OLR Bill Analysis
AN ACT CONCERNING THE ESTABLISHMENT OF THE SUSTINET PLAN.
This bill establishes a 14-member SustiNet Health Partnership Board of Directors that must make legislative recommendations, by January 1, 2011, on the details and implementation of the “SustiNet Plan,“ a self-insured health care delivery plan administered by a public authority and intended to extend insurance coverage to the state's uninsured population. The bill specifies that these recommendations must include:
1. establishment of a public authority with the power to contract with insurers and health care providers, develop health care infrastructure (“medical homes”), set reimbursement rates, create advisory committees, and encourage the use of health information technology;
2. provisions for the phased-in offering of the SustiNet Plan to state employees and retirees, HUSKY A and B beneficiaries, people without employer-sponsored insurance (ESI), people with unaffordable ESI, and small and large employers ;
3. guidelines for development of a model benefits package; and
4. public outreach and methods of identifying uninsured citizens.
The board must also establish a number of separate committees to address and make recommendations concerning health information technology, medical homes, clinical care and safety guidelines, and preventive care and improved health outcomes. The bill also establishes an independent information clearinghouse to provide employers, consumers, and the general public with information about SustiNet and private health care plans.
The bill expands eligibility for adults under HUSKY A and B beginning July 1, 2012.
Finally, the bill creates task forces addressing obesity, tobacco usage, and the health care workforce.
EFFECTIVE DATE: July 1, 2009, except that the sections on indentifying uninsured children (§ 17) and Medicaid and HUSKY eligibility expansion (§ 12) take effect July 1, 2011, and the three task forces (§§ 18-20) take effect upon passage.
§ 1 — DEFINITIONS
The bill defines the “SustiNet Plan” as a self-insured health care delivery plan, administered by the public authority and operated by a public-private partnership that is designed to ensure that is enrollees receive high-quality health care coverage without unnecessary costs. “Public authority” means the public authority recommended by the SustiNet Health Partnership board of directors (see § 2).
“Standard benefits package” means a set of covered benefits with out-of-pocket cost-sharing limits and provider network rules, subject to the same coverage mandates that apply to small group health insurance sold in the state. It includes (1) coverage of medical home services; inpatient and outpatient hospital care; generic and name-brand prescription drugs; laboratory and x-ray services; durable medical equipment; speech, physical, and occupational therapy; home health care; vision care; family planning; emergency transportation; hospice; prosthetics; podiatry; short-term rehabilitation; identification and treatment of developmental delays from birth through age three; and evidence-based wellness programs; (2) a per individual and per family deductible that excludes drugs; (3) preventive care with no copayment; (4) prescription drug coverage with copayments; (5) office visits for other than preventive care with copayments, mental and behavioral health services coverage, including tobacco cessation services, substance abuse treatment services, and obesity prevention and treatment services (these services must have parity with coverage for physical health services); and (6) dental coverage.
A “small employer” is a person, firm, corporation, limited liability company, partnership, or association actively engaged in business or self-employed for at least three consecutive months, which, on at least 50% of its working days during the preceding twelve months, employed up to 50 people, the majority of whom worked in the state.
§ 2 — ESTABLISHING THE SUSTINET HEALTH PARTNERSHIP BOARD OF DIRECTORS
The bill establishes the SustiNet Health Partnership board of directors consisting of 14 members as follows:
1. the state comptroller or her designee;
2. the healthcare advocate or his designee;
3. a representative of an employer-based association, appointed by the governor;
4. a representative of an employer with 50 or fewer employees, appointed by the lieutenant governor;
5. an expert in health care delivery and a person experienced in health information technology, both appointed by the Senate president pro tempore;
6. a representative of Medicaid and Husky plan beneficiaries, and a representative of a nonprofit health advocacy association, appointed by the House speaker;
7. a representative of the Connecticut Hospital Association, appointed by the Senate majority leader;
8. a representative of the Connecticut State Medical Society, appointed by the House majority leader;
9. a representative of the Connecticut Nurses Association, appointed by the Senate minority leader;
10. a representative of private employers, appointed by the House minority leader; and
11. a representative of labor unions and a representative of business management, both appointed by the State Employee Bargaining Agent Coalition.
The commissioners of the departments of Social Services (DSS), Public Health (DPH), Mental Health and Addiction Services (DMHAS), and Insurance (DOI), are ex-officio, non-voting board members. The comptroller and healthcare advocate serve as board chairpersons.
Initial appointments must be made by July 15, 2009. If an appointing authority fails to appoint a member by that time, the Senate president pro tempore and the House speaker jointly make that appointment. A quorum is seven members.
Board members' terms are staggered. The initial term for members appointed by the governor, lieutenant governor, and Senate president pro tempore is two years. For those appointed by the House speaker and Senate majority leader, the term is three years. For the House majority leader and Senate minority leader appointments, the term is four years. And the term is five years for the initial appointment of the House minority leader. After the initial term, board members serve five-year terms.
Within the 30 days before a term expires, the appointing authority can reappoint a current member or appoint a new one. Board members can be removed by their appointing authority for misfeasance, malfeasance or willful neglect of duty.
The bill specifies that the board is not a department, institution, or agency of the state.
§ 3 — DUTIES OF THE SUSTINET BOARD OF DIRECTORS
Designing the Sustinet Plan
The SustiNet Health Partnership board of directors must design and establish procedures to implement the “SustiNet Plan,” a self-insured health care delivery plan. The SustiNet Plan must be designed to:
1. improve the health of state residents;
2. improve the quality of health care and access to health care;
3. provide health insurance coverage to Connecticut residents who would otherwise be uninsured;
4. increase the range of health care insurance coverage options available to residents and employers; and
5. slow the growth of per capita health care spending both in the short-term and in the long-term.
By January 1, 2011, the board must submit its design and implementation procedures in recommended legislation to the Appropriations and the Finance, Revenue, and Bonding committees.
Designing the Public Authority
The board must offer recommendations (the bill does not state to whom the recommendations go) on the establishment of a public authority authorized to:
1. have perpetual succession as a body politic and corporate and to adopt bylaws for regulation and conduct of its operations, adopt an official seal; and maintain an office at a place it designates;
2. sue and be sued;
3. adopt guidelines, policies and regulations necessary to implement the bill's provisions (other state quasi-public agencies are not authorized to adopt regulations);
4. invest any funds in specified ways (the authority may delegate its investment powers to the state treasurer);
5. contract with insurers or other entities for administrative purposes, such as claims processing and credentialing of providers, taking into account their capacity and willingness to offer networks of participating providers both within and outside the state and their capacity and willingness to help finance the administrative costs involved in establishment and initial operation of the SustiNet plan and reimbursing them using per capita fees or other methods that do not create incentives to deny care;
6. solicit bids from individual providers and provider organizations to insure adequate provider networks and provide all SustiNet Plan members with excellent access to high-quality care throughout the state and, in appropriate cases, outside the state's borders;
7. establish appropriate deductibles, minimum benefit packages, and out-of-pocket cost-sharing levels for different providers that may vary based on quality, cost, provider agreement to refrain from balance billing SustiNet Plan members, and other factors relevant to patient care and financial sustainability;
8. commission surveys of consumers, employers, and providers on issues related to health care and health care coverage;
9. negotiate on behalf of providers participating in the SustiNet Plan to obtain discounted prices for vaccines and other health care goods and services;
10. contract for such professional services as financial consultants, actuaries, bond counsel, underwriters, technical specialists, attorneys, accountants, medical professionals, consultants, and bio-ethicists as the board deems necessary;
11. purchase reinsurance or stop loss coverage, set aside reserves, or take other prudent steps that avoid excess exposure to risk in the administration of a self-insured plan;
12. enter into interagency agreements for performance of SustiNet Plan duties that may be implemented more efficiently or effectively by a state agency, including DSS and the office of the state comptroller;
13. set payment methods for providers that reflect evolving research and experience both within the state and elsewhere, promote patient health, prevent unnecessary spending, and ensure sufficient compensation to cover the reasonable cost of furnishing necessary care;
14. arrange loans on favorable terms that facilitate the development of necessary health care infrastructure, including community-based providers of medical home services and community-based preventive care service providers;
15. arrange for reduced price consultants to help health care providers restructure their practices and offices to function more effectively and efficiently in response to changes in health care insurance coverage and service delivery attributable to the implementation of the SustiNet Plan;
16. arrange for continuing medical education courses for physicians, nurses, and other clinicians, including training in culturally competent delivery of health care services;
17. appoint advisory committees to successfully implement the SustiNet Plan, further the objectives of the authority, and secure necessary input from various experts and stakeholder groups;
18. establish and maintain an Internet web site that provides for timely posting of all public notices issued by the authority or the board and such other information the authority or board deems relevant in educating the public about the SustiNet Plan;
19. raise funds from public and private sources outside of the state budget to contribute toward support of its mission and operations;
20. make optimum use of opportunities created by the federal government for securing new and increased federal funding, including increased reimbursement revenues;
21. submit preliminary recommendations for the implementation of the SustiNet Plan to the General Assembly, not later than 60 days after the date of federal health care reform enactment; and
22. perform other acts and activities necessary to carry the authority's purposes and powers under the bill.
§ 4 — SUSTINET PLAN
The board of directors must develop the procedures and guidelines for the SustiNet Plan which must comport with these five Institute of Medicine (IOM) principles:
1. health care coverage should be universal;
2. health care coverage should be continuous;
3. health care coverage should be affordable to individuals and families;
4. the health insurance strategy should be affordable and sustainable for society; and
5. health care coverage should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.
The board must recommend (the bill does not specify to whom the recommendations go) that the authority establish action plans with measurable objectives in such areas as:
1. effective management of chronic illness,
2. preventive care,
3. reducing racial and ethnic disparities in health care and health outcomes, and
4. reducing the number of uninsured state residents.
The board must include recommendations that the authority monitor the progress made toward achieving these objectives and modify the action plans as necessary. It must identify all potential funding sources that will be used to establish and administer the SustiNet Plan. It must annually report to the legislature, beginning July 1, 2010, on (1) the authority's action plans and progress toward meeting these objectives, (2) the status of health care in the state, and (3) the design and implementation of the SustiNet Plan. (But as noted in § 3 above, the bill requires the board to submit its design and implementation procedures by January 1, 2011. )
§§ 1 AND 5 — HEALTH INFORMATION TECHNOLOGY
The bill delineates how electronic health records will be established for SustiNet members and how participating providers may gain access to hardware and approved software for interoperable electronic medical records. For these purposes, the bill defines:
1. “electronic medical record” as a record of a person's medical treatment created by a licensed health care provider and stored in an interoperable and accessible digital format;
2. “electronic health record” as an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards and that can be created, managed, and consulted by authorized clinicians and staff across multiple health care organizations;
3. ”subscribing provider” as a licensed health care provider that (a) either is a participating provider in the SustiNet plan or provides services in the state and (b) agrees to pay a proportionate share of the cost of health care technology goods and services, consistent with board-adopted guidelines; and
4. “approved software” as electronic medical records software approved by the board, after receiving recommendations from the information technology committee the bill establishes.
Information Technology Committee and Plan Development
The board must establish an information technology committee to make a plan for developing, acquiring, financing, leasing, or purchasing fully interoperable electronic medical records software and hardware packages for subscribing providers.
The plan must include the development of a payment system that allows subscribing providers to pay for approved software and hardware and to receive other support services for the implementation of electronic medical records. The committee must recommend methods to coordinate the development and implementation of electronic health and medical records with DPH, Office of Health Care Access (OHCA), and other state agencies to ensure “efficiency and compatibility. ” The committee must determine appropriate financing options, including financing through the Connecticut Health and Educational Facilities Authority.
Software and Hardware Options and Availability
The board must recommend that the public authority (1) provide approved software to subscribing providers and participating providers (the bill does not define this term), consistent with the bill's capital acquisition, technical support, reduced-cost digitization of existing records, software updating, and software transition procedures and (2) develop and implement procedures to ensure that individual providers and hospitals have access to hardware and approved software for interoperable electronic medical records and establishment of electronic health records for SustiNet Plan members.
The information technology committee must consult with technology specialists and health care providers to identify potential software and hardware options that meet the needs of the full array of health care practices. Any recommended electronic medical records packages the committee recommends for possible purchase must interact with other pertinent practice management modules including patient scheduling, claims submission, billing, and tracking of laboratory orders and prescriptions.
Any recommended system must also include:
1. automated patient reminders concerning upcoming appointments;
2. recommended preventive care reminders;
3. automated provision of test results to patients when appropriate;
4. decision support, including notice of recommended services not yet received by a patient;
5. notice of potentially duplicative tests and other services;
6. notice of potential drug interactions and past adverse drug reactions to similar medications;
7. notice of possible violation of patient wishes for end-of-life care; and
8. notice of services provided inconsistently with care guidelines.
The committee must recommend that any approved software be able to gather information to help the board assess health outcomes and track the accomplishment of clinical care objectives. The board must ensure that SustiNet Plan providers who use approved software can electronically transmit to, and receive information from, all laboratories and pharmacies participating in the plan, without the need to construct interfaces other than those constructed by the authority.
The board, on behalf of subscribing providers, must recommend that the public authority seek vendors to provide reduced-cost, high-quality digitization of paper medical records for use with approved software. The vendors must be bonded, supervised and covered entities under the federal Health Insurance Portability and Accountability Act, that is, subject to the act's privacy requirements.
The information technology committee must recommend a system of integrating information from subscribing providers' electronic medical records systems into a single electronic health record for each SustiNet Plan member. This integrated record must be updated in real time and accessible to any participating or subscribing provider serving the member.
The bill requires all recommendations on electronic health and medical records to be developed in a manner consistent with board approved guidelines for safeguarding privacy and data security, which include recommended remedies and sanctions in cases where guidelines are not followed.
Condition of Participation in SustiNet
Under the bill, the committee must recommend that use of electronic medical records become a condition of provider participation in the SustiNet plan by July 1, 2015, with possible time extensions or exemptions made for special hardships for providers who cannot meet the timeframe and whose participation in SustiNet is necessary to assure geographic access to care. It authorizes the board to provide additional support to these providers. (But it is not clear what kind of support the board can provide. )
The bill includes specific incentives to help providers meet the goal of adoption of electronic medical records by July 1, 2015. The committee must develop and implement appropriate financial incentives for early subscriptions by participating providers, including discounted fees.
The committee must develop recommended methods to eliminate or minimize transition costs for providers, who, before July 1, 2010, implemented comprehensive electronic medical or health records systems. This can include technical assistance in transitioning to new software and development of modules to help existing software connect to the integration system.
The committee must recommend that the public authority share with subscribing providers systemic cost savings achieved by implementing electronic medical and health records. The amount of savings the board shares with a provider is limited to the amount of net financial loss the provider experienced during the first five years of the implementation process.
The committee must also recommend that the structure of electronic health records encourage the provision of medical home functions (see below). Electronic health records must generate automatic notices to medical homes that (1) report when an enrolled member receives services outside the medical home, (2) describe member compliance or noncompliance with provider instructions, and (3) identify the expiration of refillable prescriptions.
§ 6 — MEDICAL HOMES
Medical Home Advisory Committee
The board must establish a medical home advisory committee composed of physicians, nurses, consumer representatives, and other qualified individuals chosen by the board. The committee must develop procedures for the authority and proposed regulations for the operation of medical homes providing services to SustiNet Plan members. (It is not clear what agency would promulgate these regulations. ) The committee must forward its recommendations to the board.
Medical Home Functions
The committee must recommend that the board define medical home functions on an ongoing basis, incorporating evolving research on delivery of health care services. It must recommend that if provider infrastructure limits prevent all SustiNet Plan members from enrolling in a medical home, then enrollment in medical homes must be implemented in phases with priority given to members where cost savings appear most likely, including members with chronic health conditions.
The committee, subject to revision by the board, must recommend that the functions of a medical home include:
1. Assisting members to safeguard and improve their own health by:
a. advising members with chronic health conditions on how to monitor and manage their conditions;
b. working with members to set and accomplish goals related to exercise, nutrition, and tobacco use, among other behaviors;
c. implementing best practices to insure members understand and follow medical instructions; and
d. providing translation services and culturally competent communication strategies.
2. Care coordination that includes:
a. managing transitions between home and hospital;
b. proactive monitoring to ensure members receive all recommended primary and preventive care services;
c. providing basic mental health care, including screening for depression, with referral for those who require additional assistance;
d. addressing workplace, home, school, and community stress;
e. referring to nonmedical services such as housing, nutrition, domestic violence programs, and support groups; and
f. ensuring information about members with complex health conditions is shared when multiple providers are involved and that they follow a single integrated treatment plan; and
3. Providing 24-hour access by telephone, secure email, or quickly scheduled office appointments in order to reduce the need for hospital emergency room visits.
The committee must recommend that the public authority assist in developing community-based resources to enhance medical home functions, including linguistically and culturally competent member education and care coordination.
Health Care Providers Who Can Serve as a Medical Home
Under the bill, the committee must recommend that (1) a licensed health care provider who is capable of providing all core medical home functions as prescribed by the board can serve as a medical home and (2) a group practice or community health center serving as a medical home must identify, for each member, a lead provider with primary responsibility for the member's care. In appropriate cases, as determined by the board, (1) a specialist may serve as a medical home and (2) a patient's medical home may temporarily be with a health care provider who is overseeing the patient's care for the duration of a temporary medical condition, including pregnancy.
The committee must recommend that each medical home provider be given a list of all medical home functions, including patient education, care coordination, and 24-hour accessibility. It must recommend that if a provider does not wish to perform certain functions outside core medical home functions in his or her office, the provider must arrange for other qualified entities or individuals to perform these functions in a way that integrates them into the medical home's clinical practice. These qualified entities or individuals may be employed by or under contract with the authority, health care insurers, or other individuals. They must be certified by the authority based on the quality, safety, and efficiency of the service they provide. At the medical home provider's request, the authority must make all arrangements required for a qualified entity or individual to perform any medical home function (not just non-core functions) the core provider does not assume.
The committee must recommend that all of the medical home functions are reimbursable under the SustiNet Plan. The committee must recommend that in setting payment levels for those functions that are not normally reimbursed by commercial insurers, the authority may use different possible rate-setting mechanisms, including using Medicare rate-setting methods or setting a monthly case management fee.
The committee's recommendations must include a requirement that the medical home provider discuss possible referral with the specialist to determine if it is medically indicated and if so, what tests should be done in advance. The bill requires the SustiNet Plan to reimburse providers for this consultation.
§ 7 — HEALTH CARE PROVIDER COMMITTEE; CLINICAL CARE AND SAFETY GUIDELINES
The bill requires the board to establish a health care provider committee to develop clinical care and safety guidelines for use by participating health care providers. The committee must choose from existing nationally and internationally recognized care guidelines. It must continually assess the quality of evidence, the relevant costs, and the risks and benefits of treatments. It must forward its recommendations to the board. The committee must have provider and consumer members.
Under the bill, the committee must recommend that participating SustiNet providers receive confidential reports comparing their practice patterns with their peers. The report must include opportunities for continuing education.
The committee must recommend quality of care standards for particular medical conditions. Such standards may reflect outcomes over the entire care cycle for each health care condition, adjusted for patient risk and general consistency of care with approved guidelines and other factors. The committee must recommend that providers who meet or exceed the standards for a particular condition be publicly recognized and made known to SustiNet members, including those who have been diagnosed with that particular medical condition.
The committee must recommend procedures requiring hospitals and their staffs, physicians, nurse practitioners, and other participating providers to periodically conduct quality of care reviews and develop quality of care improvement plans. Such reviews must identify potential problems manifesting as adverse events or events that could have resulted in negative patient outcomes. As appropriate, they must incorporate confidential consultation with peers and colleagues, opportunities for continuing medical education, and other interventions and supports to improve performance. To the maximum extent permissible, the reviews must incorporate existing peer review mechanisms and be subject to the law's protections concerning peer review (CGS § 19a-17b).
The board, in consultation with hospital representatives, must develop safety standards for implementation in these hospitals. The board must establish procedures to monitor and impose sanctions to ensure compliance with the standards. The board may also establish performance incentives to encourage hospitals to exceed such safety standards. (It is not clear whether the board enforces these sanctions and provides the incentives if it is to recommend these for the public authority. )
The committee must recommend that the authority may provide participating providers with information about prescription drugs, medical devices, and other goods and services used in health care delivery. This information can address emerging trends involving the use of goods and services that the authority judges are less than optimally cost effective. The committee must recommend that the public authority may give participating providers free samples of generic or other prescription drugs. And the committee must recommend that the authority also use procedures and incentives to encourage participating providers to furnish SustiNet members with appropriate evidence-based health care.
§ 8 — PREVENTIVE HEALTH CARE AND COMMUNITY-BASED PREVENTIVE HEALTH INFRASTRUCTURE
The bill requires the board of directors to establish a preventive health care committee to make recommendations to improve health outcomes for members (presumably SustiNet members) in areas of nutrition, physical exercise, tobacco use, addictive substances, and sleep, taking into account programs already underway in the state. The committee must include providers, consumers, and others chosen by the board. These recommendations may be targeted to special member populations where they are most likely to benefit members' health. They can include behavioral components and financial incentives for participants. By July 1, 2010 and annually afterward, the committee must submit its recommendations to the board and to the Public Health, Appropriations, and Finance, Revenue, and Bonding committees.
The board must recommend that the SustiNet plans sold to employers or individuals cover community-based preventive care services that can be administered safely in community settings. Examples of these services are immunizations, simple tests, and health care screenings; and examples of locations are workplaces, schools, or other community locations. The board must recommend that community-based preventive care providers must use the patient's electronic health record to confirm that the service is needed and is not contraindicated. They must furnish test results or documentation of the service to the patient's medical home or primary care provider.
§ 9 — ENROLLMENT OF VARIOUS GROUPS IN SUSTINET
State Employees and Retirees
The board must develop recommendations that ensure that, beginning July 1, 2011, SustiNet becomes the only source of health care coverage for qualified state employees and retirees and their dependents, including those who would have qualified under laws in effect on January 1, 2009. The SustiNet benefits, access to providers, and cost-sharing rules must be consistent with collective bargaining agreements. SEBAC retains jurisdiction over policy and practice matters that pertain exclusively to coverage for state employees and retirees, and may overrule any board decision concerning them that would reduce benefits or access to or quality of care, or increase enrollee costs when compared to “governing laws” in effect on January 1, 2009.
HUSKY PLAN Part A and B Beneficiaries
The board must develop recommendations to ensure that HUSKY Plan Part A and Part B beneficiaries enroll in SustiNet.
Those Not Offered Employee Sponsored Insurance (ESI)
The bill requires the board to make recommendations to ensure that people not offered employer sponsored insurance (ESI) and who do not qualify for Medicare can enroll in SustiNet beginning October 1, 2011.
Those Offered Unaffordable or Inadequate ESI
The board must make recommendations to provide an option for enrollment in SustiNet to certain state residents who are offered ESI. This option is available on and after July 1, 2011. To be eligible for this option: (1) an individual must be ineligible for Medicare and (2) (a) the individual has family income at or below 400% FPL and the cost of the employee's share of ESI premiums is 2% or more of household income above what the individual would pay to enroll in SustiNet, (b) the individual's diagnosed health conditions make it highly probable that he or she will incur out-of-pocket costs over 7. 5% of household income, or (c) the actuarial value of the individual's ESI is less than 80% of the median actuarial value of health coverage offered by large employers in the northeast. The board must make recommendations for establishing a simplified enrollment procedure for those individuals who can enroll in the SustiNet plan under these provisions.
§ 10 — OFFERING SUSTINET TO EMPLOYERS THROUGH EXISTING CHANNELS
The bill requires the board to recommend that the authority (1) use various ways to sell SustiNet to employers, including public and private purchasing pools, agents, and brokers and (2) be able to offer multi-year contracts that have predictable premiums. The board must recommend policies and procedures to ensure that employers can easily and conveniently purchase SustiNet plan coverage for their workers and dependents. These policies and procedures may include participation requirements, timing of enrollment, open enrollment, enrollment length, and other matters deemed appropriate by the board. The board must recommend policies and procedures to prevent adverse selection. “Adverse selection,” in this context, means purchase of SustiNet Plan coverage by employers with unusually high-cost employees and dependents under circumstances where premium payments do not fully cover the probable claims costs of the employer's enrollees.
The board must recommend that (1) small employers (up to 50 employees) can purchase SustiNet beginning on July 1, 2011 and (2) the authority be allowed to use small group rating rules for setting premiums.
The board must recommend that larger employers can begin offering SustiNet on July 1, 2015. Further, to prevent adverse selection, it must recommend that the authority can take past claims experience and other employee and dependent characteristics into account in setting premiums, just as is done now in the insurance market for these types of employers.
The board must recommend that all employers be offered a standard benefits package that cannot be any less comprehensive than the model benefits packages established by the bill (see§ 14).
§ 11 — INFORMATION CLEARINGHOUSE
The bill establishes an independent information clearinghouse to provide employers, individual consumers, and the general public with information about the care covered by the SustiNet Plan and by private health plans. The Office of the Healthcare Advocate (OHA) is responsible for establishing the clearinghouse and contracting with an independent research organization to operate it.
The purpose of the clearinghouse is to offer comparative information about quality of care, health outcomes for particular health conditions, access to care, patient satisfaction, adequacy of provider networks, and other performance and value information. The bill charges OHA with developing such specifications, in consulatation with the board and private insurers.
The board must recommend that the SustiNet Plan and health insurers must submit data to the clearinghouse, the latter as a licensing condition. Self-insured group plans may provide data voluntarily. Dissemination of information provided by any self-insured plan is limited, based on negotiations between the clearinghouse and the plan.
The clearinghouse must begin making its information public by August 1, 2012 and update it annually. It must avoid disseminating information that identifies individual patients or providers. To the extent possible, it must also adjust health outcomes based on patient risk levels so that provider outcome performance is more accurately captured.
§ 12 — EXPANSION OF MEDICAID AND HUSKY ELIGIBILITY
The bill directs the DSS commissioner, to the extent allowed by federal law, to take all necessary steps to ensure that beginning July 1, 2012, HUSKY A includes all adults with incomes below 185% of the FPL, whether or not they are the custodial parents or caretaker relatives of minor children.
The bill also directs the commissioner to make adults with incomes between 186% and 300% FPL eligible for HUSKY B beginning July 1, 2012, to the extent permitted by federal law. Benefit levels and cost-sharing responsibilities for these adults must be comparable to those for households with children in HUSKY Part B at the same income level. After accounting for differences in utilization between adults and children, it requires adults to be charged premiums that are no less than twice the amount charged to the household of a child enrolled at the same income level, calculated as a percentage of the federal poverty level.
§ 13 — INDIVIDUAL MARKET REFORMS
The bill specifies that on or after July 1, 2011, the same rating rules existing in the small group market must apply in the individual market. That is, premiums may not be based on medical underwriting and pre-existing conditions may not be excluded, except where it would be permitted if the policy were sold in the small group market (i. e. , based on gaps in continuous health coverage before enrolling in health insurance).
§ 14 — VALUE-BASED BENEFITS DESIGN
The bill requires OHA, within available appropriations, to develop model benefit packages that contribute the greatest possible amount of health benefit for enrollees, based on medical and scientific evidence, for the premium cost typical of private, employer-sponsored insurance in the northeast. By December 1, 2010, and then biennially, the office must report to the board and to the Public Health, Human Services, Labor and Public Employees, Appropriations, and Finance, Revenue and Bonding committees on the updated model benefits package. It may contract with an independent research organization for assistance.
After receiving these models, the board may modify the standard benefit package if it believes an adjustment would either yield better health outcomes for the same expenditure of funds, or provide additional health benefits or reduced cost-sharing for particular groups that justify an increase in net costs.
OHA must recommend guidelines for an incentive system to recognize employers who provide employees with benefits that are equivalent to or better than the model benefit packages.
By December 1, 2010, OHA must report on these guidelines and recommendations to the governor, comptroller, and the Public Health, Labor and Public Employees, and Appropriations Committees.
§ 15 — PUBLIC EDUCATION AND OUTREACH CAMPAIGNS
The bill requires the board to develop recommendations for public education and outreach campaigns to inform the public of SustiNet's availability and encourage enrollment. These campaigns must use community-based organizations to reach underserved populations. They must be based on evidence of the cost and effectiveness of similar efforts in this state and elsewhere. The board must continuously evaluate their effectiveness, and change strategy as needed.
§ 16 — AUTOMATIC ENROLLMENT
The board, in collaboration with state and municipal agencies, must, within available appropriations (the bill does not appropriate any funds for the board), develop and implement recommendations to identify uninsured individuals. Such recommendations may include:
1. the Department of Revenue Services modifying state income tax forms to ask taxpayers to identify existing health coverage for each household member;
2. the Department of Labor (DOL) modifying its unemployment insurance claims forms to request information about health insurance status for applicants and their dependents; and
3. hospitals, community health centers, and other health care providers to identify uninsured individuals who seek health care, and transmit such information to the board and DSS.
§ 17 — IDENTIFYING UNINSURED CHILDREN
The bill directs the DSS and education commissioners to consult with the board in their existing obligation to jointly establish procedures for sharing data from the National School Lunch Program to identify income eligible children for enrollment in or HUSKY A and B. And it permits their procedures to cover enrollment in the SustiNet Plan.
§ 18 — OBESITY TASK FORCE
The bill creates a task force to study childhood and adult obesity. It must examine evidence-based strategies for preventing and reducing obesity and develop a comprehensive plan that will result in a reduction in obesity.
The task force includes the following members:
1. a representative of a consumer group with expertise in childhood and adult obesity, appointed by the House speaker;
2. two academic experts in childhood and adult obesity, one each appointed by the Senate president pro tempore and the governor;
3. two representatives of the business community with expertise in the subject, one each appointed by the House majority and minority leaders; and
4. two health care practitioners with expertise on the topic, one each appointed by the Senate majority and minority leaders.
These members may be members of the General Assembly.
The commissioners of public health, social services, and economic and community development and a representative of the SustiNet board are ex-officio, non-voting members. Appointments must be made within 30 days after the effective date of this provision. Vacancies are filled by the appointing authority. The members appointed by the House speaker and the Senate president pro tempore serve as chairpersons. The first meeting must be held within 30 days after the bill's effective date. The Public Health Committee staff serves as the task force's administrative staff.
By July 1, 2010, the task force must report to the Public Health, Human Services, and Appropriations committees. The task force terminates when the report is submitted or January 1, 2011, whichever is later.
§ 19 — TOBACCO USE TASK FORCE
The bill establishes a task force to study tobacco use by children and adults. It must examine evidence-based strategies for preventing and reducing tobacco use and developing a comprehensive plan to cause a reduction in tobacco use by children and adults.
Its members are as follows:
1. a representative of a consumer group with expertise in tobacco use by children and adults, appointed by the House speaker;
2. two academic experts in the field, one each appointed by the Senate president pro tempore and the governor;
3. two representatives of the business community with expertise on the topic, one each appointed by the House majority and minority leaders;
4. two health care practitioners with expertise in the field, one each appointed by the Senate majority and minority leaders.
These task force members may be legislators.
The commissioners of public health, social services, and economic and community development and a representative of the SustiNet board are ex-officio, non-voting members. Appointments must be made, vacancies filled, and meetings held as described for the obesity task force. The chairpersons are the members appointed by the House speaker and the Senate president.
By July 1, 2010, the task force must report to the Public Health, Human Services, and Appropriations committees. It terminates when it submits the report or January 1, 2011, whichever is later. The Public Health Committee staff serves as administrative staff.
§ 20 — HEALTH CARE WORKFORCE TASK FORCE
The bill establishes a task force to study the state's health care workforce. It must develop a comprehensive plan for preventing and remedying state-wide, regional, and local shortages of necessary medical personnel. Its members are as follows:
1. a representative of a consumer group with expertise in health care, appointed by the House speaker;
2. two academic experts on health care workforce, one appointed by the Senate president pro tempore, and the other by the governor;
3. two representatives of the business community with expertise in health care, one each appointed by the House majority and minority leaders; and
4. two health care practitioners, one each appointed by the Senate majority and minority leaders.
The commissioners of public health, social services, and economic and community development, the president of UConn, the chancellors of the Connecticut State University System and the regional Community-Technical Colleges , and a representative of the SustiNet board are ex-officio, non-voting members. Legislators may be on the task force. Appointments must be made, vacancies filled, and meetings held as described above for the previous two task forces. The chairs are the members appointed by the House speaker and the Senate president.
The Public Health Committee staff serves as administrative staff for the task force. The task force must report by July 1, 2010 to the Public Health, Human Services, and Appropriations committees. The task force terminates as described above.
The House referred the bill (File 615) to the Insurance and Real Estate Committee on May 5. That committee reported out a substitute bill on May 6 that makes numerous changes to the original file. The substitute creates the 14-member SustiNet Health Partnership Board of Directors instead of a nine-member SustiNet Authority. It also directs the board to make legislative recommendations on the design and implementation of the SustiNet Plan, rather than providing those details as in the original file. The substitute eliminates a number of provisions in the original bill including the creation of a “SustiNet Account,” a “shared responsibility” requirement for certain employers and employees involving payments to the account, automatic enrollment, eligibility redetermination, evaluation of outcomes and policy changes, reporting requirements, indemnification of SustiNet Authority personnel and officers, and certain definitions.
Public Health Committee
Joint Favorable Substitute
Human Services Committee
Labor and Public Employees Committee
Insurance and Real Estate Committee
Joint Favorable Substitute