of permanently residing under color of law who are (1) receiving home and community-based services that are equivalent to the services provided under the Medicaid waiver portion of the Connecticut home-care program for the elderly, established pursuant to section 17b-342, (2) receiving nursing facility care under the state-funded medical assistance program on June 30, 2011, shall continue to receive coverage for such services or care for as long as the individual meets Medicaid eligibility requirements for such services or care except for alien status, or (3) are receiving nursing facility care and have applied for state-funded medical assistance before June 1, 2011, and would otherwise be eligible for such assistance, shall be provided such assistance for as long as the individual meets Medicaid eligibility requirements for nursing facility care except for alien status, except such aliens who are (A) children and pregnant women, and (B) whose date of admission is less than five years before the date services are provided shall receive coverage until such time as the state plan amendment concerning federal funding for the provision of services to such aliens is approved.

      (b) The Commissioner of Social Services 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 intent to adopt regulations 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 18 Sp. Sess. P.A. 97-2, S. 146, 165; October 29 Sp. Sess. P.A. 97-1, S. 17, 23; P.A. 99-279, S. 11, 45; P.A. 00-83, S. 3, 5; June Sp. Sess. P.A. 01-9, S. 109, 131; May 9 Sp. Sess. P.A. 02-7, S. 22; P.A. 04-258, S. 16; Sept. Sp. Sess. P.A. 09-5, S. 64; P.A. 11-44, S. 118.)

      History: June 18 Sp. Sess. P.A. 97-2 effective July 1, 1997; Oct. 29 Sp. Sess. P.A. 97-1 made qualified aliens eligible for benefits under the HUSKY Plan, Part B, effective October 30, 1997; P.A. 99-279 extended the eligibility of certain qualified aliens or other lawfully residing immigrant aliens for state-funded medical assistance from July 1, 1999, to July 1, 2001, effective July 1, 1999; P.A. 00-83 extended provisions of section to aliens who formerly held the status of permanently residing under color of law, added references to "state-administered general assistance medical aid", and provided that alien who formerly held such status who is a domestic violence victim or who has mental retardation shall be eligible for state-funded assistance or the HUSKY Plan, Part B, effective July 1, 2000; June Sp. Sess. P.A. 01-9 extended the deadline for certain aliens to apply for assistance until June 30, 2002, effective July 1, 2001; May 9 Sp. Sess. P.A. 02-7 extended the deadline for certain aliens to apply for assistance until June 30, 2003, effective August 15, 2002; P.A. 04-258 deleted provision that prohibited Commissioner of Social Services from accepting applications for assistance pursuant to section on or after June 30, 2003, effective July 1, 2004; Sept. Sp. Sess. P.A. 09-5 designated existing provisions as Subsec. (a) and amended same by replacing former eligibility criteria with criteria re certain qualified aliens receiving home care services or nursing facility care, and adding provision re coverage for children and pregnant women who were admitted into U.S. less than 5 years prior to date services are provided, and added Subsec. (b) allowing commissioner to implement policies and procedures while in the process of adopting final regulations, effective October 5, 2009; P.A. 11-44 amended Subsec. (a) by replacing provision re home care services with provision re home and community-based services equivalent to services offered under Sec. 17b-342 in Subdiv. (1), by replacing "September 8, 2009" with "June 30, 2011" in Subdiv. (2), and by replacing "September 8, 2009" with "June 1, 2011" in Subdiv. (3), effective June 13, 2011.

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      Sec. 17b-257c. Payments to long-term care facilities for care of illegal immigrants admitted to acute care or psychiatric hospitals. Eligibility. Regulations. (a) The Commissioner of Social Services, after consultation with the Commissioner of Mental Health and Addiction Services and the Secretary of the Office of Policy and Management, may provide, within available appropriations, payments to long-term care facilities for the care of certain illegal immigrants who were admitted to a long-term care facility before July 1, 2011. Payments may be made to cover the costs of care, as well as other incidentals as determined by the Commissioner of Social Services, for illegal immigrants who have been admitted to an acute care or psychiatric hospital and for whom services available in a long-term care facility are an appropriate and cost-effective alternative. Such individuals must be otherwise eligible for Medicaid, have resided in this state for at least five years and be unable to return to their country of origin due to medical illness or regulations barring reentry of persons who are ill or disabled or based upon a decision by the Immigration and Naturalization Service not to proceed with deportation.

      (b) The Commissioner of Social Services shall implement the policies and procedures necessary to carry out the provisions of subsection (a) of this section while in the process of adopting such policies and procedures in regulation form, provided notice of intent to adopt the regulations is published in the Connecticut Law Journal within twenty days after implementation. Such policies and procedures shall be valid until the time final regulations are effective.

      (P.A. 98-239, S. 7, 35; P.A. 99-279, S. 15, 45; P.A. 11-44, S. 119.)

      History: P.A. 98-239 effective July 1, 1998; P.A. 99-279 amended Subsec. (a) to provide that payments may cover the costs of other incidentals as determined by the Commissioner of Social Services for illegal immigrants, effective June 29, 1999; P.A. 11-44 amended Subsec. (a) by adding as condition for payment that illegal immigrants were admitted to long-term care facility before July 1, 2011, effective June 13, 2011.

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      Sec. 17b-260d. Home and community-based services waiver serving persons with acquired immune deficiency syndrome or human immunodeficiency virus. The Commissioner of Social Services shall apply for a home and community-based services waiver pursuant to Section 1915(c) of the Social Security Act that will allow the commissioner to develop and implement a program for the provision of home or community-based services, as defined in 42 CFR 440.180, to not more than fifty persons currently receiving services under the Medicaid program who (1) have tested positive for human immunodeficiency virus or have acquired immune deficiency syndrome, and (2) would remain eligible for Medicaid if admitted to a hospital, nursing facility or intermediate care facility for the mentally retarded, or in the absence of the services that are requested under such waiver, would require the Medicaid covered level of care provided in such facilities.

      (Sept. Sp. Sess. P.A. 09-5, S. 63; P.A. 11-44, S. 93.)

      History: Sept. Sp. Sess. P.A. 09-5 effective October 5, 2009; P.A. 11-44 changed maximum number of persons served from 100 to 50, deleted provision re services to avoid institutionalization, deleted former Subsec. (b) re report to General Assembly and made a technical change, effective July 1, 2011.

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      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 (e) 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 poverty 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. 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 17b-751b. 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 a special needs trust, as defined in 42 USC 1396p(d)(4)(A). For purposes of determining whether a beneficiary under a special needs trust, who has not received a disability determination from the Social Security Administration, is disabled, as defined in 42 USC 1382c(a)(3), the Commissioner of Social Services, or the commissioner's designee, shall independently make such determination. The commissioner shall not require such beneficiary to apply for Social Security disability benefits or obtain a disability determination from the Social Security Administration for purposes of determining whether the beneficiary is disabled.

      (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. Medical assistance shall also be provided to any child in the voluntary services program operated by the Department of Developmental Services who is not receiving Medicaid benefits, has not yet qualified for Medicaid benefits or is otherwise ineligible for benefits. To the extent practicable, the Commissioner of Children and Families and the Commissioner of Developmental Services 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; P.A. 09-8, S. 3; 09-66, S. 1; P.A. 10-179, S. 66; P.A. 11-176, S. 3.)

      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; P.A. 09-8 made technical changes in Subsec. (a); P.A. 09-66 amended Subsec. (h) by deleting "because of institutional status" and adding provisions re medical assistance to be provided to children in Department of Developmental Services' voluntary services program who are not receiving Medicaid benefits, effective July 1, 2009; P.A. 10-179 amended Subsec. (a) by deleting provision requiring contracts to include provisions for collaboration of managed care organizations with the Nurturing Families Network, effective July 1, 2010; P.A. 11-176 amended Subsec. (c) by adding provisions re determining whether a beneficiary under a special needs trust is disabled, effective July 13, 2011.

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      Sec. 17b-261a. Transfer or assignment of assets resulting in the imposition of a penalty period. Return or partial return of asset. Regulations. (a) Any transfer or assignment of assets resulting in the imposition of a penalty period shall be presumed to be made with the intent, on the part of the transferor or the transferee, to enable the transferor to obtain or maintain eligibility for medical assistance. This presumption may be rebutted only by clear and convincing evidence that the transferor's eligibility or potential eligibility for medical assistance was not a basis for the transfer or assignment.

      (b) Any transfer or assignment of assets resulting in the establishment or imposition of a penalty period shall create a debt, as defined in section 36a-645, that shall be due and owing by the transferor or transferee to the Department of Social Services in an amount equal to the amount of the medical assistance provided to or on behalf of the transferor on or after the date of the transfer of assets, but said amount shall not exceed the fair market value of the assets at the time of transfer. The Commissioner of Social Services, the Commissioner of Administrative Services and the Attorney General shall have the power or authority to seek administrative, legal or equitable relief as provided by other statutes or by common law.

      (c) The Commissioner of Social Services may waive the imposition of a penalty period when the transferor (1) in accordance with the provisions of section 3025.25 of the department's Uniform Policy Manual, suffers from dementia at the time of application for medical assistance and cannot explain transfers that would otherwise result in the imposition of a penalty period; or (2) suffered from dementia at the time of the transfer; or (3) was exploited into making such a transfer due to dementia. Waiver of the imposition of a penalty period does not prohibit the establishment of a debt in accordance with subsection (b) of this section.

      (d) An institutionalized individual shall not be penalized for the transfer of an asset if the entire amount of the transferred asset is returned to the institutionalized individual. The partial return of a transferred asset shall not result in a reduced penalty period.

      (1) If there are multiple transfers of assets to the same or different transferees, a return of anything less than the total amount of the transferred assets from all of the separate transferees shall not constitute a return of the entire amount of the transferred assets.

      (2) If the circumstances surrounding the transfer of an asset and return of the entire amount of the asset to the institutionalized individual indicates to the Department of Social Services that such individual, such individual's spouse or such individual's authorized representative intended, from the time the asset was transferred, that the transferee would subsequently return the asset to such individual, such individual's spouse or such individual's authorized representative for the purpose of altering the start of the penalty period or shifting nursing facility costs, that may have been borne by such individual, to the Medicaid program, the entire amount of the returned asset shall be considered available to such individual from the date of transfer. If such individual demonstrates to the department that the purpose of the transfer and its subsequent return was not to alter the penalty period or qualify such individual for Medicaid eligibility, the entire amount of the returned asset is considered available to the individual from the date of the return of the transferred asset.

      (3) The conveyance and subsequent return of an asset for the purpose of shifting costs to the Medicaid program shall be regarded as a trust-like device. Such asset shall be considered available for the purpose of determining Medicaid eligibility.

      (4) For purposes of this section, an "institutionalized individual" means an individual who is receiving (A) services from a long-term care facility, (B) services from a medical institution which are equivalent to those services provided in a long-term care facility, or (C) home and community-based services under a Medicaid waiver.

      (e) The Commissioner of Social Services, pursuant to section 17b-10, shall implement the policies and procedures necessary to carry out the provisions of this section while in the process of adopting such policies and procedures in regulation form, provided notice of intent to adopt regulations is published in the Connecticut Law Journal not later than twenty days after implementation. Such policies and procedures shall be valid until the time final regulations are effective.

      (June Sp. Sess. P.A. 01-2, S. 4, 69; June Sp. Sess. P.A. 01-9, S. 129, 131; June 30 Sp. Sess. P.A. 03-3, S. 62; P.A. 04-16, S. 7; P.A. 05-209, S. 4; 05-280, S. 40; P.A. 11-44, S. 104.)

      History: June Sp. Sess. P.A. 01-2 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; June 30 Sp. Sess. P.A. 03-3 designated existing provisions as Subsec. (a), added Subsec. (b) providing that transfer of assets resulting in imposition of a penalty period is presumed to be made with intent of allowing transferor to remain eligible for medical assistance, added Subsec. (c) re transfers resulting in imposition of a penalty period creating a debt due and owing to the department, added Subsec. (d) permitting commissioner to grant financial relief to nursing facility that demonstrates severe financial hardship due to imposition of transfer of assets penalties, added Subsec. (e) permitting commissioner to waive transfer of assets penalty period when transferor suffers from dementia or was exploited into making transfer, added Subsec. (f) providing that department, when determining medical assistance eligibility, shall review transfers of assets involving real property occurring in the 60 months preceding the date the individual applied for medical assistance and that federal law governs transfers of assets not involving real property, added Subsec. (g) permitting commissioner to establish threshold limits re annual asset transfers not subject to penalty and added Subsec. (h) requiring commissioner to implement policies and procedures necessary to carry out purposes of section while in the process of adopting regulations, effective August 20, 2003; P.A. 04-16 made technical changes in Subsec. (h); P.A. 05-209 deleted former Subsec. (a) re authority of commissioner to seek waiver of federal law for establishing penalty period for transfers of assets for less than fair market value, deleted former Subsec. (d) re commissioner's authority to grant financial relief to nursing homes experiencing severe financial hardship due to imposition of revised transfer of asset penalty period, deleted former Subsec. (e) re commissioner's authority to waive penalty period when transferor suffers from dementia, deleted former Subsec. (f) re 60-month penalty period for transfers of assets involving real property, deleted former Subsec. (g) re commissioner's authority to set threshold limits for transfers not subject to imposition of penalty period, and redesignated existing Subsecs. (b), (c) and (h) as new Subsecs. (a), (b) and (c), respectively, effective July 6, 2005; P.A. 05-280 added new Subsec. (c) re commissioner's authority to waive penalty period when transferor suffers from dementia and redesignated existing Subsec. (c) as new Subsec. (d), effective July 13, 2005; P.A. 11-44 added new Subsec. (d) re return or partial return of an asset and redesignated existing Subsec. (d) as Subsec. (e), effective June 13, 2011.

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      Sec. 17b-261i. Administrative services for Medicaid recipients. Regulations. (a) The Commissioner of Social Services shall contract with one or more entities, on a risk or non-risk basis, to provide administrative services to elderly and disabled Medicaid recipients, including those who are also eligible for Medicare and those enrolled in a dually eligible special needs plan. Services provided pursuant to such a contract may include, but not be limited to, care coordination, utilization management, disease management, provider network management, quality management, and customer service.

      (b) The Commissioner of Social Services 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 intent to adopt regulations 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.

      (c) The commissioner shall submit a report to the Council on Medical Assistance Program Oversight, not later than thirty days after making any policy change pursuant to this section.

      (Sept. Sp. Sess. P.A. 09-5, S. 60; P.A. 10-179, S. 77; P.A. 11-44, S. 170.)

      History: Sept. Sp. Sess. P.A. 09-5 effective October 5, 2009; P.A. 10-179 amended Subsec. (c) by replacing reference to Medicaid Managed Care Council with reference to Council on Medicaid Care Management Oversight, effective July 1, 2010; P.A. 11-44 amended Subsec. (c) by replacing "Council on Medicaid Care Management Oversight" with "Council on Medical Assistance Program Oversight", effective July 1, 2011.

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      Sec. 17b-261k. Protected amount for the community spouse of an institutionalized Medicaid applicant. Regulations. Section 17b-261k is repealed, effective July 1, 2011.

      (P.A. 10-73, S. 1; P.A. 11-44, S. 178.)

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      Sec. 17b-261m. Administrative services organization. Contract for services. Establishment of rates. (a) The Commissioner of Social Services may contract with one or more administrative services organizations to provide care coordination, utilization management, disease management, customer service and review of grievances for recipients of assistance under Medicaid, HUSKY Plan, Parts A and B, and the Charter Oak Health Plan. Such organization may also provide network management, credentialing of providers, monitoring of copayments and premiums and other services as required by the commissioner. Subject to approval by applicable federal authority, the Department of Social Services shall utilize the contracted organization's provider network and billing systems in the administration of the program. In order to implement the provisions of this section, the commissioner may establish rates of payment to providers of medical services under this section if the establishment of such rates is required to ensure that any contract entered into with an administrative services organization pursuant to this section is cost neutral to such providers in the aggregate and ensures patient access. Utilization shall not be a factor in determining cost neutrality.

      (b) Any contract entered into with an administrative services organization, pursuant to subsection (a) of this section, shall include a provision to reduce inappropriate use of hospital emergency department services. Such provision may include intensive case management services and a cost-sharing requirement.

      (P.A. 10-179, S. 20; P.A. 11-44, S. 115; 11-61, S. 124.)

      History: P.A. 10-179 effective July 1, 2010; P.A. 11-44 designated existing provisions as Subsec. (a) and amended same by adding provision allowing commissioner to establish rates for providers, and added Subsec. (b) re contract provision to reduce inappropriate use of hospital emergency department services, effective July 1, 2011; P.A. 11-61 amended Subsec. (a) by adding provision excluding utilization as factor in determining cost neutrality, effective July 1, 2011.

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      Sec. 17b-261n. Coverage for low-income adults under Medicaid program. Amendment to state Medicaid plan to establish alternative benefit package. Regulations. (a) The Commissioner of Social Services shall, subject to federal approval, administer coverage under the Medicaid program for low-income adults in accordance with Section 1902(a)(10)(A)(i)(VIII) of the Social Security Act. To the extent permitted under federal law, eligibility for individuals covered pursuant to this section shall be based on the rules used to determine eligibility for the state-administered general assistance medical assistance program, including, but not limited to, the use of medically needy income limits, a one-hundred-fifty-dollars-per-month employment deduction and a three-month extension of assistance for individuals who become ineligible solely due to an increase in earnings. The commissioner may amend the Medicaid state plan to establish an alternative benefit package for individuals eligible for Medicaid in accordance with the provisions of this section and as permitted by federal law. For purposes of this section, "alternative benefit package" may include, but is not limited to, limits on any of the following: (1) Health care provider office visits; (2) independent therapy services; (3) hospital emergency department services; (4) inpatient hospital services; (5) outpatient hospital services; (6) medical equipment, devices and supplies; (7) ambulatory surgery center services; (8) pharmacy services; (9) nonemergency medical transportation; and (10) licensed home care agency services.

      (b) The commissioner may implement policies and procedures necessary to administer the provisions of this section while in the process of adopting such policies and procedures in regulation form, provided the commissioner prints notice of intent to adopt regulations in the Connecticut Law Journal not later than twenty days after the date of implementation. Such policies and procedures shall remain valid for three years following the date of publication in the Connecticut Law Journal unless otherwise provided for by the General Assembly. Notwithstanding the time frames established in subsection (c) of section 17b-10, the commissioner shall submit such policies and procedures in proposed regulation form to the legislative regulation review committee not later than three years following the date of publication of its intent to adopt regulations as provided for in this subsection. In the event that the commissioner is unable to submit proposed regulations prior to the expiration of the three-year time period as provided for in this subsection, the commissioner shall submit written notice, not later than thirty-five days prior to the date of expiration of such time period, to the legislative regulation review committee and the joint standing committees of the General Assembly having cognizance of matters relating to human services and appropriations and the budgets of state agencies indicating that the department will not be able to submit the proposed regulations on or before such date and shall include in such notice (1) the reasons why the department will not submit the proposed regulations by such date, and (2) the date by which the department will submit the proposed regulations. The legislative regulation review committee may require the department to appear before the committee at a time prescribed by the committee to further explain such reasons and to respond to any questions by the committee about the policy. The legislative regulation review committee may request the joint standing committee of the General Assembly having cognizance of matters relating to human services to review the department's policy, the department's reasons for not submitting the proposed regulations by the date specified in this section and the date by which the department will submit the proposed regulations. Said joint standing committee may review the policy, such reasons and such date, may schedule a hearing thereon and may make a recommendation to the legislative regulation review committee.

      (c) Effective July 1, 2011, no payment shall be made to a provider of medical services for services provided prior to April 1, 2010, to a recipient of benefits under this section.

      (June Sp. Sess. P.A. 10-1, S. 24; P.A. 11-44, S. 116.)

      History: June Sp. Sess. P.A. 10-1 effective June 22, 2010; P.A. 11-44 designated existing provisions as Subsec. (a) and amended same by deleting provision re implementation of policies and procedures while adopting regulations, adding provision allowing commissioner to amend Medicaid state plan to establish an alternative benefit package and defining "alternative benefit package", added Subsec. (b) re implementation of policies and procedures, and added Subsec. (c) limiting payments to providers for services provided prior to April 1, 2010, effective July 1, 2011.

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      Sec. 17b-261o. Imposition of penalty period when undue hardship exists. Exception. (a) Except as provided in subsection (c) of this section, the Commissioner of Social Services shall not impose a penalty period pursuant to subsection (a) of section 17b-261 or subsection (a) of section 17b-261a if such imposition would create an undue hardship.

      (b) For purposes of this section, "undue hardship" exists when (1) the life or health of the applicant would be endangered by the deprivation of medical care, or the applicant would be deprived of food, clothing, shelter or other necessities of life, (2) the applicant is otherwise eligible for medical assistance under section 17b-261 but for the imposition of the penalty period, (3) if the applicant is receiving long-term care services at the time of the imposition of a penalty period, the provider of long-term care services has notified the applicant that such provider intends to discharge or discontinue providing long-term care services to the applicant due to nonpayment, (4) if the applicant is not receiving long-term care services at the time of the imposition of a penalty period, a provider of long-term care services has refused to provide long-term care services to the applicant due to the imposition of a penalty period, and (5) no other person or organization is willing and able to provide long-term care services to the applicant.

      (c) The commissioner shall impose a penalty period pursuant to subsection (a) of section 17b-261 or subsection (a) of section 17b-261a if (1) the applicant made a transfer or assignment of assets to deliberately impoverish such applicant in order to obtain or maintain eligibility for medical assistance, or (2) the transfer or assignment of assets was made by the applicant's legal representative or the joint owner of the assets. The commissioner may waive the imposition of a penalty period pursuant to this subsection if (A) the applicant suffers from dementia or other cognitive impairment and cannot explain the transfer or assignment of assets, (B) the applicant suffered from dementia or other cognitive impairment at the time the transfer or assignment of assets was made, (C) the applicant was exploited into making the transfer or assignment of assets due to dementia or other cognitive impairment, or (D) the applicant's legal representative or the record owner of a jointly held asset made the transfer or assignment of assets without the authorization of the applicant.

      (P.A. 11-176, S. 1.)

      History: P.A. 11-176 effective July 1, 2011.

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      Sec. 17b-261p. Notice re determination of penalty period. Filing claim of undue hardship. Nursing home involvement. (a) As used in this section and section 17b-261o, "applicant" means an applicant for or recipient of medical assistance pursuant to section 17b-261.

      (b) If the Commissioner of Social Services, in determining an applicant's eligibility for medical assistance pursuant to section 17b-261, intends to impose a penalty period as a result of a transfer or assignment of assets pursuant to section 17b-261 or section 17b-261a, the commissioner shall provide a preliminary notice to the applicant. Such notice shall include a statement that the applicant may contest the imposition of a penalty period by (1) filing a claim of undue hardship, as defined in section 17b-261o, or (2) providing evidence to rebut the presumption resulting in the imposition of a penalty period pursuant to subsection (a) of section 17b-261a. The applicant shall have fifteen days after the date on which the preliminary notice is postmarked to contest the imposition of a penalty period indicated in such preliminary notice. The commissioner shall grant one extension of time to file such claim or provide such evidence if requested by the applicant and shall grant additional extensions of time if reasonable. Failure to file a claim of undue hardship under this subsection shall not prohibit an applicant from making a claim of undue hardship at an administrative hearing.

      (c) If the applicant contests the imposition of a penalty period pursuant to subsection (b) of this section, the commissioner shall provide an interim decision notice to the applicant not later than ten days after the applicant files a claim or provides evidence pursuant to subsection (b) of this section. The interim decision notice shall denote the commissioner's decision to either reverse or uphold the imposition of a penalty period indicated in the preliminary notice. If the commissioner decides to uphold the imposition of a penalty period, the interim decision notice shall specify the projected commencement and expiration dates of such penalty period.

      (d) When the commissioner determines the eligibility of an applicant for medical assistance under section 17b-261, the commissioner shall provide a final decision notice to the applicant. Such final decision notice shall include (1) a statement confirming any determination the commissioner made with regard to the imposition of a penalty period pursuant to this section, and (2) a description of the applicant's appeal rights.

      (e) If, during the course of a penalty period, an applicant receives notice from a provider of long-term care services that the provider intends to (1) discharge the applicant, (2) discontinue providing long-term care services to the applicant, or (3) refuse to provide long-term care services to the applicant because of the imposition of a penalty period against the applicant pursuant to subsection (a) of section 17b-261 or subsection (a) of section 17b-261a, the applicant shall have not more than sixty days after receiving such notice to file a claim of undue hardship with the commissioner. Not later than ten days after receiving such claim, the commissioner shall provide a final decision notice to the applicant. Such final decision notice shall inform the applicant whether or not (A) the commissioner has determined that undue hardship exists, and (B) the penalty period shall be waived.

      (f) (1) A nursing home, on behalf of an applicant, may request an extension of time to claim undue hardship pursuant to subsections (b) and (e) of this section if (A) the applicant is receiving long-term care services in such nursing home, (B) the applicant has no legal representative, and (C) the nursing home provides certification from a physician that the applicant is incapable of caring for himself or herself, as defined in section 45a-644, or incapable of managing his or her affairs, as defined in section 45a-644. The commissioner shall grant such request to allow a legal representative to be appointed to act on behalf of the applicant.

      (2) The commissioner shall accept any claim filed pursuant to subsection (b) of this section by a nursing home and allow the nursing home to represent the applicant with regard to such claim if the applicant or the legal representative of the applicant gives permission to the nursing home to file a claim pursuant to subsection (b) of this section.

      (P.A. 11-176, S. 2.)

      History: P.A. 11-176 effective July 1, 2011.

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      Sec. 17b-263. (Formerly Sec. 17-274b). Utilization of outpatient mental health services. Contracts for services. Fee schedule and payment for services. (a) The Commissioner of Social Services shall extend the provisions of section 17-134d-11 of the regulations of Connecticut state agencies to monitor and control Medicaid recipient utilization of outpatient mental health services. The commissioner shall contract, through a competitive bidding process, for recipient surveillance and review services. Such contract shall authorize the imposition of utilization controls, including but not limited to, prior authorization requirements based on medical appropriateness and cost effectiveness.

      (b) Notwithstanding the provisions of subsection (d) of section 17b-239, the commissioner shall establish a service-specific fee schedule for hospital outpatient mental health therapy services, except for partial hospitalization and other comprehensive services as defined by the commissioner. Payment for partial hospitalization services shall be considered payment in full for all outpatient mental health services.

      (June Sp. Sess. P.A. 91-8, S. 10, 63; P.A. 93-262, S. 1, 87; P.A. 11-233, S. 5.)

      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. 17-274b transferred to Sec. 17b-263 in 1995; P.A. 11-233 amended Subsec. (b) by deleting provision re rate paid to be rate established in Sec. 17b-239(d) and adding provision requiring commissioner to establish service-specific fee schedule, effective July 1, 2011.

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      Sec. 17b-263a. Amendment to state Medicaid plan to include assertive community treatment teams and community support services. (a) On or before December 31, 2006, the Commissioner of Social Services, in consultation with the Commissioner of Mental Health and Addiction Services, shall take such action as is necessary to amend the Medicaid state plan to include assertive community treatment teams and community support services within the definition of optional adult rehabilitation services. Such community treatment teams shall provide intensive, integrated, multidisciplinary services to adults with severe psychiatric disabilities, including, but not limited to, persons who are homeless, persons diverted or discharged from in-patient programs or nursing homes and persons diverted or released from correctional facilities, or who are at risk of incarceration, and such teams shall provide intensive community care management through case managers, nurses and physicians and shall include, but not be limited to, vocational, peer and substance abuse specialists. The Commissioner of Social Services shall adopt regulations, in accordance with the provisions of chapter 54, for purposes of establishing the services specified in this subsection. The Commissioner of Social Services may implement policies and procedures for purposes of establishing such services while in the process of adopting such policies or procedures in regulation form, provided notice of intention to adopt the regulations is printed in the Connecticut Law Journal no later than twenty days after implementation and any such policies and procedures shall be valid until the time the regulations are effective.

      (b) For purposes of this section, the Commissioner of Social Services shall enter into a memorandum of understanding with the Department of Mental Health and Addiction Services that delegates responsibility to the Commissioner of Mental Health and Addiction Services for the clinical management of adult rehabilitation services provided to adults eighteen years of age or older who are otherwise receiving mental health services from said department. For purposes of this section, the term "clinical management" describes the process of evaluating and determining the appropriateness of the utilization of behavioral health services, providing assistance to clinicians or beneficiaries to ensure appropriate use of resources and may include, but is not limited to, authorization, concurrent and retrospective review, discharge review, quality management, provider certification and provider performance enhancement. The Commissioner of Social Services and the Commissioner of Mental Health and Addiction Services shall jointly develop clinical management policies and procedures for purposes of this section. The Commissioner of Social Services may implement policies and procedures necessary to carry out the purposes of this section, including any necessary changes to existing behavioral health policies and procedures concerning utilization management, while in the process of adopting such policies and procedures in regulation form, in accordance with the provisions of chapter 54, provided the commissioner publishes notice of intention to adopt the regulations in the Connecticut Law Journal not later than twenty days after implementing such policies and procedures. Policies and procedures implemented pursuant to this subsection shall be valid until the earlier of the time such regulations are effective, or December 1, 2006.

      (P.A. 05-280, S. 84; P.A. 11-215, S. 9.)

      History: P.A. 05-280 effective July 13, 2005; P.A. 11-215 amended Subsec. (a) by deleting requirement that commissioner consult with Community Mental Health Strategy Board.

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      Sec. 17b-263b. Pilot program for individuals ages nineteen to twenty-one with a mental disorder and chronic health condition. Eligibility. Section 17b-263b is repealed, effective July 1, 2011.

      (P.A. 05-280, S. 11; P.A. 11-44, S. 178.)

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      Sec. 17b-263c. Medical homes. Regulations. (a) The Commissioner of Social Services may establish medical homes as a model for delivering care to recipients of assistance under medical assistance programs administered by the Department of Social Services.

      (b) The commissioner may implement policies and procedures necessary to (1) establish medical homes as provided for in subsection (a) of this section, and (2) pursue optional initiatives authorized pursuant to the Patient Protection and Affordable Care Act, P.L. 111-148, and the Health Care and Education Reconciliation Act of 2010, relating to: (A) Coverage of family planning services; (B) the establishment of a temporary high risk pool for individuals with preexisting conditions; (C) the establishment of an incentive program for the prevention of chronic diseases; (D) the provision of health homes to medical assistance beneficiaries with chronic conditions; (E) the establishment of Medicaid payments to institutions for mental disease demonstration project; (F) the establishment of a dual eligible demonstration program; (G) the establishment of a balancing incentive payment program for home and community-based services; (H) the establishment of a "Community First Choice Option"; (I) the establishment of a demonstration project to make bundled payments to hospitals; and (J) the establishment of a demonstration project to allow pediatric medical providers to organize as accountable care organizations while in the process of adopting such policies and procedures in regulation form, provided the commissioner prints notice of the intention to adopt the regulations in the Connecticut Law Journal not later than twenty days after the date of implementation of such policies and procedures. Such policies and procedures shall remain valid for three years following the date of publication in the Connecticut Law Journal unless otherwise provided for by the General Assembly. Notwithstanding the time frames established in subsection (c) of section 17b-10, the commissioner shall submit such policies and procedures in proposed regulation form to the legislative regulation review committee not later than three years following the date of publication of its intent to adopt regulations as provided for in this subsection. In the event that the commissioner is unable to submit proposed regulations prior to the expiration of the three-year time period as provided for in this subsection, the commissioner shall submit written notice, not later than thirty-five days prior to the date of expiration of such time period, to the legislative regulation review committee and the joint standing committees of the General Assembly having cognizance of matters relating to human services and appropriations and the budgets of state agencies indicating that the department will not be able to submit the proposed regulations on or before such date and shall include in such notice (i) the reasons why the department will not submit the proposed regulations by such date, and (ii) the date by which the department will submit the proposed regulations. The legislative regulation review committee may require the department to appear before the committee at a time prescribed by the committee to further explain such reasons and to respond to any questions by the committee about the policy. The legislative regulation review committee may request the joint standing committee of the General Assembly having cognizance of matters relating to human services to review the department's policy, the department's reasons for not submitting the proposed regulations by the date specified in this section and the date by which the department will submit the proposed regulations. Said joint standing committee may review the policy, such reasons and such date, may schedule a hearing thereon and may make a recommendation to the legislative regulation review committee.

      (P.A. 11-44, S. 110.)

      History: P.A. 11-44 effective June 13, 2011.

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      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 care management organization under a Medicaid care management 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 care management organization on behalf of an enrollee.

      (b) An applicant or recipient or legally liable relative, by the act of the applicant's or recipient's 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; P.A. 09-8, S. 5; P.A. 10-179, S. 78; P.A. 11-44, S. 84; 11-61, S. 126.)

      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; P.A. 09-8 made technical changes in Subsec. (b); P.A. 10-179 amended Subsec. (a) by replacing references to managed care with references to care management, effective July 1, 2010; P.A. 11-44 amended Subsec. (d) by adding provision requiring Commissioner of Public Health to limit reimbursement payments to providers whose rates are established under Ch. 368d, effective July 1, 2011; P.A. 11-61 amended Subsec. (d) by deleting provision added by P.A. 11-44, effective July 1, 2011.

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      Sec. 17b-265e. Medicare Part D Supplemental Needs Fund. Payment by department for nonformulary prescription drugs. Rebates required for pharmaceutical manufacturers. Contracts for supplemental rebates. Section 17b-265e is repealed, effective July 1, 2011.

      (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; P.A. 08-1, S. 2; P.A. 09-8, S. 6; 09-14, S. 2; P.A. 11-44, S. 178.)

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      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 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. 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; P.A. 11-44, S. 90.)

      History: June Sp. Sess. P.A. 07-2 effective June 26, 2007; P.A. 11-44 deleted reference to Medicare Part D Supplemental Needs Fund, effective July 1, 2011.

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      Sec. 17b-272. (Formerly Sec. 17-134m). Personal fund allowance. Effective July 1, 2011, the Commissioner of Social Services shall permit patients residing in nursing homes, chronic disease hospitals and state humane institutions who are medical assistance recipients under sections 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, and 17b-357 to 17b-361, inclusive, to have a monthly personal fund allowance of sixty dollars.

      (P.A. 81-320; P.A. 84-354, S. 1, 2; P.A. 85-367, S. 1; P.A. 87-367, S. 1, 2; June Sp. Sess. P.A. 91-8, S. 7, 63; P.A. 93-262, S. 1, 87; June 18 Sp. Sess. P.A. 97-2, S. 151, 165; P.A. 98-239, S. 3, 35; P.A. 05-280, S. 26; P.A. 11-44, S. 79.)

      History: P.A. 84-354 increased the allowance from $28 to $30; P.A. 85-367 increased the allowance to $35; P.A. 87-367 increased the allowance from to $40 and added the language re adjustments beginning July 1, 1988; June Sp. Sess. P.A. 91-8 reduced the allowance to an amount equal to the minimum permitted under Title XIX, beginning October 1, 1991, and deleted the previous $40 allowance and the language re adjustments; 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. 17-134m transferred to Sec. 17b-272 in 1995; June 18 Sp. Sess. P.A. 97-2 added a provision effective July 1, 1998, requiring the commissioner to increase personal fund allowance annually to reflect any annual inflation adjustment in Social Security income, effective July 1, 1997; P.A. 98-239 substituted "July 1, 1998" for "October 1, 1991" as applicable date and increased the allowance to $50, deleting reference to "a level equal to the minimum permitted under Title XIX of the Social Security Act" and substituted "July 1, 1999" for "July 1, 1998" as applicable date for annual increases, effective July 1, 1998; P.A. 05-280 substituted reference to Sec. 17b-361 for reference to repealed Sec. 17b-362, effective July 1, 2005; P.A. 11-44 changed date from July 1, 1998, to July 1, 2011, increased personal fund allowance from $50 to $60 and deleted provision re annual allowance increase, effective July 1, 2011.

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      Sec. 17b-274. (Formerly Sec. 17-134q). Periodic investigations of pharmacies by Division of Criminal Justice. Brand medically necessary. Procedure for prior approval to dispense brand name drug. Disclosure. (a) The Division of Criminal Justice shall periodically investigate pharmacies to ensure that the state is not billed for a brand name drug product when a less expensive generic substitute drug product is dispensed to a Medicaid recipient. The Commissioner of Social Services shall cooperate and provide information as requested by such division.

      (b) A licensed medical practitioner may specify in writing or by a telephonic or electronic communication that there shall be no substitution for the specified brand name drug product in any prescription for a Medicaid or ConnPACE recipient, provided (1) the practitioner specifies the basis on which the brand name drug product and dosage form is medically necessary in comparison to a chemically equivalent generic drug product substitution, and (2) the phrase "brand medically necessary" shall be in the practitioner's handwriting on the prescription form or, if the prohibition was communicated by telephonic communication, in the pharmacist's handwriting on such form, and shall not be preprinted or stamped or initialed on such form. If the practitioner specifies by telephonic communication that there shall be no substitution for the specified brand name drug product in any prescription for a Medicaid or ConnPACE recipient, written certification in the practitioner's handwriting bearing the phrase "brand medically necessary" shall be sent to the dispensing pharmacy within ten days. A pharmacist shall dispense a generically equivalent drug product for any drug listed in accordance with the Code of Federal Regulations Title 42 Part 447.332 for a drug prescribed for a Medicaid, state-administered general assistance, or ConnPACE recipient unless the phrase "brand medically necessary" is ordered in accordance with this subsection and such pharmacist has received approval to dispense the brand name drug product in accordance with subsection (c) of this section.

      (c) The Commissioner of Social Services shall implement a procedure by which a pharmacist shall obtain approval from an independent pharmacy consultant acting on behalf of the Department of Social Services, under an administrative services only contract, whenever the pharmacist dispenses a brand name drug product to a Medicaid or ConnPACE recipient and a chemically equivalent generic drug product substitution is available. The length of authorization for brand name drugs shall be in accordance with section 17b-491a. In cases where the brand name drug is less costly than the chemically equivalent generic drug when factoring in manufacturers' rebates, the pharmacist shall dispense the brand name drug. If such approval is not granted or denied within two hours of receipt by the commissioner of the request for approval, it shall be deemed granted. Notwithstanding any provision of this section, a pharmacist shall not dispense any initial maintenance drug prescription for which there is a chemically equivalent generic substitution that is for less than fifteen days without the department's granting of prior authorization, provided prior authorization shall not otherwise be required for atypical antipsychotic drugs if the individual is currently taking such drug at the time the pharmacist receives the prescription. The pharmacist may appeal a denial of reimbursement to the department based on the failure of such pharmacist to substitute a generic drug product in accordance with this section.

      (d) A licensed medical practitioner shall disclose to the Department of Social Services or such consultant, upon request, the basis on which the brand name drug product and dosage form is medically necessary in comparison to a chemically equivalent generic drug product substitution. The Commissioner of Social Services shall establish a procedure by which such a practitioner may appeal a determination that a chemically equivalent generic drug product substitution is required for a Medicaid or ConnPACE recipient.

      (P.A. 83-52, S. 1, 2, 4; P.A. 84-217, S. 1, 2; P.A. 89-111, S. 1; P.A. 93-262, S. 1, 87; P.A. 95-264, S. 46; P.A. 96-169, S. 13; June Sp. Sess. P.A. 00-2, S. 38, 53; May 9 Sp. Sess. P.A. 02-7, S. 50; P.A. 03-2, S. 52; June 30 Sp. Sess. P.A. 03-3, S. 84; P.A. 04-76, S. 16; P.A. 05-280, S. 16; P.A. 11-44, S. 128.)

      History: P.A. 84-217 removed language that limited payment of fee to the period from July 1, 1983, to June 30, 1984, and increased fee from $0.25 to $0.50; P.A. 89-111 added a new Subsec. (c) containing provisions for when there is to be no substitute for the specified brand name drug product; 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. 17-134q transferred to Sec. 17b-274 in 1995; P.A. 95-264 made technical changes; P.A. 96-169 amended Subsec. (b) to require the Commissioner of Social Services to cooperate and provide information as requested by the Division of Criminal Justice; June Sp. Sess. P.A. 00-2 amended Subsec. (c) to apply provisions to state-administered general assistance, general assistance and ConnPACE recipients, to require specification of the basis of medical necessity and to add provision re approval to dispense, added new Subsec. (d) requiring the Commissioner of Social Services to establish a procedure for approval of dispensing brand name drug products and added new Subsec. (e) re disclosure of the basis of medical necessity, effective July 1, 2000; May 9 Sp. Sess. P.A. 02-7 deleted former Subsec. (a) re $0.50 per prescription dispensing fee, redesignated existing Subsecs. (b) to (e) as Subsecs. (a) to (d) and amended Subsec. (c) by changing "shall establish a procedure" to "shall implement a procedure" and adding requirement that pharmacist not dispense any initial maintenance drug prescription for less than 15 days for which there is a chemically equivalent generic substitution without obtaining prior authorization from the department, such prior authorization not required for atypical antipsychotic drugs currently used by individuals at the time pharmacist receives prescription, effective August 15, 2002; P.A. 03-2 amended Subsec. (c) to add provision that chemically equivalent generic drug product substitution be available "at a lower cost" as condition precedent to requiring prior authorization for dispensing brand name drug product, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (c) to delete "at a lower cost" and add provision re dispensing of brand name drug in cases where the brand name drug is less costly than the generic drug when factoring in manufacturers' rebates, effective August 20, 2003; P.A. 04-76 amended Subsecs. (b) to (d), inclusive, by deleting references to "general assistance"; P.A. 05-280 amended Subsec. (c) by deleting provision specifying that prior authorization procedure shall not require approval other than initial prescriptions for brand name drug products and adding requirement that length of authorization for brand name drugs shall be in accordance with Sec. 17b-491a, effective July 1, 2005; P.A. 11-44 amended Subsecs. (b), (c) and (d) by deleting references to state-administered general assistance, effective July 1, 2011.

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      Sec. 17b-274a. Maximum allowable costs for generic prescription drugs. Implementation of maximum allowable cost list. The Commissioner of Social Services may establish maximum allowable costs to be paid under the Medicaid, ConnPACE and Connecticut AIDS drug assistance programs for generic prescription drugs based on, but not limited to, actual acquisition costs. The department shall implement and maintain a procedure to review and update the maximum allowable cost list at least annually, and shall report annually to the joint standing committee of the General Assembly having cognizance of matters relating to appropriations and the budgets of state agencies on its activities pursuant to this section.

      (May 9 Sp. Sess. P.A. 02-1, S. 118; May 9 Sp. Sess. P.A. 02-7, S. 53; P.A. 04-76, S. 17; P.A. 11-44, S. 126.)

      History: May 9 Sp. Sess. P.A. 02-1 effective July 1, 2002; May 9 Sp. Sess. P.A. 02-7 required department to implement and maintain a procedure to review and update the maximum allowable cost list at least annually and to report annually to the General Assembly, effective August 15, 2002; P.A. 04-76 deleted reference to "general assistance"; P.A. 11-44 deleted reference to state-administered general assistance, effective July 1, 2011.

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      Sec. 17b-274c. Voluntary mail order option for maintenance prescription drugs and drugs covered under the Medicare Part D program. (a) The Commissioner of Social Services may establish a voluntary mail order option for any maintenance prescription drug covered under the Medicaid, ConnPACE or Connecticut AIDS drug assistance programs.

      (b) Notwithstanding any provision of the general statutes or regulations adopted pursuant thereto, the Commissioner of Social Services may provide a voluntary mail order option, regardless of a mail order pharmacy's location, for any prescription drug covered under the Medicare Part D program established pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

      (May 9 Sp. Sess. P.A. 02-1, S. 120; P.A. 04-76, S. 19; Nov. 2 Sp. Sess. P.A. 05-2, S. 5; P.A. 11-44, S. 127.)

      History: May 9 Sp. Sess. P.A. 02-1 effective July 1, 2002; P.A. 04-76 deleted reference to "general assistance"; Nov. 2 Sp. Sess. P.A. 05-2 designated existing provisions as Subsec. (a) and added Subsec. (b) authorizing commissioner to provide a voluntary mail order option for any prescription drug covered under the Medicare Part D program, effective December 1, 2005; P.A. 11-44 amended Subsec. (a) by deleting reference to state-administered general assistance, effective July 1, 2011.

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      Sec. 17b-274d. Pharmaceutical and Therapeutics Committee. Membership. Duties. Preferred drug lists. Supplemental rebates. Administrative hearings. (a) Pursuant to 42 USC 1396r-8, there is established a Pharmaceutical and Therapeutics Committee within the Department of Social Services.

      (b) The Pharmaceutical and Therapeutics Committee shall be comprised as specified in 42 USC 1396r-8 and shall consist of fourteen members appointed by the Governor. Five members shall be physicians licensed pursuant to chapter 370, including one general practitioner, one pediatrician, one geriatrician, one psychiatrist and one specialist in family planning, four members shall be pharmacists licensed pursuant to chapter 400j, two members shall be visiting nurses, one specializing in adult care and one specializing in psychiatric care, one member shall be a clinician designated by the Commissioner of Mental Health and Addiction Services, one member shall be a representative of pharmaceutical manufacturers and one member shall be a consumer representative. The committee may, on an ad hoc basis, seek the participation of other state agencies or other interested parties in its deliberations. The members shall serve for terms of two years from the date of their appointment. Members may be appointed to more than one term. The Commissioner of Social Services, or the commissioner's designee, shall convene the committee following the Governor's designation of appointments. The administrative staff of the Department of Social Services shall serve as staff for said committee and assist with all ministerial duties. The Governor shall ensure that the committee membership includes Medicaid participating physicians and pharmacists, with experience serving recipients of medical assistance.

      (c) Committee members shall select a chairperson and vice-chairperson from the committee membership on an annual basis.

      (d) The committee shall meet at least quarterly, and may meet at other times at the discretion of the chairperson and committee membership. The committee shall ensure that each meeting includes an opportunity for public comment. The committee shall comply with all regulations adopted by the department, including notice of any meeting of the committee, pursuant to the requirements of chapter 54.

      (e) The Department of Social Services, in consultation with the Pharmaceutical and Therapeutics Committee, may adopt preferred drug lists for use in the Medicaid and ConnPACE programs. To the extent feasible, the department shall review all drugs included on the preferred drug lists at least every twelve months, and may recommend additions to, and deletions from, the preferred drug lists, to ensure that the preferred drug lists provide for medically appropriate drug therapies for Medicaid and ConnPACE patients. For the fiscal year ending June 30, 2004, such drug lists shall be limited to use in the Medicaid and ConnPACE programs and cover three classes of drugs, including proton pump inhibitors and two other classes of drugs determined by the Commissioner of Social Services. Not later than June 30, 2005, the Department of Social Services, in consultation with the Pharmaceutical and Therapeutic Committee, shall expand such drug lists to include other classes of drugs, except as provided in subsection (f) of this section, in order to achieve savings reflected in the amounts appropriated to the department, for the various components of the program, in the state budget act.

      (f) Nonpreferred drugs in the classes of drugs included on the preferred drug lists shall be subject to prior authorization. Prior authorization is not required for any mental-health-related drug that has been filled or refilled, in any dosage, at least one time in the one-year period prior to the date the individual presents a prescription for the drug at a pharmacy. If prior authorization is granted for a drug not included on a preferred drug list, the authorization shall be valid for one year from the date the prescription is first filled. Antiretroviral classes of drugs shall not be included on the preferred drug lists.

      (g) The Department of Social Services shall publish and disseminate the preferred drug lists to all Medicaid providers in the state.

      (h) The department may negotiate supplemental rebate agreements with manufacturers that are in addition to those required under Title XIX of the Social Security Act. The committee shall ensure that the pharmaceutical manufacturers agreeing to provide a supplemental rebate pursuant to 42 USC 1396r-8(c) have an opportunity to present evidence supporting inclusion of a product on the preferred drug lists unless a court of competent jurisdiction, in a final decision, determines that the Secretary of Health and Human Services does not have authority to allow such supplemental rebates, provided the inability to utilize supplemental rebates pursuant to this subsection shall not impair the committee's authority to maintain preferred drug lists. Upon timely notice, the department shall ensure that any drug that has been approved, or had any of its particular uses approved, by the United States Food and Drug Administration under a priority review classification, will be reviewed by the Pharmaceutical and Therapeutics Committee at the next regularly scheduled meeting. To the extent feasible, upon notice by a pharmaceutical manufacturer, the department shall also schedule a product review for any new product at the next regularly scheduled meeting of the Pharmaceutical and Therapeutics Committee.

      (i) Factors considered by the department and the Pharmaceutical and Therapeutics Committee in developing the preferred drug lists shall include, but not be limited to, clinical efficacy, safety and cost effectiveness of a product.

      (j) The Pharmaceutical and Therapeutics Committee may also make recommendations to the department regarding the prior authorization of any prescribed drug.

      (k) A recipient who is denied a nonpreferred drug may request an administrative hearing in accordance with section 17b-60.

      (l) The Commissioner of Social Services may contract with a pharmacy benefits organization or a single entity qualified to negotiate with pharmaceutical manufacturers for supplemental rebates, available pursuant to 42 USC 1396r-8(c), for the purchase of drugs listed on the preferred drug lists established pursuant to subsection (e) of this section.

      (May 9 Sp. Sess. P.A. 02-1, S. 121; May 9 Sp. Sess. P.A. 02-7, S. 52; P.A. 03-2, S. 19; 03-278, S. 63; June 30 Sp. Sess. P.A. 03-3, S. 83; P.A. 04-258, S. 8, 43; May Sp. Sess. P.A. 04-2, S. 41; P.A. 05-280, S. 18; 05-288, S. 71; Sept. Sp. Sess. P.A. 09-5, S. 38; P.A. 10-72, S. 1; 10-179, S. 67; P.A. 11-25, S. 10; 11-44, S. 125.)

      History: May 9 Sp. Sess. P.A. 02-1 effective July 1, 2002; May 9 Sp. Sess. P.A. 02-7 amended Subsec. (h) by adding provision re implementation of supplemental rebate program subject to determination by a court of competent jurisdiction re federal authority to allow such rebates, effective August 15, 2002; P.A. 03-2 amended Subsec. (a) to require committee to convene on or before March 31, 2003, amended Subsec. (e) to require Department of Social Services to adopt preferred drug list on or before July 1, 2003, to replace provision re department's adoption of preferred drug list upon recommendation of committee with provision re adoption of preferred drug list in consultation with committee, and to substitute "department" for "committee" re review of drugs included in the preferred drug list, and amended Subsec. (i) to add "the department and" re development of the preferred drug list, effective February 28, 2003; P.A. 03-278 made technical changes in Subsec. (h), effective July 9, 2003; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (b) to increase size of committee from 11 to 14 members, to further specify the professional qualifications required of the committee membership, and to add provisions re committee may seek participation of other state agencies and interested parties, and re committee to convene after Governor's designation of appointments, amended Subsec. (e) to add references to the Medicaid and ConnPACE programs re use of preferred drug list, to provide that for fiscal year ending June 30, 2004, preferred drug list is limited to proton pump inhibitors and two other classes of drugs to be determined by commissioner and to add provision re notice to legislative committees, amended Subsec. (j) to add "in accordance with the plan developed and implemented pursuant to section 17b-491a" and added new Subsec. (l) re application of section to state-administered general assistance program, effective August 20, 2003; P.A. 04-258 amended Subsec. (a) by deleting provision re date by which committee was to convene, amended Subsecs. (e) through (i), inclusive, by replacing "preferred drug list" with "preferred drug lists" and making conforming changes, amended Subsec. (e) by providing that use of preferred drug list would be expanded to HUSKY Plan, Part A and Part B upon the Department of Social Services entering into a contract for the provision of prescription drug coverage pursuant to Sec. 17b-266a, adding provision re use of preferred drug lists for the fiscal year ending June 30, 2004, only in the Medicaid and ConnPACE programs, deleting provision re notification by commissioner by January 1, 2004, of classes of drugs on preferred drug list and adding provision re expansion of drug lists by June 30, 2005, to include other classes of drugs, amended Subsec. (f) by adding "medications used to treat diabetes, asthma or cancer" to the types of drugs not subject to prior authorization requirements, moved provision in former Subsec. (l) re application of section to state-administered general assistance program to Subsec. (e), and added new Subsec. (l) re commissioner's authority to negotiate with pharmaceutical manufacturers for supplemental rebates for drugs on preferred drug lists, effective July 1, 2004; May Sp. Sess. P.A. 04-2 amended Subsec. (f) by deleting "medications used to treat diabetes, asthma or cancer" re the types of drugs not subject to prior authorization requirements, effective July 1, 2004; P.A. 05-280 amended Subsecs. (a), (b), (e) and (h) to (j), inclusive, to delete "Medicaid" from the name of the Pharmaceutical and Therapeutics Committee, amended Subsec. (b) to substitute "recipients of medical assistance" for "all segments of the Medicaid population", amended Subsec. (e) by substituting "may" for "shall" re adoption of preferred drug lists, amended Subsec. (f) by providing that nonpreferred drugs in the classes of drugs included on the preferred drug lists shall be subject to prior authorization, specifying that the length of prior authorization shall be for one year from the date the prescription is first filled and exempting mental-health-related and antiretroviral classes of drugs from inclusion on the preferred drug lists, amended Subsec. (h) by providing that department may negotiate supplemental rebate agreements with manufacturers that supplement those required by Title XIX of the Social Security Act, amended Subsec. (j) by removing provision that limited committee's recommendation to drugs covered by Medicaid in accordance with the plan developed pursuant to Sec. 17b-491a, and replaced former Subsec. (k) re Medicaid recipients appeal of preferred drug list determinations utilizing Medicaid fair hearing process with new Subsec. (k) providing that a recipient denied a nonpreferred drug may request an administrative hearing in accordance with Sec. 17b-60, effective July 1, 2005; P.A. 05-288 made a technical change in Subsec. (f), effective July 13, 2005; Sept. Sp. Sess. P.A. 09-5 amended Subsec. (f) to add provision re exemption of mental-health-related drugs from prior authorization and delete provision re mental-health-related drugs not included on preferred drug lists, effective October 5, 2009; P.A. 10-72 amended Subsec. (d) by adding provision re opportunity for public comment at each meeting, effective July 1, 2010; P.A. 10-179 amended Subsec. (e) by deleting provision requiring department to expand preferred drug list for use in HUSKY Plan in consultation with committee, effective July 1, 2010; P.A. 11-25 made a technical change in Subsec. (e); P.A. 11-44 amended Subsec. (e) by deleting references to state-administered general assistance, effective July 1, 2011.

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      Sec. 17b-274e. Prescription drugs. Utilization of cost-efficient dosages. A pharmacist, when filling a prescription under the Medicaid, ConnPACE or Connecticut AIDS drug assistance programs, shall fill such prescription utilizing the most cost-efficient dosage, consistent with the prescription of a prescribing practitioner as defined in section 20-571, unless such pharmacist receives permission to do otherwise pursuant to the prior authorization requirements set forth in sections 17b-274 and 17b-491a.

      (June 30 Sp. Sess. P.A. 03-3, S. 82; P.A. 11-44, S. 129.)

      History: June 30 Sp. Sess. P.A. 03-3 effective August 20, 2003; P.A. 11-44 deleted reference to state-administered general assistance and made a technical change, effective July 1, 2011.

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      Sec. 17b-276. (Formerly Sec. 17-134s). Competitive bidding process for nonemergency transportation services. Disclosure of payment source. Fee schedules. (a) The Commissioner of Social Services shall identify geographic areas of the state where competitive bidding for nonemergency transportation services provided to medical assistance recipients to access covered medical services would result in cost savings to the state. For the identified areas, the Commissioner of Social Services, in consultation with the Commissioner of Transportation, the Commissioner of Public Health and the Secretary of the Office of Policy and Management, shall purchase such nonemergency transportation services through a competitive bidding process. Any transportation providers awarded a contract or subcontract for the direct provision of such services shall meet state licensure or certification requirements and the nonemergency transportation requirements established by the Department of Social Services, and shall provide the most cost effective transportation service, provided any contractor awarded a contract solely for coordinating such transportation services shall not be required to meet such licensure or certification requirements and provided the first such contracts for the purchase of such services shall not exceed one year. Prior to awarding a contract pursuant to this section, the Commissioner of Social Services shall consider the effect of the contract on the emergency ambulance primary service areas and volunteer ambulance services affected by the contract. The commissioner may limit the geographic areas to be served by a contractor and may limit the amount of services to be performed by a contractor. The commissioner may operate one or more pilot programs prior to state-wide operation of a competitive bidding program for nonemergency transportation services. By enrolling in the Medicaid program or participating in the competitively bid contract for nonemergency transportation services, providers of nonemergency transportation services agree to offer to recipients of medical assistance all types or levels of transportation services for which they are licensed or certified. Effective October 1, 1991, payment for such services shall be made only for services provided to an eligible recipient who is actually transported. A contract entered into pursuant to this section may include services provided by another state agency. Notwithstanding any provision of the general statutes, a contract entered into pursuant to this section shall establish the rates to be paid for the transportation services provided under the contract. A contract entered into pursuant to this section may include services provided by another state agency and shall supersede any conflicting provisions of the regulations of Connecticut state agencies pertaining to medical transportation services. Any contractor awarded a contract for coordinating nonemergency transportation services for medical assistance recipients, who also coordinates transportation services for nonmedical assistance recipients, shall disclose to any transportation provider, with whom it subcontracts to provide nonemergency transportation services under this section, the source of payment at the time the service is requested.

      (b) Notwithstanding any other provision of the general statutes, for purposes of administering medical assistance programs, including, but not limited to, programs administered pursuant to Title XIX or Title XXI of the Social Security Act, the Department of Social Services shall be the sole state agency that sets emergency and nonemergency medical transportation fees or fee schedules for any transportation services that are reimbursed by the department for said medical assistance programs. Effective July 1, 2011, the Commissioner of Social Services shall reduce, by not more than ten per cent, the rates in effect on December 31, 2010, for emergency ambulance transportation fees that are directly reimbursed by the Department of Social Services, provided the commissioner may increase such rates at such time when the commissioner determines there are sufficient funds and a reasonable need for such rate increase.

      (P.A. 85-505, S. 12, 21; P.A. 86-403, S. 37, 132; June Sp. Sess. P.A. 91-8, S. 8, 63; P.A. 93-262, S. 1, 87; P.A. 96-268, S. 15, 34; May 9 Sp. Sess. P.A. 02-7, S. 61; P.A. 03-278, S. 64; P.A. 09-210, S. 8; P.A. 11-44, S. 130; 11-61, S. 125.)

      History: P.A. 86-403 made technical changes; June Sp. Sess. P.A. 91-8 required that medical transportation service providers offer medical assistance recipients all types and levels of service which are provided, and that payment of services shall only be rendered to providers who transport eligible recipients; 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. 17-134s transferred to Sec. 17b-276 in 1995; P.A. 96-268 replaced "medical transportation services" with "nonemergency transportation services", required consultation with Commissioners of Transportation and Public Health and the Secretary of the Office of Policy and Management, required transportation providers to meet licensure or certification requirements, required commissioner to consider the effect of a contract on the emergency ambulance primary service areas, required transportation providers to agree to offer Medicaid recipients all types of services provided, allowed contracts to include services provided by other state agencies and required contracts to establish rates to be paid for services, effective July 1, 1996; May 9 Sp. Sess. P.A. 02-7 designated existing provisions as Subsec. (a) and amended same by adding provisions re contract may include services provided by another state agency and supersedes any conflicting provisions of medical transportation services regulations, and added Subsec. (b) re exclusive authority of Department of Social Services in setting emergency and nonemergency medical transportation fees for medical assistance programs, effective August 15, 2002; P.A. 03-278 made technical changes in Subsec. (a), effective July 9, 2003; P.A. 09-210 amended Subsec. (a) by adding provision requiring contractors that coordinate nonemergency transportation services for medical assistance recipients and for persons not receiving medical assistance to disclose the source of payment to transportation provider, effective July 1, 2009; P.A. 11-44 amended Subsec. (b) by deleting reference to state-administered general assistance program, effective July 1, 2011; P.A. 11-61 amended Subsec. (b) by adding provision re reduction of rates in effect on December 31, 2010, for emergency ambulance transportation, effective July 1, 2011.

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      Sec. 17b-278a. Coverage for treatment for smoking cessation. The Commissioner of Social Services shall amend the Medicaid state plan to provide coverage for treatment for smoking cessation. Notwithstanding the provisions of section 17b-280a, such treatment may include coverage for prescription drugs, including over-the-counter drugs and counseling.

      (P.A. 99-250, S. 1; P.A. 02-4, S. 19; P.A. 08-184, S. 61; P.A. 11-44, S. 106.)

      History: P.A. 02-4 mandated provision of coverage for treatment ordered by licensed healthcare professional in accordance with plan approved by General Assembly committees, deleting provisions re treatment ordered by licensed physician to extent permitted by federal law and re coverage limited to maximum of $400 per person per year, effective July 1, 2002; P.A. 08-184 added provision re all prescriptive options for smoking cessation being available to patients whose initial treatment is not successful, effective July 1, 2008; P.A. 11-44 deleted provisions re treatment ordered by a health care professional and commissioner's plan to provide smoking cessation services, and added provision re coverage for treatment including prescription drugs, over-the-counter drugs and counseling, effective January 1, 2012.

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      Sec. 17b-278g. Medical assistance for eyeglasses and contact lenses. Regulations. (a) To the extent permitted by federal law, no payment shall be provided by the Department of Social Services under the Medicaid program for more than one pair of eyeglasses every two years, except payment may be provided under the Medicaid program for an additional pair of eyeglasses during the two-year period when a Medicaid recipient's health care provider determines that such eyeglasses are necessary because of a change in the recipient's medical condition. Said department shall administer the payment for eyeglasses and contact lenses as cost effectively as possible.

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

      (P.A. 10-3, S. 28; 10-179, S. 49; June Sp. Sess. P.A. 10-2, S. 6; P.A. 11-44, S. 94; 11-48, S. 1.)

      History: P.A. 10-3 effective May 1, 2010; P.A. 10-179 replaced provision re medical assistance program with provision re Medicaid program and substituted provision requiring department to use its best efforts to reduce costs with provision requiring department to administer payment for eyeglasses and contact lenses as cost effectively as possible, effective May 7, 2010; June Sp. Sess. P.A. 10-2 designated existing provisions as Subsec. (a) and added Subsec. (b) re implementing policies and procedures while adopting regulations, effective June 22, 2010; P.A. 11-44 replaced provision requiring payment for 1 pair of eyeglasses per year to payment for 1 pair every 2 years, effective July 1, 2011; P.A. 11-48 amended Subsec. (a) by adding exception to allow payment for an additional pair of eyeglasses during the 2-year period, effective July 1, 2011.

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      Sec. 17b-280. (Formerly Sec. 17-134bb). Reimbursement rate for legend drugs. Dispensing fee. Reimbursement for over-the-counter drugs and products. Dispensing fee exception. Enhanced dispensing fee. (a) The state shall reimburse for all legend drugs provided under medical assistance programs administered by the Department of Social Services at the lower of (1) the rate established by the Centers for Medicare and Medicaid Services as the federal acquisition cost, (2) the average wholesale price minus sixteen per cent, or (3) an equivalent percentage as established under the Medicaid state plan. The state shall pay a professional fee of two dollars to licensed pharmacies for each prescription dispensed to a recipient of benefits under a medical assistance program administered by the Department of Social Services in accordance with federal regulations. On and after September 4, 1991, payment for legend and nonlegend drugs provided to Medicaid recipients shall be based upon the actual package size dispensed. Effective October 1, 1991, reimbursement for over-the-counter drugs for such recipients shall be limited to those over-the-counter drugs and products published in the Connecticut Formulary, or the cross reference list, issued by the commissioner. The cost of all over-the-counter drugs and products provided to residents of nursing facilities, chronic disease hospitals, and intermediate care facilities for the mentally retarded shall be included in the facilities' per diem rate. Notwithstanding the provisions of this subsection, no dispensing fee shall be issued for a prescription drug dispensed to a ConnPACE or Medicaid recipient who is a Medicare Part D beneficiary when the prescription drug is a Medicare Part D drug, as defined in Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

      (b) The Department of Social Services may provide an enhanced dispensing fee to a pharmacy enrolled in the federal Office of Pharmacy Affairs Section 340B drug discount program established pursuant to 42 USC 256b or a pharmacy under contract to provide services under said program.

      (P.A. 89-296, S. 2, 9; June Sp. Sess. P.A. 91-8, S. 9, 63; May 9 Sp. Sess. P.A. 02-1, S. 122; P.A. 03-2, S. 11; June 30 Sp. Sess. P.A. 03-3, S. 52; P.A. 04-76, S. 20; 04-258, S. 10; May Sp. Sess. P.A. 04-2, S. 85; P.A. 05-280, S. 4; Sept. Sp. Sess. P.A. 09-5, S. 71; P.A. 10-179, S. 23; P.A. 11-44, S. 76.)

      History: June Sp. Sess. P.A. 91-8 divided the subsection into Subdivs., substituted "Medicaid" for "medical aid" and June 30 Sp. Sess. P.A. 03-3 relettered existing provision as Subsec. (a), provision amended to provide effective October 1, 2003 professional dispensing fee paid to pharmacies lowered from $3.60 to $3.30, added new Subsec. (b) to allow commissioner to provide an enhanced dispensing fee to a pharmacy enrolled in, or under contract to provide services, under the federal Office of Pharmacy Affairs drug discount program, effective August 20, 2003, added a new Subdiv. (2) re payment for legend and nonlegend drugs and basing the payment on the actual package size dispensed, limitation on the reimbursement of over-the-counter drugs as of October 1, 1991, and the inclusion in the rate of the cost of over-the-counter drugs for nursing facilities, chronic disease hospitals and the intermediate care facilities for the mentally retarded; Sec. 17-134bb transferred to Sec. 17b-280 in 1995; May 9 Sp. Sess. P.A. 02-1 amended Subdiv. (1) to provide that reimbursement for legend drugs applies to the Medicaid, state-administered general assistance, general assistance, ConnPACE and Connecticut AIDS drug assistance programs and that, effective September 1, 2002, the dispensing fee paid to licensed pharmacists is $3.85 per prescription, effective July 1, 2002; P.A. 03-2 deleted "Notwithstanding any provision of the regulations of Connecticut state agencies concerning payment for drugs provide to Medicaid recipients (1) effective July 1, 1989", provided that effective March 1, 2003, the dispensing fee is $3.60 per prescription and made technical changes, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-3 designated existing provisions as Subsec. (a) and, effective October 1, 2003, lowered professional dispensing fee paid to pharmacies from $3.60 to $3.30 and added new Subsec.(b) re enhanced dispensing fee to pharmacy enrolled in, or under contract to provide services under, the federal Office of Pharmacy Affairs drug discount program, effective August 20, 2003; P.A. 04-76 amended Subsec. (a) by deleting references to "general assistance"; P.A. 04-258 amended Subsec. (a) by deleting "Effective October 1, 2003," and by lowering the professional dispensing fee paid to pharmacies from $3.30 to $3.15, effective July 1, 2004; May Sp. Sess. P.A. 04-2 amended Subsec. (a) to delete "state-administered general assistance" from the list of programs for which commissioner pays a professional fee to licensed pharmacies for dispensing drugs to program recipients, effective July 1, 2004; P.A. 05-280 amended Subsec. (a) by substituting "Centers for Medicare and Medicaid Services" for "Health Care Finance Administration", providing that reimbursement rate for legend drugs shall be the lower of rate established by said Centers, the average wholesale price minus 14% or an equivalent percentage as established under the Medicaid state plan, deleting language re commissioner's authority to establish and periodically revise estimated acquisition cost in accordance with federal regulations, and providing that no dispensing fee shall be issued for prescription drugs dispensed to a ConnPACE or Medicaid recipient who is a Medicare Part D beneficiary when the prescription drug is a Medicare Part D drug, effective July 1, 2005; Sept. Sp. Sess. P.A. 09-5 amended Subsec. (a) by changing professional fee from $3.15 to $2.65 and adding provision applying fee to drugs dispensed under state-administered general assistance program, effective October 5, 2009; P.A. 10-179 amended Subsec. (a) by changing professional fee per prescription from $2.65 to $2.90, effective May 7, 2010; P.A. 11-44 amended Subsec. (a) by replacing names of medical assistance programs with "medical assistance programs administered by the Department of Social Services", restating provision re professional fee to require state to pay fee to licensed pharmacies, decreasing professional fee from $2.90 to $2, decreasing rate to average wholesale price minus sixteen per cent, and making technical changes, effective July 1, 2011.

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      Sec. 17b-280a. Payment for over-the-counter drugs under medical assistance program. Exceptions. Notwithstanding any provision of the general statutes, no payment shall be made under a medical assistance program administered by the Department of Social Services, except for the medical assistance program established pursuant to section 17b-256, for an over-the-counter drug, except for (1) insulin and insulin syringes, (2) nutritional supplements for individuals who are required to be tube fed or who cannot safely ingest nutrition in any other form, and as may be required by federal law, and (3) effective January 1, 2012, smoking cessation drugs as provided in section 17b-278a. On or before August 1, 2011, the Commissioner of Social Services shall provide notice to pharmacists who provide services to beneficiaries of a medical assistance program administered by the department that such pharmacists may bill the department for supplies utilized in the treatment of diabetes using the durable medical equipment, medical surgical supply fee schedule. The commissioner shall provide a copy of such notice 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.

      (P.A. 10-3, S. 12; 10-179, S. 48; June Sp. Sess. P.A. 10-1, S. 50; P.A. 11-44, S. 107.)

      History: P.A. 10-3 effective May 1, 2010; P.A. 10-179 changed May 1, 2010, to June 1, 2010, and added exception for medical assistance program established pursuant to Sec. 17b-256, effective May 7, 2010; June Sp. Sess. P.A. 10-1 deleted reference to on and after June 1, 2010, and added exception for nutritional supplements for certain individuals, effective June 22, 2010; P.A. 11-44 inserted Subdiv. (1) and (2) designators, added Subdiv. (3) re smoking cessation drugs, added provisions re notice to pharmacists and General Assembly, and made technical changes, effective July 1, 2011.

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      Sec. 17b-282d. Commissioner to modify nonemergency dental services. Regulations. (a) The Commissioner of Social Services shall modify the extent of nonemergency adult dental services provided under the Medicaid program. Such modifications shall include, but are not limited to, providing one periodic dental exam, one dental cleaning and one set of bitewing x-rays each year for a healthy adult. For purposes of this section, "healthy adult" means a person twenty-one years of age or older for whom there is no evidence indicating that dental disease is an aggravating factor for the person's overall health condition.

      (b) The commissioner may implement policies and procedures necessary to administer the provisions of this section while in the process of adopting such policies and procedures in regulation form, provided the commissioner prints notice of intent to adopt regulations in the Connecticut Law Journal not later than twenty days after the date of implementation. Such policies and procedures shall remain valid for three years following the date of publication in the Connecticut Law Journal unless otherwise provided for by the General Assembly. Notwithstanding the time frames established in subsection (c) of section 17b-10, the commissioner shall submit such policies and procedures in proposed regulation form to the legislative regulation review committee not later than three years following the date of publication of its intent to adopt regulations as provided for in this subsection. In the event that the commissioner is unable to submit proposed regulations prior to the expiration of the three-year time period as provided for in this subsection, the commissioner shall submit written notice, not later than thirty-five days prior to the date of expiration of such time period, to the legislative regulation review committee and the joint standing committees of the General Assembly having cognizance of matters relating to human services and appropriations and the budgets of state agencies indicating that the department will not be able to submit the proposed regulations on or before such date and shall include in such notice (1) the reasons why the department will not submit the proposed regulations by such date, and (2) the date by which the department will submit the proposed regulations. The legislative regulation review committee may require the department to appear before the committee at a time prescribed by the committee to further explain such reasons and to respond to any questions by the committee about the policy. The legislative regulation review committee may request the joint standing committee of the General Assembly having cognizance of matters relating to human services to review the department's policy, the department's reasons for not submitting the proposed regulations by the date specified in this section and the date by which the department will submit the proposed regulations. Said joint standing committee may review the policy, such reasons and such date, may schedule a hearing thereon and may make a recommendation to the legislative regulation review committee.

      (P.A. 11-44, S. 81; 11-61, S. 158.)

      History: P.A. 11-44 effective July 1, 2011; P.A. 11-61 amended Subsec. (a) by making a technical change in definition of "healthy adult", effective July 1, 2011.

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      Sec. 17b-290. Definitions. As used in sections 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session*:

      (1) "Applicant" means an individual over the age of eighteen years who is a natural or adoptive parent or a legal guardian; a caretaker relative, foster parent or stepparent with whom the child resides; or a noncustodial parent under order of a court or family support magistrate to provide health insurance, who applies for coverage under the HUSKY Plan, Part B on behalf of a child and shall include a child who is eighteen years of age or emancipated in accordance with the provisions of sections 46b-150 to 46b-150e, inclusive, and who is applying on his own behalf or on behalf of a minor dependent for coverage under such plan;

      (2) "Child" means an individual under nineteen years of age;

      (3) "Coinsurance" means the sharing of health care expenses by the insured and an insurer in a specified ratio;

      (4) "Commissioner" means the Commissioner of Social Services;

      (5) "Copayment" means a payment made on behalf of an enrollee for a specified service under the HUSKY Plan, Part B;

      (6) "Cost sharing" means arrangements made on behalf of an enrollee whereby an applicant pays a portion of the cost of health services, sharing costs with the state and includes copayments, premiums, deductibles and coinsurance;

      (7) "Deductible" means the amount of out-of-pocket expenses that would be paid for health services on behalf of an enrollee before becoming payable by the insurer;

      (8) "Department" means the Department of Social Services;

      (9) "Durable medical equipment" means durable medical equipment, as defined in Section 1395x(n) of the Social Security Act;

      (10) "Eligible beneficiary" means a child who meets the requirements specified in section 17b-292, except a child excluded under the provisions of Subtitle J of Public Law 105-33 or a child of any municipal employee eligible for employer-sponsored insurance on or after October 30, 1997, provided a child of such a municipal employee may be eligible for coverage under the HUSKY Plan, Part B if dependent coverage was terminated due to an extreme economic hardship on the part of the employee, as determined by the commissioner;

      (11) "Enrollee" means an eligible beneficiary who receives services under the HUSKY Plan, Part B;

      (12) "Family" means any combination of the following: (A) An individual; (B) the individual's spouse; (C) any child of the individual or such spouse; or (D) the legal guardian of any such child if the guardian resides with the child;

      (13) "HUSKY Plan, Part A" means assistance provided to children, caretaker relatives and pregnant women pursuant to section 17b-261 or 17b-277;

      (14) "HUSKY Plan, Part B" means the health insurance plan for children established pursuant to the provisions of sections 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session*;

      (15) "HUSKY Plus programs" means two supplemental health insurance programs established pursuant to section 17b-294a for medically eligible enrollees of the HUSKY Plan, Part B whose medical needs cannot be accommodated within the basic benefit package offered to enrollees. One program shall supplement coverage for those medically eligible enrollees with intensive physical health needs and the other program shall supplement coverage for those medically eligible enrollees with intensive behavioral health needs;

      (16) "Income" means income as calculated in the same manner as under the Medicaid program pursuant to section 17b-261;

      (17) "Parent" means a natural parent, stepparent, adoptive parent, guardian or custodian of a child;

      (18) "Premium" means any required payment made by an individual to offset or pay in full the cost under the HUSKY Plan, Part B;

      (19) "Preventive care and services" means: (A) Child preventive care, including periodic and interperiodic well-child visits, routine immunizations, health screenings and routine laboratory tests; (B) prenatal care, including care of all complications of pregnancy; (C) care of newborn infants, including attendance at high-risk deliveries and normal newborn care; (D) WIC evaluations; (E) child abuse assessment required under sections 17a-106a and 46b-129a; (F) preventive dental care for children; and (G) periodicity schedules and reporting based on the standards specified by the American Academy of Pediatrics;

      (20) "Primary and preventive health care services" means the services of licensed physicians, optometrists, nurses, nurse practitioners, midwives and other related health care professionals which are provided on an outpatient basis, including routine well-child visits, diagnosis and treatment of illness and injury, laboratory tests, diagnostic x-rays, prescription drugs, radiation therapy, chemotherapy, hemodialysis, emergency room services, and outpatient alcohol and substance abuse services, as defined by the commissioner;

      (21) "Qualified entity" means any entity: (A) Eligible for payments under a state plan approved under Medicaid and which provides medical services under the HUSKY Plan, Part A, or (B) that is a qualified entity, as defined in 42 USC 1396r-1a, as amended by Section 708 of Public Law 106-554, and that is determined by the commissioner to be capable of making the determination of eligibility. The commissioner shall provide qualified entities with such forms as are necessary for an application to be made on behalf of a child under the HUSKY Plan, Part A and information on how to assist parents, guardians and other persons in completing and filing such forms;

      (22) "WIC" means the federal Special Supplemental Food Program for Women, Infants and Children administered by the Department of Public Health pursuant to section 19a-59c.

      (October 29 Sp. Sess. P.A. 97-1, S. 2, 23; P.A. 99-279, S. 18, 45; P.A. 00-196, S. 53; P.A. 01-137, S. 2, 9; June 30 Sp. Sess. P.A. 03-3, S. 73; P.A. 05-44, S. 2; P.A. 10-179, S. 61; June Sp. Sess. P.A. 10-1, S. 32; P.A. 11-25, S. 11.)

      *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. 99-279 amended Subdiv. (10) to provide that a child of a municipal employee may be eligible for coverage under the HUSKY Plan, Part B if dependent coverage was terminated due to an extreme economic hardship on the part of the employee, as determined by the commissioner, effective July 1, 1999; P.A. 00-196 made technical changes in Subdivs. (21) and (22); P.A. 01-137 amended Subdiv. (22) to redefine "qualified entity" by deleting language contained in the federal definition of term and adding reference to such federal definition, effective July 1, 2001 (Revisor's note: In Subdiv. (22), the word "that" was inserted editorially by the Revisors after "(B)" for proper form); June 30 Sp. Sess. P.A. 03-3 amended introductory language to add reference to Sec. 17b-261f, effective August 20, 2003; P.A. 05-44 amended Subdiv. (13) to redefine "HUSKY Plan, Part A" to include assistance provided to caretaker relatives and pregnant women pursuant to Sec. 17b-261 or 17b-277, effective July 1, 2005 (Revisor's note: An erroneous reference to Sec. 17b-261f was deleted editorially by the Revisors to correct a codification error); P.A. 10-179 amended Subdiv. (11) by deleting reference to managed care plan, deleted former Subdiv. (15) defining "HUSKY Plus programs", redesignated existing Subdiv. (16) as Subdiv. (15), deleted former Subdiv. (17) defining "managed care plan", redesignated existing Subdivs. (18) to (23) as Subdivs. (16) to (21) and amended redesignated Subdiv. (17) by replacing "capitation rate" with "cost", effective July 1, 2010; June Sp. Sess. P.A. 10-1 added new Subdiv. (15) defining "HUSKY Plus programs" and redesignated existing Subdivs. (15) to (21) as Subdivs. (16) to (22), effective July 1, 2010; P.A. 11-25 made a technical change in Subdiv. (21).

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      Sec. 17b-292. HUSKY Plan, Part B. Eligibility. Expedited eligibility under HUSKY Plan, Part B. Presumptive eligibility under Medicaid. Single point of entry 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.

      (f) The commissioner shall implement presumptive eligibility for children applying for Medicaid and may, if cost effective, implement presumptive eligibility for children in families with income under three hundred per cent of the federal poverty level applying for the HUSKY Plan, Part B. 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 benefits 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. 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 an administrative services organization. If there is more than one administrative services organization, upon enrollment in an administrative services organization, an eligible HUSKY Plan, Part A or Part B beneficiary shall remain enrolled in such organization 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 organization, 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 the 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; P.A. 09-8, S. 8; P.A. 10-179, S. 62; June Sp. Sess. P.A. 10-1, S. 26; P.A. 11-25, S. 12.)

      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; P.A. 09-8 made a technical change in Subsec. (j); P.A. 10-179 amended Subsec. (e) by deleting provision re payment of premium costs to managed care organization, amended Subsec. (h) by deleting provision requiring commissioner to develop a contract for managed care enrollment brokerage services, amended Subsec. (i) by replacing provision requiring single point of entry servicer to enroll beneficiaries in managed care plan with provision requiring servicer to enroll beneficiaries in administrative services organization, effective July 1, 2010; June Sp. Sess. P.A. 10-1 amended Subsec. (f) by adding provision permitting commissioner to implement presumptive eligibility for children in families with income under 300% of federal poverty level and by replacing reference to completed application for Medicaid with reference to completed application for benefits, effective June 22, 2010; P.A. 11-25 made technical changes in Subsecs. (i) and (j).

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      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. Copayments under the HUSKY Plan, Part B, shall be the same as those in effect for active state employees enrolled in a point-of-enrollment health care plan, provided the family's annual combined premiums and copayments do not exceed the maximum annual aggregate cost-sharing requirement. The cost-sharing requirements imposed by the commissioner shall be 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.

      (2) In accordance with federal law, 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 and, for the fiscal years ending June 30, 2012, to June 30, 2016, inclusive, may annually increase the premium requirement based on the percentage increase in the Consumer Price Index for medical care services; and

      (3) The commissioner shall 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; P.A. 10-3, S. 8; 10-179, S. 22; P.A. 11-44, S. 109.)

      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; P.A. 10-3 amended Subsec. (a) by requiring that copayments be the same as for active state employees enrolled in point-of-enrollment health care plan provided the family's premiums and copayments do not exceed maximum annual cost-sharing requirement, effective April 14, 2010; P.A. 10-179 amended Subsec. (a) by dividing existing Subdiv. (1) into Subdivs. (1) and (2) and redesignating existing Subdiv. (2) as Subdiv. (3), by changing the maximum premium requirements for families with 1 child from $30 to $38 per month and maximum premium per family from $50 to $60 per month in redesignated Subdiv. (2)(B) and by deleting reference to managed care plan in redesignated Subdiv. (3), effective July 1, 2010; P.A. 11-44 amended Subsec. (a)(2) by adding provision re premium requirement to be in accordance with federal law, deleting premium requirement provisos and exception, and adding provision re increase in premiums for fiscal years ending June 30, 2012, to June 30, 2016, effective June 13, 2011.

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      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 Council on Medical Assistance Program Oversight 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; P.A. 10-179, S. 68; P.A. 11-44, S. 171.)

      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; P.A. 10-179 amended Subsec. (a) by changing "Medicaid Managed Care Council" to "Council on Medicaid Care Management Oversight", effective July 1, 2010; P.A. 11-44 amended Subsec. (a) by replacing "Council on Medicaid Care Management Oversight" with "Council on Medical Assistance Program Oversight", effective July 1, 2011.

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      Sec. 17b-301a. Prohibited acts re medical assistance: Definitions. As used in this section and section 17b-301b:

      (1) "Knowing" and "knowingly" means that a person, with respect to information: (A) Has actual knowledge of the information; (B) acts in deliberate ignorance of the truth or falsity of the information; or (C) acts in reckless disregard of the truth or falsity of the information, without regard to whether the person intends to defraud;

      (2) "Claim" (A) means any request or demand, whether under a contract or otherwise, for money or property and whether or not the state has title to the money or property that (i) is presented to an officer, employee or agent of the state, or (ii) is made to a contractor, grantee or other recipient, if the money or property is to be spent or used on the state's behalf or to advance a state program or interest, and if the state provides or has provided any portion of the money or property that is requested or demanded, or if the state will reimburse such contractor, grantee or other recipient for any portion of the money or property that is requested or demanded, (B) does not include a request or demand for money or property that the state has paid to an individual as compensation for state employment or as an income subsidy with no restrictions on that individual's use of the money or property;

      (3) "Person" means any natural person, corporation, limited liability company, firm, association, organization, partnership, business, trust or other legal entity;

      (4) "State" means the state of Connecticut, any agency or department of the state or any quasi-public agency, as defined in section 1-120;

      (5) "Obligation" means an established duty, whether fixed or not, arising from (A) an express or implied contractual, grantor-grantee or licensor-licensee relationship, (B) a fee-based or similar relationship, (C) statute or regulation, or (D) the retention of an overpayment; and

      (6) "Material" means having a natural tendency to influence, or be capable of influencing, the payment or receipt of money or property.

      (Sept. Sp. Sess. P.A. 09-5, S. 1; P.A. 11-44, S. 153.)

      History: Sept. Sp. Sess. P.A. 09-5 effective October 5, 2009; P.A. 11-44 amended Subdiv. (2) by redefining "claim", added Subdiv. (5) defining "obligation" and added Subdiv. (6) defining "material", effective June 13, 2011.

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      Sec. 17b-301b. Prohibited acts re medical assistance. Penalties. (a) No person shall:

      (1) Knowingly present, or cause to be presented, a false or fraudulent claim for payment or approval under a medical assistance program administered by the Department of Social Services;

      (2) Knowingly make, use or cause to be made or used, a false record or statement material to a false or fraudulent claim under a medical assistance program administered by the Department of Social Services;

      (3) Conspire to commit a violation of this section;

      (4) Having possession, custody or control of property or money used, or to be used, by the state relative to a medical assistance program administered by the Department of Social Services, and intending to defraud the state or wilfully to conceal the property, deliver or cause to be delivered less property than the amount for which the person receives a certificate or receipt;

      (5) Being authorized to make or deliver a document certifying receipt of property used, or to be used, by the state relative to a medical assistance program administered by the Department of Social Services and intending to defraud the state, make or deliver such document without completely knowing that the information on the document is true;

      (6) Knowingly buy, or receive as a pledge of an obligation or debt, public property from an officer or employee of the state relative to a medical assistance program administered by the Department of Social Services, who lawfully may not sell or pledge the property;

      (7) Knowingly make, use or cause to be made or used, a false record or statement material to an obligation to pay or transmit money or property to the state under a medical assistance program administered by the Department of Social Services; or

      (8) Knowingly conceal or knowingly and improperly avoid or decrease an obligation to pay or transmit money or property to the state under a medical assistance program administered by the Department of Social Services.

      (b) Any person who violates the provisions of subsection (a) of this section shall be liable to the state for: (1) A civil penalty of not less than five thousand five hundred dollars or more than eleven thousand dollars, or as adjusted from time to time by the federal Civil Penalties Inflation Adjustment Act of 1990, 28 USC 2461, (2) three times the amount of damages that the state sustains because of the act of that person, and (3) the costs of investigation and prosecution of such violation. Liability under this section shall be joint and several for any violation of this section committed by two or more persons.

      (c) Notwithstanding the provisions of subsection (b) of this section concerning treble damages, if the court finds that: (1) A person committing a violation of subsection (a) of this section furnished officials of the state responsible for investigating false claims violations with all information known to such person about the violation not later than thirty days after the date on which the person first obtained the information; (2) such person fully cooperated with an investigation by the state of such violation; and (3) at the time such person furnished the state with the information about the violation, no criminal prosecution, civil action or administrative action had commenced under sections 17b-301c to 17b-301g, inclusive, with respect to such violation, and such person did not have actual knowledge of the existence of an investigation into such violation, the court may assess not less than two times the amount of damages which the state sustains because of the act of such person. Any information furnished pursuant to this subsection shall be exempt from disclosure under section 1-210.

      (Sept. Sp. Sess. P.A. 09-5, S. 2; Sept. Sp. Sess. P.A. 09-7, S. 181; P.A. 11-44, S. 154.)

      History: Sept. Sp. Sess. P.A. 09-5 effective October 5, 2009; Sept. Sp. Sess. P.A. 09-7 made technical changes in Subsec. (a), effective October 5, 2009; P.A. 11-44 amended Subsec. (a) in Subdiv. (2) by replacing "to secure the payment or approval by the state of" with "material to", in Subdiv. (3) by replacing provision re defrauding the state with provision re violating section, in Subdiv. (7) by replacing "to conceal, avoid or decrease" with "material to" and by adding Subdiv. (8) re concealing, avoiding or decreasing an obligation to pay or transmit money or property to the state, and amended Subsec. (b)(1) by replacing minimum civil penalty of $5,000 with $5,500, replacing maximum civil penalty of $10,000 with $11,000 and adding provision re adjustment of penalty under federal Civil Penalties Inflation Adjustment Act, effective June 13, 2011.

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      Sec. 17b-301d. Civil action by individual. Consent for withdrawal. Manner of service. Complaint under seal. Intervening in action by Attorney General. (a) A person may bring a civil action in the superior court for the judicial district of Hartford against any person who violates subsection (a) of section 17b-301b, for the person who brings the action and for the state. Such civil action shall be brought in the name of the state. The action may thereafter be withdrawn only if the court and the Attorney General give written consent to the withdrawing of such action and their reasons for consenting.

      (b) A copy of the complaint and written disclosure of substantially all material evidence and information the person possesses shall be served on the state by serving the Attorney General in the manner prescribed in section 52-64. The complaint shall be filed in camera, shall remain under seal for at least sixty days and shall not be served on the defendant until the court so orders. The court, upon motion of the Attorney General, may, for good cause shown, extend the time during which the complaint remains under seal. Such motion may be supported by affidavits or other submissions in camera. Prior to the expiration of the time during which the complaint remains under seal, the Attorney General shall: (1) Proceed with the action in which case the action shall be conducted by the Attorney General, or (2) notify the court that the Attorney General declines to take over the action in which case the person bringing the action shall have the right to conduct the action.

      (c) If the court orders that the complaint be unsealed and served, the Superior Court shall issue an appropriate order of notice requiring the same notice that is ordinarily required to commence a civil action. The defendant shall not be required to respond to any complaint filed under this section until thirty days after the complaint is served upon the defendant.

      (d) If a person brings an action under this section, no person other than the state may intervene or bring a related action based on the facts underlying the pending action.

      (Sept. Sp. Sess. P.A. 09-5, S. 4; P.A. 11-44, S. 155.)

      History: Sept. Sp. Sess. P.A. 09-5 effective October 5, 2009; P.A. 11-44 amended Subsec. (d) by deleting reference to federal False Claims Act, effective June 13, 2011.

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      Sec. 17b-301e. Prosecution by Attorney General. Withdrawal. Settlement. Limits on individual's participation. Division of proceeds. Attorneys' fees and costs. (a) If the Attorney General, pursuant to section 17b-301d, elects to proceed with the action, the Attorney General shall have the primary responsibility for prosecuting the action and shall not be bound by any act of the person bringing the action. Such person shall have the right to continue as a party to the action, subject to the limitations set forth in this section.

      (b) The Attorney General may withdraw such action notwithstanding the objections of the person bringing the action if the Attorney General has notified the person of the filing of the motion and the court has provided the person with an opportunity for a hearing on the motion.

      (c) The Attorney General may settle the action with the defendant notwithstanding the objections of the person bringing the action if the court determines, after a hearing, that the proposed settlement is fair, adequate and reasonable under all the circumstances. Upon a showing of good cause, such hearing may be held in camera.

      (d) Upon a showing by (1) the Attorney General that unrestricted participation during the course of the litigation by the person bringing the action would (A) interfere with or unduly delay the Attorney General's prosecution of the case, or (B) be repetitious, irrelevant or for purposes of harassment; or (2) the defendant that unrestricted participation during the course of the litigation by the person bringing the action would be for purposes of harassment or would cause the defendant undue burden or unnecessary expense, the court may, in its discretion, impose limitations on the person's participation, including, but not limited to, limiting the number of witnesses that such person may call, limiting the length of the testimony of any such witnesses, limiting the person's cross-examination of any such witnesses or otherwise limiting the participation by the person in the litigation.

      (e) If the court awards civil penalties or damages to the state or if the Attorney General settles with the defendant and receives civil penalties or damages, the person bringing such action shall receive from the proceeds not less than fifteen per cent but not more than twenty-five per cent of such proceeds of the action or settlement of the claim, based upon the extent to which the person substantially contributed to the prosecution of the action. Any such person shall also receive an amount for reasonable expenses which the court finds to have been necessarily incurred, plus reasonable attorneys' fees and costs. All such expenses, fees and costs shall be awarded against the defendant.

      (f) Notwithstanding the provisions of subsection (e) of this section, where the action is one that the court finds to be based primarily on disclosures of specific information that was not provided by the person bringing the action relating to allegations or transactions (1) in a criminal, civil or administrative hearing, (2) in a report, hearing, audit or investigation conducted by the General Assembly, a committee of the General Assembly, the Auditors of Public Accounts, a state agency or a quasi-public agency, or (3) from the news media, the court may award from such proceeds to the person bringing the action such sums as it considers appropriate, but in no case more than ten per cent of the proceeds, taking into account the significance of the information and the role of the person bringing the action in advancing the case to litigation. Any such person shall also receive an amount for reasonable expenses that the court finds to have been necessarily incurred, plus reasonable attorneys' fees and costs. All such expenses, fees and costs shall be awarded against the defendant.

      (Sept. Sp. Sess. P.A. 09-5, S. 5; P.A. 11-44, S. 156.)

      History: Sept. Sp. Sess. P.A. 09-5 effective October 5, 2009; P.A. 11-44 amended Subsec. (f) by adding "that was not provided by the person bringing the action" re action based on disclosure of specific information, effective June 13, 2011.

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      Sec. 17b-301i. Court's jurisdiction over civil actions brought by certain individuals. (a) No court shall have jurisdiction over an action brought under section 17b-301d (1) against a member of the General Assembly, a member of the judiciary or an elected officer or department head of the state if the action is based on evidence or information known to the state when the action was brought; or (2) that is based upon allegations or transactions that are the subject of a civil suit or an administrative civil penalty proceeding in which the state is already a party.

      (b) Unless opposed by the state, the court shall dismiss an action or claim brought under section 17b-301d if allegations or transactions that are substantially the same as those alleged in the action or claim were publicly disclosed (1) in a state criminal, civil or administrative hearing in which the state or its agent is a party, (2) in a report, hearing, audit or investigation conducted by the General Assembly, a committee of the General Assembly, the Auditors of Public Accounts, a state agency or quasi-public agency, or (3) by the news media, except the court shall not dismiss such action or claim if the action or claim is brought by the Attorney General or the person who is an original source of information.

      (c) For purposes of this section, "original source" means an individual who (1) voluntarily discloses to the state information on which the allegations or transactions in an action or claim are based, prior to public disclosure of such information as described in subdivisions (1), (2) and (3) of subsection (b) of this section, or (2) has knowledge that is independent of and materially adds to the publicly disclosed allegations or transactions and has voluntarily provided the information to the state before filing an action or claim under this section.

      (Sept. Sp. Sess. P.A. 09-5, S. 9; P.A. 11-44, S. 157.)

      History: Sept. Sp. Sess. P.A. 09-5 effective October 5, 2009; P.A. 11-44 amended Subsec. (a) by deleting former Subdiv. (3) re action based on public disclosure of allegations or transactions and deleting definition of "original source", deleted former Subsec. (b) re court's jurisdiction over action brought under Sec. 17b-301d, added new Subsec. (b) re court's dismissal of action or claim brought under Sec. 17b-301d and added Subsec. (c) defining "original source", effective June 13, 2011.

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      Sec. 17b-301k. Discrimination in employment because of acts in furtherance of civil action prohibited. Remedies. Attorneys' fees and costs. (a) Any employee, contractor or agent who is discharged, demoted, suspended, threatened, harassed or in any other manner discriminated against in the terms and conditions of employment because of lawful acts done by the employee, contractor, agent or associated others in furtherance of an action under sections 17b-301c to 17b-301g, inclusive, including investigation for, initiation of, testimony for or assistance in an action filed or to be filed under sections 17b-301c to 17b-301g, inclusive, or efforts to stop a violation of sections 17b-301a to 17b-301p, inclusive, shall be entitled to all relief necessary to make the employee, contractor or agent whole. Such relief shall include reinstatement with the same seniority status such employee would have had but for the discrimination, two times the amount of any back pay, interest on any back pay and compensation for any special damages sustained as a result of the discrimination, including litigation costs and reasonable attorneys' fees. An employee may bring an action in the Superior Court for the relief provided in this section.

      (b) A civil action or claim under this section may not be brought more than three years after the date on which the retaliation occurred.

      (Sept. Sp. Sess. P.A. 09-5, S. 11; P.A. 11-44, S. 158; 11-61, S. 119.)

      History: Sept. Sp. Sess. P.A. 09-5 effective October 5, 2009; P.A. 11-44 designated existing provisions as Subsec. (a) and amended same to add contractors and agents re persons entitled to relief and add provision re efforts to stop a violation of Secs. 17b-301a to 17b-301p, and added Subsec. (b) re time limitation on bringing civil action or claim, effective June 13, 2011; P.A. 11-61 amended Subsec. (a) by adding "associated others" re persons entitled to relief and making technical changes, effective June 21, 2011.

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      Sec. 17b-301l. Time for bringing civil action. State's intervention in action. A civil action under sections 17b-301c to 17b-301g, inclusive, may not be brought: (1) More than six years after the date on which the violation of subsection (a) of section 17b-301b is committed, or (2) more than three years after the date when facts material to the right of action are known or reasonably should have been known by the official of the state charged with responsibility to act in the circumstances, but in no event more than ten years after the date on which the violation is committed, whichever last occurs. If the state elects to intervene and proceed with an action brought under sections 17b-301c to 17b-301g, inclusive, the state may file its own complaint or amend the complaint of a person who has brought an action under sections 17b-301c to 17b-301g, inclusive, to clarify or add detail to claims in which the state is intervening and to add any additional claim under which the state contends that it is entitled to relief. For statute of limitation purposes, any such state pleading shall relate back to the filing date of the complaint of the person who originally brought the action to the extent that the claim of the state arises out of the conduct, transactions or occurrences set forth or attempted to be set forth in the prior complaint of such person.

      (Sept. Sp. Sess. P.A. 09-5, S. 12; P.A. 11-44, S. 159.)

      History: Sept. Sp. Sess. P.A. 09-5 effective October 5, 2009; P.A. 11-44 added provision re state's election to intervene and proceed with an action, effective June 13, 2011.

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      Sec. 17b-306a. Child health quality improvement program. Purpose and scope. Annual reports. (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 Council on Medical Assistance Program Oversight 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.

      (c) The Commissioner of Social Services, in collaboration with the Council on Medical Assistance Program Oversight, shall, subject to available appropriations, prepare, annually, a report concerning health care choices under the HUSKY Plan, Part A. Such report shall include, but not be limited to, a comparison of the performance of each managed care organization, the primary care case management program and other member service delivery choices. The commissioner shall provide a copy of each report to all HUSKY Plan, Part A members.

      (P.A. 07-185, S. 14; Sept. Sp. Sess. P.A. 09-5, S. 57; P.A. 10-179, S. 69; P.A. 11-44, S. 172.)

      History: P.A. 07-185 effective July 1, 2007; Sept. Sp. Sess. P.A. 09-5 added Subsec. (c) requiring Commissioner of Social Services in collaboration with Medicaid Managed Care Council to issue report re health care choices for HUSKY Plan, Part A members, effective October 5, 2009; P.A. 10-179 amended Subsecs. (b) and (c) by replacing "Medicaid Managed Care Council" with "Council on Medicaid Care Management Oversight", effective July 1, 2010; P.A. 11-44 amended Subsecs. (b) and (c) by replacing "Council on Medicaid Care Management Oversight" with "Council on Medical Assistance Program Oversight", effective July 1, 2011.

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      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, who are ineligible for other publicly funded health insurance plans and who are ineligible for the high-risk pool established pursuant to Section 1101 of the Patient Protection and Affordable Care Act, P.L. 111-148. 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) (1) 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: (A) One hundred fifteen dollars per month for individuals whose gross annual income is below one hundred fifty per cent of the federal poverty level; (B) one hundred 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; (C) fifty 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 (D) thirty-five 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.

      (2) Notwithstanding the provisions of this subsection, for the fiscal years ending June 30, 2010, June 30, 2011, and each fiscal year thereafter, the Commissioner of Social Services shall only provide premium assistance to state residents who are eligible for such assistance and who are enrolled in the Charter Oak Health Plan on May 31, 2010.

      (d) The Commissioner of Social Services shall determine minimum requirements on the amount, duration and scope of benefits under the Charter Oak Health Plan. Each participating insurer or administrative services organization shall provide an internal grievance process by which an enrollee in the Charter Oak Health Plan may request and be provided a review of a denial of coverage under the plan.

      (e) The Commissioner of Social Services shall seek proposals from entities with which it contracts 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.

      (f) 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; P.A. 10-3, S. 11; 10-179, S. 64; P.A. 11-25, S. 13; 11-44, S. 80.)

      History: June Sp. Sess. P.A. 07-2 effective July 1, 2008; P.A. 10-3 amended Subsec. (c) by designating existing provisions as Subdiv. (1) and making technical changes therein and by adding Subdiv. (2) to limit premium assistance for fiscal years ending June 30, 2010, and June 30, 2011, to eligible state residents enrolled in the plan on April 30, 2010, effective April 14, 2010; P.A. 10-179 amended Subsec. (d) by adding reference to participating administrative services organization and replacing "insured" with "enrollee in the Charter Oak Health Plan", deleted former Subsec. (e) re entities with which commissioner may enter into contracts and redesignated existing Subsecs. (f) and (g) as Subsecs. (e) and (f), effective July 1, 2010; P.A. 11-25 made a technical change in Subsec. (e); P.A. 11-44 amended Subsec. (a) by adding provision limiting eligibility to residents ineligible for the high risk pool, amended Subsec. (c)(1)(A) by decreasing premium assistance from $175 to $115 per month, amended Subsec. (c)(1)(B) by decreasing premium assistance from $150 to $100 per month, amended Subsec. (c)(1)(C) by decreasing premium assistance from $75 to $50 per month, amended Subsec. (c)(1)(D) by decreasing premium assistance from $50 to $35 per month, amended Subsec. (c)(2) by making provisions applicable to each fiscal year after the fiscal year ending June 30, 2011, and replacing "April 30, 2010" with "May 31, 2010", and amended Subsec. (d) by deleting exception for preexisting condition exclusion, effective September 1, 2011.

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