Human Services Committee

JOINT FAVORABLE REPORT

Bill No.:

HB-5617

Title:

AN ACT MAKING REVISIONS TO THE CHARTER OAK HEALTH PLAN.

Vote Date:

3/18/2008

Vote Action:

Joint Favorable Substitute Change of Reference to Appropriations

PH Date:

2/26/2008

File No.:

SPONSORS OF BILL:

Human Services Committee

REASONS FOR BILL:

To delay the implementation of and make revisions to the Charter Oak Health Plan.

RESPONSE FROM ADMINISTRATION/AGENCY:

M. Jodi Rell, Governor, State of Connecticut submitted written testimony: “Thank you, Senator Harris, Representative Villano and other distinguished members of the Human Services Committee for this opportunity to provide you with testimony against Raised Bill No. 5617, An Act Delaying Implementation of and Making Revisions to the Charter Oak Health Plan.

“In 2007, we participated in one of the genuine success stories of the General Assembly session.

● We took action to approve the Charter Oak Health Plan and, for the first time, bring affordable health coverage to Connecticut's uninsured adults.

● We took action on behalf of our uninsured constituents, who have been struggling to find health insurance they can afford.

● We took action to safeguard our uninsured constituents' health, financial security and peace of mind.

● And we took action to place Connecticut once again as a national leader in the health care field, to show that our state could forge a practical, successful approach to a problem that has defied a national solution.

“The legislation to create Charter Oak set a start date of July 1, 2008. My administration has been working long and hard to put the pieces in place to meet this implementation date. July 1 is less than five months away – a very short time for government, but a very long time if you are facing medical expenses without the protection of health coverage.

“Now, with Raised Bill No. 5617, you are in danger of undoing the progress you voted to begin last year. While those in government write bills like No. 5617 at the State Capitol, people in our communities have to read bills from their doctor and hospital -- and far too often they cannot afford to write the checks to cover those bills.

“While some in government talk about delay, the people we are here to serve talk at the kitchen table about how to speed up the Charter Oak program because need they need the health care coverage now. While legislative action in 2007 raised the hopes of our uninsured adults, Raised Bill No. 5617 has the potential to dash those same hopes.

“Raised Bill No. 5617 calls for delaying implementation of Charter Oak until July 2009. That is only part of the problem in this flawed and misguided proposal – because Raised Bill No. 5617 mandates program changes that would effectively kill Charter Oak before it has a chance to begin, no matter the year. The bill would strip Charter Oak of its defining factor – affordability. It would do this by raising benefit levels and cutting out-of-pocket costs to the point that overall costs to both consumers and taxpayers would be unreasonable and prohibitive. Uninsured adults could forget about an affordable monthly premium. Taxpayers could forget about an affordable helping hand to the uninsured.

“In fact, the provisions of Raised Bill No. 5617 are oxymoronic. You can't legislate a monthly maximum premium of $250 if you also legislate a super-rich benefits package and virtually non-existent co-payments. Connecticut needs you to fight for the uninsured, not to delay and dither while another year – or two -- goes by. But no one has to take my word for the negative impact of delaying Charter Oak while destroying its affordability. Let me quote two excerpts from the many messages I received yesterday from Connecticut residents (copies of emails sent to legislators who will vote on Raised Bill No.5617.

1. The negative health and financial implications that any delay would have on so many of your constituents is so great, that this should NOT even be a consideration…To do anything other than push forward with the implementation of Charter Oak Health Plan for the already established July 1 2008 start date, regardless of the difficulties, would be a serious breach of your duties and responsibilities. A delay in the implementation would certainly result in tremendous financial hardship for some and suffering or death from lack of early care (or care at all) for others.

'Furthermore, I think that if you do foolishly choose to vote for any delay in implementation of the Charter Oak Health Plan, you should likewise choose to cancel your own personal and family health insurance coverage! This will allow you to suffer in solidarity a similar fate with the tens of thousands of Connecticut residents which you are choosing to delay coverage for.

'Yes, I am suggesting that you walk a mile in the shoes of those without a safety net, those whose illness will result in financial ruin, and those most likely to suffer and die for lack of proper medical care! Yes, it will indeed be a very enlightening experience for you to feel the pain of the disenfranchised…I thank you for taking the time to read this letter and I again implore you to vote for the July 1, 2008 start up date for the Charter Oak Health Care Plan.'

2. 'I am a Connecticut resident who just spent over $350 this month alone on my necessary medications, because I have a business, and can't get health insurance. I must pay cash for doctor's visits, and this keeps me from staying current on bills. I contacted DSS about the Charter Oak Health Plan over a year ago, and have been waiting for it. This program cannot be postponed another year!!

'Many other adults like myself work hard, and yet struggle just to afford health care. Sometimes adults go without necessary treatment because they don't have the money. There is a higher death rate among the uninsured. This is simply inhumane. Therefore I insist you defeat Bill 5617, and get the Charter Oak Plan up and running by July 1st!!'

“To provide further citizen input, following are several comments from Connecticut residents in 2007. They represent many others who have called and written to my administration. They are still waiting. Any proposal to delay Charter Oak to 2009 would be incomprehensible and unacceptable.

'Your proposed maximum monthly premium of $250, with no maximum income limit, would be wonderful, and I would gladly sign on to that…I would be pleased to pay more than $250 per month, even twice that amount if necessary, to make this plan happen…I understand there are significant co-pay and deductibles, but I have them now, anyway…If you need to negotiate a more flexible premium schedule for different income levels I encourage you to do so – anything to get this plan in place, as soon as possible!'

'It is so anxiety-producing to have to take $1,242 out of my savings every month…I know the Governor's plan is coming in the fall, but by then all my savings will be depleted and I will have to start on my retirement funds…Still, I am very grateful for your attention and the Governor's plan. I just wish it would come sooner.'

'I have just received a notice from a friend concerning Charter Oak Health Plan. This sounds as if this would be very important to me. I am currently receiving Cobra benefits that will end late this year. I am 58 years old and finding new employment with benefits is not easy.'

'This plan would be life saver to my parents and I'm sure to countless others in similar circumstances.  Please let me know when we can hope for this plan to be implemented…I would like to say that I am so thrilled that this problem is being addressed and this proposal sounds absolutely wonderful.'

'My dad only takes home $191 a week and it is him and my mother. I do not know how my parents survive and they need the health insurance.'

Senator John McKinney, Senate Minority Leader testified: “I'm here today to speak in opposition to House Bill 5617, AN ACT DELAYING IMPLEMENTATION OF AND MAKING REVISIONS TO CHARTER OAK HEALTH PLAN.

“As we all know, the Charter Oak health plan was established in 2007 each seeks to aid residents who have been uninsured for at least six months in eligible for publicly funded healthcare. These individuals are forced to buy healthcare on the prohibitively expensive individual policy market. Under Charter Oak they would through DSS be provided with an affordable version of healthcare maxed at $250 per month. The Governor's plan as it was introduced is based on a public-private partnership that strikes a balance between individual responsibility and government assistance for the lowest income participants.

“As you know, the current plan for Charter Oak includes like a full prescription package with descriptions being filled at $10-$15. It is not restricted for enrollees with pre-existing conditions, there is a lifetime benefit of up to $1 million. And I believe represents a real opportunity for people who currently have no insurance and cannot afford insurance on the private market to be so insured. Under House Bill 5617, and the changes to the plan effectively adds significant cost drivers and mandates that would prohibit the ability to have a premium of $250.

“It is difficult to argue against adding dental services as a mandate, adding vision care, and one, which I feel strongly about, is parity for mental health. But, I think we have to recognize that is not what Charter Oak was designed to do. As the Charter Oak was not designed as a solution to universal healthcare, charter or is not designed as a solution to, as I understand it, we have about 92% of our population that has some healthcare coverage. It was not designed to fill an entire void of 8%.

“Charter was designed, I think, specifically, to provide access to a very niche group of individuals. And as such, I think delaying implementation would be a mistake. Is Charter Oak going to solve all our problems? No. it is not. I do think we need to get it up and running as soon as possible to see if it can provide coverage to a Section of our population that right now has no insurance coverage.”

Attorney General Richard Blumenthal submitted written testimony: “I appreciate the opportunity to support House Bill 5617. This proposal addresses many problems concerning the affordability and efficacy of the many of Connecticut's working poor. Unfortunately, some of the statutory limitations and co-payment requirements would prevent many intended beneficiates of this plan from participating.

“House Bill 5671 eliminates the requirement that families be uninsured for six months prior to being eligible for participation in the Charter Oak Health Plan. No family should have to wait six months without needed medical services as a prerequisite to qualifying for Charter Oak benefits. Further, under this legislation, monthly premiums should not exceed $250 while annual deductibles should not be more than $100. Co-payments for emergency room visits should be limited to $20 rather than the current $150.

“Very significantly, this measure would require that all mandated benefits, including mental health coverage, be provided under this plan. This requirement is especially important because the proposed plan would not currently cover the same mental health benefits that the state mandates for all private health insurance plans. Finally, the bill establishes an independent appeal process, eliminates maximum coverage for prescription drugs and medical equipment and requires contracting for Charter Oak Health Plan administration be conducted separately from HUSKY.

“Importantly, this legislation also requires that any insurer offering Charter Oak coverage have at least an 85% medical loss ratio, meaning that at least 85% of the funds go to medical coverage rather than administrative costs and profit. Adjusting these elements of the plan will ensure more uninsured Connecticut citizens receive more and better health care through Charter Oak. I urge the committee's favorable consideration of House Bill 5617.”

Representative Kevin Witkos testified:We hold a promise to the people of Connecticut to provide quality, affordable healthcare. And the Governors Charter Oak health plan is the best vehicle which the state can fulfill its promise. However, the bill House Bill 5617, which is before your Committee, which delays implementation of the Charter Oak health plan, not only delay the implementation of the program but I think it will permanently dismantle it altogether. Passing this bill would be detrimental to the goal of providing every adult and child access to affordable healthcare in Connecticut.

“The middle class needs our help now more than ever. With this program we can reduce the annual deductible from a maxim of $1000 down to $100. We will illuminate any coinsurance requirements. And we are going to add dental and vision services as mandated benefits. And we are going to eliminate the $4000 on durable medical equipment. The Charter Oak health plan specifically mandates that the monthly premium cannot exceed $250. It is something that Connecticut families can budget for. And it is the unknown, there are so many things happening now in our economy, I am digressing from my written testimony to something that is personal.

“That when people try to make their budgets, they know how much money they have coming in their paycheck. Sometimes, they have the ability to work overtime but often times not. They have to make hard decisions with their family budget. Whether they can go out to eat that time or whether they, which bills they are not going to pay this month because, well, who has a lesser of a late payment fee. The healthcare is something that we all need, that we all rely on. And heaven forbid, we are all healthy, but it is a time that you really need it, you have been in place.

“It is the time that you look forward to pull out that insurance ID card when the first question in the doctor's office is do you have health insurance and who is it? And they want to see a photocopy of your card. So for every resident to pull that health card ID out that will say Charter Oak health plan, is something that we need to do in the State of Connecticut. The RFPs are out, the money has been spent already on this program.

“We are starting to get some of the things back, and I would urge this Committee to please vote against this bill.”

Representative Pamela Z. Sawyer submitted written testimony: “I want to thank the Human Services Committee for the opportunity to express my opposition to HB 5617. I believe this bill defeats the legislature's intent to make healthcare accessible to those uninsured and harms any progress the Department of Social Services had made thus far in doing so.

“Last June, the legislature appropriated $13 million to the Charter Oak Health Plan to establish health coverage through a public-private partnership. The plan will help all adults who don't receive insurance through work or don't qualify for state assistance to purchase affordable plans from participating providers for no more than $250 a month.

“DSS is currently reviewing RFP's from Managed Care Providers and plans to have the program functioning by June 2008 – that's only 4 months away! Furthermore, this bill will scare quality managed care providers from submitting proposals and will reduce the number of providers in the pool necessary to keep costs low.

“The committee should allow the Charter Oak Health Plan to progress and develop as originally intended. It would be premature to make any assessments on its value and effectiveness until the program is up and running. Delaying progress will simply incur unexpected costs. I respectfully request the committee not take action on this bill.”

Robert L. Genuario, Secretary, Office of Policy and Management testified: “The bill proposes many costly changes to the proposed benefit package and eligibility requirements. For instance, the bill

● Eliminates the six month requirement for being uninsured;

● Caps monthly premiums at $250;

● Revises the annual deductible from $1,000 to $100;

● Eliminates the 20% deductible;

● Reduces non emergency ER visit co-pays from $150 to $20;

● Eliminates the $1 million life time benefit cap;

● Includes dental and vision benefits and adds comprehensive mental health coverage;

● Adds a requirement for monthly reporting to the Medicaid Managed Care Council;

● Separates the Charter Oak procurement from the HUSKY procurement; and

● Requires a medical loss ratio of at least 85%.

“It is understandable that the legislature wants to make the Charter Oak package a very rich benefit. However, the intent of the Charter Oak plan was to create an affordable plan with basic coverage. The changes included in this bill would essentially create an expansion of the HUSKY program, and with substantial cost increases. Although difficult to quantify, premium costs could increase 30% to 40%, pushing the annualized cost from $53 million to well over $70 million.

“While the fiscal implications of this bill are huge, a more discouraging point is that this bill would delay implementation by one year. We simply cannot wait longer to provide an affordable health plan to those who do not qualify for HUSKY or for other state medical assistance programs. Last year during hearings on the Charter Oak proposal, members of the legislature continually asked the question, “How will you keep the benefit affordable? Do you think $250 is a realistic monthly premium?” I can tell you that the changes proposed in Raised Bill 5617 would with absolute certainty create a product that is unaffordable—both to the individuals who need health coverage now, and to the state.”

Michael P. Starkowski, Commissioner of the Connecticut Department of Social Services testified: “I also want to voice my strong opposition to this legislation. As a practical matter, HB No. 5617 would permanently dismantle Charter Oak under the guise of an implementation delay with enriched benefits that would effectively prevent its implementation due to increased cost to enrollees and taxpayers. Charter Oak, from its inception, was carefully crafted to balance the costs to the individual and the costs to the state.

These changes would completely and permanently derail the implementation because they would alter the fundamental structure, which made Charter Oak an affordable health coverage program.

“Specifically, the legislation:

● Reduces the annual deductible from a maximum of $9000 to $100

● Eliminates any coinsurance requirement

● Reduces the copayment for misuse of emergency rooms from $100 to $20

● Eliminates $1 million lifetime benefit

● Eliminates the $7,500 annual limitation on pharmacy (this had already been increased by DSS from $2,500 to $7,500, based on legislative and advocacy concerns)

● Eliminates the $4,000 annual limitation on durable medical equipment (this too had already been increased by DSS from $2,000 to $4,000, based on legislative and advocacy concerns)

● Adds dental services as a mandated benefit

● Adds vision care as a mandated benefit

● Mandates mental health parity

● Eliminates the six-month requirement for being uninsured.

“Moreover, the bill removes all of the flexibility the state has to negotiate any flexibility in the benefit package. With these changes, it is inconceivable that the Charter Oak monthly premium could remain under $250 without an enormous government subsidy. This is altogether counter to the premise of Charter Oak.

“As DSS tries to guarantee continuity of services for HUSKY and Charter Oak enrollees with the same set of health insurers and with the same set of healthcare providers; and as DSS tries to achieve efficiencies through a combined bidding /contracting process, this bill would specifically prohibit these practices which will benefit the state and, most of all, the vulnerable children and adults we are here to serve.

“While we respect the Legislature's right to review and revise programs, we also believe that Connecticut adults need affordable health coverage, and they need it in 2008.   The problem with Raised Bill No. 5617 (besides needless delay) is that Charter Oak will probably never happen if the program cost to the State of Connecticut is too high.  We saw this last year at the legislature -- a proposal for expensive, universal health care failed because of the high price tag. As approved by the Legislature in 2007, Charter Oak is a good, workable plan.

“Charter Oak offers hope for a great many of our citizens. I urge the committee to reject this legislation.

“In summary, Raised Bill No. 5617:

Would not only delay the Charter Oak Health Plan for another year, it would effectively prevent it happening at all.

It completely disrupts the program and needlessly hurts the uninsured adults in Connecticut who are waiting anxiously for their chance for affordable coverage beginning on July 1, 2008.

The delay called for by the bill is bad enough – and the other specific provisions in the bill would make Charter Oak unaffordable for both consumers and taxpayers.

It would also overturn the program as legislated last session (including the July 1, 2008, start date).

Governor Rell, the Office of Policy and Management, the Department of Social Services, the Department of Public Health and the Office of Healthcare Access strongly oppose the bill, on behalf of Connecticut's uninsured adults who are waiting for Charter Oak to help them access health coverage.

Raised Bill No. 5617 is extremely detrimental to the thousands of uninsured adults in Connecticut who could benefit from the Charter Oak Health Plan in July. 

“Together, Raised Bill No. 5617 and the anti-joint procurement portion of Raised Bill No. 5618 represent a giant step backward when Connecticut is on the verge of great progress in covering our uninsured adults – while planning to streamline this new coverage with our existing, highly successful HUSKY program for children and low-income parents.”

J. Robert Galvin, M.D., MBA, MPH, State Health Commissioner testified: “We are opposed to House Bill 5617, AN ACT DELAYING IMPLEMENTATION OF AND MAKING REVISIONS TO THE CHARTER OAK HEALTH PLAN. The act seeks to delay the implementation of the Charter Oak health plan. The Charter Oak health plan is a practical plan that will increase access to health insurance coverage for Connecticut's uninsured residents who are ineligible for other publicly funded health insurance plans. A delay in the implementation of the Charter Oak plan equates to a delay in health insurance access for the state residents and places them at continued increased risk until such time as the plan is made available.

Further, he lays in accessing healthcare coverage will force uninsured residents and their families to forego healthcare or accumulate debt trying to pay out-of-pocket. The Department of Social Services has issued a request for proposal that includes provision of the Charter Oak plan from the HUSKY A and HUSKY B. Section I part e of House Bill 5617 indicates a separation of the Charter Oak plant from HUSKY A and B ASOs.

“The Department of Public Health proposes not only the delay in implementation of the Charter Oak plan, but also any potential delay in identifying NCOs for the HUSKY A and B plans that are to go into effect July 1, 2008. In the meantime, thousands of Connecticut residents would continue to be uninsured.”

Kevin Lembo, State Healthcare Advocate submitted written testimony: “I'm here to testify in support of certain aspects of Raised House Bills 5617, An Act Delaying Implementation of and Making Revisions to the Charter Oak Health Plan. As you know from my previous testimony on Charter Oak, I am very concerned with the state putting out an insurance product that offers less consumer protections than the state requires other health insurers to offer. The state should not be in the business of marketing and setting the precedent for the proliferation of limited benefit plans as a part of the solution to the problems of uninsurance. “What will remain are a significant number of people who are underinsured. The consumer protections in the insurance statutes should have meaning for all residents of the state and I appreciate that you are considering revising the Charter Oak Plan to take into consideration the concerns raised by a wide range of advocates.

“The revisions contained in Raised House Bill 5617 have become even more important since the release of the Charter Oak RFP. DSS has represented that while bidders must bid on the package in the RFP (which contains some changes that include coverage of most of the consumer protections in the insurance statutes), we have learned that bidders are also allowed to submit bids on a different benefits package of their choosing that falls within or near the $250 premium DSS has established. This obviously could result in changes to the possible package and benefit limits that Commissioner Starkowski has guaranteed would be covered under Charter Oak. This would undercut the work that has been done to ensure that Charter Oak is meaningful insurance coverage.

“Beyond these concerns, there are two glaring and critical changes to Charter Oak that are necessary and, thankfully, rectified in this bill. I am pleased to see language in Raised House Bill 5617 that reflects the importance of the right to external appeal and compliance with utilization review laws. But I am especially pleased to see the inclusion of mental health parity which was essentially singled out for exclusion because of a purported belief that it costs too much to provide. Study after study shows that this is not the case. (Three of them to are attached to our testimony.) We cannot and should not discriminate against people with mental or nervous conditions and the failure to include mental health parity in the Charter Oak plan is discrimination. Thank you for your attention to this issue by including mental health parity in the Charter Oak plan in Raised House Bill 5617.

“We also support the de-linking of the HUSKY contracts from the Charter Oak contracts. The products are not similar in the populations targeted for coverage, the regulations governing them or the delivery system for services. At first glance it might seem logical that using the number of HUSKY covered lives (over 320,000) might be leverage to attract bidders, but because the products are so different, that leverage disappears. At least one large local insurer has expressed that exact sentiment to DSS – federal laws governing HUSKY are detailed and more involved than any law governing Charter Oak which is purely a state product. Additionally, Charter Oak has been linked to HUSKY in terms of reimbursement rates and provider networks. We find it hard to believe that providers who are already resisting taking HUSKY patients will treat Charter Oak enrollees in a commercial model at similar reimbursement rates. Finally, the HUSKY system is designed with a certain range of providers in mind and a focus on concentration of care delivery at clinic settings. The Charter Oak population is targeted to what typically would be a commercially insured population. Finally, care settings and program design in Charter Oak are likely to be drastically different than the in HUSKY program.

“I have been clear since Charter Oak was proposed that it could work, but there were many adjustments that needed to be made to make it work. While Charter Oak has evolved from a universal health plan, to an affordable plan, to now a bridge to commercial insurance, the need for the codification of consumer protections and the prevention of ad hoc changes to the plan is clearly necessary. The inclusion of mental health parity and the right to external appeal are common sense changes that allow Charter Oak enrollees the same protections as you and I already expect under our state's insurance laws as a matter of long-standing public policy.

“We also support the inclusion of a medical loss ratio of eighty-five percent as a mechanism to ensure proper performance under the Charter Oak plan. “

Cristine A Vogel, Commissioner, Office of Health Care Access submitted written testimony in opposition to HB 5617.

NATURE AND SOURCES OF SUPPORT:

Marty Milkovic, Executive Director of the Connecticut Oral Health Initiative testified: “I am here to support House Bill 5617, and in particular, the addition of dental care to the Charter Oak plan. We support this and the other important parts of the bill that contain improvements to the bill.

“Good oral health is strongly linked to overall health. It is a cost-effective way to improve overall health. In fact oral health overall nationally is only about 4% to 5% of overall healthcare costs. That pays big dividends. In a recent Wall Street Journal article it was reported that a number of health insurance companies were adding certain dental procedures to their regular healthcare programs because they recognize that doing that kind of preventative care would reduce costs later. And that is because poor oral health has been linked to a number of other conditions, other health problems including heart disease, low birth weight babies, diabetes, HIV/AIDS, osteoporosis, clogged arteries, stroke, and bacterial endocarditis.

“In addition to adding dental care we also support the other improvements to the Charter Oak plan that are contained in House Bill 5617. Not the least of which is elimination of six-month waiting, production of certain out-of-pocket costs that were mentioned earlier, inclusion of important coverage for vision and mental-health services, and the added external appeals procedure. And finally, we really support another important aspect of the bill that would require separate contracting the plan and HUSKY.

“Now while there may be some reasons to think about linking HUSKY and Charter Oak, I think the overall risks to both programs and to the clients for both programs really outweigh any benefit. That joint RFP has already dissuaded some bidders from applying. And it is certainly going to cause some great confusion on both plans are attempting to ramp up, rushing to ramp up on July 1st. Really, we need to do this right. We need to give the public enough time to comment on this and providers to comment on this. We need enough time for you and the rest of the Legislature to look at this, and for DSS to design this so that we really have a program that works.

“So I really appreciate your concern about oral healthcare and inclusion of it in this bill and strongly encouraged to keep that in. “

Maggie Adair, Public Policy Director at the Connecticut Association for Human Services testified: “CAHS supports House Bill 5617, An Act Concerning Delaying Implementation of and Making Revisions to the Charter Oak Health Plan. While we commend Governor Rell for attempting to expand health care coverage to some of Connecticut's uninsured, the Charter Oak Plan is ill-conceived and will end up only covering healthy people who can afford to pay the monthly premiums. This is unsustainable. Media coverage has uncovered public documents that acknowledge that the Charter Oak Plan is geared to avoiding high-risk patients in efforts to hold in health care costs. We are concerned that the Charter Oak Plan does not offer mental health parity, considering that Connecticut has made so much progress in addressing the rights and needs of individuals with mental health issues. We want to continue that progress.

“House Bill 5617 proposes revisions to the Charter Oak plan to make it more affordable and realistic, including: lower monthly premiums, annual deductibles, and co-payments; no dollar cap on a lifetime benefit; and no maximum limit on prescription drugs or durable medical equipment. The bill also makes a person who is uninsured immediately eligible for the Charter Oak Plan. The bill also ensures that the Charter Oak Plan include comprehensive coverage for dental, vision, and mental health services, as well as prevention, wellness and disease management programs. These are critical components that must be addressed.

“Most importantly, this bill requires that the Department of Social Services separate the Charter Oak Contract from the much larger contract for HUSKY Plan, Part A and Part B. The contract proposal that was issued earlier this year folded the tiny Charter Oak Plan into the enormous HUSKY proposal and required that the bidder must bid on both plans. If the Charter Oak Plan is realistic and sustainable, then it should be issued as a separate contract. Folding it into the larger HUSKY plan makes it very unclear if the Charter Oak Plan would attract a bidder standing on its own.”

Shirley Berger, Attorney with Connecticut Legal Services testified: “On March 31st, there will be only two HUSKY HMOs in this capacity remaining in the program. On April 1st, HUSKY A participants have to choose either of those two HMOs or fee-for-service program. This is going to be incredibly disruptive and confusing. We know that because of past experience when we had people choosing. This population has some reasonably sophisticated people in it but also many people who are not.

“If you do not understand how to coordinate which medical providers they've got with these various programs to ensure continuity of care, which can be very important. Also, on April 1st, you are doing something wonderful in the state, which is the PCCM pilot. We are talking about moving into a new managed-care system before we even see a PCCM, which is save money in other states and has better outcomes whether it can be beneficial, we want to implement statewide here. And then in August, again, we are going to ask the HUSKY A participants to choose a new HMO. So people are starting all over as soon as a start to get settled in. It is going to be confusing. I'm worried about disruptions in medical care.

“The DSS has issued an RFP to combine both Charter Oak which serves about 3000 people with the HUSKY A HMOs, again, as my colleague Jane McNichol said, we are moving too fast, we're not learning lessons we need to do this right. But they cover different groups of people, they have different types of coverage, they are wholly different models, it makes no sense to combine them in an RFP. And we urge you not to allow that.”

Donald Thompson, President and CEO of StayWell Health Center, Inc. testified: “As you recall, in 2006, Governor Rell announced additional capital funds for the expansion and renovation of fourteen primary care facilities operated by the thirteen federal qualified health centers in Connecticut. These facilities are the medical homes, or primary health providers, for over 219,000 patients in our state. The critical funding the Governor provided will allow us to medically treat and care for an additional 85,000 patients a year. We are the largest provider of medical services to the uninsured or underinsured in this state. We currently care for one-quarter of Connecticut's Medicaid population and 60% of the state's SAGA clients.

“The community health centers view The Charter Oak Health Plan as a key initiative that will provide coverage for the working poor and those individuals who are having difficulty finding affordable health insurance coverage. In doing so, the Charter Oak Plan will provide greater access to services for patients and families who may now be using hospital emergency departments rather than establishing a medical home at an FQHC that would provide continuity of care.

“If the goal of the Charter Oak Plan is to provide a comprehensive medical insurance policy for under $250 a month to individuals without insurance for a least six months, provide premium assistance to consumers who have incomes below 300% of poverty, include individuals with preexisting conditions, and screen children in our state for eligibility under the HUSKY program, as a provider of health services, I clearly am in favor of any program the state offers to reduce our uninsured rolls which total between 200,000 to 400,000, depending on whose numbers you believe.

“Whatever this committee's, and the legislature's decision is in establishing a program to provide accessible and affordable health care, all the federally qualified health centers in the state join me in affirming that we look forward to our continued role in the delivery of these services to all those who walk into our facilities across the state. We have, and will continue, to serve all patients no matter what level of income they have and whether they are insured or not. That is our pledge to you and all the people of this state.”

Cheri Bragg, Keep the Promise Coordinator testified: “I am here today to testify in support of HB 5617. The Keep the Promise Coalition strongly supports delaying implementation of the Charter Oak Health Plan until important revisions can be made. We have grave concerns about any state-sponsored health plan that does not follow our state mental health parity mandate, which states that mental health services cannot cost more than medical and surgical coverage. There is no reason for mental health not to be covered at the same level as all other health concerns. Doing otherwise is simply discrimination. The brain is just another organ and coverage should equal that of any other organ in the body.

“Studies show that mental health parity has an insignificant impact on cost. The Congressional Budget Office agrees and reports a 0.4% estimated cost impact. On top of this, those findings do not take into account the cost savings that would be realized from decreased visits to emergency rooms, physicians, and other significantly more costly outcomes. Therefore any statements that adding mental health parity to the Charter Oak plan would be cost-prohibitive is not backed up by the facts.

“We are also concerned about existing limitations on prescription drug coverage. Many necessary psychiatric medications would not be covered resulting in cost-prohibitive bills to the insured. Furthermore, if someone qualifies for the Charter Oak Health Plan, they would not be eligible for other prescription drug assistance. This is history repeating itself as many Medicaid recipients who were previously were eligible for prescription drug assistance programs, now are not eligible due to Medicaid Part D. Please don't let this plan place arbitrary limits on inpatient and outpatient mental health services and ignore Connecticut's own laws designed to protect all insured residents from discrimination in mental health care.

Alan Atherton, President of the National Alliance on Mental Illness testified: “I've been down the Capitol Hill in arguing for federal parity laws and, and I have been proud of the State of Connecticut for having one of the best is parity laws in the nation. And now I'm here because we're about to embark on the Charter Oak health plan that systematically discriminates against the mentally ill. And I am saying, what is going on? Why is this happening? So I am here to support House Bill 5617 which is supposed to fix that problem among other things.

“It is going to cost some money. But it is not going to cost and I quote from the Department of Social Services documents, dramatic increases in the target premiums. The increased cost for mental-health parity are comparatively insignificant, and they are particularly insignificant when you consider the kind of cost of providing the right services for the mentally ill will offset.

It was a consultant who worked for the Department of Social Services that said, there should be limits on mental-health benefits and prescription drugs to avoid selection issues associated with chronic users of these services because failing to do this would take on a bad risk.

“Now I can quote some bad risks of not providing these kinds of services that far outweigh the kind of cost increases and several people will tell you would be involved, comparatively, in significant cost increases. And those are the risks of increased emergency care, the risk of increased homelessness, the risks of social disruption that you get when people who are plagued with mental illnesses are not properly treated, and just the risk of decreased productivity. And I can tell you that this is a social imperative, and you would understand what I mean. People with mental illness deserve an even chance. But the fact of the matter is that it is just good business. It is just good business to treat the mentally ill way they should be treated. Because the overall results of the productivity of society will dramatically improve.

“To reiterate, Charter Oak health plan cannot stand it is the wrong thing to do the way it is. House Bill 5617 fixes it and I urge you to support that. Because we cannot back an insurance plan fed treats mental healthcare differently than other healthcare treatments. And it systematically attempts to exclude those that are most in need of its services.”

Barbara Albert of Hartford testified: “I'm here to express my support House Bill 5617. This health plan excludes Connecticut's current Mental Health Parity Law, mandating that coverage for mental-health services be no more costly than other medical services. There are also limits on inpatient and outpatient care.

“Connecticut will not only be violating its own law this health plan also violates the federal law, Section 504 of the Rehabilitation Act of the Americans with Disabilities Act, also federal Medicare beneficiary rights, our constitutional rights to life liberty and what I prefer to call the alleged pursuit of happiness. “

Janine Sullivan-Wiley, Executive Director of the Northwest Regional Mental Health Board testified: “As for the Charter Oak Plan, I am deeply concerned that it does not provide full parity for treatment of all illnesses – in other words it somehow thinks it will work to have lower coverage for treatment of mental illness and substance use disorders.

“As young people enter the job market, they often get jobs that do not provide health insurance. They have to buy it themselves. ,I have also seen how mental illness often strikes that age group, and it is critically important that it be covered to the same extent as other illnesses. Otherwise we are simply shifting the cost. Having the right coverage is not simply fair, it makes good sense. It means that whether a person develops a cardiac problem or a mental health problem, they can get the treatment that they need - the right treatment, in the right amount. People should not be told that – 'whoops! Sorry, but the illness that you got has an early cut off. You're out.' Don't leave them out.

“With proper treatment, people with mental illness ,and substance use disorders can and do recover. They are our co-workers, our children, our neighbors. 'They' are 'us.'. Please hold up the implementation so that you can amend this health care plan to provide the coverage – fair and complete coverage ,for all illnesses. Do not shortchange the people who will be getting this plan and thinking it is a real plan for health care coverage. Both of the things I am asking for today are about fairness and about putting in place what people need to be successful in their communities. “

Marcia Bok, National Association of Social Workers Connecticut Chapter submitted written testimony: “I want to support HB 5618 which would provide continuous eligibility for HUSKY. We can definitely simplify the procedure for establishing continuous eligibility so that children and parents do not lose their coverage. Since last July, 10,000 people are missing from HUSKY A. Without continuous coverage, children have gaps in coverage as they move form HUSKY A to HUSKY B and vice versa. Such churning not only creates gaps in coverage but increases paperwork for program administrators and for providers.

“We want eligible children and adults to receive HUSKY A and B. We don't want to put obstacles in the way of receiving needed coverage. We need to provide information and outreach and simplify eligibility procedures and we must focus on retention and enrollment, given the complexity of the program. We should simplify proof of income, make children eligible for HUSKY for at least one year, eliminate premiums and co-pays for HUSKY A adults, keep working families on HUSKY for up to 24 months and provide outreach to help families apply for and keep HUSKY coverage. I think we all agree that HUSKY is a vital program for children and families. I think we would also all agree that we want to encourage and not discourage utilization of the program for eligible individuals and families. Thank you very much for your attention.”

“HB5617 Delaying and revising the Charter Oak Plan is a tremendous improvement to the law that was passed during the 2007 legislative session. For NASW/CT there are two improvements that are key: 1. Including comprehensive mental health coverage (as well as dental and vision coverage) and 2. Establishing an external appeals process for consumers. At the Informational Forum that was held this past fall on the Governor's Charter Oak Plan, it was very clear how few people would have actually benefited from this plan. Clearly, legislators listened and have worked very hard to improve the Plan and make it a health insurance plan that would make it affordable and comprehensive.”

Cinda Cash, Executive Director, CT Women's Consortium submitted written testimony: “CWC is urging your support of HB 5617. CT's current mental health parity law, which is a national model, mandates that a health plan that offers coverage for medical and surgical conditions must offer coverage for the diagnosis and treatment of mental or nervous conditions. Coverage for mental health services cannot be at a greater expense than the medical and surgical coverage. [Sec. 38a-514(b)] Unfortunately, if the Charter Oak Plan is approved as is, it will be in violation of our state's mental health parity law.

“Living with a behavioral health issue is challenging at best. Stigma continues to exist and is reinforced for many by the lack of needed services in a timely and efficient manner. The Charter Oak Plan offers an opportunity to recognize this access problem and, by applying CT's mental health parity law, can offer meaningful coverage to those who would eligible for the Charter Oak Plan and in need behavioral health services.

“The rationale that coverage for mental health services would be too expensive to include in the Charter Oak plan is short sighted. Lack of coverage results in expenses that occur when those in need have limited or no options for obtaining care. Within the health care delivery system, there is an increase in Emergency Department visits and inpatient hospitalizations and those expenses – both fiscal and emotional - spill over to other systems, such as the criminal justice and child welfare.

“I would encourage you to continue to keep CT's commitment to its citizens with behavioral health needs by ensuring that our state's mental health parity law is reflected in the Charter Oak Plan. “

Terry Edelstein, President/CEO, Community Providers Association submitted written testimony: “We have significant concern about the “unknowns” in the implementation of the Charter Oak Plan as they relate to the provision of behavioral health services.

“It is our understanding that mental health and addiction treatment services are being “carved out” of the basic Charter Oak Plan, however, there is no clear specification about what the extent of these benefits will be.

Will people with mental illness and addictions be covered under the same health insurance mandates and behavioral health parity as those with other illnesses, or will the mandate be reduced?

Will Connecticut's forward-thinking behavioral health parity legislation be in full force or will it be diminished in scope?

“We support the provisions of HB 5617 (lines 48 – 53) that require that 'the commissioner shall ensure that the plan includes comprehensive coverage for dental, vision and mental health services consistent with the provisions of section 38a-514…'

We urge you to review the full benefit package in the Charter Oak Plan before authorizing the state to implement the program.”

Ellen Andrews, Executive Director, CT Health Policy Project submitted written testimony: “We are very optimistic about the Charter Oak Plan and the potential to provide coverage to thousands of Connecticut residents who struggle every day to access health care. HB-5617, AA Delaying Implementation of and Making Revisions to the Charter Oak Plan, contains important consumer protections and gives state policymakers more time to ensure development of a sustainable program that will effectively cover the people who need it. Among other protections, the bill remedies an important injustice in the current Charter Oak Plan – that people must be uninsured for six months before becoming eligible. This leaves out those who have purchased individual coverage, either for need or because they do not want to place themselves and their families in the financial jeopardy that accompanies uninsurance. It is unfair and counterproductive to exclude these Connecticut residents, who have been making significant sacrifices to pay for expensive individual coverage. The bill also reduces consumer cost sharing, adds back critical services such as dental, vision and comprehensive mental health benefits, removes unrealistic caps on benefits, provides consumers access to outside utilization review, and includes the very reasonable standard that Charter Oak managed care companies must spend at least 85 percent of revenues on medical services.

“The bill also separates the Charter Oak Plan procurement from HUSKY. This is critical for several reasons. As you are aware, the HUSKY program has had a troubled past. While we are confident that recent changes will improve the program immeasurably, linking two essentially new programs serving different populations with different needs and different rights under law just adds to complexity and reduces flexibility in both. It is also likely that more managed care organizations would be interested in participating in either program alone. In fact, ConnectiCare indicated to DSS an interest in bidding only on the Charter Oak Plan which is currently precluded, denying consumers and the state another option to cover Connecticut's uninsured. We urge passage of HB-5617.”

Sheldon Toubman, Staff Attorney with New Haven Legal Assistance Association submitted written testimony: “I urge you to pass favorably on HB 5617. This bill addresses the frightening prospect which about 330,000 low income HUSKY recipients are facing that they will twice -- in a matter of weeks-- be required to go through substantial turmoil under the HUSKY program, because of DSS' unilateral decision to link contracting with HMOs under the HUSKY and Charter Oak Health Plans. HB 5617 will also improve access to care under the Charter Oak plan.

“No responsible policy-maker would intentionally restrict access to health care for 330,000 poor children and their parents to advance an untested program that might, in three years, provide about 33,000 people with limited insurance coverage. Nevertheless, this will be the effect of the Governor's Charter plan on the low-income children and families enrolled in HUSKY if a course correction is not made -- and quickly.

“Last fall, in contract negotiations with the HMOs which have run the HUSKY program for the state, the Governor required that the HMOs agree to be subject to the state Freedom of Information Act (FOIA). When the two largest HMOs refused to accept this requirement, the Governor announced the termination of their contracts. As a result, two HMOs are scheduled to leave the program on March 31, 2008 (one of the refusers, Anthem Health Plans, has since signed a FOIA commitment but another HMO, though having previously signed it, is leaving anyway). Since January 1, 2008, all HMOs are operating as administrative agents only; DSS is now making all policy and medical decisions.

“The Governor was right in taking this action in favor of transparency, especially given the history of serious problems under the HUSKY HMOs, from inflated provider lists to routine denials of covered services. However, this positive transformation, effective April 1st, will necessarily involve substantial confusion.

“Notices are going out now to all families in HUSKY instructing them to enroll in either CHNCT or Anthem (the two remaining HMOs) or in traditional “fee-for-service” Medicaid, by April 1st. To avoid changing doctors, families must ensure that their providers participate in the plan they pick, or convince their providers to enroll in that plan. DSS is working with advocates and providers to try to reduce the disruption, but, inevitably, it will take at least a few weeks to straighten out all of the glitches.

“DSS also is required by state law to implement a pilot program of primary care case management (PCCM) for HUSKY by April 1st. PCCM is a well-tested alternative to HMOs that was adopted in last year's legislative session. In 2003, Oklahoma terminated HMO contracts in its Medicaid program and quickly implemented a statewide program of PCCM, which both improved access to care and saved $4.3 million in the first year. As in Oklahoma, PCCM can help address the disruptions caused by the departure of the HUSKY HMOs.

“Unfortunately, DSS is not seriously looking for alternative ways to manage HUSKY in the long run. Instead, if DSS has it way, just after the dust settles from the major changes on April 1, families in HUSKY, and their providers, will receive another notice saying they have to make yet another change, to one of several different HMOs, just three months later.  This second disruption results directly from DSS' decision to combine HUSKY with Charter Oak. DSS has issued a joint request for proposals on which HMOs must bid to begin operations under both programs on July 1st.

“Requiring such a major upheaval twice over such a short period of time will cause severe disruption in access to care for HUSKY enrollees and will undermine efforts to enroll new providers in HUSKY by April 1st. The linkage of these two programs is not required (or even authorized) by the legislature-- nor even logical. The two programs serve different populations with different benefits and costs. Medicaid is an entirely government-funded entitlement; Charter Oak is modeled on private insurance, with a limited state subsidy.

“In fact, in combining the two programs, DSS may be violating its obligation under federal law to operate its Medicaid program in the “best interests of the recipients,” as required under 42 U.S.C. 1396. DSS officials have for months acknowledged that the reason that HUSKY and Charter Oak are linked is concern that, standing alone, the Charter Oak plan will not attract HMOs as carriers because it is too risky a “product.” But forcing vulnerable kids and parents on HUSKY to make two major changes in three months, in order to further an unrelated program for other people, is clearly not what is best for them. Moreover, one HMO has specifically declined to bid on Charter under the joint RFP, based in part on DSS' decision to bid Charter Oak in "combination with the HUSKY Program," indicating the opposite of the intended effect has resulted from the decision to combine the two programs.

“Since the Governor does not appear to be willing to delay the return of HMOs to HUSKY or to separate Charter Oak from HUSKY, and thus avoid this double turmoil after the April 1st changes and allow the HUSKY program to stabilize, it is necessary for the legislature to step in now to do so.

“SB 5617 will make substantial improvements to Charter Oak and delay its implementation for one year to allow for this. Among the substantial improvements made possible by 5617 are:

Mental health parity is required

Drug and durable medical equipment caps are removed

Cost-sharing is reduced

Comprehensive dental and vision care is required to be covered

Six-month waiting period is removed

Authorization to provide more limited "alternative" benefits is removed

Lifetime maximum benefit cap is removed

External appeals are required

“The removal of the authorization for a more limited 'alternative' benefits package is particularly important in light of DSS' recently stated willingness to let the HMOs have free reign on benefit design- commitments at the 12/5/07 legislative forum and in DSS' January 3, 2008 follow-up letter to legislators notwithstanding. DSS has made clear to potential bidders that, if they cannot come in with a premium of $250 to do that which DSS is asking of them, then they are free to submit a bid to change the benefits in any way they wish so as to meet the premium target— making a mockery of the commitments which DSS has made over the last few months to include most of the insurance mandates and make other changes.

“Finally, I note that if the Charter Oak plan is as good as it has been represented to be by DSS, it should be able to stand on its own two feet, without needing to be supported by the vulnerable children and parents on HUSKY. 5617 therefore wisely requires that any contracting under it and under HUSKY be done separately.”

See Also: RESPONSE FROM ADMINISTRATION/AGENCY:

Attorney General Richard Blumenthal

Kevin Lembo, State Healthcare Advocate

Also submitting written testimony in support of HB 5617:

Shawn M. Lang, Director of Public Policy, Connecticut AIDS Resource Coalition

Barbara S. Bunk and Christine H. Farber The Connecticut Psychological Association Inc.,

Phil Sherwood, Legislative Director, Connecticut Citizen Action Group

Gina Carucci, D.C., Legislative Committee Chair, Connecticut Chiropractic Association

NATURE AND SOURCES OF OPPOSITION:

See: RESPONSE FROM ADMINISTRATION/AGENCY:

M. Jodi Rell, Governor, State of Connecticut

Representative Kevin Witkos

Representative Pamela Z. Sawyer

Robert L. Genuario, Secretary, Office of Policy and Management

Michael P. Starkowski, Commissioner of the Connecticut Department of Social Services

J. Robert Galvin, M.D., MBA, MPH, State Health Commissioner

Cristine A Vogel, Commissioner, Office of Health Care Access

Also submitting written testimony in opposition of HB 5617:

Mark Masselli, President/ CEO, Community Health Center Inc.

Larry McHugh, President, Middlesex County Chamber of Commerce

Debra A. Jurasus

Richard Kritz

Cheryl Douglas of Clinton

Christine Cali-Brophy of Black Rock

Marie R. Kritz

Marshall Hurteau of Old Saybrook

Nancy Osborne

Noreen and Mark Corley of East Hartland

Reported by: Heather Dorsey, Assistant Clerk
Jeanie B. Phillips, Clerk

Date: March 25, 2008