Substitute Senate Bill No. 637
Substitute Senate Bill No. 637
PUBLIC ACT NO. 97-240
AN ACT CONCERNING THE RECOMMENDATION OF THE
MEDICAID MANAGED CARE COUNCIL AND EARLY PERIODIC
DENTAL SCREENING.
Be it enacted by the Senate and House of
Representatives in General Assembly convened:
Section 1. Section 17b-28 of the general
statutes is repealed and the following is
substituted in lieu thereof:
(a) There is established a council which shall
advise the Commissioner of Social Services on the
planning and implementation of a system of
Medicaid managed care and shall monitor such
planning and implementation and shall advise the
Waiver Application Development Council,
established pursuant to section 17b-28a, on
matters including, but not limited to, eligibility
standards, benefits, access and quality assurance.
The council shall be composed of the chairmen and
ranking members of the joint standing committees
of the General Assembly having cognizance of
matters relating to human services and public
health, or their designees; two members of the
General Assembly, one to be appointed by the
president pro tempore of the Senate and one to be
appointed by the speaker of the House of
Representatives; the director of the Commission on
Aging, or his designee; the director of the
Commission on Children, or his designee; two
community providers of health care, to be
appointed by the president pro tempore of the
Senate; two representatives of the insurance
industry, to be appointed by the speaker of the
House of Representatives; two advocates for
persons receiving Medicaid, one to be appointed by
the majority leader of the Senate and one to be
appointed by the minority leader of the Senate;
one advocate for persons with substance abuse
disabilities, to be appointed by the majority
leader of the House of Representatives; one
advocate for persons with psychiatric
disabilities, to be appointed by the minority
leader of the House of Representatives; ONE
ADVOCATE FOR DEPARTMENT OF CHILDREN AND FAMILIES
FOSTER FAMILIES, TO BE APPOINTED BY THE MAJORITY
LEADER OF THE SENATE; two members of the public
who are currently recipients of Medicaid, one to
be appointed by the majority leader of the House
of Representatives and one to be appointed by the
minority leader of the House of Representatives;
two representatives of the Department of Social
Services, to be appointed by the Commissioner of
Social Services; two representatives of the
Department of Public Health, to be appointed by
the Commissioner of Public Health; two
representatives of the Department of Mental Health
and Addiction Services, to be appointed by the
Commissioner of Mental Health and Addiction
Services; TWO REPRESENTATIVES OF THE DEPARTMENT OF
CHILDREN AND FAMILIES, TO BE APPOINTED BY THE
COMMISSIONER OF CHILDREN AND FAMILIES; TWO
REPRESENTATIVES OF THE OFFICE OF POLICY AND
MANAGEMENT, TO BE APPOINTED BY THE SECRETARY OF
THE OFFICE OF POLICY AND MANAGEMENT; ONE
REPRESENTATIVE OF THE OFFICE OF THE STATE
COMPTROLLER, TO BE APPOINTED BY THE STATE
COMPTROLLER; and the members of the Health Care
Access Board who shall be ex-officio members and
who may not designate persons to serve in their
place. The council shall choose a chair from among
its members. [, and the staff of the public health
committee shall provide] THE JOINT COMMITTEE ON
LEGISLATIVE MANAGEMENT SHALL ARRANGE FOR
administrative support to such chair. The council
shall convene its first meeting no later than June
1, 1994.
(b) The council shall make recommendations
concerning (1) guaranteed access to enrollees and
effective outreach and client education; (2)
available services comparable to those already in
the Medicaid state plan, including those
guaranteed under the federal Early and Periodic
Screening Diagnosis and Treatment Program; (3) the
sufficiency of provider networks; (4) the
sufficiency of capitated rates provider payments,
financing and staff resources to guarantee timely
access to services; (5) participation in managed
care by existing community Medicaid providers; (6)
the linguistic and cultural competency of
providers and other program facilitators; (7)
quality assurance; (8) timely, accessible and
effective client grievance procedures; (9)
coordination of the Medicaid managed care plan
with state and federal health care reforms; (10)
eligibility levels for inclusion in the program;
(11) cost-sharing provisions; (12) a benefit
package; and (13) other issues pertaining to the
development of a Medicaid Research and
Demonstration Waiver under Section 1115 of the
Social Security Act.
(c) The Commissioner of Social Services shall
seek a federal waiver for the Medicaid managed
care plan. Implementation of the Medicaid managed
care plan shall not occur before July 1, 1995.
(d) [On July 1, 1994, and monthly thereafter,
the] THE Commissioner of Social Services shall
provide monthly reports on the plans and
implementation of the Medicaid managed care system
to the council.
(e) [On October 1, 1994, and quarterly
thereafter, the] THE council shall report its
activities and progress ONCE EACH QUARTER to the
General Assembly.
Sec. 2. Section 17b-266 of the general
statutes is amended by adding subsection (e) as
follows:
(NEW) (e) Providers of comprehensive health
care under this section shall report to the
Commissioner of Social Services all spending by
service category, as defined by the commissioner
and set forth in any contract under subsection (b)
of this section.
Sec. 3. (NEW) The Commissioner of Social
Services, in entering any contract pursuant to
section 17b-266 of the general statutes concerning
managed care that covers children, pregnant women
and related coverage groups under the Medicaid
program, shall require the following in said
contract:
(1) A specific description of the managed care
organization's obligation to provide the full
range of services required by the Early Periodic
Screening Detection and Treatment program pursuant
to 42 USC 1396a, including, but not limited to:
(A) Case management services, as defined in 42 USC
1396d; (B) assistance with transportation and with
scheduling appointments; and (C) periodic
screening examinations;
(2) Definitions of medically necessary
services under the Early Periodic Screening
Detection and Treatment program that clarify the
obligations of the managed care organization to
provide services that maintain a child's optimal
health regardless of whether the services result
in an improvement in health status;
(3) Provisions that define procedures for
prior authorization, including provisions that
require that any utilization review of behavioral
health services and other specialty services for
children be performed by reviewers with special
training in children's health care needs;
(4) Provisions that clarify the requirement
that the Early Periodic Screening Detection and
Treatment program includes all medically necessary
services under Medicaid, and that limits on
treatment that are not based on medical necessity,
including upper limits on the amount of particular
types of treatment of any kind, are prohibited;
(5) A requirement that participants in the
Medicaid managed care program receive notice and
an opportunity to be heard consistent with chapter
54 of the general statutes prior to the reduction
or termination of any service that has been
prescribed for them and prior to the effective
date of the reduction or termination of service,
with notice given to the managed care organization
member or the member's parent or guardian, if the
member is a child;
(6) A requirement that sets forth time periods
that the managed care organization must meet,
including, but not limited to, scheduling: (A)
Urgent care appointments within twenty-four hours;
(B) appointments for routine care within
seventy-two hours; (C) appointments for periodic
screening examinations under the Early Periodic
Screening Detection and Treatment program within
four weeks; (D) appointments for routine dental
and vision care services within four weeks; (E)
appointments for mental health services that are
not urgent or emergent within two weeks; (F)
authorization for emergency care within four
hours; (G) authorization for urgent care within
six hours; and (H) authorization of routine care
within seventy-two hours;
(7) A requirement that a child be
automatically enrolled in the mother's managed
care organization upon birth of the child;
(8) A requirement that managed care
organizations coordinate their services with the
following programs by means of a memorandum of
understanding that sets forth how the managed care
organization will refer members to the program,
how the program will provide their respective
services to assure that services are not
duplicated and how the managed care organization
will assure that all services received both inside
and outside the managed care organization are
coordinated through a primary care provider or,
when necessary because of a child's mental or
physical health condition, through the provision
of case management services, as defined at 42 USC
1396d: (A) Healthy Families Connecticut; (B)
Healthy Start; (C) the Special Supplemental Food
Program for Women, Infant and Child (WIC); (D)
Birth-to-Three programs; (E) Special Education
programs; and (F) other programs operated by the
Departments of Children and Families, Public
Health, Mental Health and Addiction Services and
Mental Retardation that provide services to those
receiving Medicaid services under the Medicaid
managed care program;
(9) Requirements that managed care
organizations have the capacity to provide
services to their members in the members' primary
languages, including the provision of qualified
bilingual, bicultural providers in their networks
as necessary to meet their members' needs;
(10) A requirement that managed care
organizations provide their members with the
following information upon the request of the
member: (A) Up to date lists of providers in the
managed care organization's networks, including
whether the provider is accepting new patients;
(B) timely access to the members' own medical
record and other plan records; and (C) plan
protocols for confidentiality;
(11) A requirement that managed care
organizations contract with school-based health
centers located in the managed care organizations'
geographic areas for the full range of services
provided by the school-based health centers;
(12) Requirements that managed care
organizations include family members in a child's
treatment program unless specifically
contraindicated, that the organization provide
family therapy when medically necessary regardless
of whether all family members are part of the plan
and the provision of transportation to the family
member; and
(13) Provisions for intermediate and graduated
sanctions for violations of the contract terms
that are in addition to the termination of the
entire contract, including: (A) Corrective action
plans; (B) receiverships; (C) withholding
capitation payments; (D) payment for medically
necessary out of network care, when medically
necessary services within the scope of the
contract are not provided in a timely fashion; (E)
suspension or freezing of enrolment; (F)
adjustment to current enrolment; and (G) fines.
Sec. 4. (NEW) The Department of Social
Services, in consultation with the Medicaid
Managed Care Council and the Children's Health
Council, shall develop model memoranda of
understanding, for the purposes of subdivision (8)
of section 3 of this act.
Sec. 5. (a) There is established a task force
to study methods to enhance employer-based health
insurance.
(b) The task force shall consist of the
following members:
(1) An advocate for persons without health
insurance and a representative of organized labor,
each appointed by the speaker of the House of
Representatives;
(2) A representative of companies that offer
health insurance to small groups and individuals
and a representative of businesses in Connecticut,
each appointed by the president pro tempore of the
Senate;
(3) Two small-business owners, each appointed
by the majority leader of the House of
Representatives;
(4) A representative of a managed care
organization, appointed by the majority leader of
the Senate;
(5) A representative of a local chamber of
commerce, appointed by the minority leader of the
House of Representatives;
(6) A representative of a municipality,
appointed by the majority leader of the House of
Representatives;
(7) A representative of organized medicine,
appointed by the minority leader of the Senate;
(8) The Secretary of the Office of Policy and
Management, or his designee;
(9) The State Comptroller, or his designee;
(10) The chairpersons and ranking members of
the joint standing committee of the General
Assembly having cognizance of matters relating to
public health, or their designees;
(11) The chairpersons and ranking members of
the joint standing committee of the General
Assembly having cognizance of matters relating to
insurance and real estate, or their designees;
(12) The chairpersons and ranking members of
the joint standing committee of the General
Assembly having cognizance of matters relating to
commerce, or their designees;
(13) The chairpersons and ranking members of
the joint standing committee of the General
Assembly having cognizance of matters relating to
finance, revenue and bonding, or their designees;
and
(14) The chairpersons and ranking members of
the joint standing committee of the General
Assembly having cognizance of matters relating to
appropriations, or their designees.
(c) All appointments to the task force shall
be made no later than thirty days after the
effective date of this section. Any vacancy shall
be filled by the appointing authority.
(d) The speaker of the House of
Representatives and the president pro tempore of
the Senate shall select the chairpersons of the
task force from among the members of the task
force. The chairpersons shall schedule the first
meeting of the task force, which shall be held no
later than sixty days after the effective date of
this section.
(e) The joint committee of the General
Assembly having cognizance of matters relating to
Legislative Management shall provide
administrative staff of the task force.
(f) Not later than January 1, 1998, the task
force shall submit a report on its findings and
recommendations to the joint standing committees
of the General Assembly having cognizance of
matters relating to public health and insurance
and real estate, in accordance with the provisions
of section 11-4a of the general statutes. The task
force shall terminate on the date that it submits
such report or January 1, 1998, whichever is
earlier.
Sec. 6. (NEW) (a) Not later than September 1,
1997, and annually thereafter, the Commissioner of
Public Health shall, within available
appropriations, provide to the Medicaid Managed
Care Council established pursuant to section
17b-28 of the general statutes, as amended by this
act, an inventory of safety net providers in this
state. To the extent such information is provided
to the commissioner by the contractor, the
inventory shall include (1) a catalog of direct
and population-based services provided to both
insured and uninsured clients at each site, (2)
the number of services provided at each site, and
(3) the payer mix of clients.
(b) The commissioner shall, to the extent
information is available to him and within
available appropriations, develop an ongoing
monitoring system to identify safety net provider
reductions in services including, but not limited
to, medical social work, outreach, psychological
testing and home visitation.
(c) At such time as the commissioner
identifies that a safety net provider is at risk
of closing or of reducing services, he shall
convene a public hearing at which local health
officials and any interested legislators and
members of the public may discuss the community
public health impact of changes to the safety net
and potential solutions.
(d) For purposes of this section, "safety-net
provider" means community health centers,
school-based health centers, local health
districts, nonprofit visiting nurse associations,
family planning clinics and public dental clinics.
Sec. 7. (NEW) The Department of Social
Services shall develop mechanisms to streamline
eligibility for the Medicaid Expansion Program,
including, but not limited to, (1) development of
mail-in applications, (2) collaboration with
community organizations in outreach programs to
maximize enrolment of eligible clients and (3)
training of department staff in eligibility for
and benefits available under Medicaid managed
care.
Sec. 8. (NEW) (a) Any dentist licensed
pursuant to chapter 379 of the general statutes
and who participates in the Medicaid managed care
program under section 17b-266 of the general
statutes may provide services exclusively to
persons eligible for the Early Periodic Screening
Detection Treatment program pursuant to 42 USC
1396d who are qualified under said Medicaid
managed care program.
(b) No person contracting with dentists
pursuant to the Medicaid managed care program
shall, as a requirement for participation require
that a dentist participate in a plan that does not
exclusively provide services to persons eligible
for the Early Periodic Screening Detection
Treatment program who are qualified under said
Medicaid managed care program.
Sec. 9. (NEW) The Commissioner of Social
Services shall develop a form to be used by
managed care companies that contract with the
Medicaid managed care program. Said form shall be
standard for all such contracts and confirm the
credentials of any such managed care company.
Sec. 10. This act shall take effect from its
passage, except that section 7 shall take effect
October 1, 1997.
Vetoed June 27, 1997