OLR Bill Analysis

sSB 1371

AN ACT ESTABLISHING THE CONNECTICUT SAVES HEALTH CARE PROGRAM.

SUMMARY:

This bill establishes the Connecticut Saves Health Care Commission and program. It requires the commission to provide affordable health insurance policies to certain state residents, determine covered benefits and cost-sharing requirements, set terms for reinsurance coverage, improve quality of care, reduce health care spending, establish enrollment and premium collection procedures, educate residents on the program and important public health matters, promote information technology use, and adopt regulations. It creates a Blue Ribbon Commission to evaluate the program and report to the legislature.

It requires the Department of Social Services (DSS) commissioner to (1) screen every program-eligible person for HUSKY eligibility and (2) apply for a Medicaid waiver to use federal funds for certain individuals not currently HUSKY eligible. The bill increases HUSKY income eligibility limits.

The bill requires the Department of Public Health (DPH) to expand the state's network of school-based health clinics (SBHCs), establish primary care clinics, adopt regulations regarding the SBHCs and clinics, and publish “Plans for a Healthy Connecticut.

It makes numerous appropriations in unspecified amounts from the General Fund for FY 08 to implement the bill's requirements.

EFFECTIVE DATE: Upon passage, except for the appropriations, which are effective July 1, 2007.

CONNECTICUT SAVES HEALTH CARE

The bill establishes a 12-member Connecticut Saves Health Care Commission (“commission”) to implement and administer the Connecticut Saves Health Care program (“program”) to provide affordable health insurance policies to eligible people. The insurance commissioner must approve the policies.

Commission Membership and Reporting ( 2)

The bill requires member appointments by July 1, 2007, as follows: (1) the House speaker appoints two; (2) the Senate president pro tempore appoints two; (3) the governor appoints two; (4) the House majority leader, Senate majority leader, House minority leader, and Senate minority leader each appoint one; and (5) the Insurance and Real Estate Committee chairpersons each appoint one. Members, who may be legislators, serve a three-year term and may not serve more than two consecutive terms. The appointing authority must fill any vacancy.

The bill requires the House speaker and Senate president to select chairpersons from the membership. The chairperson must schedule and hold the first commission meeting within 60 days of the bill's passage (but this may or may not be after July 1, 2007, the date by which appointments are to be made). (Apparently the members do not need to have a particular expertise or represent a particular sector. The bill does not address whether members are compensated or reimbursed for expenses. )

Beginning January 1, 2008, the commission must annually submit a report to the Insurance and Real Estate, Human Services, and Public Health committees on program implementation progress, including any recommended changes to the employer or resident contributions or state funding.

Commission Responsibilities ( 3)

Make Insurance Available. The bill requires the commission to arrange and procure health insurance policies for program enrollees. In doing so, it must negotiate and contract with insurers and health care centers (i. e. , HMOs) authorized to do business in the state. The bill requires to commission to:

1. determine covered benefits and an enrollee's out-of-pocket cost-sharing to assure affordable access to necessary health care (presumably “medically necessary”);

2. survey employer-based health coverage in New England to assist in determining the benefits and cost-sharing;

3. reimburse health care providers (but “health care providers” is not defined);

4. credential health care providers for participation in the program; and

5. issue the same Connecticut Saves card to all program enrollees (apparently a coverage identification card).

The bill allows the commission to delegate the duties of reimbursing and credentialing health care providers and preventing and managing chronic disease to a third-party administrator.

Improve Quality of Care. The commission must improve quality of care through numerous measures, including:

1. obtaining and publishing data pertinent to quality of care;

2. encouraging integrated health care systems development by incorporating procedures such as case management, registries, feedback to physicians, and a team-based approach to patient-centered care; and

3. preventing and managing chronic disease.

Reduce Health Care Spending. The commission must reduce unnecessary health care spending and control health care cost growth through numerous measures, including:

1. administrative simplification,

2. provider reimbursement policies,

3. prevention and management of chronic disease,

4. consumer quality report cards,

5. error reporting,

6. strengthening certificate of need procedures, and

7. e-health initiatives.

Establish Procedures. The commission must:

1. devise and implement systems for voluntary and automatic enrollment;

2. establish and implement policies and procedures for interstate coverage issues for state residents working or receiving health care in other states and residents of other states working or receiving health care in Connecticut (although residents of other states are not eligible for the program under the bill); and

3. arrange with the Department of Revenue Services (DRS) for employers' and state residents' premium contributions to be sent automatically to DRS through payroll withholding or other means and DRS to send those contributions to the Comptroller. (The bill does not specify an account or fund in which to deposit contributions. )

Educate Residents. The commission must educate state residents on the program and the importance of preventive care and assessments and communicate general public health messages. It must educate residents about the health insurance policies available through the program by:

1. preparing educational materials;

2. conducting informational sessions or workshops;

3. contracting with nonprofit and community-based organizations for outreach to hard-to-reach populations; and

4. training, consulting with, and reimbursing licensed health insurance brokers for help in educating residents.

Promote Information Technology. The commission must promote information technology use by (1) contracted insurers and HMOs; (2) individuals applying to, enrolled in, or seeking information about the program; and (3) people providing information to the program. It must arrange for technical support, training, and assistance on effective information technology use.

The commission must require each contracted insurer and HMO to operate a commission-certified electronic health record system that meets interoperability standards by October 1, 2007. The commission must establish the electronic health record standards by regulations. (The October 1, 2007 date may not allow enough time for the commission to develop standards and publish regulations and for insurers and HMOs to then implement compliant e-record systems. )

Adopt Regulations. The bill requires the commission to adopt regulations to implement and administer the program.

Appropriations ( 16-18)

The bill makes unspecified appropriations to the commission from the General Fund for FY 08 to (1) implement the program, (2) lower employer costs of providing health insurance to employees and their dependents by at least 10%, and (3) pay program reinsurance premiums.

PROGRAM HEALTH INSURANCE POLICIES

Affordable Policy ( 4)

The bill requires the commission to make available to prospective program enrollees a health insurance policy that is affordable to most state residents and offers specified benefits.

The policy must have an actuarial value that at least equals the sum of the actuarial value, for average New England enrollees in employer-based insurance during the previous year, of (1) all coverage, excluding dental coverage and (2) dental coverage. (The bill does not define “average New England enrollee. ”)

The policy must cover office visits; inpatient and outpatient hospital care; mental and behavioral health care, including substance abuse treatment; prescription drugs, including brand name and generic drugs; maternity care, including prenatal and postpartum care; oral contraceptives; durable medical equipment; speech, physical and occupational therapy; home health care; hospice services and extended care as alternatives to institutionalization; preventive and restorative dental care; and basic vision care. It must also cover, as prescribed by a physician, (1) personalized nutrition, exercise plans, and smoking cessation services and (2) examinations, screenings, and immunizations for adults and children, including well-child and –baby care, which must be provided without out-of-pocket cost-sharing.

Premium Payments and Reinsurance ( 5)

The bill requires the commission to prospectively adjust premium payments for the policies under the program to fully compensate for any differences between the program enrollee's average risk level and the state's nonelderly (presumably under age 65) population. (It is unclear what this provisions means. )

The bill permits the commission to subsidize, during the first three years the program is implemented and within available appropriations, the cost of reinsurance premiums related to the program. The bill requires that premium payments made to the program on behalf of enrollees be used to pay for any remaining reinsurance premium cost. (Reinsurance is insurance for insurance companies, i. e. , it helps spread the insured risk, thus, lessening the liability for the primary insurer. )

For subsidized reinsurance, the commission must establish risk corridors and coinsurance percentages (i. e. , terms of reinsurance) based on best practices from other states.

The bill requires the commission to issue a report containing recommendations on future financing for reinsurance to the Insurance and Real Estate Committee by January 1, 2011. It also requires, if the General Assembly does not take action to the contrary by the end of the 2012 regular session, reinsurance premiums for the third and each subsequent year to be paid entirely by payments made to the program by or on behalf of enrollees.

This section of the bill presents a number of issues. It (1) does not identify the entity or entities purchasing reinsurance (presumably it is the contracted insurers and HMOs) and (2) permits subsidized reinsurance while also requiring unsubsidized reinsurance for the third year. The bill does not identify when the commission must implement the program, so it is unclear whether the 2011 and 2012 dates are appropriate. (However, section 8 requires “default” enrollment of anyone eligible but not enrolled by July 1, 2008. This presumes the program will be operational before then. )

Eligibility, Application, and Enrollment ( 6-8)

The bill opens the program to “eligible individuals,” defined as people under age 65 who have been a state resident for at least six months. The bill permits a person other than an eligible individual to apply for coverage under the program at full cost (it is unclear if this means eligible individuals are not paying full cost, and the bill does not discuss setting the cost of policies) if the person:

1. is a state resident;

2. is age 65 or older;

3. is employed by, or whose spouse is employed by, an employer that offered insurance (presumably health insurance, and it is unclear if this applies if the employer offered a self-insured benefit plan) on or before October 1, 2006, but no longer offers it; and

4. would have qualified to participate in insurance in effect on October 1, 2006 (but this means that the person is not eligible for the program if he or she was not qualified to participate in any employer insurance that was in effect before October 1, 2006).

The bill permits an employer to purchase full or partial coverage under the program for a retired employee who is a state resident at full cost, as determined by the comptroller. (It is unclear if this means that the comptroller is the one determining the cost of the plans issued through the program, or just the cost of coverage provided by employers for their retirees. )

Mandatory Enrollment. The bill requires an “eligible individual” who is not enrolled in the program by July 1, 2008 to be enrolled by default when:

1. DRS or the Labor Department receives a report of the person's income;

2. a state income tax form is filed that lists the person as a household member; or

3. the person seeks health care.

The bill does not indicate (1) how DRS, the Labor Department, or health care providers are to know if the person is not already enrolled in the program, (2) by what means they are to effect a default enrollment, (3) in what policy the person becomes enrolled, or (4) how to have premium contributions collected on behalf of the person. It is also unclear whether this provision violates federal HIPPA privacy rules.

BLUE RIBBON COMMISSION ( 15)

The bill establishes a nine-member Blue Ribbon Commission to (1) study the program's effect on the cost of providing, and the accessibility of, medical care to state residents; (2) develop recommendations for applying the program to Medicare recipients; and (3) report its findings and recommendations to the Human Services and Public Health committees by January 30, 2008. The commission terminates on the date it reports to the committees.

Commission membership includes the DSS commissioner and comptroller, or their designees, and other members appointed by 30 days after the bill's effective date. The governor, House speaker, Senate president pro tempore, House majority leader, Senate majority leader, House minority leader, and Senate minority leader each appoint one member. Members may be legislators. The appointing authority must fill any vacancy.

The bill requires the governor's appointee to be the commission chairperson, who must schedule and hold the commission's first meeting within 60 days after the bill's effective date. The bill specifies that the Insurance and Real Estate Committee's administrative staff will staff the commission (although the committee does not receive a copy of the commission's report under the bill).

HUSKY AND MEDICAID CHANGES

DSS Screening for Medicaid or Husky Eligibility ( 9 & 19)

The bill requires DSS to screen each person eligible for or purchasing coverage in the Connecticut Saves Health Care program to determine if they are eligible for Medicaid or the State Children's Health Insurance Program (SCHIP). The screening will also be used to determine income for purposes of establishing premium payments under the program. It requires individuals (presumably only those who qualify) to enroll in one or the other public program, unless they object.

The bill requires relevant information to be obtained through state-maintained or state-accessible data and through the individual's self-attestation to the maximum extent feasible.

The bill requires the following information to be made available to DSS and the comptroller for purposes of Medicaid or SCHIP eligibility and establishing program premium payments:

1. eligibility and enrollment information for individuals enrolled in means-tested assistance programs other than HUSKY;

2. new hire information and quarterly reports provided to the Labor Department;

3. state income tax information that DRS maintains;

4. information showing individuals' U. S. citizenship, including information obtained from birth certificates and other vital records; and

5. federal information about new hires, quarterly earnings, Social Security numbers, immigration status, and other data pertinent to income or other components of Medicaid and SCHIP eligibility.

The bill requires the comptroller and DSS commissioner to enter into agreements with other state agencies providing or receiving information for the program. The agreements must require that:

1. the information is used only to verify or establish income or eligibility for matching federal Medicaid or SCHIP funds and

2. each agency providing information train and monitor staff and contractors who have access to the information and inform them of all applicable state and federal privacy and data security requirements.

The bill requires the DSS commissioner, within available appropriations, to develop and operate the information infrastructure needed to conduct the screenings, and take all feasible steps to maximize federal funds for this purpose. The DSS commissioner, in consultation with data privacy and security experts, must develop and implement policies and procedures that maintain data security and prevent inadvertent, improper, and unauthorized access to or disclosure, inspection, use, or modification of the information.

The bill gives individuals about whom information is provided the right to (1) obtain, at no cost, copies of all information that must identify the agency that released the information and (2) correct any misinformation or complete any incomplete information. Individuals must be promptly informed (it is not clear by whom) if any breach of privacy occurs including any rights and remedies available as a result of the breach.

The bill makes an unspecified appropriation to DSS from the General Fund for FY 08 to develop and operate the information technology infrastructure.

Increase in Medicaid Eligibility Income Limits ( 10)

By January 1, 2008, the bill requires the DSS commissioner to submit to the federal Centers for Medicare and Medicaid Services a Medicaid State Plan amendment to increase the income limits for Medicaid coverage for adults. DSS must extend coverage to parents, guardians, and caretaker relatives with incomes up to 300% of the Federal Poverty Level (FPL). Currently, parents and caretaker relatives of children receiving HUSKY A (Medicaid) qualify with income up to 150% of the FPL. (The bill does not specify that these adults must be caretaker relatives of HUSKY A children. )

Childless Adult Coverage. The bill also specifies that DSS may extend Medicaid coverage to any other individuals between the ages of 19 and 64 up to this same income level. They can be covered at the state's option through the amendment. Currently, only a limited number of non-elderly adults can receive Medicaid coverage, and the income limit is far below 300% of FPL (about 56%).

By January 1, 2008, the bill requires the commissioner to apply for a Section 1115 Medicaid waiver to authorize the use of SCHIP funds for individuals between 19 and 64 with incomes at or below 185% of FPL who are not otherwise eligible for Medicaid, either “under mandatory eligibility or at state option through state plan amendment. ” (This appears to require the use of SCHIP funds to pay for Medicaid coverage for these adults. But, the federal Deficit Reduction Act of 2005 prohibits states from using SCHIP funds to pay for health insurance coverage for childless adults. )

The bill allows the state to meet federal budget neutrality requirements (necessary for all Section 1115 waivers) by claiming unspent uncompensated care payments to hospitals or taking other measures. But these measures may not result in the following for individuals who would have qualified for Medicaid, HUSKY, or State-Administered General Assistance (SAGA):

1. a reduction in covered services or access to care;

2. an increase in deductibles, premiums, or other out-of-pocket costs; and

3. a reduction in enforceable individual coverage guarantees.

The bill provides that if budget neutrality prevents the bill's coverage up to 185% of FPL, the coverage should be available at the highest possible lower income level.

Using SCHIP to Expand Coverage ( 10)

The bill requires the DSS commissioner to cover individuals over the age of 18, including pregnant women, if this is necessary to access all federal SCHIP block grant funds allotted to the state. The commissioner must do this even if these individuals are not eligible for Medicaid.

Currently, the state uses SCHIP funds to cover children in families with incomes between 185% and 300% of FPL (HUSKY B), as well as 18- and 19-year-old children (HUSKY A, which is part of the Medicaid program) with income up to 185% of FPL. Younger children in families with income below 185% are eligible for HUSKY A, and their parents or caretaker relatives qualify for HUSKY A if their income is less than 150%. Likewise, pregnant women are eligible for HUSKY A coverage with incomes up to 185% of FPL.

It appears that the bill would require DSS to cover pregnant women with higher incomes under the HUSKY B program using available SCHIP funds, which federal law allows. It is not clear how high the federal government would allow the state to set the income limit for this group.

PUBLIC HEALTH REQUIREMENTS

School-Based Health Centers ( 11 & 20)

By September 1, 2009, the bill requires the Department of Public Health (DPH) to expand the state's network of school-based health clinics (SBHCs) so that all public school children in the state have ready access to them. DPH must license the SBHCs, which must provide physical and behavioral health care, including dental care, with appropriate connections to other services in the state such as local health departments, community health centers, hospitals, social service providers, mental health and family service agencies, youth service bureaus, pediatricians, and other primary care physicians and adolescent medical specialists.

The bill makes an unspecified appropriation to DPH from the General Fund for FY 08 for the SBHC expansion.

Primary Care Clinics ( 12 & 21)

The bill directs DPH, by July 1, 2009, to establish a sufficient number of primary care clinics to supplement other primary care resources so that all state residents have ready access to necessary primary care. DPH must license the clinics which must physical and behavioral health care, and dental care. The clinics must link with specialty care providers, other primary care providers and pharmacies. Each clinic must be or operated by a (1) federally qualified health center (FQHC), (2) health center determined by DPH to be substantially similar to an FQHC, or (3) a hospital. (FQHCs are community health centers that receive federal funding and meet specific criteria, including those governing the services they provide. )

Each primary care clinic, under the bill, must provide a wide range of primary care services and stay open outside of normal business hours to provide access to urgent, but nonemergency care.

Under the bill, physicians and other health care providers providing their services for a minimum number of hours to the clinics at a reduced rate must receive certain incentives. These include reduced medical malpractice insurance DPH offers or arranges, loan forgiveness from post-secondary educational institutions receiving funding from the state, and partial payment of educational loans. (It is unclear how the partial loan payment process would work. )

The bill makes an unspecified appropriation to DPH from the General Fund for FY 08 to establish the primary care clinics.

DPH Regulations ( 13)

The bill requires DPH to adopt regulations implementing the SBHC and primary care clinic provisions and to establish requirements for (1) services provided by the primary care clinics and their hours of operation and (2) provision of services to primary care clinics by physicians and other providers, including the number of hours. (Presumably this is related to the incentives discussed above. )

Plans for a Healthy Connecticut ( 14)

Beginning January 1, 2008 and biennially afterward, the bill requires DPH to publish “Plans for a Healthy Connecticut. ” DPH must develop these plans with assistance from state and local agencies, health care experts, and the public. Each plan must include information relating to:

1. access to essential health care;

2. health care quality;

3. health care costs;

4. data collection and analysis needs;

5. health status and health care disparities, including those based on race, ethnicity, gender, age, sexual orientation, residence, health status, diagnosis, immigration status, education, employment, English-language fluency, and other relevant factors; and

6. wellness preservation and health problem prevention.

For each of the above listed items and for any others included in the plan, the bill requires the plan to include (1) an assessment of the current status of each item in Connecticut; (2) an analysis of recent public and private efforts to address each; (3) recommendations for future public and private actions to address each item; and (4) a statement of measurable goals and objectives, with defined time frames, that reasonably can be achieved with sufficient public and private sector resources and commitment.

BACKGROUND

Related Bills

Several legislative committees have favorably reported bills broadly addressing health care access that contain provisions similar or related to those in sSB 1371. They are:

Bill Number

Committee

sSB 1

Public Health

sSB 3

Human Services

SB 70

Insurance

SB 1127

Human Services

sHB 6158

Children

sHB 6652

Insurance

sHB 7314

Labor

sHB 7375

Human Services

COMMITTEE ACTION

Insurance and Real Estate Committee

Joint Favorable Substitute

Yea

12

Nay

7

(03/13/2007)