CHAIRMAN: Senator Slossberg

Representative Abercrombie


SENATORS: Markley, Slossberg

REPRESENTATIVES: Abercrombie, Ackert,

Bowles, Butter, Case, Cook, McGee, Miller, Morris, Ritter, Rutigliano, Santiago, Wood, Zupkus

SENATOR SLOSSBERG: We're going to get our hearing started. If people can either close the door or come on in and, excuse me, we'd be convening the Human Services Committee public hearing agenda.

Today's Tuesday, March 4, and our first hour is reserved for public officials and so we would ask that -- I know staff is working hard to get us all our testimony and organized and I believe that we'll get started then with Commissioner Bremby is here this morning.

Good morning Commissioner. Thank you for being here. We appreciate it.

COMMISSIONER RODERICK BREMBY: Morning Senator Slossberg, Representative Abercrombie, distinguished members of the Committee. I'm Rod Bremby. I'm the Commissioner of the Connecticut Department of Social Services.

Delighted to be here this morning to testify before you on two bills raised on behalf of the department and in addition we've submitted extensive written materials which are on today's agenda which impact the department.

Beginning with House Bill 5325, AN ACT ELIMINATING THE HOME CARE COST CAP, this proposal would remove the 60 percent cost cap on waiver services in the Connecticut Home Care Program for Elders. The current 100 percent cost cap on the overall service plan, both state plan and waiver, would remain in effect, as costs cannot exceed 100 percent of the net cost of institutional care.

The department proposes this change because experiences show us that the cost cap sometimes result in utilizing higher cost state plan services to supplement the waiver service array.

Having the cost cap on waiver service limits care managers' ability to develop cost-effective, person-centered care plans. Furthermore, no other Medicaid waiver administered by DSS has such a limit on waiver services.

There is no reason for the distinction between waiver and state plan services, since both qualify equally for the 50 percent federal match. This bill brings the waiver in line with the remaining 1915(c) waiver programs, but still maintains cost neutrality at or by CMS.

This waiver consistently demonstrates cost neutrality and savings to the state, as the average cost of a waiver, state plan services averages $18,500.00 compared to 60,000 for nursing facility care.

We ask for your support for this proposal.

House Bill 5442, AN ACT CONCERNING THE STATE ADMINISTERED GENERAL ASSISTANCE PROGRAM is a technical bill. This proposal makes minor and technical changes to remove obsolete provisions concerning statutes governing the SAGA program.

In addition, this proposal resolves ambiguity in the statute with regard to determining how married recipients are treated. While the statute currently addresses the treatment of unemployed and transitional single individuals, it does not explicitly discuss how married individuals should be treated.

In the absence of language, the department has calculated the benefit for those married couples as it would for families that have dependent children. This had led to disproportionate benefit amounts for single individuals versus married couples in certain instances.

For example, a married individual in a western region of the state would receive a significantly higher tax benefit or higher benefit -- TFA benefit than an unmarried individual receive in the same region, despite the married recipient having pooled resources at their disposal. By removing the single qualifier in this subsection it would eliminate the ambiguity, allowing for more equitable benefit awards.

The proposal also clarifies the asset limit that is already current policy for married couples.

Lastly, the proposal seeks to clarify Section 17(b)-196 which is intended to pay benefits to a TFA family assistance unit out of State SAGA funds for the incremental difference between what the family was receiving when the child qualified as a member of the assistance unit and what the family now receives after the child's disqualification from TFA due to age.

However, it has recently come to the department's attention that as written, the existing provision and statute could be read to justify assistance at the level an individual person would receive pursuant to TFA and that the provision arguably conflicts with the standards of assistance as set forth in Section 17(b)-192.

We ask for your support for this proposal as well. There's additional written comments that have been submitted for the record.

For Senate Bill 325, AN ACT CONCERNING MEDICAID RECIPIENTS WITH COMPLEX MEDICAL NEEDS, the Department of Social Services recognizes the importance of these services and we are immensely proud of the many supports we provide our most vulnerable clients. Connecticut's Medicaid program has the most broad and expansive coverage of almost any Medicaid program in the country.

While we appreciate the intent of this legislation, the department believes the intent can be accomplished more effectively by minor adjustments to the department's draft regulations governing payment for customized wheelchairs.

The department recognizes the complex rehabilitation technology differs in many ways from other durable medical equipment, where many of the services currently are regulated. Customized wheelchairs represent greater than 90 percent of complex rehabilitation technology, which the department has long administered separately from DME.

We believe it makes more sense to incorporate the remainder of complex rehabilitation services into the customized wheelchair regulation. Further, the department is convening a work group made up of industry representatives and consumers to assist in implementing this regulation.

A minor note here and that is we are looking at a small portion of the regulation and not the overall regulation to be recrafted. A minor expansion of this working group could serve both purposes. Nevertheless, DSS must oppose Senate Bill 325 in its current form because (1) it conflicts with existing requirements, including federal law, recently adopted state law, and department regulations, (2) will have a substantial increased fiscal impact, and (3) is overly prescriptive and impinges on the department's ability to administer the Medicaid program.

The testimony that we provide, some verbal, some written, outlines in detail the specific reasons why the department must oppose this regulation.

First, the legislation is in conflict with the department's draft regulations governing payment for customized wheelchairs. The draft regulations implement state statute 17(b)-278i and update the existing customized wheelchair regulations to adapt the changes in clinical practice and technology.

These regulations were publicly posted on January 31, 2014. Public notice was published on February 11, 2014, and there will be a public hearing on the regulations on March 31, 2014. Public comment period will run through March 13.

We welcome comments to improve those regulations, including broadening the scope of applicable regulations to include all complex rehabilitation technology.

Finally, the department is interested in developing a separate and distinct fee schedule and payment methodology to govern those products, recognizing that they are frequently custom manufactures and not off-the-shelf products. The department opposes the payment methodology contained in this legislation, as both are prohibitively expensive and purposefully opaque.

For reasons detailed below, the department believes a payment methodology based upon the vendor's actual acquisition cost is both more fiscally responsible and fair to the dealers, and we therefore are more than willing to work with the industry to implement these changes.

Finally, the department estimates the net cost to the state based on increased fee schedule amounts plus the lost savings associated with the reuse program scheduled to begin in June 1, 2014 could approach $3.6 million per year.

The Department of Social Services additionally opposes this regulation or this legislation because sections of it conflict with federal and state requirements, are potentially costly, or seriously interferes with the department's ability to responsibly and effectively administer our programs.

The department must have flexibility to adjust a variety of aspects of the Medicaid program to accommodate changes in clinical practice, changes in federal requirements, and changes in the program.

Again, there is more written comments provided for the record.

Senate Bill 235, AN ACT CONCERNING TEMPORARY NURSING HOME BED REDUCTIONS. This bill would allow nursing homes to temporarily reduce the number of licensed beds in order to bill bed hold days and receive a higher Medicaid rate based on lower bed capacity. This policy would result in unfunded costs and would not result in increased services or reward quality of care.

Additionally, this policy directly contradicts the current rebalancing initiative by reducing the number of available beds, while retaining the same institutional infrastructure, effectively negating the cost benefits of the rebalancing effort.

The department also believes this policy would administratively be burdensome to implement and would likely result in a rapid destabilization of available nursing home beds.

We're also concerned this bill would place the department in the difficult and arbitrary position of mediating bed reductions and bed restorations between competing facilities across the state. Furthermore, this bill does not provide the Commissioner any discretion to deny such rate increase nor specifically allow the Commissioner to rescind the rate increase after a restoration of licensed beds.

With approximately 65 percent of nursing homes below 95 percent occupancy and assuming most nursing homes with less than 95 percent occupancy would participate in this policy, it is estimated that approximately 1,350 beds would initially be removed from the system in order to access the higher Medicaid rate and bed hold days.

Additionally, the Money Follows the Person program anticipates an additional 3,000 nursing home residents will move into community settings over the next several years, greatly adding to the cost of this proposed policy.

The department is opposed to this proposal. Senate Bill 251, AN ACT CONCERNING PROGRAMS ADMINISTERED BY THE DEPARTMENT OF SOCIAL SERVICES. This proposal seeks to dictate how the documents submitted by recipients are received, processed by the department at the initial intake.

While we understand the intent of the bill, we have several significant concerns related to this proposal. First, we believe that this is largely duplicative of existing regulations and practices with regards to how and where documents are accepted.

The bill is also overly broad to the extent it fails to distinguish between the numerous of documents for a wide variety of programs administered by DSS and maybe submitted to the department or its contractors or partners.

We believe this could potentially create operational issues for other entities, as they will be required to implement new processes for accepting DSS documents as well.

Lastly the bill would mandate the department to use inefficient and expensive technologies that have been considered, but rejected, due to the cost of implementation or maintenance.

The department opposes this proposal as it is duplicative, inefficient, and would likely result in administrative costs to the department.

While we provided additional comments, I'll step through just a few of those comments for additional clarity.

With respect to Section 1(a)(1), the department accepts manually submitted documents at all regional offices. Application are required by regulation to be accepted at regional offices. So you know, while we don't object to this provision, it's unnecessary.

Section 1(a)(2), the department does not accept all documents by fax due to poor experiences with the technology. DSS has received faxes exceeding 3,300 pages from representatives of Medicaid long-term applicants. The submissions have been illegible, disorganized meaning every other page contains content, and massive faxes at our scanning center contributed significantly to the initial processing difficulties when launching ConneCT. Requiring DSS to accept all types of documentation via fax is to mandate an inefficient and aging technology. DSS makes fax submissions available when DSS can be reassured that documents that are submitted are appropriate for that use.

For example, one-page expedited Medicaid applications are currently accepted by fax. Requiring the availability of fax submission will require widespread document redesign, IT system adjustments, and future inefficiency as facsimile becomes an obsolete technology. It is also likely to require renegotiation of contracts with current processing vendors with associated cost.

We object to this provision. Section 1(a)(3) DSS accepts documents through the mail to designated locations; therefore, this proposed provisions is unnecessary.

Section 1(a)(4) DSS offers clients the ability to apply for benefits online and will soon offer the ability to submit certain information, as well as changes in address and income through its ConneCT website as well.

We strongly object to a statutory requirement that we be required to accept emails with attachments for any type of document. This would require significant IT costs in order to create a secure system with additional firewalls and document screening capacity. This requirement would require the risk -- will increase the risk of systemic slow downs and the possibility of malicious software, ad ware, or viruses that could harm statewide communication systems.

It would also require DSS to develop new electronic processes for distributing work in new formats and potentially require software or hardware upgrades to existing systems in the regional offices.

DSS has considered this option previously and has determined that at this time it is not cost effective nor is it secure.

Under Section 1, applicants and clients are already informed of where they can submit documents. Requiring all documents to be submitted anywhere will cause operational inefficiencies and delays in processing and significant operational costs.

Section 1(b), this proposal is largely redundant with existing DSS policy and regulation and could have significant operational consequences for not only DSS, but the Connecticut Health Insurance Exchange.

Skipping over to Section 1(b)(3), the date of receipt for documents sent directly to DSS Scanning Center is the date such documents are received and not the date scanned. The date of receipt for documents dropped off at regional offices and forwarded by DSS to the Scanning Center is the date the documents are submitted at the office. Date of receipt is electronically associated with the submitted documents at the Scanning Center and within ConneCT. This is established policy and practice.

Section 1(b)(4), this language is overly broad. DSS has numerous agencies and contractors acting on our behalf. Not all have the authority or capacity to accept documentation unrelated to their particular service. Only specific agencies and contractors are authorized to accept confidential identifying documentation. We carefully select which agencies and contractors can receive documents from clients and enters into confidentiality agreements and other agreements to ensure proper handling of data.

This provision suggests that a Medicaid recipient could drop off medical bills with an emergency shelter provider who DSS contracts with and DSS would have to accept such bills as received by DSS. The likely intended purpose of this provision is therefore already established practice at DSS and at least somewhat accounted for in the regulations with regard to applications.

The last comment on this one is that currently a client or applicant's online benefits account shows an applicant what documents DSS has received from that client. Adding a received date to each document or an image of each document may be technologically feasible, but it will require additional IT resources at a time when such resources are at a premium, as DSS is in the midst of replacing EMS under extremely tight deadlines for federal funding of the project.

Each additional statutory demand that results in IT resources being moved away from ES replacement threatens the ability of the agency to get federal funds for EMS replacement or operation -- ongoing operation and maintenance of that equipment. We expect to receive tens of millions of dollars for the project, which is well underway. Given the significant federal reimbursement placed at risk, we cannot afford to question or suggest that that risk be assumed.

Senate Bill 250, AN ACT CONCERNING FAIR HEARINGS. This bill requires DSS to (1) notify any persons requesting a hearing that they may have an in-person hearing if there is a specific need and that such hearing must be requested, (2) establish a unit for administrative appeals for which the Commissioner must appoint an administrator who must report to the Commissioner and may only be removed for cause, and (3) create an exception to the Uniform Administrative Procedure Act to prohibit DSS hearing officers from communicating with any other employee of the agency, including counsel, unless advance notice is provided to all parties and all parties have the opportunity to participate on the record.

First, with regard to the notification requirement, currently DSS schedules and provides in-person hearings as requested and necessary. For example, hearings for nursing home residents and people who are homebound are in-person hearings and are held where the individual is located. In-person hearings require hearing officers to travel to a home, a facility, or regional offices, which is much more time consuming than conducting the hearings by video conference.

If the department were required to solicit in-person hearings, the number of those hearings would dramatically increase. The department already struggles to provide timely hearings. This proposed additional requirement would drain hearing resources even further. The decline in efficiency this presents would require the department to hire vastly more hearing officers with requisite fiscal impact.

Second, requiring the Administrative Hearings Manager to report directly to the Commissioner unnecessarily adds an area of immediate oversight for the Commissioner and interferes with the Commissioner's ability to organize the agency as he or she sees fit. The current reporting structure complies with federal and state requirements and we do not recommend changing it.

Finally, there's no reason to exempt DSS from a section of UAPA Section 4-181, which clearly permits hearing officers to communicate with other employees of the agency to receive aid and advice from such employees regarding matters of law. To prohibit DSS hearing officers from communicating about agency laws and regulations with other members of the agency without providing advance notice to all parties would severely hamper the accuracy and efficiency of the work.

There is no reason why hearing officers should not have the ability to consult with the department's program and legal staff in order to obtain advice regarding how the agency interprets its law.

The hearing officers are required to be objective to the facts. DSS administers numerous complex and ever-changing state and federal programs requiring hearing officers to conduct hearings across a broad range of subject areas and legal requirements. Hearing officers must be impartial to the facts of the case and must apply agency law and regulations consistently.

Hearing officers should be able to continue to seek assistance in understanding agency law and regulation from other members of the agency without notifying all parties of a hearing and providing opportunity for parties to participate on the record. Such a requirement would be unnecessarily burdensome and time consuming and increases the likelihood of erroneous decisions being issued. It is legally unnecessary and with unjustly hampered DSS hearing officers treating them differently from hearing officers in other state agencies whose actions would continue to be governed by the UAPA. Currently, some 95 percent of these hearings are routine. Over five to six years a third of these hearings the clients prevailed.

This proposal strives to make the hearing officer an independent judge, apart from the agency, immune from supervision. The law does not require that degree of separation. Federal Medicaid regulations, for example, require only that the hearing officer must not have been directly involved in the initial determination of the action in question.

The department is opposed to this proposal.

Section -- or Senate Bill 254, AN ACT CONCERNING PRESUMPTIVE MEDICAID ELIGIBILITY FOR THE CONNECTICUT HOME CARE PROGRAM FOR THE ELDERLY. This bill would provide presumptive eligibility for applicants for the Connecticut Home Care Program for Elders. The department appreciates and shares in the desire to ensure that persons have prompt access to home care services. However, in the current form, we do not believe this proposal -- we do not believe that this proposal is operational, given the current allocation of resources in existing department processes for determining eligibility. Additionally, we believe this could potentially lead to additional administrative and staffing costs for the program.

We are concerned that by granting presumptive eligibility we are removing the incentive to complete the full long-term care application. Once services begin, applicants may not understand the need to continue to complete the application or to complete one in a timely manner in order to ensure continuity of services.

It is difficult to begin receiving services and then have those services taken away if the applicant is subsequently found ineligible rather than delay the implementation of such services to start.

Approximately 20 percent of these applications are not found to be eligible. The department does share in the proponent's premise that ensuring timely access to services though and has initiated a number of measures to assist with this. For example, we designated four offices as long-term application processing hubs in October.

These hubs are responsible for processing all long-term applications within a designated catchment area. Each applicant -- application is assigned to a specific worker who receives -- who serves as a point of contact. We expect this new configuration will result in more timely eligibility determinations. We are also currently renewing the long-term care application processing best standards within the four hubs, as well as other states, to gain greater efficiencies.

In summary, the requirements of this bill would add multiple layers to the eligibility process in timeframes that are nor achievable. Also, there is the potential for significant cost to the department, both for services that ultimately are not eligible for federal match because the application process was never completed, as well as the additional staffing costs to be able to complete this process.

As an alternative, the department is open to working with stakeholders to review other potential opportunities to accomplish a reduced waiting time for the home care program.

Senate Bill 5324, AN ACT CONCERNING MEDICAID APPLICATIONS BY MARRIED PERSONS. Senate bill 5324 or House bill 5324 would require that the department collect extensive data pertaining to the assets of institutionalized Medicaid applicants and their community spouses.

This bill is closely related to Senate Bill 177, a Community Spouses' Allowable Assets, which proposes to increase the amount of assets that the community spouse of an institutionalized Medicaid applicant is allowed to retain to $117,240.00 the maximum amount permitted under federal law. This amount does not include the home and one car, which community spouses are also allowed to retain. Only 13 states currently allow the community spouse to keep the full federal maximum of $117,240.00 without adjustment, as is proposed in this bill.

The department provided remarks earlier this session. The department has proposed increases in the amount of assets protected for community spouses in past years, due to our belief that it will result in a significant fiscal impact to the state.

However, we are willing to explore this further and will work with proponents of Senate Bill 177 and the Office of Policy and Management to determine if changes to the program are fiscally feasible at this time.

While quantifiable data will be important to a continuing dialogue the reporting requirements of House Bill 5324 are onerous and burdensome. It would require that we conduct two parallel eligibility determinations on every long-term care Medicaid application when a spouse is living in the community, as well as collect aggregate and report the data proposed by this legislation.

House Bill 5324 would add to the already extensive workload of our staff and would affect our ability to process long-term care Medicaid applications as expeditiously as possible at a time when improving our application timeliness and reducing our pending applications is of paramount importance.

The department is also opposed to the requirement that we report this information to another executive agency head. Executive agencies often work together and share data for the administration of programs.

However, we do not -- we do so in a way that is not intrusive to another's operation or scope. This bill would create a hierarchal reporting structure between two equal agencies that is inconsistent with the current tenor and operations.

We reiterate our willingness to discuss increases in community spouses' protected assets, including ways to quantify costs in ways that do not place an undue burden on the agency.

That completes my oral testimony. I'm available to answer questions. We brought along with us today a number of subject matter experts from the agency and collectively we're ready to answer any questions you might have.

SENATOR SLOSSBERG: Thank you, Commissioner and thank you for your testimony and note that there is a significant amount here, so I'm sure that many people have many questions, and probably want to digest a lot of this and I -- so you know what, I think I'm just going to start and ask if my Co-Chair would like to ask. Are you ready?

REP. ABERCROMBIE: Sure. Thank you Madam Chair.

Sure I can start with a few of the questions that come to mind from the beginning.

First of all, I'd like to take this opportunity to thank you publicly for changing the date of the regs for the wheelchairs from March 1 to June 1 to give people the opportunity (inaudible). I know that it's an issue that we are getting a lot of comments about, so I do appreciate you taking the time to really try and vent this out and not just push the regs through, you know, without giving people the opportunity to comment on it, so I'd like to start with that.

I'd like to move onto the community spouse. So in 2012 we implemented the community spouse going to the federal level, which was 117, then we pulled it back. So I guess at this point the reason why this keeps coming up is because there's a feeling that this is a good policy to go to -- to the 117. And every time we try to introduce this bill we get pushed back saying that it's going to cost a huge amount of money, yet we can't find any data to validate that.

So that's why I think we're here today with this bill again trying to figure out, you know, the devil's in the details. Where's the middle? And, you know, your comments that you raised here, I still don't get -- I still don't believe get us to where we need to be on this particular bill.

I know you've talked about, you know, you'd be willing to perhaps look into this maybe a little bit more deeply, maybe have some conversations. I'd be more than willing to listen to those, but I think at this point, you know, it -- it's clear that it's something that we -- there's a lot of support for it to got to the federal amount and I think we really need to figure out where do we go from here on that particular one.

And, you know, if you want to comment as we go along that's fine. If you want to wait till the end, whatever works for you Commissioner is -- is fine with me.

On the fair hearings, there's -- so -- so for the fair hearings, how many continuances does an average participant have, do you know?

If you could put the microphone on and just for the record state your name, that'd be great. Thank you.

BRENDA PARRELLA: I'm Brenda Parrella. I'm the Agency Legal Director at DSS. I oversee the unit that -- within which is the administrative hearing's function.

I don't know the average number of continuances. We generally grant requests for continuances. Things are scheduled and then the clients are notified after the fact, so that if it conflicts or it's a problem for them to attend, we -- we generally reschedule.

We don't refuse to continue unless we see a pattern of continuing over and over and over. They -- clients generally have continued benefits during this period where they're waiting for there hearing and there's times when it looks to us like it might be an abuse of avoidance of the hearing while the benefits are continued and then we step in to --

REP. ABERCROMBIE: So there isn't statutorily a number in place currently?


REP. ABERCROMBIE: There isn't. Okay. And what is the job description for someone to be a hearing officer?

BRENDA PARRELLA: Hearing officers come up through the DSS ranks as eligibility workers. I -- I can't remember the number of years, I don't have the job spec in front of me, I think it's five to seven years of eligibility experience. We look for people who really know the program, cause the meat and potatoes of their work is eligibility, so familiarity with making those decisions the broadest range of familiarity, experience interpreting uniform policy a manual, which you are probably aware has its challenges.

Sometimes we end up getting experience as quality control reviewers, because their experience is similar to hearing officers reviewing the work of others. It's really -- the function is really about reviewing the work of the eligibility to see if there's an error.

REP. ABERCROMBIE: So when a notice goes out for a hearing, a fair hearing right? Doe the applicant at that point have the opportunity to say if they want to have the hearing in person? How does that procedure work?

BRENDA PARRELLA: We -- they -- they can request an in-home hearing. Usually we can identify if a person is in a nursing home and we -- we can see that, the hearing is scheduled in a nursing home. If a person is apparently homebound, we can schedule that or they request and say they want the hearing in their home.

We've even had people ask because of chemical sensitivities that they don't have to the regional office, so we --we generally accommodate requests.

REP. ABERCROMBIE: But more so in the in-person portion of it? So you send me an application for the hearing, right, or to schedule the hearing? At that point, do I have the opportunity to say that I want it to be an in-person hearing?

BRENDA PARRELLA: Yes, you can at any time say that. And if there's some valid reason, we provide them. Generally, the person goes to the regional office where there's video and they video conference and the hearing officer can be in central office, can be outposted to say New Haven.

The client goes to their regional office closest to where they live, the office that serves them, and they video conference in.

REP. ABERCROMBIE: Did you want to, at that point Commissioner, add anything to it and then I'll give my colleagues the opportunity to ask some questions also.

COMMISSIONER RODERICK BREMBY: Yes, thank you. I appreciate very much your opening comments about delaying the implementation of the regulations.

As you know, there's a lot of information that's out there and we want to make sure that we have the opportunity to correct for the misinformation. With respect to House Bill 5324, in the past the agency opposed this bill due to a projected cost that -- or post to a cost.

In this instance, what we're saying is that we'd be willing to work with proponents and (inaudible) to determine if it's fiscally feasible at this time. Albeit a policy that has a lot of support, I think it's incumbent upon us to be able to identify, able to work through, and hopefully quantify the impact, operational impacts, as well as at a cost of the bill.

Lastly, this new reporting structure is something that we are opposed to in the bill because we know of no other provision within the statute where an agency head reports to another agency head any information or anything else. So that's the context in which we offer the opportunity to work with anyone and on moving this forward or to further understand the fiscal feasibility of the bill.

REP. ABERCROMBIE: So if I may, Madam Chair, just one more followup on that particular.

SENATOR SLOSSBERG: Okay. (Inaudible).

REP. ABERCROMBIE: Thank you. So I think what I'm hearing from you is that there's an opportunity to perhaps not go to the 117, but at least increase it maybe halfway at this point? Is that what I'm hearing from you?

COMMISSIONER RODERICK BREMBY: I wish I had stated that, but I cannot. That is something that the administration would need to take a position on and I am not empowered to do so, but I am willing to put into play the resources of the agency to explore what the fiscal reality of the implementation of this bill might be.

REP. ABERCROMBIE: Thank you. I thought maybe I'd get you on one, but you can't blame me for trying. Thank you. Thank you, Madam Chair.


SENATOR MARKLEY: Thank you, Madam Chair. And thank you Commissioner.

Let me just, if I can shoot around because I've -- like so many of us I have to step out to another meeting in a moment. On Senate Bill 253 concerning the nursing home bed reductions, I guess what I'd ask is that you'd illuminate a little bit what you mean by, let's say, the sense in which this would contradict the current rebalancing, an issue of, by reducing the number of available beds while retaining the same institutional infrastructure, negating the cost benefits of the rebalancing efforts.

Obviously, a part of the rebalancing initiative, which seemed to be to reduce the number of -- to take off unused beds out of the system. And this seems to be the goal that's involved her. From the testimony, it seems like you have a different way of approaching this, which I can understand. I guess I'd ask what it is that you're doing that is contradictory to what this bill would do.

COMMISSIONER RODERICK BREMBY: I think what is contradictory in this bill is that the rebalancing lends itself to the customer, the person who is in the facility, having a choice to move out of the facility and so it is something that is driven by consumer choice. It is measured. It is -- it has a rational step forward.

In this case, any nursing home that is below the threshold of occupancy can decide to take beds out of the system and still be paid for those beds. So the infrastructure still exists, but they will continue to be compensated. So that defeats the efficiency games of a consumer choice directed rebalancing approach. It is fundamentally different in terms of cost.

SENATOR MARKLEY: They would be paid for those beds -- my understanding of the bill -- let me say when the industry came to me with the bill, it wasn't put in quite those terms. In what sense would they be paid for those costs after the beds were removed? Not at the full compensation rate I wouldn't imagine. Is there some mothballed rate for these beds?

CHRIS LAVIGNE: Mothball rate. My name is Chris Lavigne. I'm the Director of Reimbursement at DSS. About 25 to 30 percent of the Medicaid rate is related to fixed costs that can include fair rent, capital costs, and administrative and general costs. So as the beds get reduced, say from 100 beds to 75 beds, those costs and those buckets will get divided by a lower denominator, so it will result in higher costs in the rate for those components, where direct cost is related to the services on a per resident basis.

SENATOR MARKLEY: Okay, thank you. Let me ask you one more on that bill, which is, you refer to the difficulty of the department having to mediate bed reductions and restorations in different facilities across the state. It would seem to me the department to some extent is in that position already in making decisions about opening and closing facilities, beds, all -- all kinds of things.

That that sort of mediation is what the department, difficult as it may be, is what the department is tasked with. In what way is this a different sort of difficulty?

CHRIS LAVIGNE: We see the bill would open up the opportunities to -- for about 150 -- about 65 percent of the industry to ask for the higher rate. So you have nursing homes in close proximity within the community. So trying to manage whose going to drop beds first and how many and then if things turn, whose going to get them -- whose going to get to add them back when things, when they hit the thresholds.

So that really places the department in a position of, you know -- you know, it's not in our fee. It's not -- there's no process there. It could be, you know, viewed and appealed by other nursing homes as they want to do the same thing for the volume that they want to add or -- or decrease, so.

SENATOR MARKLEY: Okay. Thank you both very much.


REP. MCGEE: Thank you Madam Chair. And to you Commissioner, thank you. It's been a -- a pleasure sitting here sort of absorbing everything that you've -- you read and building on all your great experiences. I -- I want to go to Senate Bill 251, AN ACT CONCERNING PROGRAMS ADMINISTERED BY THE DEPARTMENT OF SOCIAL SERVICES.

So while -- while I understand sort of the objections or disagreements with -- with the bill and I think you, in your first paragraph you -- you outline why, I think you know, it's really important that we not pursue it and that is the bill would mandate the department to use inefficient or expensive technologies that have been considered, but rejected due to the cost of implementation or maintenance.

So before I get to my question, I -- I want to go down to one, I don't think it's cool to have 3,300 pages being faxed over. Killing a lot of trees and messing up your fax machine. And then also, you talk about how DSS strongly objects the statutory requirement that it would be to -- to accepting emails and it goes on and you have different sections.

I think it's cool, but a couple things that I'm concerned about is what's the overall impact that this will have on a client or an applicant that's sort of waiting for whatever service to be rendered.

And then -- and then also, I think lastly, you know, how much does this improvement to technology, how much does it actually cost. Have we done an analysis on it? And then also, how long would it take?

And these are just, I think, basic questions probably that you -- I'm almost certain you have an -- an answer for, but I'm just -- I'm really concerned, because I've had a lot of people in my district alone, and I'm sure there are others, that applications have been lost and things have been lost in the mail or what have you and technology is rapidly taking over sort of the submission of documentation and all that good stuff, so I'm just really -- I want to hear more where we go and how much -- what all of that costs.

Have you done any cost analysis, et cetera?

COMMISSIONER RODERICK BREMBY: I appreciate the questions and I think I want to start by providing a context.

July 8 DSS implemented statewide transformative system, ConneCT, which is a stop gap until we can replace the eligibility management system, which is a legacy system some 26 years old, but it's a stop gap. But what we desired to do with that system was the -- was to use the appropriate technology where possible to increase the amount of access to the agency online and over a phone system -- one phone system as opposed to 12, which have been obsolete for quite sometime.

We always -- and we'll always continue to allow people to come to our offices. In fact, we got 400,000 visitors to our 12 offices last year alone. And so the desire was to not over technilize the system, but to use the appropriate amount of technology.

Having said that, since July 8 we have scanned almost 4.4 million pieces of paper into the system. Since November we have produced an automated capture so we can track every single document that comes in or vendor and know exactly where it is in the process.

Pre-July 7 -- July 8, documents would get lost often at the regional offices or anywhere else in transit. So we don't want to go back to that system. In fact, July 8 when the system came up, we still had 200,000 pieces of work to be performed in the 12 regional offices while the new system was up. Over that same period of time, that 200,000 work items have been reduced to zero and we've been able to track that, in addition to bringing up a new system.

So the email in and of itself is not your typical email. We would love to be able to just send email messages back and forth, but we cannot. That email has to be encrypted to ensure the safeguarding of information, sometimes health information, of our customers. And so it's not your typical email system. To encrypt that system would require additional expense. With email also comes along things that people try to attach to email.

Sometimes they attach viruses and other things that will not just take down DSS's system. We're part of a larger email system, so it's the state's email infrastructure that we're trying to protect with that notion.

In terms of the applications being lost, I can say today with -- without any hesitation that documents that are coming in to Scan Optics are tracked. Those are not being lost anymore.

With respect to the phone system, a year ago this time the -- the prevailing complaint that I heard was that I can't get anyone at a DSS office and this has been going on for weeks or I get a voicemail box, the mail box is full, and all of those things. But since July 8 we've processed over 330,000 phone calls with an eligibility service worker, which is a rate that is unprecedented.

Now there is a functional issue that we need to reconcile and we're working on it and that is the wait times. Wait times are too long. We know that. We get that, but we're working on that. The wait times are excessive. We get that. We're working on it, but wait times being long as opposed to not being able to reach anyone, we think we're making some progress, but we're not where we want to be.

We have not costed out the impact of all of the requested suggestions, but what we can tell you based upon the process that we're using is that it's overly laborious and it would just -- it would tie the system up. Now it's either that or we could hire an army to try to chase down the paper and -- but I think that's out of our realm as well. So those are brief comments back to some of the questions that you asked.

REP. MCGEE: Thank you. I just have one other comment. I -- I appreciate that very robust response, but it's just -- it's really hard for me to understand, given where we are with technology and how advanced we are, that we couldn't find -- and I understand safeguarding, I understand crypting or encrypting or whatever the terminology that you used, but I -- I get all of that, but I'm almost certain that there is some software or something that would help to enhance or address sort of that gap in -- in response time.

So and maybe that's something that you're working on and I hear it. You know, you all are addressing that, but it's just something that I'm sitting here like, well why wouldn't we and how much would that be? So thanks a lot and we can -- we can continue in dialogue.

COMMISSIONER RODERICK BREMBY: We'd lover to continue the dialogue further. What we can also share with you is data. Prior to January 2012, since 1989 -- 88, 89, when EMS went into service, the agency never tracked timeliness of processing, looking at standard of (inaudible).

We were using alternate measures, but since January 2012, starting to track and count in a different way, we've been improving. We have improved our timeliness. We have improved across the board. Again, we're not where we need to be, but now knowing where we were, we're making great improvement.

One last item on the point that you were making about improvement and that is we've also hired over 200 people to add to that work since January 2012. So we've added more people, we've changed our process, we've added technology.

And so the curve sometimes takes a while, but we believe we will soon be current and also timely. So we're -- we're working on it. It is one of the key transitions that we're making within the agency. One of the three transformations that's underway.

REP. MCGEE: Thank you Commissioner. Thank you Madam Chair.

SENATOR SLOSSBERG: Thank you both. Are there other questions? I know I have a number that -- just a few that I'd like to go through and I appreciate you going through all of this with us Commissioner.

Just as a followup on just one or two things. The conversation we're just having on wait times is, you know, a never ending problem that we have and I definitely recognize the great strides and improvement that the agency has made.

And -- and I also appreciate your comment that we're not where we -- you know, we're not at the end of this process and we're not where we want to be. I think it would be really helpful for the committee to have some of that trend data.

And then also, I know we do a lot of predictive modeling, if there's some way that you can show us at what point do we expect to be at what we would all consider to be a reasonable wait time? We're still an hour, two hours. It's wonderful.

At least you get someone now, so that's a huge and vast improvement, but people are still struggling with this and I think the committee would really like to be able to know, you know, yes the trend looks great, but at what point do we get into the realm of what we all think is a reasonable wait time. And -- and how are we getting there is the other question. Is -- you know, we've hired 200 new people and you've added the technology and you've worked on the processes.

What is now happening that's going to get us from where we are right now to that more reasonable space? Can you speak to that?

COMMISSIONER RODERICK BREMBY: Absolutely. I appreciate the questions. Great questions.

Again, everything starts with context. July 8 system went up. We're not even eight months into the new technology, but we're still using a system -- core system that's almost 25, 26 years old. So new technology that takes a part of it. Puts it into play seeing some progress, but we're not where we're going to be. Now, what will change? What's different?

One of the issues is the call volumes are being driven by artificial demand. What I mean by that is that the number of calls that we receive today are vastly more than are expected or necessary even under optimal conditions, but conditions are not optimal and so it's producing a higher call volume.

Let me be very clear. Not too many months ago, for example, the federal government changed the SNAP allocation policy. So every one of our 220,000 households had their SNAP benefits reduced. We were required to provide a notice to every one of those 220,000 households. On the notice, for all 220,000 households, was the Benefit Center number.

So a large number of the 220,000 households called to try to figure out what was going on. We didn't cue, we didn't anticipate, we didn't plan for an additional 220,000 calls hitting the system.

Now, having thought through that differently, we know of a way to offload those calls since there's just informational calls. There's nothing related to eligibility. There's no changes you can make. The federal government's policy changed the amount that they would get. That's really what they needed to know, but they didn't need to talk to an eligibility service worker to do that. And again, 220,000 households got that notice. A large number of them called.

If we can get our system stable day in and day out, meaning operational, so that our workers can go in, retrieve the documents, work the documents without any sluggishness, we will make even more progress on the work that needs to be completed. Until that happens, EMS and CSS or ConneCT are not linked.

So we have people in EMS that get notices that you have not returned your material in a timely way. There may have been documents in ConneCT receipted. We're matching those documents up now to reduce the number of notices, because the notices prompt additional calls. So there's operational, there's technical, and there's process changes that will drive down the wait times.

We believe again, that the call volumes that we're getting now are artificial, they're excessive because process, technology, instability are creating more questions for our customers than answers that they need.

So we've also looked at some expedited centers and so we're looking at setting up a center to expedite calls where people are, you know, desperately needing to talk with someone, but we're going to do that through secondary customers.

We're continuing to work with Best to stabilize the system, Best, IBM, Deloitte, everyone involved. We have begun the process of pricing out call back systems. When you call for an airline reservation, for example, or some utilities, if your wait time exceeds a threshold you get -- you're given the option to press a button and call -- have the system call you. So we're pricing out those sorts of things.

So there are any number of changes, but taken as a whole we believe that we can dramatically reduce the wait time that is currently being experienced.

Now having said the wait times are excessive, the wait times are upward of 50 minutes or so. What we also know is the average length of time before someone hangs up is about 17 minutes. So while there's a wait time, there's also a disconnect time that we're aware of. And so that wait time is not experienced by all people so, but again we're not …

SENATOR SLOSSBERG: Thank -- thank you for -- I --I appreciate the explanation and I do know that there's a lot of moving parts here and I think it's really useful to hear some of the challenges that you're trying to address and it's not one thing that is going to change this. It's a whole variety of things and, you know, I think I still come back to, you know, it would be really useful for us to have an understanding of, if you can, when timing, you know, when do we think we're going to have enough of these operational issues under control that we can see a difference.

And, you know, just two specific things on that that you mention that I would be very, you know, interested in learning more about and potentially be supportive of. The idea of that call-back system I think is probably a really good thing, because we know we have a lot of constituents that call and they have limited minutes on their phones and so they can't wait.

It just doesn't work. There's no way to -- there's just no way to do that. So if there is a call back -- a way to do a call-back system and I don't know the ins and outs of that, but perhaps that would be something that would be really useful.

The other thing that actually -- I'm going to put Kate on the -- on the hot seat for a second, that Kate had mentioned at a forum we were at last night was that for those clients who are on Medicaid, that sometimes the better choice and the easier choice is to call the ASO number. So when you say we sent out 200,000 notices or, you know, there are various different changes. I'm wondering, on those notices when we put out the benefit center number, I don't know whether we're also putting out the ASO number with that, and if we are or are not, I'd be curious to hear your thoughts on whether maybe that's a way of diverting some of the flood of phone calls to places where we're -- you know, we know that they'll get a live person whose knowledgeable and able to help them.

COMMISSIONER RODERICK BREMBY: The -- the episodic notices that are typically just to acquire information about why a change has occurred, that does not require any eligibility access, we have a vendor in mind. We have a strategic partner in mind that we can access and put that number down at the bottom of the notice and they will process the calls.

If there is a call that really truly needs to be back with us, then we will have a loop back into DSS for the eligibility service worker to take care of. So that's well under way in terms of being developed

But Kate is absolutely right in some calls related to the ASO. If a person's trying to find a physician. If they're finding a -- a dentist or needing help with finding a specialist or something like that. The best call is the ASO. That is not necessarily at the bottom of a notice, but we're trying to publicize that resource as it -- as it sits with the ASO, not only for providers, but also for customers.

The ASO provides tremendous support for a lot of our customers who are in our Medicaid program. But eligibility, again, back to that one statewide number.

SENATOR SLOSSBERG: Yeah. I think the big -- that, you know, obviously that's a big challenge and I think that leads me into, you know, when we're talking about eligibility on -- on two levels that leads me into our discussion on Senate Bill 254 and the Presumptive Eligibility for the Home Care Program for the Elders.

You know, I understand the administration's opposition to the bill and it's, you know, I -- I understand that. But I'm sure you also understand that the challenge that we are having, which I, you know, is -- goes back again to that eligibility.

You know, on the one hand talking about regular eligibility that's being worked on now with ConneCT and then trying to have EMS talk to ConneCT about the challenges there. Long-term care eligibility seems to still be out there as the -- the -- we're not making a lot of progress in that area and so we've got big challenges there and, you know, as far as we were concerned and this is something that I think has a lot of support.

Doing -- you know, having presumptive eligibility for this limited program to really get a sense of, you know, does this work? How much does it cost? How many people are not, you know, are getting -- are becoming eligible who actually it turns out they shouldn't be eligible? What are the real numbers for this?

And I know we've always had some estimates on this, but I don't know that they're, you know, we -- we haven't done it, so we don't know for sure what it -- what it actually looks like, but we have to be moving forward with -- with that long-term care eligibility because we know that if we can keep people in their homes, they are going to live a better life.

We know that they're going to, you know, at the end of the day it saves the state dollars in the long run, but more importantly, it's a better quality of life. So maybe you could talk about long-term care eligibility a little bit, because that's really what, you know, we can't -- we can't just walk away from this and say okay someday we'll get this resolved. So where are we (inaudible).

COMMISSIONER RODERICK BREMBY: Great set of questions on long-term care. Long-term care applications represent less than 7 percent of the applications that we receive each month. Long-term care applications are those that have been least timely processed. This is the area that we've turned a lot attention since October and structured in a way that we process long-term care applications.

The growth of long-term care applications over the last ten, 15 years has been constant and growing. This is an area where resources have not been provided historically and we are providing additional resources. When I say resources, I mean staff.

Not too many years ago, the look-back period for long-term care applications increased from two years to five years, which more than doubles the amount of potential documents that the staff would need to process. So there is a huge lift here.

This process though is not burdened by the technical operations. This is largely a manual process because of the look back in the scanning or the review of the documentation. I don't want to say scanning here and scanning over there -- the review of the documents.

So what we're looking at and we've already started with the four hubs that are -- that help to refine the catchment areas is process these using best practice. If a long-term care application comes in and does not require an asset review, those are moving along a lot faster.

If there are long-term care waiver apps that don't have a lot of assets, I mean those move along quite well as well, but there are some that are just like the -- well they're very intense. And so we have to look at assets and perform that -- that review.

What we'd like to do or what I would be inclined to do is, in terms of the cost we can share with you the number of applications that we receive that are rejected, that are not eligible and we can contrast that against what that cost might be if you extrapolate providing presumptive care and then have to either move the services back to one out of every five or the state absorb that cost for one out of five applicants. It is a fairly significant hit.

SENATOR SLOSSBERG: Do you know if the -- if you have that data by program? So in other words, if we're looking just at the Connecticut Home Care Program for Elders, do you know -- do we -- do you know how many come back in terms of rejection specifically?


KATHY BRUNI: I'm Kathy Bruni. I'm the manager of the Alternate Care Unit.


KATHY BRUNI: Thank you. We see about 20 percent of the applications being ultimately denied home care program recipients.

SENATOR SLOSSBERG: Okay. So it's about 20 percent. Okay, that's a pretty significant number. Surprise. That's news to us. So that's interesting. Can you, you know, when you talk about this particular -- again, going back to timing on this. Can you provide us with some data on how long it takes? Because we've had, you know, I think in our last hearing we had somebody come up and talking about, you know, 375 days.

And, you know, substantially longer than the federal statutory requirement of 90 days. So you know, even though I recognize that, you know, you're talking about it's largely a manual process, it's very time intensive, you know, we've -- we've got to be striving to get to those 90 days in one way shape or another.

I see you're ready to go, all right so go (inaudible).

COMMISSIONER RODERICK BREMBY: No I -- I here you. We are committed. We've got to do better in this space. But there are some things that we are doing, including some structural changes to consolidate our waiver programs under one -- one direction. So one waiver program sitting someplace else in the long-term care sitting in another place really doesn't work too well.

SENATOR SLOSSBERG: How does that help actually streamlining eligibility though? How long -how long it's going to take to go through the paperwork and figure out if somebody's eligible?

COMMISSIONER RODERICK BREMBY: Their -- I want to talk about the different components of the process. The assessment and the look back and see how (inaudible).

KATHY BRUNI: This is actually a process that we did lean.

SENATOR SLOSSBERG: That was my next question, so thank you for answering.

KATHY BRUNI: When we take a referral for the home care program, we get some basic financial and functional information and make a decision initially about what level of the program we feel that client might be eligible for. And it's not unusual for when the care manager from the access agency to find out the income and asset information somewhat different than they provided over the phone.

So the -- we now have an automated, web-based system within Alternate Care that allows for the exchange of documents between the access agencies and the department's Alternate Care Unit. Because I'm not proud of how many documents we have trouble putting our hands on. So this is the way that we've addressed that problem since November with -- with some success.

So the information cues up in a financial cue and the person has to be determined functionally eligible for the waiver program before the Medicaid application can be processed as a long term care application. So what we're looking for is basically a summary document that summarizes the assessment that says yes this person is functionally eligible for the waiver.

We review that information. The eligibility staff in my unit then communicate to the district office hub that says the person is financially eligible for the waiver. Go ahead and process the application as a waiver.

If it's a state-funded application, we process it right -- we process it within the Alternate Care Unit. So then when the application is processed and the worker's ready to grant, they have to request a document again from the Alternate Care Unit that is -- provides information on the amount of the care plan, the provider ID number, the waiver indicator, things like that, that are needed for the eligibility system in order for the claims to pay. So that document is exchanged.

Then they say, okay we granted the case, so then we send the automated memo through the system back to the access agency that says start services and then generates the eligibility determination document to the client.

SENATOR SLOSSBERG: All right, well, I appreciate the -- you know, the flow.

KATHY BRUNI: It's complicated.

SENATOR SLOSSBERG: I understand it's complicated. Maybe I'll ask a really simple question. What would it take from us for you guys to be able to get these done within the statutory frame -- required framework?

COMMISSIONER RODERICK BREMBY: We think that more attention. We've leaned the process initially. We're looking at this consolidation of effort under one authority. We're adding additional resources bodies. We're looking for any best practices in any other state, but we think we're right on the path.

We can identify the documents. There's a lot of things in place now to produce those outcomes that we haven't had before. We were scattered. We had different processes across the state. The process wasn't clear.

So I think we have just about everything we need to be successful, but we are in the process of adding some resources, but when those resources hit I think we'll begin to see some additional improvement right away.

SENATOR SLOSSBERG: Okay, that's -- that's exciting to hear and you said it exactly the way I was going to ask you it, which was you have what you need. So I guess the only other question that I would ask is if you can provide to us some sense of when are we going to see that -- to see change. You know, when are -- you know, and I'm not putting you on the spot for this minute.

But if you can help us to be able to see, okay we're finally getting to the place where we have what we need and now we need to just sort of work this, but we're expecting at x period of time, by this particular date, in and around then, we're going to be turning the curve.

And I think that's really what we're looking for. I think people recognize that you've worked with an incredibly difficult system for a really long, long time, come in, and really turned things around. So, you know, so we appreciate the effort that you're making and the changes that you're making.

It's always easier though when you're hearing the concerns from people to be able to explain the context, but then also be able to say then you have what they need we're expecting that by x or around then we're going to be seeing some significant changes. So if you can provide that to us, I think that would make a whole lot of people, you know, much more comfortable with where we are and what we're doing with that.

So I'm going to leave that discussion. I realize this has been, you know, a long colloquy here, a long discussion, a long back-and-forth, but I do have to just go back to fair hearings for just a moment. So thank you Kathy.

Thanks for coming back up Brenda. I appreciate it. I just wanted to ask, you know, this is another one of those long-standing issues that we've heard from people many, many times because I think that the challenge is that when you have constituents who get a notice that they're going to have the opportunity for a fair hearing, it is very different than a -- an administrative review of whether the worker has, you know, done what they were supposed to do according to the steps.

And there's a sense of, you know, a hearing officer walks out of a room with the -- with the person who's going to be defending the work that they did and then you've got your constituent or your consumer there and there's this sense of I don't have a shot of making this -- at this being fair.

And so I think that there's a lot of challenges with that and I just -- if you can tell me how many hearing officers do we have for DSS?

BRENDA PARRELLA: We currently have 20.

SENATOR SLOSSBERG: Can you use your microphone, please?

BRENDA PARRELLA: We currently have 20 hearing officers. Five are dedicated to a newly established subunit for access health hearings.

The idea that there's an appearance -- I think what you're saying is that there's an appearance of bias in that the hearing officer walks out of a room with an eligibility worker who's presented the department's case. That should never happen. We don't -- if a hearing officer is out posted to a regional office, they don't hear any cases involving workers in that office. For exactly that reason, that we don't want an appearance of bias.

So, for example, someone out posted to Waterbury isn't going to sit in the same room with a Waterbury worker who's made a decision and be reviewing their decision and having that worker present to them, when they could later eat in the cafeteria or something together. So we specifically avoid that.

We do get a lot of hearing requests. We've been averaging about 25,000 hearing requests a year. And that's a lot to manage, which is why we're protective of additional time-consuming steps in scheduling and dispatching decisions. I -- I guess I'm not sure what else …

SENATOR SLOSSBERG: No I appreciate that answer. Because I do think that that is some, you know, some of the comments that we have received here. That people do walk in. So I -- I appreciate you saying that and I think that's something that we -- we need to make sure we understand and followup. And when I say we, I mean that's, you know, the Legislators hearing that and asking those questions.

Can you tell me, in terms of those 20 hearing officers, are these -- are they full-time hearing officers? This is what they -- this is their full-time work at this point. They're not doing other things at the same time they're -- they're hearing cases?

BRENDA PARRELLA: Each hearing officer is in the same job specification, which is, I believe, hearing officer. They all take the same exam, which involves a combination of sort of a written component to try to test writing skills and a component that's a multiple choice eligibility component, broad range of eligibility questions. There's -- as you know, there's a lot of programs the department administers and the hearing officers hear all of them.

So they hear everything from child support enforcement actions to Medicaid coverage issues to long-term care eligibility disputes involving the availability of assets, including trusts. It's a -- it's a broad range of issues. Some of which are very straight forward formalistic things, like food stamps eligibility.

There's a -- there's a very clear this is how you calculate someone's eligibility for food stamps and the amount they'll receive each month to things that can be really quite gray where there's an overlay of federal law or case law and the hearing officers, who are not attorneys, just get the full range of all those kinds of challenges. From the very basic for a seasoned eligibility person to very challenging, even for an attorney sometimes, some of the issues sometimes that can be raised.

So the issue of their access to information and support from the agency about our own programs is important to us, because we don't want to leave them without the resources. There's a lot of issues that no one person having worked in the department for a while myself, there's just a lot to know. There's a lot of detail. There's a lot of complexity. And things change all the time.

There's always changes in the state and federal rules. Hearing officers are in a position of wanting to interpret correctly the law and be impartial to the facts and they never communicate with an agency member about the facts of a case. If they're looking for support and assistance from the agency in anyway, it's too -- it's -- what is the agency policy?

Am I understanding this correctly? You know, I'm confused by something. The facts they're not allowed to present, you know, for assistance.

SENATOR SLOSSBERG: So if they ask, they're -- they're having a hearing and they're getting information, but they need to go back and get more information about a program or a policy -- if they go back and ask for that information and they receive information, does that information also get transmitted to the consumer?

BRENDA PARRELLA: No it's not required to be. And if you think about the number of hearings we have and the scheduling challenges we have and also, the types of hearings and the clients, for us to notify a client every time a hearing officer had a question about department policy.

The client would actually be notified, the hearing officer has this question, would you like to share something for the record …

SENATOR SLOSSBERG: I think that's exactly my point, Brenda.


SENATOR SLOSSBERG: Is that when you have a consumer who's coming for an appeal, you know, whether -- and -- and part of the challenge may be that when you're coming for an appeal, I think people have a sense that they're going to something that feels sort of like court. And I know that the Commissioner's testimony was well, you know, what we're asking for and this is sort of -- is to have it look more like independent judges making independent decisions.

I think that's exactly what we're talking about, and where we're at, maybe where we need to continue the conversation with the agency because the consumer is coming in with the idea that they are going to have a fair hearing that is with someone who is independent, where the decision they're making is based on the evidence presented in the record and not some conversation that they're having on the side, you know, and asking for that information.

I understand from what you're explaining to me, which I appreciate, is that that's -- that is not the way it is set up and then so I think the next question would be is, is there any reason why we couldn't set it up that way, if that's what, you know, we thought really made sense.

BRENDA PARRELLA: I would have concerns about that. First, the majority of the hearings are pretty straightforward issues of eligibility. I think that people do, indeed, get fair hearings. When -- I don't think there should be an impression -- well it's not the expectation.

It's not what an administrative hearing is at the administrative level that you're appearing before a court. You're appearing before someone who wants to accurately, consistently apply the law. And who's impartial to the facts. That's what people get.

They have a right to appeal that to court. They can request reconsideration of an agency decision. They can appeal an agency decision to court. But they're not before an independent body. They're -- the whole structure of an administrative hearing in every agency is that you're coming before the agency to have the agency review its own work to see if it's accurate. And then you can appeal that to court. There -- it's -- it's a contested case. There's the ability to have representation. It's on the record.

Every decision is translated to whatever the language is of the client. We have Language Line interpreters available for whatever the language is of the client. The majority of clients are not represented by counsel. I think the hearing officers try really hard to make sure the clients understand what they need to put on the record for a decision to be made for the hearing officer to review the issue.

But the bulk of the hearings are pretty narrow eligibility issues. We have hearings where attorneys represent clients. They are generally in situations where it's a long-term care eligibility case and there's a question of assets and the availability of assets. And it's usually the private bar representing a person, a family disputing whether or not these assets should have been available for the purposes of calculating someone's eligibility for Medicaid. So we -- we -- there's a -- there's attorneys we see there.

We see legal services attorneys on certain issues, some of them eligibility issues, some of them issues, such as whether something's medically necessary and testing the parameters of how we apply our definition of medical necessity. Some of these can be -- involve a lot of legal argument and, as I said, the hearing officers aren't lawyers.

In some instances, the Attorney General's Office represents the department in these hearing, so that the department worker or contractor, as the case may be, has representation, which is separate from the hearing officer.

I think we're really mindful of the concept of a fair hearing and I think we do it within the law. There's a lot of challenges in operationalizing the hearing program because of the volume and the number of things that get resolved prior to hearing.

So we have to schedule so much, but we don't hold nearly as much as we schedule because often something scheduled -- it then gets the attention of the worker and gets resolved before the hearing takes place. There's a lot of juggling that goes on to keeping the schedule going, keeping it moving.

But I -- I've been in that unit, working in that unit for about 13 years now and we try very hard to give the fair hearing within the context of an administrative hearing, which is different than being before a court. I don't think that…

SENATOR SLOSSBERG: No I -- I understand that and I -- I thank you -- I thank you for that and for the explanation and I -- and I hope you understand we're asking questions based on the responses that we get from consumers, and I think that what I'm trying to get at is sort of what the system is and what the goal is and what the construct and so what the expectation should be and then the question, quite frankly, I think more for the policy makers to decide is this -- is this doing what we, you know, is this the policy direction that we want to be going in. And, you know, and dealing with that.

And so I, you know, I understand where you are and -- and the challenges that you have in terms of addressing this within a very overburdened system and a lot of -- and 25,000 hearing requests a year is an awful lot of hearings to try to juggle and put together.

So I think this is obviously something that we, you know, we've been talking about for a long time. I think we have to continue to have an in-depth conversation about how to possibly address the, you know, when we start talking about a contested hearing and we've got lawyers on both sides, it sort of feels like at that point it should be more like a -- a traditional hearing versus a straight up eligibility review.

But I'm not -- I'm not sure and I think that we've probably taken -- you and I could probably talk about this for a very, very long time. And I -- and I actually hope that we will continue to do that and I'm sure as we hear from people throughout the day we will continue to do that.

But having said that, I think, again, thank you very much for your answers Brenda. I look forward to working with you to resolve some of the concerns that have been raised so, Representative Bowles, I believe has a -- would like to speak and then Representative Butler. Thank you again.

REP. BOWLES: Thank you Madam Chair. Thank you Commissioner for joining us today. Appreciate your testimony. I would like to briefly just go back to the Presumptive Eligibility for Home Care Program and I guess you're going to be inviting staff up, but I'm particularly interested -- who makes the assessment in terms of functionality? What -- what staff are involved? Is this a medical staff, RNs? How is that process?

KATHY BRUNI: That's done by the contractor, one of the access agencies and there's very specific requirements for care managers in the regulations. They can be social workers or nurses with a specific number of years of experience.

REP. BOWLES: Okay there's certainly obvious functionality issues associated, which would make somebody eligible, obviously for -- for the program.

KATHY BRUNI: They have to be determined to be nursing home level of care.

REP. BOWLES: Okay. I guess what I'm trying to get at and I appreciate the dialogue Commissioner you had with the Senator relative to giving us some assurance that you are meeting your expectations moving forward and cutting down the time frame involved with that.

I'm just wondering as a -- in -- in -- is there a way to go ahead and trigger presumptive eligibility through some of the steps without hitting, in other words, out of the 20 percent that you're testifying are not deemed eligible, you know, for this particular program. How many of them are deemed not eligible because of functionality issues?

KATHY BRUNI: The 20 percent refers to those only determined ineligible financially. They've already been determined to be functionally eligible and we've communicated with the district office worker to process that application as a long-term care application for the waive.

REP. BOWLES: Okay. You -- you answered my question. I was -- I was trying to assess whether or not, if there was a functionality issue you could -- you could make the presumption. So that's the first thing you take a look at. Okay, once they're deemed that then -- so all the -- and you're just -- you're just saying that the ineligibility is a result of financial circumstances.

KATHY BRUNI: If they're not functionally eligible for the waiver, we'll look at them for another level of the program.

REP. BOWLES: Okay. Thank you very much. That answers my question. Thank you.

SENATOR SLOSSBERG: Whoops. Sorry. Representative Butler.

REP. BUTLER: Thank you Madam Chair. And thank you Commissioner Bremby for appearing before us again. And I've read most of your testimony, so I'm good with this. I just have a quick question about the -- about the fair hearings. A quick couple of questions. Hopefully, nothing earth shattering.

There's something about fair that, you know, evokes a lot of questions. Anyway, my question is, seeing that you only have 20 staff that have to review like over 2,000 cases, when -- when a hearing concludes, I know that time frames might vary, but is there typically an announcement right after the conclusion of hearings as to how it's reconciled or is it something that has to be deliberated on further after that and notify the people of the results?

BRENDA PERRELLA: Hearing officers don't issue decisions on the spot. They have 60 days from the close of the record or the filing of final briefs, whichever is later to issue a decision.

Some -- some decisions lend themselves to being quickly issues. Others are more ponderous and require review of more different authorities to consider and take longer, but it -- under statute, we should be issuing decisions within 90 days from the date the hearing was requested. To be honest, we don't always make that time frame, but we try to.

REP. BUTLER: Yes. You anticipate my next question. My next question is you're required to actually make a notification of that rendering of that decision within 90 days and …

BRENDA PERRELLA: From the date of the request.


BRENDA PERRELLA: From 60 days from close of the record.


BRENDA PERRELLA: It just doesn't always work perfectly.

REP. BUTLER: Okay and do you have any percentage of how often you meet that goal or don't meet that goal?

BRENDA PERRELLA: Oh, you know I don't have those statistics with me, but we do keep them and we actually do issue decisions generally timely. Our struggle is in scheduling them timely. We have such an overwhelming number to schedule with a limited number of actual hearing rooms where the hearings can take place and hearing officers. We fill their days with hearings scheduled every half hour.

The hearing officers are very timely in issuing their decisions. It's the scheduling of them within the -- that initial piece that starts the clock for the 90 days. That's the tough spot. Not so much how long the hearing officers take to issue their decisions. We're generally timely. I can get you the stats on that.

The struggle is scheduling them early enough in that 90-day period. By statute, which is a set -- which only applies to the department. It isn't in the Uniform Administrative Procedures Act, but currently our own statute tells us to schedule within 30 days. We have trouble getting things scheduled within 30 days with the volume we have.

REP. BUTLER: Right. Well -- and thank you for that candid answer. And, matter of fact, we would just like to, you know, look into this so we can see how we could better support you in making this whole process better, so thank you for your testimony.

BRENDA PARRELLA: Well I'm happy to have you interested. I think about a lot how to better manage that -- that work, so.

REP. BUTLER: Thank you.

SENATOR SLOSSBERG: Thank you. Thank you very much. Are there any other questions from the committee members? Thank you so much Commissioner. We look forward to continuing to work with you on a whole host and variety of very complex and important questions that come before us, so thank you again.

COMMISSIONER RODERICK BREMBY: Well thank you. We appreciate your interest and your support.

SENATOR SLOSSBERG: Okay. We have now exceeded our first hour, so we are going to be bouncing back and forth between the public and the public official.

So our -- our next bill -- the next bill we're going to be hearing is Senate Bill 325. And so our first speaker is Don Clayback and then after we're done with Don we'll be going to Anne Foley.

Good afternoon. If you'd just state your name for the record, please.

And Don, if you'd turn your microphone on too. Thank you.

DON CLAYBACK: Hello, my name is Don Clayback. I'm with the National Coalition for Assistive and Rehab Technology. And thank you Co-Chairs Slossberg and Abercrombie for having us here today to talk about this bill.

I'm here today to talk in support of the passage of SB 325. Let me just give you a quick overview of NCART. We're a national association focused on protecting and promoting access to what we call Complex Rehab Technology. Complex Rehab Technology are individually medically -- medically necessary and individually configured manual and power wheelchairs, seating and positioning systems, and other adaptive devices that require evaluation, fitting, configuration, adjustment and programming.

These products are used by a small group of folks with high-level disabilities and they depend on them both to meet their medical needs and also to improve their function on a daily basis.

Our membership has -- we have about 300 locations across the country, so we're a national group, but here in Connecticut we have three of our members are active here in providing these products to the Medicaid recipients and our three companies we estimate comprise about 95% of the services that are provided in the state.

I wanted to highlight, and I'm not going to go over all my written testimony, but I'd like to just highlight some of the main points and tie this into the bill that we're talking about around recognizing complex rehab technology.

One of the things that we -- we struggle with on a national and a state level is the recognition of these specialized products. Complex Rehab Technology is different than standard durable medical equipment, but we're grouped in that same category and it presents challenges when it comes to coverage and payment and other standards that are set up from a provider perspective.

The -- we have some examples of our technology here in the room. If you can see there's two power wheelchairs that have both mechanical systems that enable them to be -- the position can be changed for someone that's sitting in that wheelchair on a -- on a daily basis.

You have the base of the wheelchair. You have the seating system that provides positioning and pressure relief and then you have the control system that people use to actually operate the wheelchair. Much different than the chair that you're going to see in a hospital hallway or a drugstore and that's our biggest challenge is because of the uniqueness of the products and because of the need that people have to customize these products to their own capabilities.

It requires a lot of time that's involved in the evaluation process and requires a company that has a high level of capabilities, both in terms of trained staff and just the assembly and servicing aptitudes that the companies need to have.

SENATOR SLOSSBERG: Don if you will -- if you will just summarize, I'm sure there'll be some questions for you.

DON CLAYBACK: Okay, great. So yeah to summarize I think what we're looking to do is -- we think this bill will provide needed recognition for these specialized products. It'll establish improved safeguards and standards for both the state and the beneficiaries.

And it will also provide a stable economic environment for the small group of providers that are still in this business. As I mentioned there's a very small number of companies that are currently providing it. So thank you.

SENATOR SLOSSBERG: Thank you for your testimony. Can you tell me, are there any companies in Connecticut that do this?

DON CLAYBACK: Yes. There's -- there's by our estimation there's two companies that do approximately 90 percent of the business. And there's another three or four companies that basically take care of that 10 percent.

And when we have these types of discussions I bring up that point that, in terms of the challenges within this market, both from how complicated the service needs to be and the payment challenges, I think it's a testament that there's only two companies that really are -- remain in this business and I would attribute that to the challenges that go along with it.

SENATOR SLOSSBERG: Okay. Thank you. Can you also tell me how is -- I know you have legislation in Congress pending in regard to this.


SENATOR SLOSSBERG: Can you tell us a little about that?

DON CLAYBACK: Yes. We've got similar legislation that we've introduced on a federal level in Congress. It's called the Ensuring Access to Quality Complex Rehab Technology and pretty much mirrors the bill that we're looking here to introduce in Connecticut.

It was introduced last year. We currently have about 100 members of Congress signed on. It's introduced both in the House and the Senate side. And it has very solid bipartisan support, along with key committee support.

SENATOR SLOSSBERG: Okay. And can you tell me have any other states adopted this legislation that you're proposing before us today?

DON CLAYBACK: Yes. We have -- and we just started really last year doing our state initiative to follow the federal bill. It was passed last year in the state of Washington. Currently, there is legislation, obviously introduced here in Connecticut, along with the state of Colorado. And I expect similar legislation to be introduced in New York and Pennsylvania within the next 90 days.

SENATOR SLOSSBERG: Okay. And is it your testimony that you don't expect that this would change actually the financial reimbursement that is -- that comes with this change in -- change in definition? Thank you Kathy.

DON CLAYBACK: Yeah. I think the definition itself and some of the safeguards that we're proposing in the legislation would not impact -- we don't think there's a financial cost. In fact, we think there's -- the financial impact is a savings because it's going to increase safeguards around these products.

But there is legislation to modify the current payment system to get it more in line with the federal Medicare program and I suspect that will have some cost, although right now we're not sure exactly what that might be.

SENATOR SLOSSBERG: Okay. Thank you very much. Are there questions? I guess there are no further questions then.


SENATOR SLOSSBERG: Thank you. Oh do you? I asked them all. Boy it's a good day. Thank you very much for your testimony. We appreciate it.

Our next speaker is Anne Foley. Good afternoon.

ANNE FOLEY: Good afternoon Senator Slossberg, Representative Abercrombie, and members of the Human Services Committee. I'm Anne Foley, Undersecretary at the Office of Policy and Management and I'm here today in my capacity as Chair of the Child Poverty and Prevention Council to ask for favorable action on House Bill 5323, AN ACT CONCERNING THE CHILD POVERTY AND PREVENTION COUNCIL.

So the Child Poverty Council was created in -- in 2004 to develop and promote a plan to reduce child poverty in the state. And then two years later it was merged with the Prevention Council. And so as part of our prevention activities we produce a report annually on the funding of prevention services in the state with detailed information about prevention services provided by state agencies.

So in addition to that, separately, current law requires that the Governor include a prevention report in the Governor's biannual budget document and the production of that report requires significant state resources and is duplicative of the reporting efforts performed by the council that I just outlined. So what this bill seeks to is to consolidate the requirements of the Governor's prevention report into the annual report by the council.

So there's three main reasons that we're doing this. First of all, the -- we think that a separate biannual prevention report is unnecessary and duplicative. And what we've done in the bill is streamline both the reporting frequency, making this an annual report, and also including all of the pertinent data from the prevention report into a more comprehensive council report.

The second reason is that the -- the Governor's report is really reporting on what the Governor's proposing. It's not providing information on what we're actually spending on prevention services in the state. So we think that it's much more useful information to depict the actual investment that the state's making in prevention services.

And finally, the original intent of the prevention report in the Governor's biannual budget was to raise the level of awareness and importance of primary prevention programs. And so we think that it makes sense for the prevention data required in a prevention report to be collected, analyzed, and discussed through the Child Poverty and Prevention Council, which is really a forum for interagency collaboration on prevention initiatives.

So that's one provision in the bill. The other provision in the bill is that the bill adds the agency heads of the Department of Housing, the Department of Agriculture, and the Office of Early Childhood or their designees to the council. And those recommendations were -- were put forward by the council at their -- at their most recent meeting.

So I'd like to thank Representative Zupkus is here with us today for her participation as a member of the council and I want to thank you all for raising the bill for us and ask that you act favorably on the bill. And I can answer any questions that you have.

SENATOR SLOSSBERG: Thank you very much and thank you for the work as the Chair of this council. So does anybody have any questions? Representative Zupkus.

REP. ZUPKUS: Great. Thank you Madam Chair. And I just wanted to say thank you for coming because it does do good work, that council, and I'm glad to be a part of it. And anytime we can curtail duplication and -- that's a good thing. And, you know, adding these people on I think will really expand and make it even for a better council. So thank you for coming and I encourage my colleagues to support that. Thank you so much.


Representative Wood.

REP. WOOD: Just briefly. Thank you always for your good perspective and fairness on dealing with so many things and educating us. So I always appreciate that. And I agree with Representative Zupkus on eliminating the duplication and expanding the council make a lot of sense. So I look forward to supporting this. Thank you.

ANNE FOLEY: Thank you so much.

REP. ABERCROMBIE: Any further questions?

Thank you very much. We appreciate your time.


REP. ABERCROMBIE: Now we'll be going back to the public portion and just to -- so people realize, when the public does come up they are limited to three minutes. We do appreciate when you hear the bill -- when you hear the buzzer going off to round up your comments.

With that, Ed Mambruno. Followed by Nancy Shaffer.

Good afternoon sir. Thank you for being here.

ED MAMBRUNO: Good afternoon, Senator Slossberg, Representative Abercrombie. My name is Ed Mambruno. I'm the independent ombudsman for the Department of Developmental Services. I also am a Commissioner of the Commission on Human Rights and Opportunities, a position I've held since 2001.

I'm here to support passage of Complex Rehab Technology Bill 325. This important legislation needs to be passed so that people with disabilities get the specialized equipment that they need. CRT is an important piece of legislation because many disabled individuals need specialized wheelchairs that are fit for their needs and not just some standardized wheelchair that's off the rack, if you will.

As ombudsman for the department, I serve as an advocate for all individuals with an intellectual disability. Many consumers have a medical condition that warrants individually designated equipment to meet their specific needs.

I also understand that this bill, which many people have said will increase $3.7 million is a small price to pay when you're thinking that a standardized wheelchair can, in effect, cost that much in medical bills to an individual that, because they're sitting in the wrong type of features, will inherit a pressure sore, problems with their posture, respiratory ailments, and the list goes on. Just one medical stay will cost a half million dollars.

You have to have a wheelchair that is specific to your needs. It has to be customized, and I believe that is the word that needs to be looked at is "customized". You cannot, and I'll repeat it, sit in a standardized wheelchair and believe that you're going to feel the same way that you would if it was, you know, a customized wheelchair.

I've had issues with pressure sores that were eliminated by sitting in a chair that was built for me. That had specific seating, that had a tilt, that had a recline. These features eliminated all the medical issues that I once had and believe that many of the individuals that I advocate for have the same issues that I have or will have if they're put in an inferior wheelchair.

This is a significant issues that really needs to be looked at and I believe a fiscal note is not something that you can measure against someone's health. Thank you and if there are any questions, I'd be happy to take them.

REP. ABERCROMBIE: Thank you. And thank you for being here today and with your comments. I agree with you. I think it goes to quality of life and I don't think we can put a price tag on that. So I agree with you there. So thank you.

ED MAMBRUNO: And one more thing if I may.


ED MAMBRUNO: Over the last years that I have been ombudsman I've noticed a significant increase in community involvement of our consumers and that is -- the main reason is the customized wheelchair that they have. They're able to interact in the community. They're able to keep up with the people walking besides them. They have customized joysticks in the back. If they are not able to, you know, control the chair themselves and this is -- speaks volumes when you're acting in the community, instead of sitting in a group home or institution, which we are doing our best to eradicate.

REP. ABERCROMBIE: I agree. Questions from colleagues? Representative Ackert.

REP. ACKERT: Thank you Madam Chair. And thank you for you advocacy. What are the hurdles that will be, I should say eliminate or limited with the passage of this legislation that you can specifically maybe speak to? In other words --

ED MAMBRUNO: Can you repeat that please?

REP. ACKERT: In other words, this piece of -- you said you were in support of this legislation because it will help in terms of, you know, is it the financial component? Is it the -- what is the hurdles that this -- if we pass this -- makes something go away that struggles now?

ED MAMBRUNO: I believe what is going to happen is individuals who were going to receive a customized chair or seating -- seat will now be forced to go into a standardized chair, a one-size-fits-all, if you will, and that is something that everyone is different. Everyone needs different things and chairs are just the same thing. It needs everything -- everyone needs to be customized to what they're in. And I believe that will more or less hack away at some of those functions that they may be able to receive now and then those will be eliminated in the future. We don't want to see that.

If you have a pressure -- a proclivity for a pressure sores, a tilt in space will eliminate that if you use it, you know, every hour or depending upon how often or, you know, you use it or how bad your skin is.

REP. ACKERT: Now I know the value of the chairs. I serve with a representative who sits right behind me that uses one and can't speak more highly for the value of his chair. I was just -- and I appreciate you being here and I'll listen to more testimony and I -- I can't thank you enough for taking the time.

Thank you, Madam Chair.

ED MAMBRUNO: Thank you very much.

REP. ABERCROMBIE: Representative Wood.

REP. WOOD: Thank you, Madam Chair, and thank you very much for your testimony.

Like my colleague, Representative Ackert, I have also heard about this bill from Representative Molgano and the benefits he has of his chair. Who's pushing to have this changed? Am I missing something? Let me read through -- bouncing between a couple Committees I'm trying to get up to speed.

No, you know what, thank you for your testimony. I'm going to read up on this and then let you know if I have any questions. Thank you.

REP. ABERCROMBIE: Sorry about that. I wasn't sure what you were referring to. Oh it's to change the benefit. That's what it is. It's to change the benefit because right now they're blocked in with durable medical equipment. That's what it is. Yeah. Thank you very much for your testimony. We appreciate it. Nancy Shaffer, followed by -- oh. Representative Morris. I'm sorry.

REP. MORRIS: I'm glad you --

REP. ABERCROMBIE: Sorry I missed you.

REP. MORRIS: I'm glad you've given an explanation.

REP. ABERCROMBIE: I apologize.

REP. MORRIS: I think I was going to do the same thing as Representative Wood and offline try to figure some of this out. But your last comment has me -- are we saying that without this -- without this bill they automatically get the standard chair, standard equipment?

REP. ABERCROMBIE: I think that's some of the challenges. That's why we thought it was important to do a hearing on this and for all of us to listen to the testimony of what they go through to get a customized chair.

REP. MORRIS: And -- okay and maybe I missed it because I was trying to read between everything. So in order to get a customized chair, what do you have to go through?

ED MAMBRUNO: You have to first have a therapist say, then write a prescription or write actually about a ten-page evaluation to the insurance company or the Department of Social Services why you need a -- I'll give you an example, a tilt in space. An elevator that, you know, lifts you eight inches.

My chair, for example, has a feature that will put me in a standing position. My insurance company denied that. After all of my papers I submitted I grieved it. Went to the anthem and because I had all the papers and said it would increase circulation, strengthen your bones, stretch your muscles, I mean the list goes on, they still refused it. They're afraid of a woodworking effect that everyone will want this feature. It's approximately $5,000. Now that's -- that's ridiculous. I have the feature.

Your rehab services paid for it and within three months my therapist saw significant improvement in my everything, just about everything. My legs stretched. Everything was -- was, you know, the feature worked very well.

REP. MORRIS: Now -- now obviously --

ED MAMBRUNO: You need a prescription from your doctor that (inaudible). So you need two prescriptions, an evaluation from your therapist, a doctor's prescription, even though a doctor doesn't know anything about your condition, other than you are a paraplegic or quadriplegic and so on. They're just going to write a prescription as to what the therapist has stated in their evaluation.

So you need a few, you know, people to review your condition and justify why you need this piece of equipment.

REP. MORRIS: How -- how often if not would you say that the private insurers that you went to first are denying individuals this equipment? So then ultimately end up having to go through this more extensive process in order for Medicaid to pick it up.

ED MAMBRUNO: I can only speak for myself and say that I have been denied stronger motors because they said that, you know, when they evaluate you you're only evaluated on what you use in your home. So because I drive from here down the street to work they didn't take that into account, and I needed better motors to be able to do that.

Eventually, they saw the forest for the trees and improved the motors, but you go through -- you go through hoops and the hoops aren't just hoops, the hoops are on fire.


ED MAMBRUNO: So you really have to --

REP. MORRIS: Yeah, obviously -- yeah, obviously you're very articulate and you now advocate for yourself very well. What would be your anecdotal observation in terms of -- of other people who are disabled who may not be as articulate and self-empowering as you?

ED MAMBRUNO: That's why I am here. I'm advocating for the individuals I serve for the Department of Developmental Services who are all on Title 19, who are all (inaudible). Who all are eventually going to go through the Department of Social Services for a refund -- a federal reimbursement and that -- I believe that is where they say the rub is.

REP. MORRIS: Do you know whether the Department of Developmental Services or whether it would be DSS that would have data that would indicate to us how many people are being impacted here?

ED MAMBRUNO: I'm just testifying today, you know, for the individuals I serve and (inaudible) and not for my agency or anyone else. It's for my -- for the individuals I serve and advocate for.

REP. MORRIS: Okay. I was curious whether you might have known both.

ED MAMBRUNO: No, I'm sorry.

REP. MORRIS: Well we'll delve into that further.

ED MAMBRUNO: I just happened to return to work a few days ago and haven't really had a lot of time to do any research into the -- back into the details that you're speaking of right now.

REP. MORRIS: Well let me say you did a phenomenal job advocating for your constituency, for yourself, and everyone else. Thank you very much for your time.

ED MAMBRUNO: Thank you.

REP. ABERCROMBIE: Any further questions?

Thank you very much. We appreciate your time.

Just to follow up Representative Morris, yes we can get that information from DSS how many.

Nancy Shaffer, followed by Jillian Cacopardo. Did I say it right?

Oh good. Thank you.

NANCY SHAFFER: Good afternoon Representative Abercrombie, Senator Slossberg, and members of the Human Services Committee. I'm not sure how often one ombudsman is followed by another ombudsman. I don't think that does happen very often, but it's an honor to follow Mr. Mambruno.

So my name is Nancy Shaffer and I'm the state long-term care ombudsman and I appreciate that you've allowed us to come and double team you a little bit here. Brian Capshaw is a resident of a skilled nursing facility and he is also the President of our Resident Council Coalition and he is also on a national, he was elected to a national board for leadership in long-term care. So he has a lot to offer in kind of being able to advocate and answer your questions as well.

So you have my written testimony and I would like to really highlight a couple of things that I think are important regarding Raised Bill Number 5322 AN ACT CONCERNING NURSING HOME FACILITY MINIMUM STAFFING LEVELS.

And the first thing I think is of importance to note is that Connecticut has the rather dubious and I have to say shameful distinction of being the second lowest state in the country for minimum staffing ratio requirements. And that is very unfortunate.

In 2002 -- I'm sorry, 2000, the Centers for Medicare and Medicaid Services established safe guidelines for staffing and at that time they recommended that residents receive a minimum of 2.75 nursing hours each day. In Connecticut our minimum standard is 1.9.

So I'm not sure why it is that Connecticut has chosen not to make a commitment to increase that -- that level of minimum standard staffing, but I think it is time to really very much give it another serious and significant look at increasing.

One of the things that it's important to note is that most nursing homes in the state already are exceeding the minimum standard. So this isn't going to be a burden to them financially. They already done that.

And I want to end by talking a little bit about a study that, again, the Centers for Medicare and Medicaid Services did and that was they compared national data from 2001 to 2012 and about patient characteristics. And what they found in that timeframe, 2001 to 2012, that the nursing home residents at a national level, these are some of the increases that they've seen over time.

And that was 107 percent increase in residents with psychiatric diagnoses. Nineteen percent increase in residents with dementia diagnosis. Forty-one percent increase folks who needed bathing assistance. Forty percent increase in those that needed toileting assistance. Thirty-nine percent increased in dressing dependence. So and that list goes on and that is in my testimony. And I think that that's significant.

When -- having worked in nursing homes for a couple of decades and I think if any of us would go into a nursing home today we would see that the nursing staff is pulled in many, many directions and, you know, it's not unusual for them to have to multitask. Things that are so significant and of such great importance not only to the physical well being, but to the emotional well being of those residents.

So I -- I sincerely thank the committee for reraising this bill. It's been before various committees numbers of times over the years and I do hope that you can support this on behalf of the residents. I'll let Brian speak. Thank you very much.

BRIAN CAPSHAW: Thank you Nancy for allowing me to testify with you and members of the committee, Representative Abercrombie. I submitted my testimony as well and I'm just going to highlight a couple areas.

I have some personal knowledge. I have an MBA from Indiana University, so I'm a numbers guy. So I track my hours per resident per day every day. So I'm going to give you some personal examples.

In my nursing home at Aurora Senior Living at East Hartford, early in 2013 the ratios in my nursing home were as follows: On January 30, we were at 2.74. February 27, we were at 2.67. And March 27, we were at 2.77.

On March 30, the Department of Public Health finished their annual survey and we got cited for understaffing. We were not meeting the staffing needs as the law states you have to meet the needs of the residents and we were not doing that, but it shouldn't have taken the Department of Public Health to come in and tell them. Someone should be doing that on a regular basis.

And as Nancy said, I work for the Consumer Voice for National Long-Term Care out of Washington D.C. and they have submitted testimony as well on this. And we understand this legislation is not seen as a cure all, but it is an important first step in addressing the problem of understaffing in nursing homes and the nursing home residents deserve the improvements that this bill would supply.

And they've taken the time -- this is a three-year process just to get to this stage. It started in 2012, when Senator Markley ran it through the Office of Fiscal Analysis to see what the cost would be and it does show there is little or no cost to the state for this bill.

And then in 2012, we sat with Senator Slossberg to discuss it. And then we took the time to sit with Charles (inaudible) from the Attorney General's office to make sure the language was fine. And in 2013, during the off session, we sat with Representative Abercrombie and Senator Markley again and we got to this point.

And I'd like to thank those people who took the time to sit with me and go over this legislation. We urge passage on this bill.

REP. ABERCROMBIE: Thank you. Thank you for your testimony. We do appreciate it.

Questions from committee members.

Representative Ackert.

REP. ACKERT: Thank you Madam Chair.

I'm considered myself kind of a numbers guy too, so I can -- and I'm looking at the legislation and I heard that Connecticut is at 1.9. You state the average standard should be about 2.75. This is for such daily hours of nursing care in a 24-hour period, correct?

NANCY SHAFFER: That's right.

REP. ACKERT: Okay. Does this -- and I'm just reading it real quick -- does this satisfy -- does this get us to that level. I see two and a tenth nursing staff hours per resident from I guess you'd say daily hours and not less than six-tenths. So does this get us to 2.7 hours? Is that what it is, this legislation?

NANCY SHAFFER: That's what we're asking it to -- yes.

REP. ACKERT: Okay. So this is -- I'm just -- does it comply with what would you would say would be comparable to the -- you said national standards?

NANCY SHAFFER: Well the national standards were set in 2000 and that was 2.75.

REP. ACKERT: Correct.

NANCY SHAFFER: Other data in other studies indicate that it really should be 4.2 hours per day.


NANCY SHAFFER: And, you know, I think as you can see from the acuity, the increased acuity from even just a decade ago, the need for those increased hours per day.

REP. ACKERT: Yeah. I saw that in your testimony and I thank you and I was just trying to make sure I'm reading the legislation right. Section B says, you know, on or after October 1, 2014, submit staffing, maintain nursing levels to resident ratio of not less than two and one-tenth nursing hours, so that's 2.1 and then the additional, I guess overnight hours probably would be considered to be six-tenths. So we're at -- that's 2.7.

NANCY SHAFFER: Right, okay. Yes, I see what you're …

REP. ACKERT: Okay, so we're still less than …


REP. ACKERT: Okay, I just want to make sure I'm viewing the numbers correctly here. So I do appreciate your testimony and thank you. And thank you Madam Chair.

NANCY SHAFFER: You're welcome.

REP. ABERCROMBIE: One follow-up question. So in your testimony you stated that there are few nursing homes that are already at the minimum standard. How many nursing homes are actually affected by this legislation?

NANCY SHAFFER: I think the Office of Fiscal Analysis did some work on that and …

BRIAN CAPSHAW: Came back with two, Marshall Lane in Derby and Mattatuck in Waterbury.

REP. ABERCROMBIE: I'm hoping that that helps Representative Ackert. This actually only affects two that are at that lower…

NANCY SHAFFER: One of the concerns that I do have -- excuse me for interrupting, is that we do have a requirement that -- that nursing homes post the staffing on a daily basis, but what happens is that doesn't account for people who are like a certified nursing assistant who must accompany a resident who's going out to a medical appointment.

So that -- that figures in that overall number of -- of staff who are on that day, but that person isn't in the building assisting anyone. That person is out, you know, accompanying a person who needs the -- the accompaniment, but that's -- that's -- you're down a person just there.

And so there could be multiple people out on a given day that require a nursing assistant to go with them. Or you have call outs that maybe, you know, weren't filled. So that's not always going to be reflective of exactly what's in the home that day. Thank you.

REP. ABERCROMBIE: Any further questions? Thank you very much.

NANCY SHAFFER: Thank you again very much.

REP. ABERCROMBIE: We appreciate your time.

NANCY SHAFFER: I appreciate it.

REP. ABERCROMBIE: Jillian. Jillian I'm not going to say your last name because I did it right the first time, so I'm not going to mess it up this time. Followed by Julia Evans Starr.

JILLIAN CACOPARDO: Good afternoon. Thank you. My name is Jillian Cacopardo. I'm a physical therapist and have been practicing for 12 years, 11 of which have been at Gaylord Hospital in Wallingford. If you're unfamiliar with Gaylord, we provide care to those patients with complex rehab and medical needs in a long-term acute care hospital setting.

I'm here as a clinician to support passage of the Complex Rehab Technology Bill. This is important legislation that needs to be passed to help people with disabilities get the specialized equipment that they need.

As a physical therapist, I currently run Gaylord Hospital's Wheelchair Clinic. It is here that we are able to assess patients for appropriate equipment that provide them with mobility and proper positioning to allow someone to get out of bed, mobilize within their home and within their community, and minimize their risk for pressure sores.

This equipment includes, but is not limited to customized manual and power wheelchairs, back supports and seat cushions, custom molded seating support services, and standing frames. The process to properly provide the specialized equipment is something that cannot be completed in one day. This is due to the diagnoses of the patients we see and the complexity of their needs. Some of these diagnoses include spinal cord injury, cerebral palsy, amyotrophic lateral sclerosis or Lou Gehrig's disease, spina bifida, muscular dystrophy, and multiple sclerosis to just name a few.

Not every patient is the same nor does the disease process manifest itself the same from patient to patient. This is why a separate Complex Rehab Technology Bill is so important. Patients come in different shapes and sizes, as do their needs. These needs cannot be met with something that comes out of a box. They require customization, adjustment, and modifications to this equipment.

Customized equipment allows a patient with muscular dystrophy to independently operate a power wheelchair, as well as power seating functions with only a small flick of the index finger, the only remaining functional hand movement he has left. This allows him to maneuver throughout his home and change his position, thus allowing him to not have to rely so heavily on his caregivers.

A customized seating system allows a patient with a long-standing history of quadriplegic spinal cord injury to prevent further progression of pressure sores due to such severe curvature of his spine. This allows him to stay out of hospital and keep health care costs down.

A properly configured, ultra-lightweight, manual wheelchair allows a patient to maximize his ability to propel his wheelchair 16 hours a day so he can return to college to finish obtaining his degree to allow him to work full time and become a productive member of society.

The previous examples are real life stories of people I've had the pleasure of helping. These positive outcomes could not have been completed solely. It takes the team effort of the provider along with the clinician to ensure that these outcomes can occur. The most rewarding part of my job is when the team approach results in a smiling patient and caregiver.

If the Complex Rehab Technology Bill does not pass, there are serious consequences that could result, including putting our patients at risk for serious medical complications and increased health care costs. Complex Rehab Technology is vital to the adolescents and adults with disabilities that I treat.

It helps reduce health care costs and provides independence and safety. The Complex Rehab Technology Bill will improve people's access to specialized equipment and add safeguards to make sure only qualified companies provide these products and services. Thank you.

REP. ABERCROMBIE: You were a little bit nervous, but you did a great job. Thank you for being here. Just a couple of quick questions for you.

So when you get the order to be the physical therapist for someone, after that, is there like a team meeting with the doctor to decide what are the next steps?

JILLIAN CACOPARDO: Not necessarily with the doctor. We actually meet -- in our clinic we meet with the patient and the vendor. That's the team approach. We evaluate the patient, write a letter of medical necessity, then that goes to the doctor.

REP. ABERCROMBIE: Vendor being?

JILLIAN CACOPARDO: Vendor being, sorry, the provider of the equipment. So the companies within Connecticut.

REP. ABERCROMBIE: Oh, okay. So you do interact with them and then you put your --

JILLIAN CACOPARDO: Oh, absolutely.

REP. ABERCROMBIE: Oh, okay. I didn't realize that.


REP. ABERCROMBIE: And then you put in the recommendations to the provider who has to be the one that writes the script?


REP. ABERCROMBIE: Oh. Oh. So go through the procedure for me. That'd be --

JILLIAN CACOPARDO: So when we get a referral, we set up the actual appointment. So it's myself, the patient, and the provider. So the provider being, you know, the companies within Connecticut that they would actually provide the equipment. We just provide the service as the therapist. But we evaluate the patient and then during that evaluation process we write the letter of medical necessity, which, you know, I think somebody mentioned to be up to ten pages. It can definitely be more than that on a good day.

Once that process is done within that day, you know, we finish up our letter. The packet is then sent to the insurance -- or to the doctor for them to sign off on. So the doctor isn't necessarily there at the appointment.

REP. ABERCROMBIE: Is the ten-page referral that you do, is that a standard form through the agency?

JILLIAN CACOPARDO: That was just, I don't know the right word for it, but yeah, the Department of Social Services just enacted that mandatory January 1, and it's actually more than ten pages.

REP. ABERCROMBIE: So what was the procedure before that?

JILLIAN CACOPARDO: It's the same thing. We had -- we had our own form letter, but now there's just a standardized -- standardized paperwork that we need to send to DSS once we're completed.

REP. ABERCROMBIE: And that's about ten pages you said?


REP. ABERCROMBIE: Wow. Okay. Okay. Thank you.

Questions from my colleagues?

Representative Case.

REP. CASE: So when you do -- you're doing this now, before, or was it January 1st of this year the DSS changed the paperwork for you. What was the process before? How much paperwork was it?

JILLIAN CACOPARDO: It was the same process. We went through the same procedures. My letter was probably a little bit less. I'd say it was about five or six pages. They're looking for a lot more and ruling out the same types of equipment versus, you know, going with our recommendation of, you know, "X" wheelchair versus why doesn't "Y" or "Z" also work when they're within the same category.

REP. CASE: Okay, I just heard the Commissioner saying they're trying to cut down on paperwork and here we are hearing we're going for more. I hear you and I agree with your testimony and I appreciate you coming forward. You know, having somebody in my own family in the past recent six months where I've had to advocate for him to get out of the hospital. He's been in a wheelchair since he was seven years of age. He's 80 now. But he needed one of the lifts to go through the house and no insurance company would touch it. Had all doctor's orders, had the president of the hospital write a letter, everything. We said the heck with it, you know, we paid for it ourselves and to this day after getting out of the hospital he is much better off at home with that equipment. But we couldn't-- we had the scripts, everything but no insurance company would touch it. So, we need to work on this and get everybody so they have equal rights. I appreciate it.

REP. ABERCROMBIE: Thank you, Representative. Any further questions?

Thank you very much. We appreciate you being here today.

Julie Evans Starr followed by Dr. David Walshin.

JULIA EVANS STARR: Hi. Good afternoon Representative Abercrombie, Senator Slossberg, Representative Wood and esteemed members of the Human Services Committee. My name is Julie Evans Starr. I'm the Executive Director of Connecticut's Legislative Commission on Aging. I want to thank you for the opportunity to come before you today.

As you know, the Commission on Aging is a nonpartisan public policy office devoted to preparing our state for a significantly changed demographic and improving the quality of life of older adults of today and tomorrow.

I want to talk about three, maybe four, bills very quickly because I know there's a lot of people who are waiting.

But I wanted to start with House Bill 5325, AN ACT ELIMINATING THE HOME CARE COST CAP. I don't think there will be any controversy with this bill. I'm so glad you've introduced it. It eliminates the 60 percent cost cap on waiver services under the Connecticut Home Care Program. We support this bill. It has served as a barrier -- that 60 percent -- for some people needing specific services. An example of that is the Adult Family Living service, which is new to the Connecticut Home Care Program as a service. And so, because it provides seven days of care, which is new and exciting and really going to help people, but people would exceed that 60 percent cost cap. They don't anticipate that it's going to increase the dollar amount spent because they really reserve the 60 percent cost cap so that you can get another set of services with the extra 40 percent. So, now that the services are more robust in the first category, that's the purpose of this bill. And the cap is unnecessary. It's only specific and limiting to the Connecticut Home Care Program for Elders and the Department itself said there is no fiscal impact for it. So, that's really positive.

So, we'll move on to Senate Bill 253, AN ACT CONCERNING TEMPORARY NURSING HOME BED REDUCTIONS. We simply want to give you some background information on this. The bill incentivizes nursing facilities to voluntarily and temporarily reduce their bed capacity. It's -- Senator Markley made an important distinction that it's different from taking beds temporarily off line versus reducing the number of state beds. So, our lens is -- I have the honor and privilege of co-chairing the Money Follows the Person steering committee and have for several years and so I know a lot of the work that's been done in this area through the Department of Social Services. They've contracted, perhaps you know, with Mercer Consulting and they've done a lot of analysis in this area and they looked at long term service and support, the supply and demand on a town by town basis and the results of that were shown in the Governor's Rebalancing Plan in 2013, in January 2013. If you'd like to see that report, if you haven't already, we'd be happy to provide it. It put forward many strategies and tactics to rebalance the long term care system and the perhaps the most notable or -- yeah I would say notable-- is the reduction of-- the proposal to reduce nursing home beds by 7,000 by the year 2025. I think it was surprising. But within the national context, if you look, Connecticut ranks in the top three for the number of nursing home beds as percentage of the population. We also have a vacancy rate, at least in 2012, of 9.3 percent and that had grown from 2011 from 7.8 percent. So, that's kind of the initiative coming out of the Department of Social Services. I think, to be fair, the Department has recognized that nursing homes are indeed part of the solution. They're incentivizing them through some money that was approved by the legislature last year. We're waiting on a series of announcements to kind of be the hub of the -- really the whole continuum of care, so they will play an important role. It's really about diversifying their business model and so I think that's the perspective of the Department to help encourage and incent nursing homes to be a part of the solution to diversify. So that's the distinction there.

I also want to speak to Senate Bill 254. Of course, we've talked about this. That's AN ACT CONCERNING PRESUMPTIVE ELIGIBILITY FOR THE CONNECTICUT HOME CARE PROGRAM FOR ELDERS.

We do support this bill. We support this bill even when we heard the Commissioner's testimony. It's important to note and this committee knows very well, the extremely long timeframe that people wait to get eligibility determination from Medicaid. The Commissioner conceded that's even perhaps longer for folks who are trying to get eligibility determined for long term care services and supports, either in a nursing home or in the community. We know, through our colleagues and the folks that are doing this work, that people are waiting up to six months for these services. This bill would help people 65 years of age and older applying for the Connecticut Home Care Program to get immediate -- quicker access to key services. They are often determined functionally eligible for the program, but again, they wait and wait. And if you think about the consequences to families, and perhaps you know somebody who's had to wait for several months for services, I mean, these are folks who maybe fell and broke their hip on the ice -- I cant tell you know many times I've fallen this winter alone --and have broken a hip and need immediate care and there you are waiting. And it's very frustrating for the providers and the access agencies, the individuals and most especially, the families who are trying to help these individuals with the services that they need during this prolonged gap period. Anything that you can do to help with presumptive eligibility I think is very important.

I do want to draw your attention to a Kaiser Report that I would like to find for you and show you that showed in the states that use presumptive eligibility for their home care program quite successfully: Ohio, Washington, Pennsylvania, Iowa. There's a Kaiser Foundation Report that says that the error rate is about at two percent. So, I think we should do a little more research in that area and get to the root of it. So, with that being said, I think it's also important to note that if you need nursing home care, you can get those services immediately.

And that brings us to some legislation that's coming out of this committee, most notably Senate Bill 104 AN ACT PROVIDING FINANCIAL RELIEF TO NURSING HOMES FOR UNCOMPENSATED CARE. That's a wonderful idea and necessary bill. So, folks, if you need long term care service and support, you can get it in a nursing home before the eligibility has been determined, but you can't do the same in the community. And now nursing homes, because of that, are -- have uncompensated care and they need to get compensated and that makes a lot of sense. So, if this bill moves forward, I think the same holds true for the community providers. So, I just wanted to make that critical connection.

We were very happy to hear the Commissioner talk about the consolidated -- how did he phrase it -- the consolidation of efforts under one authority. That's the centralized cross-waiver processing unit that we've been talking about in recent years. So, that is progress to help streamline the process and bring down the prolonged period that people are waiting. So, presumptive eligibility I'll find more information out for you (inaudible) report.

And one more thing, I wanted to also offer our support for 5322, that's the minimum staffing levels. My colleague, my valued colleague, Nancy Schaffer and her -- Brian, what do we call you -- have really been the experts in this area and I just wanted to offer the Commission support for that bill as well and we'll be amending our testimony.

SENATOR SLOSSBERG: Okay, thank you very much. Appreciate you being here and for your testimony. Very interested to see the report that you're talking about as you said, and also to really understand how some of the other states do this, are able to allow for presumptive eligibility without having the incredible litany of problems that, you know, we seem to look at when we propose this. I think that data will be very helpful and as you heard we've asked the Department for additional data as well to see what we can come up with. The rejection rate at 20 percent is extremely -- sounds -- I think we all gasped. It seemed very high, so I think we have a lot of questions to ask, to follow up on and your assistance is greatly appreciated. So, I don't have any questions for you.

Representative Wood.

REP. WOOD: Thank you, Madam Chair. Thank you for your testimony and your advocacy for this area. I, too, was taken aback by two percent. Can you just -- I know you're getting the information but you said it's Ohio, Pennsylvania --

JULIA EVANS STARR: Washington and Iowa.

REP. WOOD: So, the two percent numbers based on those states. Washington and Iowa, Okay. And you will get, I guess to the clerk of the committee that information? Okay. Presumptive eligibility makes so much sense. It makes sense. Thank you very much.

SENATOR SLOSSBERG: (Inaudible). Seeing none. Thank you very much. Our next speaker is Dr. David Walshin.

Yep, if you press the button it should go on. There you go. Good afternoon.

DR. DAVID WALSHIN: Okay. Thank you Senator Slossberg and the other members of the committee. My name is Dr. David Walshin. I'm a board certified doctor specializing in physical medicine rehab. I'm either called a physiatrist, which is the correct pronunciation, or physiatrist which other people have said. I have a private practice in Stamford, Connecticut. I have been in practice for twenty years.

I'm here to speak in support of Senate Bill 325. Passage of this bill will provide better protection and access for Medicaid recipients with disabilities that live in our state.

I have seen the difference complex rehabilitation technology in the form of custom wheelchairs makes in the lives of patients. Many of these patients have diseases and illnesses such as spinal chord injury, traumatic brain injury, cerebral palsy, multiple sclerosis, et cetera, whose rehabilitation needs cannot be met by simple non-complex wheelchairs or seating. Abnormalities in muscle tone, range of motion via contractures, strength and sensation are just some of the problems that result in postural and positioning deficits that require complex rehabilitation technologies in the form of custom wheelchairs, seating and other specialized equipment such as standing frames.

The cost of treating pressure ulcers in the hospital setting can be several hundred thousands of dollars for protracted admissions requiring surgical debridements, muscle flap surgeries, and wound care using wound vacs and daily care. This is not uncommon in the setting of spinal cord injuries and the proper and prompt prescription and receipt of appropriate complex rehabilitation technology wheelchairs can reduce or prevent such occurrences.

I recall a 70 plus year old woman I saw last year in a nursing home. She developed tropical spastic paraparesis through contracting a virus in the West Indies, rendering her lower limbs completely paralyzed and her arms weakened but functional. She is an avid reader and loves to drive her motorized wheelchair to the window in the hallway near her room and read. Having the independence and mobility allows her to leave her room and feel good about herself and be involved in social activities.

I am concerned that mobility will not be factored into decision to approve such complex rehabilitation technology. We are treating, as physicians and health care providers, the whole patient, not diseases themselves. Psychosocial needs must also be met.

The physician, usually a physiatrist or sometimes an orthopedist, therapist and ATP or Assistive Technology Professional, play a combined role I the evaluation and prescription of complex rehabilitation technology. The physician, at times, and I say not the primary care physician as Mr. Marconi had said; I actually take a very active role. The physician possesses the knowledge of the medical and post-surgical problems that these patients have as well as their rehabilitative needs. The therapists have the knowledge to address medical and post-surgical needs as well as apply them towards the evaluation of complex rehabilitation technology within the realm of their training. The Assistive Technology Professionals can also assess patients' needs for complex rehabilitation technology, but they play an important role in the specifics of the equipment prescription. That is the foundation of their practice and they must be involved in all aspects of the assessment of complex rehabilitation technology from the start. Each discipline plays their role in the team effort with the goal of appropriate equipment for the patient. The physicians and therapists do not possess the degree of expertise that the Assistive Technology Professionals do with respect to specific equipment and components. Unlike the physicians and therapists, that is an integral part of their daily work.

I would never prescribe a prosthesis for an amputee without getting the prosthetist involved from the start. They deal with this on a regular basis and they are -- have their fingers on the pulse as far as what the most latest technology is.

And I know we're here discussion Senate Bill 325 which is complex rehabilitation technology, but if I could just take a little bit more time, not a lot. The other bill which we had mentioned, the Department of Social Services delaying the implementation of their new wheelchair regulations to June 1 - one of my concerns is that bill, if you read into it, wants to take away the ability of the assistive technology profession or the rehab vendor to get involved in the process. They don't even want me, they want me out. They what the physiatrist out. They basically want the therapist to make the decision then later get the vendors involved and they basically want the primary care doctors, which no disrespect to them, they're my colleagues, but in this setting, I've been dealing with these custom wheelchairs for 15 years. The primary care doctor is just a signature. At the end, that's all they want. It's a way of trying to control course. That's what the gatekeeper is. That's why we don't have referrals anymore in the outpatient setting because those people didn't want it and it delays getting proper care. The primary care doctors are just signing off on what the therapist and the rehab technology suppliers have agreed to. If there's a specialist like myself involved in the process, that's duplication. In my opinion, that's not needed. Why do you-- and a lot of times it actually causes delay.

We have a form called a 628 form that is the rehab prescription and details the specifics of the customized wheelchair in the inpatient setting and what the state requires within 90 days, you have to have all the documentation into the state or you triggered a denial and you have to do the paperwork over again. Many times, sometimes it's just getting that primary care doctor to just sign that 628, which is the difference between getting the wheelchair approved or going back and having to start all over again.

The other thing which isn't even regulation is I think sometimes 90 days is too soon. For certain patients with chronic conditions that have not changed, I think sometimes even longer than that could be six months is appropriate. If the rehab team as a whole feels that somebody's condition has changed within that timeframe we're going to let you know because we want to change the prescription. But if the condition hasn't changed, I see a lot of foot dragging and a lot of hurdles within the system that really delay receiving important wheelchairs. Somebody who has a spinal cord injury, who has no sensation, you know, all it takes is a hospitalization within a week or not being on the proper cushions and you can develop a pressure ulcer and then you're fighting from there.

REP. ABERCROMBIE: Thank you. Thank you for your testimony. Questions from committee members?

Thank you. We appreciate your time.

Deborah Zinzalet? Mom of Alex? I hope Alex is going to come up too. Alexi.

Good afternoon, welcome.

DEBORAH ZINZALET: Good afternoon. Thank you.

REP. ABERCROMBIE: Hi honey, how are you?

A VOICE: Good.

REP. ABERCROMBIE: Nice to have you here.

DEBORAH ZINZALET: Dear Committee Members. Thank you for your time today. My name is Deborah Zinzalet and this is Alexis Charbonneau. Alexis was born November 16, 2001 and is 12 years old and has had 72 fractures since birth. She has a disease called Osteogenesis Imperfecta, which is Brittle Bone Disease. She has one of the severe types of this condition.

With this disease, the body does not produce collagen, which is the cement of the bone structure. So, what happens in moving the wrong way, sneezing, coughing, a bone can fracture. So, an option for Lexi to have a manual chair-- it's not an option. Lexi could never stop or move the chair manually. Lexi's Permobil Chair goes to the ground and extends so she can reach things. She is very small framed at 12. She's three pounds and 48 inches. Oh, three feet and 48 pounds. I'm sorry. I'm nervous. I'm sorry.

For an individual that can't walk or move, these complex wheelchairs give disabled people the independence that they need. The chairs also have seating systems that help position the person to help maximize more of her medical problem. The equipment helps their doctors address the many medical complications that could come with the disability and help that state keep the health care cost down.

Every person is different so we should allow people with disabilities to get the equipment they need to help with their health care needs and try to lead some sort of independent life.

The wheelchair means everything to Alexis and we support passing Bill 325.

REP. ABERCROMBIE: Thank you. Alexis would you like to say anything, honey?

DEBORAH ZINZALET: She's nervous, too.

REP. ABERCROMBIE: That's okay. We just want to give you the opportunity, honey, if you wanted to say anything. That's fine.

How often, couple of questions, how often do you have issues with the chair that you have to have it tweaked and how long has she been in that particular chair?

DEBORAH ZINZALET: This is her first chair. Lexi doesn't grow, so we don't have to do much tweaking. But when she does have the growing spurts, then like, the back of the chair or her foot --if her feet get a little bit longer, they've got to extend it.

REP. ABERCROMBIE: So they can use that chair itself and just refurbish it to what her needs are?

DEBORAH ZINZALET: She actually has a Permobil chair -- she likes this chair because it's fast. It's small -- she has chair that will last --

REP. ABERCROMBIE: Are we going to call her speedy?

DEBORAH ZINZALET: Hot wheels, we call her. She has a chair that lets her go down to the ground and get out. And Lexi scoots, she doesn't walk, she scoots. So the other chair extends so she can reach things or-- it just gives her that little bit of -- if you try to push her she'd be like, "I'm not a baby." You know, she's been doing this since she was 18 months old, driving her chair and that's how she gets around and it's very important. She could never use a manual chair. Never.

REP. ABERCROMBIE: Absolutely, it gives her the mobility that she deserves--


REP. ABERCROMBIE: --and her independence. Questions from committee members? Representative Wood.

REP. WOOD: Thank you, Madam Chair. And thank you very much for the -- for your testimony and Lexi for being here. Question: What kind of wheel-- this wheelchair you said was 18 months old?

DEBORAH ZINZALET: Oh no. This is almost 10 years. This is her very first chair. The very first chair. This one doesn't do what the other one does. The other one goes to school with her, but my van isn't strong enough to pick the chair up because it's so heavy so we take this one like when we go places, you know? But the other one is a Permobil like the gentlemen had before.

REP. WOOD: It's a Permobil? That's what -- I wondered what you had before this--

DEBORAH ZINZALET: No, this is the very --

REP. WOOD: The original. The original for Speedy.

DEBORAH ZINZALET: Yes, the original when she was 18 months old they showed her how to drive it and actually when she had learned, she had fractured her arm, so they had to switch all the controls to the other side and she drove it then that way.

REP. WOOD: So, without this bill, Lexi, you wouldn't be able to have that wheelchair.

DEBORAH ZINZALET: She would just be in a regular chair and she cloud never push it. She'd break her arms or even try to stop it, she'd break.

REP. WOOD: Okay. Do you want to say something?

ALEXIS CHARBONNEAU: Um, the only reason I have this is because of Toby.

REP. WOOD: Thank you Toby. Alright. Thank you.


REP. WOOD: Credit and gratitude are always good. Thank you.


REP. ABERCROMBIE: Thank you for your testimony. We appreciate it. Ed Bonk followed by Robin Cobb.

Good afternoon, thank you for being here.

EDWARD BONK: Thank you Representative Abercrombie and Human Services Members for allowing me to speak. My name is Ed Bonk. I am a resident of Manchester, lifelong resident of Connecticut. I grew up in New Britain and I'm here today to support passage of Complex Rehab Technology Bill, SB 325.

It really is important legislation to get the people with complex medical needs the complex equipment that they need.

I've been a physical therapist for 32 years. About 10 years ago I transitioned into becoming an Assistive Technology Professional and a Seating Mobility Specialist, both certified by Rehab Engineer and Assistive Technology Society of North America. I've worked for Hudson Seating and Mobility for the last 10 years and Hudson is one of the complex rehab technology providers in the State of Connecticut. Hudson has probably served the disabled community since 1980. We have nine locations throughout the Northeast and two of them are in Connecticut, one Newington, our main location and another one in Pomfret Center, Connecticut.

Last year we serviced approximately 10,000 Connecticut residents. Medicaid, Medicare and other insurances. About half of those had complex rehab technology needs and about half of the complex rehab technology needs were for service as opposed to new equipment.

What I'd like to do is stress that CRT is not the Scooter Store type chairs that we've all seen on TV. It is individually configured equipment for patients for complex medical needs. These individuals have a 24-hour need for the equipment and it's a lifelong need as opposed to grandma that might need a wheelchair just to get to and from the bathroom and then she's sitting in a regular recliner chair throughout the day.

I did bring with me a complex chair. That is the blue one over there. It really has -- it's different and it's complex in the sense that it has an alternate drive system. The drive system is not driven -- or the way the chair is driven is not by a joystick, your typical type of power wheelchair but it is in the headrest. So, in the headrest there are sensors so moving the person --the person moving their head left, right and back would be able to drive the chair and also control the seat functions. As Jillian mentioned, the CRT process is a very lengthy process. When Jillian Cacopardo -- sorry Jillian. But what happens is, during that evaluation process, the therapist identifies the clinical needs of the patient, and then as an Assistive Technology Professional, we identify various different seating components in the base of the chair to help match those clinical needs, both functional and medical needs.

It's a very labor-intensive process and again, as opposed to just routine home medical equipment, how tall is the person, how much to they weigh, they need an 18 inch wide wheelchair, send it out tomorrow. This is very - the process to get a custom wheelchair, a complex rehab technology piece of equipment, can take three months from the initial evaluation till gathering all their appropriate documentation, to submitting it to the insurance or Medicaid and getting the approval. There is the initial evaluation by the clinician, as an ATP we bring in trial equipment. Connecticut Medicaid requires trials of various pieces of equipment so that is all non-reimbursed. The gathering of medical documentation, the submitting of the components to Medicaid, assembly, all that. That's all labor-intensive form the provider's perspective.

I'll wrap it up by saying I do that Representative Abercrombie for bringing up the custom wheelchair proposal, the proposed new regulations because we really believe that those are not necessary. With the new introduction of the 13 page wheelchair evaluation, the prior authorization process is very stringent. We have seen a significant reduction in utilization, both in the community and stilled nursing facilities.

I do want to thank you for allowing me to speak today and if you have any questions.

REP. ABERCROMBIE: Thank you, and thank you for being here. I urge my colleagues, if you ever get the opportunity, to go out to their facility and take a look at all the work that goes into these custom wheelchairs. It really is amazing. I have to say. I'm a field trip person, so you know I like to see what the product is that we're up here voting on. So, to me it's really important.

EDWARD BONK: Absolutely. It's an open invitation.

REP. ABERCROMBIE: So, just a quick question for you. In the private insurance, are there guidelines there that we can mirror in the Medicaid program?

EDWARD BONK: Medicare's guidelines are pretty much the most significant and then private insurances do mimic them but Medicaid's I believe are a little more lenient than Medicare to -- in their implementation and review of the process.

REP. ABERCROMBIE: So if we wanted to look at anything, it would be the Medicare?

EDWARD BONK: I think so, but again, there is much more leniency in the Medicaid in terms --

REP. ABERCROMBIE: You have-- you have someone behind you shaking his head no. Sheldon--

EDWARD BONK: Sheldon--

REP. ABERCROMBIE: So, we'll wait for Sheldon to speak when he comes up. He'll set us straight. Questions from my colleagues?

Representative Wood.

REP. WOOD: Thank you, Madam Chair, and thank you for your testimony. How many people are in regular wheelchairs versus customized wheelchairs -- percentage.

EDWARD BONK: Percentage -- I -- from the federal, I believe it's only seven percent of the, for Medicare, seven percent are in complex rehab versus the remaining in standard manual and power chairs.

REP. WOOD: I think what we're hearing today is that the bar is pretty high to qualify for -- yes, I'm seeing shaking heads, okay. Thank you. Thank you Madam Chair.

REP. ABERCROMBIE: Thank you, Ed, for being here. We appreciate it.

EDWARD BONK: Thank you very much.


ROBYN COP: Thank you for having me. I am a clinical therapist at the Hospital for Special Care in New Britain, Connecticut. I'm from Berlin, Connecticut, lifelong Connecticut resident. Love Connecticut. I'm very passionate about what I do, I've been doing it for 21 years and I'm finding it difficult for me to give my patients what I need now -- or what they need, what I say that they need as a clinical specialist.

I wrote -- you got my testimony last night, I'm not going to go from my letter, I'm going to go from my heart on what I've been seeing and feeling in the clinic.

I primarily started (inaudible) injury at my Hospital, the Hospital for Special Care, about 12 years ago. I'm finding it harder to get a quadriplegic patient, which is a patient that is paralyzed at the neck level, customized wheelchair and seating for them to be not only independent at home but safe. The second thing that I'm seeing an all time high is readmission back to the hospital's wound care. Pressure sores. And these chairs that Ed had brought actually create a patient to be able to be in them 12 hours or longer but be able to shift weight off their ischial tuberocity, or their bony prominences that they -- that we all have in our body, that would otherwise create pressure to actually breakdown through the bone, actually getting as extreme where it causes an osteomyelitis, which is an infection to the bone, which people end up in the hospital for six months or longer, with the State of Connecticut paying for that.

So, for me, as a therapist, my clinical judgment, I went to Quinnipiac University, I spent six years in college to do this job. I take it very seriously. I am having a hard time giving my patients in the long run what they need, whether it's a paraplegic patient that maybe paralyzed from the waist down, that may need a power assist wheelchair, which is a wheelchair that has motors in the wheel that allows them to push the wheelchair. But it's a less costly chair. And I know that my colleague has spoken here from Gaylord, we go through this intense process in the hospital where we put them in the least evasive chair, we try them in the cheapest, less aggressive chair and then we work our way up to where we feel that chair fits them and their need. If we put people in these manual wheelchairs, not only will cost increase because they'll be rehospitalized with morbidities, but what will happen is they will no longer be productive to society or our state or their ADLs, activities of daily living, that they can perform, they're going to be more --they're going to need more help in the house to do what they otherwise could do with the right piece of equipment.

What we do in the right places, the hospitals that have these wheelchair clinics, is you have people that are specialized working with the companies to come up with what you think is the right pieces for the puzzle. Somebody came up earlier and said every patient is different, their size is different, their hips are different, their leg length is just, you know, different, their seat elevation is different. There are so many things that if you are not in health care you don't understand what could impact their level of function, or their level of dysfunction, meaning that they'll either fall out of their chair because they don't have the right seating system or they will actually develop a sore, which is the most costly nationwide readmission for spinal cord injury in this country.

So, I'm kind of putting it in a nutshell. I know I didn't take my three minutes but this is what I'm seeing.

REP. ABERCROMBIE: So, let me just thank you for what you do. The Hospital for Special Care has a special place in my heart. It's another place I've done a field trip at and you know the work you guys do over there is just absolutely fabulous and we're just so lucky to have you guys in this state, really. You do God's work over there. So, personally, thank you very much for what you guys do.

With that, Representative Wood.

REP. WOOD: Thank you and I'm just trying to-- this is a new area for me to understand so I'm just trying to understand the pieces as people are speaking.

What are some of the typical patients who would be in a manual wheelchair who would be -- for whom a manual wheelchair would be successful?

ROBYN COP: Each person differs, but like say somebody comes in and had a stroke. They may be able to go home and propel with one arm and one leg around the house. That would be a manual chair. As to my 30 year old that I have at the hospital now, that is a diving accident, broke his neck and only has the ability to do this. So we have made him as independent as possible. He would not be able to feed himself, he would not be able to assist with catheterization, he would not be able to move around, he would not be able to pressure shift. So, if people are left home, okay, for eight hours, because the family members need to work, they need to make money, the need to be able to survive, he needs a way to be able to, number one, get out of the house, number two, to pressure relieve so that he doesn't develop a sore. We can develop sores within twenty minutes or less based on the right circumstances of the pressure over the bony area, our nutritional level and a whole slew of factors. But without these chairs, these people will not be able normally to get their medical needs met, number one, but number two, thrive in society.

REP. WOOD: How -- but if somebody has just -- this is their only action, how are they able to catheterize themselves?

ROBYN COP: They actually can actually tilt and there's special equipment -- they tilt back or they recline the chair, that's why sometimes you need two features for the chair. It's not just one option. Sometimes they have to tilt which is like a dental chair, the whole chair goes back. Other times they need to tilt and recline so they can access their -- and there is special equipment to help them. Even though they don't have hand function they can catheterize themselves.

REP. WOOD: Okay, point well made. What's the general cost of a manual wheelchair and is there a general cost to arrange for the complex medical care wheelchair.

ROBYN COP: I would have to defer to Ed to come up here and give more accurate than me because when we're doing this, as the clinicians, we're treating all day long and then do a wheelchair eval and as Jillian said, it's hard to get these wheelchair -- now the State of Connecticut, I sat on the DSS committee for the wheelchairs. The 16 page tool is very difficult for us to get done in a timely manor and then go for authorization and then what's happening is if we leave one thing out, it gets denied and kicked back to us and we need to start the process all over. So it's like a ping pong ball.

So, now we're trying to treat, yeah and that's important for you guys to understand because we're trying to treat the patients who are in the system and get them the right equipment and then something superficial is kicking it back to us to do all over again.

REP. WOOD: Could he come up and just give the answers to the general range on the mechanical wheelchairs -- manual wheelchairs.

EDWARD BONK: I would say standard manual wheelchairs are are around $300--

REP. ABERCROMBIE: Ed, just -- because if you can, can you just say your name again for the record?

EDWARD BONK: Yes. Ed Bonk from Hudson Seating and Mobility.

Standard manual wheelchairs, the chair that's way in the back there, about $300 to $500. A custom manual ultra lightweight chair like Brian's, probably $3,000 to $4,000. There are manual tilt in space chairs that are the same cost and then the complex chairs there could be $12,000, $15,000, $18,000, even more. Depending on all the components that are in them, and again, each of those components has to be medically necessary and medically justified. So that's the price range.

REP. WOOD: Thank you, so it's about $300 for the manual and anywhere up to, say, $15,000, $18,000 depending on needs. Great thank you. I appreciate those parameters.

EDWARD BONK: You're welcome.

REP. ABERCROMBIE: Ed, just a quick question for you. The chair that Ed Mambruno was-- what type of chair is that? Because I've seen -- that's the one that actually stands them up. That was amazing.

EDWARD BONK: It's a Permobil. They're actually made in Sweden. So it's the Permobil and that chair does have the capability off adding the components of the sit to stand feature.

REP. ABERCROMBIE: Great. Thank you. Any other questions?

ROBYN COP: I would just like to add one more thing if I could. Just recently I had a patient go home who we asked for a -- he needed a power wheelchair. He's an engineer in one of the major companies in the state and it was very difficult -- you were asking about what you put into these chairs-- to get him a seat elevator. He's an engineer by trade and in order for him to do his job he would need to elevate to be able to do his writing, drawings and so forth. And that has been denied and currently I've been going on three separate denials for that.

REP. ABERCROMBIE: So under the process we have right now, there's no continuation if part of the application is not filled out, it actually stop the process and then you have to start all over again?

ROBYN COP: Yep, and you have a certain time period to do it, which puts constraint on us as clinicians because you want to pick the right tool the first time. So, if somebody has a progressive disease as the physician before me was stating, you're not going to want to have it in 30 days because you're not going to know where the progression of the disease is so you want to make a commitment to a chair that's going to work for that patient as they deteriorate or get better or so forth.

REP. ABERCROMBIE: Thank you. Thank you very much for your testimony. I truly appreciate it.

Sara Wilcox followed by Frank Biondello. I hope I said it right.

SARA WILCOX: Good afternoon. My name is Sara Wilcox. I live in Storrs and have been a Connecticut resident for the last 13 years. I am here to support passage of the Complex Rehab Technology Bill. I cannot stress to you enough how important this legislation is and how important it will be for citizens now and for our future generations.

This is the only way many people with disabilities can get the specialized equipment they need. There are so many reasons this technology is important, not only to me but to others like me. Today I will focus on only a few.

On New Years Day of 2012 I was involved in a serious accident that changed my life forever. Prior to my accident, I was employed full time and operated a residential painting business out of Storrs. I have always maintained employment and was completely independent. My accident changed all of that. I suffered over 207 fractures from this wreck and I am still in need of extensive rehab. Even these conditions never made me want to stop working or give up my independence. My diagnosis, until recently, has been Infected Non-Union of Lower Left Extremity. I underwent 24 surgeries in the last 24 months, all revision surgeries in an effort to save my leg. I have not walked in over two years. My doctors have been trying to get me a wheelchair for the entire two years. I have been denied.

These denials didn't stop me from trying to move forward with my life. I wasn't able to return to my previous position due to my injuries, so I took the opportunity to reinvent myself. I looked at this as an opportunity. Not the end of my life, but the beginning of a new life. One year after my accident I enrolled full time at a Connecticut Community College. I found a part time job. I cannot stress to you how difficult it is to find a job on crutches, even for me. My only mobility device that was approved was crutches. When they wore out six months after issue and a replacement was requested by my doctor, they too were denied. I use a variety of specialty equipment. My latest device is an ultra lightweight wheelchair and I've had it for less than a week. Until recently, I was fighting to get this chair. It has been repeatedly denied. I was approved this time because I wrote a letter and sent it to over 90 people in our state and federal government. In my denial letters from Medicaid it states that I have the right to an appeal, which is what I tried to do. My appeals have never come through. I was never given a date for an appeal. I was never able to speak with anyone. However the letter I did write made an impact. My denial for the wheelchair was overturned and I now have a wheelchair that is appropriate for me.

I feel the most important thing about my devises is that they are custom fitted to me and my set of circumstances. The wheelchair I was fitted for takes into account all of my deficiencies. I cannot go into the store and purchase an off the shelf chair that does this. My specific deficiencies were taken into account by my doctors, my physical therapist, by Jay Hein at Hudson Seating and Mobility, all in an effort to keep my independence. Our bodies are all different and that is why a mobility devices need to be customized by the specific industries who focus in these areas.

My devises help me medically because they prevent the rapid deterioration of my physical body. Functionally they allow me to continue to live somewhat normally. Socially, these devices give me the confidence to engage people again. Without these custom devices I would never be able to maintain employment or even continue my education, which in my opinion is the goal we should all want for our citizens of the state, including those with physical disabilities. Many fail to see that people with disabilities are a group that can enlighten and inspire others. We need these custom devices and the qualified personnel these companies employ to do seating evaluations, repair, adjust and modify them to our specific needs.

More than anything, these customized devises allow people like me to find things we can be good at again. I cant even imagine having a child with a disability who has been denied this opportunity, which is what these custom devises are. They are opportunities for people to live up to their full potential. These complex rehab technology devises even the playing field so someone like me isn't at a disadvantage. The current regs are problematic but by delaying them until June 1 isn't fixing the problem, it only ensures that what happened to me will happen to others. This specialized equipment is vital to children and adults with disabilities. It helps to reduce health care costs and provides independence and safety. The complex rehab technology bill will help improve peoples access to specialized equipment and add safeguards to make sure only qualified companies provide these products and services. Please pass this bill. Thank you for hearing me today.

REP. ABERCROMBIE: Thank you and thank you for coming up to share your story with us. It does make a difference when we're sitting up here and putting a face with what's going on out there so thank you very much for taking the time.

Questions from colleagues? Have a great day and we wish you all the best.

SARA WILCOX: Thank you.

REP. ABERCROMBIE: Frank. Good afternoon, thank you for being here.

FRANK BIONDELLO: Good afternoon and thank you for the opportunity to speak with you today and with the committee members. My name is Frank Biondello. I'm the executive vice president for Nu Motion. Nu Motion is the country's largest provider of complex rehab technology. We have offices in 43 states with about 100 branch locations. We employ nationally 200-- excuse me, 2,000 people, with 200 people in employment here in Connecticut. We have been a provider for complex rehab technology in Connecticut for over the last 20 years.

I'm here today to support State Bill 325. I am concerned that if the current reimbursement for customized wheelchairs and other complex rehab technology remain as is, we will see a compromise with access to these much needed products and services. Today, Connecticut's Medicaid landscape, new motion is one of two companies in the state that provide an estimated 90 percent of the complex rehab technology. I believe that this low number of providers in the state directly correlates with the current situation in the country where we're seeing complex rehab providers exit the industry primarily based on the low reimbursement as well as an issue with inadequate coverage guidelines.

Currently, Connecticut Medicaid reimburses complex rehab technology at rates that are significantly below Medicare rates. Connecticut Medicaid is one of the lowest paying Medicare plans in the country for not only new equipment but also for providing ongoing services and repairs for that equipment, unlike other providers of services, such as companies that will come to your home and fix appliances and things of that nature. Our industry is not reimbursed for travel time or show up time. We have to absorb all those costs which are steadily increasing through the reimbursement from the state Medicaid program, which is also decreasing.

So, when I think you step back and you look at what's happening in the complex rehab industry, as you heard from various colleagues and physicians and therapists and consumers. The need is absolutely there for complex rehab. There's a tremendous justification process that's in place today to ensure that people are getting appropriate equipment, but the complexity, whether its administrative complexity, the complexity and the challenges from a financial standpoint, are increasing. That really challenges us as providers to be able to continue to provide the access to service that we want to provide, have been providing and would like to continue to provide, but is quite frankly threatened by the current reimbursement program and heavy administrative burden. We believe that this State Bill 325 will address these and fully support that and ask for your support as well.

REP. ABERCROMBIE: Thank you for your testimony. Questions? No? Thank you very much. We appreciate you taking the time to be here today.

Moving on to Senate Bill 250, which is AN ACT CONCERNING FAIR HEARINGS. Shelly White. And state your name for the record. Nope not there -- there you go. Not a problem. That's why we're here to help you. Thank you for being here to testify.

SHELLY WHITE: (Inaudible) Thank you Good afternoon Representative Abercrombie and members of the committee. My name is Shelly White. I'm an attorney with New Haven Legal Assistance. I'm actually the litigation director with New Haven Legal Assistance. My office does a great deal of representation of indigent individuals and families with regard to administrative appeals before the Department of Social Services and I'm here today in support of the provisions of Senate Bill 250 which is AN ACT CONCERNING THE FAIR HEARING PROCESS.

You heard extensive testimony about this from the Commissioner and from the Chief Counsel, Brenda Parella earlier today regarding this bill and their opposition to the bill. We feel very strongly about the provisions in the bill that would require separation between the hearing office part of the Department and the part of the Department, which is the legal department, with the in house counsel.

Since 1970, the United States Supreme Court announced that indigent individuals had a right to a fair hearing when they wished to dispute a denial or a termination or a modification of an essential benefit such as public assistance, Medicaid, food stamps or whatever and the essence of this right to a fair hearing is the right to an impartial hearing officer and as the Department is currently structured, hearing officers are within the legal department of the Department. It's called the Office of Legal Counsel, Regulations and Administrative Hearings, OLCRA I believe is the acronym. What that means is that the hearing officers and their supervisors, and the attorneys and their supervisors, all report directly to the chief counsel who represents the Department and the Department obviously has a vested interest in any challenge in an administrative appeal to the denial or termination of benefits. So, it is a structure that is inherently creates a conflict of interest, a much more than an appearance of impropriety but just simply hat the hearing officers are answering to the lawyers essentially in the department with respect to their positions. We don't dispute that the hearing officers may from time to time need legal advice and counsel on particularly complicated or difficult issues. What we have asked is that they -- what the law requires, what constitutional due process requires is that when they make those requests for information that they be part of the record, part of the administrative appeal so that the claimant and or their attorney knows what the problem is, what the need for additional information is and has an opportunity to provide their own legal position to the department.

And therein lies the second part of the bill which has always been problematic is that the department takes the position that it may communicate, that hearing officers and attorneys within this particular division, the legal counsel division of the department may communicate with each other ex-parte as it were without notifying the other side about their concerns. And in fact, as it stands right now, that is prohibited by 4-181 of the Connecticut General Statutes, and as it has been interpreted by the Connecticut Supreme Court in a case that is in my testimony.

I do hope that you will give every consideration to this bill. I think it is absolutely required to ensure that there is a truly fair process, a constitutionally sound process for these indigent individuals. Thank you so much for hearing me.

REP. ABERCROMBIE: Thank you for your testimony. Any questions? Thank you very much. We appreciate your time.

SHELLY WHITE: Thank you.


Steve Karp. Good afternoon. Thank you for being here.

STEVE KARP: Thank you. Good afternoon. My name is Stephen Karp. I'm the Executive Director for the National Association of Social Workers, Connecticut Chapter and we're here today in support of S.B. 251, but also to ask you to go further. When I was in graduate school, I had professor who told me that poor people get poor services. I don't think that's always the case but it surely has become the case to DSS. I'd like to just very quickly tell you a couple of stories of some of our members who work with individuals who are receiving DSS services.

Wait times are typically from an hour to three, four hours on the phone. We have a member who works for the Judicial District -- Judicial Branch, she called DSS, waited an hour, had lunch. She had to be in court. She forgot to disconnect the line. She came back from court and discovered she was still on hold.

We have a 20 something gentlemen who is addicted to drugs. He successfully got on to a methadone program. Was on a methadone program for almost two years. His father, who's assisting him, sent in all the necessary paperwork to keep his HUSKY going. Somehow DSS lost it, he lost his HUSKY, he got to the methadone clinic, discovered he could no longer get his treatments. He went back on heroin. He eventually did get back on methadone but he's now lost a lot of time in terms of his rehab.

We have another individual that -- actually a quote from the town social service director. "We spent an inordinate amount of time trying to undo the mistakes of DSS. Countless residents being denied or discontinued because DSS is behind, loses information or computer system continues to automatically generate negative notices because DSS hasn't processed paperwork timely. We are responding to emergency prescriptions and food because of this broken system. Not every community can or will.

We have a woman struggling from depression. She lost her job. It took her six months to get on to HUSKY. During that period of time she ran up significant (inaudible) debts because of the health care costs.

We could go on with more testimony in terms of stories but I want to give you a couple recommendations.

Beyond this particular bill, first of all it is very clear that there is immediate need for additional staffing. It is very clear there is immediate need for additional phone capacity to handle the volumes of phone calls. We think there should be a six-month moratorium on discontinuation of benefits, if that's possible under the federal and state laws. (Inaudible). I know that Sheldon Toubman from New Haven Legal Aid has submitted testimony with further suggestions which we also support.

Most importantly I think that, you know, these are poor, lower income individuals. Any other population I don't think we'd ever put up with this. But this is a group of folks who obviously they're not making donations to political action committees. It's very clear that we should be able to do better as the State of Connecticut. This is a problem that's been around a long time. I think the lesson to be learned here is that when you ignore an agency for years, don't give them the resources necessary, that this is the kind of problems we have. This took a long time to get to this point. It's going to take a while to get it resolved. But we do think this legislature moving forward needs to take action both immediately to deal with these problems but also to make sure DSS has resources in the future so that the populations that are being served by the agency are getting adequate care.

REP. ABERCROMBIE: Thank you. Thank you for your testimony. Questions from committee members? Thank you very much. We appreciate you being here. Sheldon, followed by Nancy Boone.

SHELDON TOUBMAN: Good afternoon Representative Abercrombie, members of the committee. My name is Sheldon Toubman, I'm a staff attorney at New Haven Legal Assistance.

Couple things that were said today-- not my written testimony. I want to respond to the issue of staffing. The Commissioner said 200 people were hired. We'll that's a couple years ago and the staffing levels today at DSS are about what they were 12 years ago. The food stamps enrollment has doubled, Medicaid enrollment has doubled, so although the Commissioner can't state it because OPM has orders, they need more staff and that's clearly in the case of the phone banking system, et cetera.

The other think I wanted to respond to was about the customized wheelchair regs. As mentioned, it's true, they delay it till June 1, but this morning, I got -- I haven't read it carefully, we promulgated the exact same regulations, but effective June 1. And just to emphasize this one little fact, there's no reference here to motorized anything. In fact, there's no reference to the word independence let alone independent mobility. The one reference to motorized wheelchairs is to take it out of existing law. The proposed to remove the one reference to motorized wheelchairs. So, delaying three months doesn't solve the problem. These regulations have to be stopped and completely rewritten.

Now, what I want to testify about -- sorry about that. Little sidebar. Raised Bill 251, which we fully support, and in addition, as Steve Karp just mentioned, we want to go a little beyond that and attached to my testimony is a proposal to fix the redetermination process. Specifically the problem which you've all heard from constituents is an endemic problem, is the Department, because it doesn't have enough staff, cannot keep up with the processing of the redetermination forms. I don't believe they're losing them anymore. I think the scanning center does acknowledge they have them and it goes into the right electronic file almost all the time, but there's not enough staff to process the redeterminations in the queue. As a result, routinely, thousands of people who have timely submitted -- timely-- completed redetermination forms and submitted them and they've gotten into the system are terminated with a notice that says "You're being terminated because you didn't do the redetermination." and in fact they are terminated at the end.

On February 14, there was a MAPOC Council meeting, I'm not sure if any of you folks were there but -- okay, but at it the Commissioner basically acknowledged something he didn't acknowledge this morning and that is they can't keep up with the processing of the redetermination. So, at one point, one of his aids did say there were going to look at something we've been asking for for over a year and a half and that is to change the default at redetermination. Unfortunately this can't work under federal law for SNAP, but it can work for everything else. And the change in default is simply this. If the system shows that a redetermination form came in on time by the deadline-- if I could just wrap up-- then the department will shut off the auto termination unless and until the redetermination form in the system is reviewed and the person is found to be ineligible. Right now the default is, if they don't do anything, because they can't get to it, all of those thousands of people are terminated because they cant get to it and the system -- the default is shutting them off.

So, completely consistent with federal law, except in the case of SNAP, we can just change that as the commissioner seemed to suggest three weeks ago -- or two week ago, was okay, but now is changing his mind I guess. It can be solved and other states have done this, like Colorado, Louisiana, they've changed the default. And until there's enough staff available to actually process all the paper that's coming in, something -- like Steve Karp said-- something has to be done because when these people are cut off they can't pay their rent. When they're cut off they cant get drugs filled at the pharmacy. We've heard of people having surgeries cancelled because they're fully eligible for Medicaid, they've done everything they're supposed to do, their paperwork shows that they're fully eligible for Medicaid but they're cut off anyway because the department simply cannot keep up. We've heard al kinds of excuses for this and we were told months and months ago that CONNECT is going to solve everything, modernization is going to solve everything, right? Now, we're hearing the story that modernization is we're only eight months into it. And so give us a break. This is fundamentally a staffing problem. If the department is unwilling or unable because of orders from OPM to fix it, then I think the legislature has to step in and say fine, we're changing the default and the language attached to my testimony solves this including a solution in part for SNAP.

Thank you very much.

REP. ABERCROMBIE: Thank you and thank you for your testimony. Any questions from committee members? Terry -- Representative Wood. Sorry.

REP. WOOD: I'm back on the customized wheelchair even though that's not why you're testifying. I'm just trying to get my head totally around what this -- you said "they". Who is "they" prom--whatever that word is--


REP. WOOD: I know what it means but-- the "they" being-- who is "they"? I'm trying to figure out who is trying to effect this change.

SHELDON TOUBMAN: I'm probably being recorded so I have to be careful what I say here, but I think that what is happening is that a system that worked pretty well, customized wheelchairs, motorized -- it's difficult, I was shaking my head earlier, it's difficult to go through the process, but it has worked pretty well. Somebody, or some bodies at DSS or OPM, I don't know, decided that this is an area where we can save money and they came to legislature and they got a bill passed in the Deficit Mitigation Act in 2012 which had something completely illegal in it. Fundamentally illegal. It said that you can't request a customized wheelchair without permission from DSS which was absurd and we did get that fixed, but there were other things that were put in there. What was not told to the legislature is that this is an area where things are working well and we really shouldn't mess with this.

As a result of the passage of that, the Department of Social Services felt that it was free to come up with new regulations. Not only that, it started denying access to services. You heard the story from Sara Wilcox the amputee who couldn't get the wheelchair, right? Unbelievable stories where people go through all the processes, clearly need the things, and can't get them. So, simultaneously they started denying access to all kinds of customized wheelchairs for people in the community like Sara. People in nursing homes were getting a lot of these cases. They're doing that already and simultaneously they, the Department of Social Services, has promulgated these 30 pages of regulations which would severely restrict access to customized wheelchairs and particularly motorized wheelchairs. And as I said at the beginning, no reference to independence, which is the primary purpose behind a wheelchair is to give people independence. These regulations have to be junked or all the problems that people have now are going to become manifested many times over. Thank you.

REP. WOOD: That's been clear this afternoon. Thank you very much. Perhaps, Madam Chair, perhaps we can get the person at DSS who is responsible for these regulations and just have a conversation, understand that side of it.

Great, thank you very much.

REP. ABERCROMBIE: Any further questions? Thank you, Sheldon. We appreciate your time.

Nancy Boone followed by Roger Senserrich. I hope that's right.

NANCY BOONE: Good afternoon. I am Nancy Boone. I'm the coordinator of the Connecticut Alliance for Basic Human Needs. I agree with Steve Karp and Sheldon. I'm here to support S.B. 251.

Although I support this bill it is only a band aid. It's not a solution to the problems you've been hearing about at DSS. The solution is for DSS to process applications and redeterminations for the benefits on which one in five of us depend. In failing to do so, DSS puts people's shelter, food, security and health at risk as you've heard. Although the number of people affected by DSS's failure is unacceptably and shamefully high, this is not about numbers. It's about people. It's about families. In the past week, I've received so many heart-breaking stories about how DSS is failing our friends, neighbors and parents and attached to my testimony are several -- several dozen emails you gotten -- I've gotten just since Thursday. My testimony looks this CABHN letterhead.

DSS has one phone line, one terribly understaffed phone line for all callers, all problems, all questions and that phone line is busy. The wait times have been and continue to be hours long and this is not getting any better. DSS sends termination letters to and actually terminates people who get their documents in on time as Mr. Toubman was explaining. This, too, is not getting any better. And as one reason, the phones and offices are so full. Even if benefits are never actually terminated, getting the notice that your benefits are going to be terminated is unsettling and causes people to call DSS and causes them to go into offices when DSS doesn't answer the phone. All of this is clogging up phone lines, in boxes and offices of not just DSS, but town social service providers around the state. It's a waste of time and it's a waste of money.

Some solutions, in addition to what's in S.B. 251, that can and should be implemented are adding enough staff to the 1-800 line to answer calls; automatically continuing benefits, instead of automatically terminating them, this is particularly important for medical benefits and QMB payments; stop please sending out termination notices if documents have been submitted as Mr. Toubman was explaining; have a phone line and email system designated for providers. We hear this over and over and over; let people do simple things like change their address or request a new EBT card by email or by leaving a message. Now people have to wait five hours to let DSS know their address changed; improve the phone interview process required for SNAP by letting people call in to a designated and answered phone line at a time that is convenient for them; and let people submit redeterminations for multiple programs at one time instead of submitting the same documentation for two different programs, two or three weeks apart.

People don't care whose fault it is. People don't care that DSS is working on it, that the computer system is old or determination letters are automatically generated. There are no excuses when it comes to people's basic needs. The Department must do better and it must do better now.

I've been here before talking to you about this and I'm wrapping up. There are still very serious problems and you can change this by requiring the Department implement these solutions.

Thank you.

SENATOR SLOSSBERG: Are there any questions? Seeing none. Thank you very much for your testimony.

Our next speaker is Roger Senserrich followed by Hannah Jurewicz -- Jurewicz, oh, not too bad. Okay. Not good enough but keep working on it. Okay. Roger, you're up.

ROGER SENSERRICH: Good afternoon. First of all, thanks Senator Slossberg, members of the committee for letting me testify today.

I'm here to speak in favor of S.B. 251. I will second those remarks from the previous testimony regarding the service that DSS is providing to clients.

The Connecticut Association for Human Services has a program called Access Benefits Online. We partner with more than thirty organizations across the state with application assistance. We have about 1,000 households every month sending applications to DSS and we get really good data from DSS tracking how successful we are with the applications.

For the last six, seven months the error rates that we're seeing in applications that we submit have doubled. Basically twice the amount of applications that we were seeing are either delayed, never processed or just wrongfully denied. We have clients forced to send applications over and over again even if we know that they are eligible.

Today I was on the phone with a client, we are sending her application for the third time. We faxed it the first time. Never made it through. DSS actually stopped taking faxes in the end of December because, according to them, they couldn't handle the volume that they were getting. We mailed it the second time, it got denied. The third time I am actually going to go to central office and drop it by hand because obviously it's not working any other way. I was three hours on the phone waiting to get a word from anyone at DSS trying to see if the application was in the system or not. It wasn't. The client actually couldn't call herself because she didn't have minutes on the phone. She had wasted two hours the day before and she had run out of minutes on her cell phone so she couldn't call DSS.

What S.B. 251 does is actually a patch. It's not really a solution. It makes DSS accept applications, not just in the mail or through the website that - even if its an improvement its actually still really cumbersome and the applications are not processed any faster. It asks clients to actually scan documents. Most clients don't have access to a scanner so they cannot upload the documentation, they have to mail them. What S.B. 251 does, it opens up the possibility that DSS can take applications via email or via fax, something that they haven't been able to do so far.

This will be small improvement. It will help clients communicate with DSS more effectively. We will be able to reach out to DSS in other ways instead of trying to get through the brick wall phone system that they have. It's not enough. As previous testimony said, DSS actually what they need is more staffing. They are using the same computing system they were using -- same computers they were using in 1989. That's when EMS was first implemented. It was state of the art in 1989. Definitely no longer state of the art. They have the same staffing that they had 12 years ago. They have twice the amount of cases and the computers are not(inaudible) EMS goes down from time to time. (Inaudible) need to be added by hand, so the system is actually not effective, serving the needs of the clients that they have.

With all said, S.B. 251, yes will be in an improvement but DSS needs more resources. They need to change procedures and they need to be held accountable. Some organization is a real improvement on the system and not this weird transition where we are seeing service getting worse instead of getting better.

SENATOR SLOSSBERG: Thank you for your testimony. Are there any questions? Thank you.

Our next speaker is Hannah Jurewicz followed by Lucy Nolan.

HANNAH JUREWICZ: Hello. I'm Hanna Jurewicz and good afternoon. I wanted to kind of echo what's been said here today about S.B. 251.

I'm the Senior Director of Dungarvin CT. Just to give you a little bit -- Dungarvin provides residential and day services for individuals with intellectual and related disabilities throughout the state. We serve homes in Torrington, the Greater Waterbury area, Bristol, Hartford, Canton, Windsor, Windsor Locks, Plymouth, Manchester. So we're all over, Middletown, New Haven. We support them as they perform meaningful work in these communities and assist them when they contribute to the commerce of their towns by shopping, dining and enjoying various recreational interests. So, today I'm testifying in favor of S.B. 251. I firmly believe this will provide easier access for individuals and I think right now it's --yes, I total agree with the other recommendations about the staffing in the system, but I do want to give you a couple of examples where it's also about the training and it's about the service in general.

So, I called DSS benefits line. I waited over two hours, as other people have testified as well. I had sent in three redeterminations and so at the same time. They only acknowledged two of them. And so, and they had said that because they had been sending them to the wrong address. So we updated the address. We thought everything was fine. The following month they are not eligible again. So we thought they fixed it but they didn't. So, the mail just kept going back to some other address. So again we updated the address, did it again. Then after an hour the representative at DSS found the checks for the individual they said that had been returned. They said they would send them out, but then they had said that we needed to apply all over again because now they had been brought back so you were no longer eligible. We had to reapply. So it's not just an admission problem. It's not just a redetermination. It's training. It's understanding, like these sort of cockamamie like answers du jour just to kind of move the people along.

Another time we called and the representative wouldn't speak to us. They said that they had to speak to the individual. We said we're the rep payee for the individual. They were not -- it was not something they could understand. So she insisted, so we had to put him on the phone and then she got off the phone with him, called us back and said that he was confused and that he didn't understand what she was talking about. Right. So, again, it's understanding what our role is in the process and understanding what rep payee really means. We asked to speak to a supervisor who might be able to help us because this representative could not and then we were passed on to another department, not a supervisor of course.

So, we talked about the same thing, the redeterminations. We've had that happen over and over again. They've lost medical benefits in addition to losing all of the other benefits. Not being able to use food stamps, not being able to get their personal care items, you know, things like oil and energy get cut off because they don't have the funds they need and have to use whatever funds they can have for covering medical care. It's just unacceptable the way that we're allowing these folks that we're supposed to be supporting to have to live and fight the system.

So, I have a number of -- most recently, a number of examples I submitted, but most recently in January we have an individual that's sitting in a hospital in Middletown. He was referred to the hospital -- may I just finish quickly?

SENATOR SLOSSBERG: If you would just surmise.

HANNAH JUREWICZ: I will. Anyway, he's sitting in one hospital. He needed to go to the Hospital for Special Care. DSS won't allow that. They won't pay for it because his birth date is wrong. But they're paying for it at the other hospital where they don't have that issue. So, he's sitting still in the hospital a month later, can't get the care he needs. He's in a holding pattern because of another DSS issue. And I'll just say -- last statement-- that this bill should go a step further and change both the adding staff, additional training and change the default action from Medicaid redetermination. The system should be reprogrammed to continue Medicaid eligibility for anyone who has timely submitted their Medicaid redetermination and DSS affirmatively reviews the form and determines that a person should be terminated.

So, thank you very much for your time. I appreciate it. Any questions.

SENATOR SLOSSBERG: Thank you, Hannah. Thank you for your testimony. You know, when you have -- when you're making a phone call to DSS on behalf of a consumer and you have these problems, how do you keep track of that? Do you document everybody you've called and everybody you've spoken to? Like, if you get on the phone with DSS do you make a note: its Tuesday, it's 2: 30, I talked to so and so, have a name and a last name and this is what they told me.

Do you keep records like that?

HANNAH JUREWICZ: We do and it fills up file cabinets at this point. We do track it.

SENATOR SLOSSBERG: I'm sure it does. I'm sure it does. So, my next question, though, is when you get to a point where you're feeling like, okay this is just not acceptable, where do you go with that? Outside of coming here and testifying, where do you go in the moment you know, when that happens? Is there some place or someone that you call where you say, "Okay, I hit a wall. What do I do now?"

HANNAH JUREWICS: Actually, it is a problem that agencies such as mine suffer with. So, the challenge is we make as many calls and go to as many people. We do -- our legislators are our only contact at this point. What ends up happening is these individuals end up accruing a debt because we end up having to provide that support or care so we have to fund whatever is not getting funded. Whether it's you know, food or personal care items or their rent, whatever. So there's no way that they can possibly pay this back. Agencies end up having to feel the mistakes and the errors and the incompetence of the system in DSS. So it's just being transferred. So, if DSS doesn't come through and these redeterminations don't happen, then the providers end up having to pick that up because we're obligated to do so. We have to make sure that they get their care.

SENATOR SLOSSBERG: I understand that. I'm asking you a systems question and that is within the system, you know, and you mentioned your legislators, is that the next step when you get, you know, okay I cant get through, and I really appreciate you giving us all of the specific examples. I think that's really helpful and useful and good to have. But when you get to that point where you're frustrated and you're not able to get somebody their benefits or get this straight, is there anybody within DSS that you call beyond that?

HANNAH JUREWICZ: No, you get the same answers.

SENATOR SLOSSBERG: Okay so you keep going around in circles. And the next person you call generally is a legislator for that consumer that you're unable to get this problem resolved with? Is that generally--

HANNAH JUREWICZ: I mean -- and what happens is we get a sympathetic response but there's little one legislator can do at a time because they get the same wall we do. So, yes, we do just to keep the concerns alive and the truth is we've just been struggling with it. It's just hitting a brick wall right now and as I say, we're the ones who end up paying for it because we can't allow them not to have what they need.

SENATOR SLOSSBERG: Okay, because I know obviously when our constituents call us with problems, with any state agency, we as legislators then go to that state agency and try to get that resolved. So, I want -- I'm glad that you call your legislator. I would hope that that would be an avenue that at least in the interim while we're continuing to try to work through these problems, and I understand, we all agree. Even the Commissioner, you heard him say it. He's not happy with where we are but that-- we've come a long way, we've got a long way to go.

Having said that, though, in the interim as an agency, if you have people in need, you know, your legislator, I would think, would be calling over to DSS or calling over quite frankly to their you know, to folks on this committee to say "I'm having trouble on behalf of my constituents." So, I would hope that that would be happening because I don't think that the default position is that you're -- obviously we all pitch in and do whatever we need to do when somebody is in need. I think that's obviously the right thing to do but having said that systemically, I would want you to be going through whatever avenues were available to you because the more people that are talking about this and experiencing this the more likely it is that we continue to keep this moving in the right direction.

HANNAH JUREWICZ: I will add that DDS has set up liaisons -- DSS liaisons in their central office for us to contact for help and that seems to help, but that pile of work for that one person is extraordinary.

SENATOR SLOSSBERG: Okay, well I appreciate knowing that and again thank you very much for your testimony.

Any questions from the members? No? Thank you very much for your good work.

Our next speaker is Lucy Nolan followed by Christy Barber.

Is Lucy here? I don't see Lucy. Okay, we'll move on to Christy Barber and if Lucy comes back, she can go next. She's not here either? Okay. Then that completes Senate Bill 251.

We're going to move on to House Bill 5322. Our first speaker is Dennis Cleary followed by Matthew Barrett. You may go together. Which puts Deborah Chernoff on deck.

MATTHEW BARRETT: Good afternoon Senator Slossberg and members of the committee for (inaudible). My name is Matthew Barrett. I am the Executive Vice President of the Connecticut Association of Health Care Facilities which is our states trade association of 167 skilled nursing facilities and rehabilitation centers. I'm delighted and privileged to have the opportunity to testify with Dennis Cleary, longstanding member of our CAHCF Board of Directors.

If I might, just on the issue of redeterminations, and offer a remark that I think is consistent with Attorney Sheldon Taubman's remark. You know, the state of -- the Commonwealth of Massachusetts employs what they refer to as a passive annual redetermination process for Title 19 cases that are stable. When I mean stable, their categorical eligibility is not likely to change much. People with disabilities people who are senior citizens, and their income and assets are not likely to change much either. Their primary source of income tends to be Social Security Disability and they've already gone through a rigorous asset determination so there's likely to be no changes in assets. Anyway the State of -- Commonwealth issues sort of a prepopulated redetermination form with the presumption that you will remain eligible for Medicaid unless you affirmatively indicate your circumstances have changed. If you do not return the form, you don't get discontinued, you continue your eligibility. I think that it's a process that works very well in that state. It meets CMS muster. It satisfies the annual redetermination process and I think that it should be considered in Connecticut over time. We've floated the idea a number of times and I think it's very consistent with Attorney Sheldon Toubman's remarks.

Having said that I would like to turn our attention quickly since it's the opportunity to testify on or at least mention briefly other bills on the agenda. The Commission on Aging I thought delivered very excellent testimony and support of presumptive eligibility for home care Senate Bill 254 and also mention legislation that was considered by this committee two weeks ago. Same issue. Crisis in Medicaid eligibility determinations and that was Senate Bill 104 offered for advanced payments for Connecticut nursing facilities.

But to the issue that brings us here today, at least our group here, it's the bill, House Bill 5322 AN ACT CONCERNING NURSING FACILITY MINIMUM STAFFING LEVELS. I submitted very lengthy written testimony for the record. And so let me just say that we think the issue, while admirable, requires further study. In many respects the proposed statutory construction conflicts with existing requirements. Certain staff that are currently eligible to be considered as part of the direct care staff would not be allowed to be considered in that way under the way the bill is written. And we view the bill, while it's been characterized as very few facilities would be affected by the new minimums, we're very concerned that actually quite a few facilities would be effected and there's no Medicaid funding trigger that would recognize the increased costs associated with those new staffing requirements. And I think Dennis will have some additional remarks concerning that. But for those reasons we would offer to work with the committee, the Office of Fiscal Analysis, OPM, Department of Public Health, DSS to really get a handle on what are the existing requirements, what are the new requirements of the bill to try to determine how would nursing homes have to staff up to meet these requirements fairly, estimate the cost associated with that and then go from there. And I understand our time is up but would Dennis have the opportunity to make a concluding remark?

DENNIS CLEARY: Madam Chairman, very briefly in regards to the staffing bill. I've been a registered nurse and a nursing home administrator for 38 years working in the State of Connecticut and I think management in nursing homes with very very scarce resources need to be able to have flexibility. This bill does not allow a facility with certain acuity of residents to have more RN's or more LPNs. In some cases less RNs and more CNAs depending on the ADL needs of their patients, and as well as the time of day of that staffing. Dementia units historically need a lot more staff on second shift as opposed to first shift because of sundowning and a lot of things that happen with that resident population. So, I think that flexibility is needed I think to tie into a time a day and a number of hours and it doesn't specify RNs, LPNs, CNAs because a particular facility might be better to have two RNs on a particular unit with a certain type of acuity than it would to have one LPN and two CNAs. It depends on the patient population. So, just to consider that.

In regards to the second bill that the industry has put forward on the temporary reduction in beds. The Commissioner had some comments this morning. I'm not quite sure where he's getting his information because he was concerned that up to 1,350 beds could be taken out of the system. I believe Money Follows the Person is estimated close to 4,000 beds that they'd like to see taken out of the system. So I wasn't quite sure why taking 1,350 in his opinion by this bill would be problematic.

What this allows is for a gradual reduction in beds. Many of them, in some cases, are substandard beds in my opinion to start with. There are many 45-year-old buildings in the State of Connecticut that still have three bed rooms. Well, I don't know about your constituents, but mine won't go in a three bed room and this would allow facilities in effect to upgrade by taking some of those excess beds out of the system where they maybe cant afford to do a complete rehab of the facility and maybe don't have enough land to do a major addition, but can start to downsize as we move through the Money Follows the Person community based services, which I thought was everybody's goal. I think if the industry wants to be part of that solution, not part of the problem. Currently, Connecticut pays about $25.00 a day less than Medicaid cost in a facility. There'd be a portion of the rate that could be rebased by DSS under this proposal. At the same time, we're very willing to work with OPM and with DSS to fine tune this language. We really see it as a work in progress and hopefully this committee can possibly get it to appropriations where that process will continue to really flush out the details. As far as the Commissioner's workload, we understand he has a lot of things on his plate, but the Department has been in charge of Certificate of Needs for nursing home beds for 35 years in the State of Connecticut. They have an office that's titled that. It's the Office of Certificate of Need and Rate Setting and that's what they do. They determine bed need in a particular area. This bill basically says we're not taking occupied beds out of service. We're taking unoccupied beds in areas that have excess beds in particular facilities with low occupancy and where within a 15-mile radius there is a low occupancy. We certainly don't want to create any shortages by any stretch of the imagination. We'd also have no problem as a work in progress if the committee wanted to put this out as a pilot bill where it had a maximum reduction of 500 beds in one particular year since that would solve a portion of the Money Follows the Person estimates. So, other than that I'm more than happy to answer any question, Madam Chairman and thank you.

MATTHEW BARRETT: Dennis is referring to Senate Bill 253 AN ACT CONCERNING TEMPORARY NURSING HOME BED REDUCTIONS. And Chairman Slossberg I want to take this opportunity to thank you for your leadership for raising the bill for a public hearing today. Earlier this morning you did hear a view that is different from the nursing home industry sector's view on the bill. We think the legislation is wholly and completely consistent and will accept the states rightsizing and rebalancing efforts in a way that is organized and in a way that frankly will keep facilities open. Open with less bed capacity, but we would really decrease the opportunity for the transfer and trauma that's associated with closing a nursing facility and a lost job and the economic impact associated with that. Thank you very much.

SENATOR SLOSSBERG: Thank you. Thank you. Representative Cook you have a question.

REP. COOK: Thank you Madam Chair. Hi guys. I have a question. In relation to the Bill 253 that we've been talking about and I heard the commissioner's testimony and I'm listening to you all and I've had to be in and out. With the bed reductions and the proposals, do we have an idea where those 1,300 proposed beds of reduction are? Are they spread throughout the state or are they primarily located in a certain location? Can you give us some kind of answer?

DENNIS CLEARY: Number one, I don't particularly think the 1,350 beds -- I think he's just taking all the current vacant beds, if every single one of them went away. Poof. I just don't see that happening. I think that they would be spread out throughout the state and they could not come from an area that has too few beds already. I think the New Haven area in particular normally has very very high occupancy because there just aren't enough beds to serve the population. So, no beds would be able to be reduced out of there under the language that says within a 15 mile radius you have to assure that there is enough beds in the system and that your facility has run low occupancy for whatever that reason is and put all those pieces together to make this work. So, it wouldn't be coming from an area that was designated area that had a shortage. It would be for excess capacity and in some cases facilities that have long standing had low occupancy.

MATTHEW BARRETT: In fact, I've gone, if I could just very briefly say that -- one of the challenges for rightsizing and rebalancing is that we have an explosion in the population of over 65 over the next 24 years and I love that Governor Malloy refers to it as the Silver Tsunami and I think he is absolutely correct. And so many nursing facilities they are experiencing low census will try to hang on, I think, as they see the population going incidents of disability among this population is actually higher, not fewer, despite all of our breakthroughs in medicine. So, we will see this sort of gradual, painful rebalancing, while nursing homes hang on waiting for that population to hit and then to be full again. I think these beds -- this proposal will take beds out of the system now. And I would say that the control of the authority the ability to control the reentry of the beds into the system, which our proposal is very clear about, rests with the department. You know, there's this -- we struggle on the rate setting bill a couple weeks ago. The industry wants to see some certainty. We want to say, "If you do this, the following will happen." The executive branch may be appropriate for them to want maximum flexibility. The same is true here but they will not have the flexibility in terms of who triggers beds coming out of the system but they'll have total control over who reenters.

REP. COOK: Thank you. Thank you Madam Chair.


SENATOR MARKLEY: Let me ask a couple questions about both the bills you mentioned. The staffing levels first.

When you say that there's the proposal simply to raise the number denies flexibility, there is currently a number of that sort and other states have such a number. Am I right about that?

DENNIS CLEARY: There is currently an amount of staff within those two time periods of the day but because most facilities are at 30 or 40 or 50 percent above that, then it really doesn't impact. But as you move that number up or more facilities are bumping up against that floor at some point, then it will eliminate the flexibility of being able to put people where you need them. Both what level the person, because remember this nursing staff is a combination of three different job classifications for the most part and I think that's where the flexibility of time of day for your resident population as well as what mix of nursing staff comprises those hours. You have x amount of budget to deal with and you need to put that mix together as best you can for your resident population.

SENATOR MARKLEY: You indicate though that if there were a way of including the right kind of flexibility in that staffing level that it's something you think you might be willing to take a look at.

DENNIS CLEARY: I've personally been certainly in favor of improving quality of nursing homes my entire life in the state of Connecticut. I think that if it was proposed as just a total number of hours per day of staffing, that it wasn't restricted to a definition of direct care staff. In a particular building the education nurse could be one of the most important people depending upon the mix of that staff. Why would she not be considered as part of the staffing of that facility? A facility with a lot of residents within infections, why wouldn't the infection control nurse be part of that nursing team and be counted as total hours, which is the way the system is now. When you look at the number of hours and that's why I'm concerned as to where the statistics come from as to only two facilities in the state would need it, because the information currently on a cost report doesn't give you that information. It gives you total number of RN hours. It doesn't tell you how many are on a unit with residents or how many are teaching CNAs or how many are supervising other nurses. They're all combined by job classification. So with this requiring a specific definition of who is even counted within the numbers as well as the time of day, I think both are problematic. If you were to look at the total number of hours per day now and say, "Geez. We'd really like to increase that." Without telling you what time of day or who to hire by ten percent a year for the next three years or whatever. But to take a 40 percent swipe at it with no dollars attached I think is going to be extremely problematic.

SENATOR MARKLEY: I -- to speak to some extent for the advocates for the bill who are right behind you and I think prepared to speak on their own behalf shortly. Certainly their concern was with the -- as I understand it-- is with the direct care nursing staff. The people that are actually on the floor dealing with patients on any given moment. And I think that's again, I'm neither in the business nor in the nursing home, nor anywhere else. I'm seeing it from a distance, but when you're -- but one's bottom line concern about staffing I think tends to be on that level so how many nurses are there for how many people walking around right now available to take care of them. And I don't know the business or the experience well enough to know what the right number minimum number in that way ought to be and certainly everybody else that's available is performing other useful functions and may even be performing more direct functions as the occasion might demand at various moments. That said, you know, when we talk about a work in progress I think one thing I'd like to see generally is for that progress to take place between sessions instead of during sessions because I think it's so difficult. And in talking about the other bill that we'll get to, to hope that that can be improved by the Appropriations Committee in the next couple of months I hardly feel like I can myself can keep up with what's in front of us right now let alone try to go deeply into other things. I'm very open to the idea on both of these bills, trying to find a way to address them before we come back in January. And I guess I would encourage you on the staffing level though because we've had such -- it has been persistent advocacy, lets say, that has brought the bill up to this point and I think it's important that whoever is working to devise something includes along with the Department and the industry and the legislators and everyone else the folks who are sufficiently moved by this to stay with it long enough to bring it before us today.

Let's go around to the bed reduction. And you were here for the Commissioner's testimony this morning. And I tried to ask him at that time -- I don't know if you can do better to address what he said than what you already said. Obviously there is a desire on all sides to reduce the number of nursing home beds. I think that it seems to me that the proposal you've brought before us does that in a sensible way by saying lets reduce nursing home beds that aren't occupied. That would be a good way to start. The Commissioner seemed to indicate perhaps that the Department wants to have more direct control over where that decision is made, not doing it just because there happened to be empty beds. The other thing they brought up more specifically was the idea that you reduce the number of beds you don't necessarily reduce the fixed costs, therefore to some extent cost per bed is going to increase. I guess I would say to the Commissioner if I could drag him back here again, wouldn't that be the case no matter how we did it? Whether you're the one deciding which beds to close. I guess his answer might be, if we shut down the whole facility then there is no overhead left there at all.

DENNIS CLEARY: Senator, the best I could get of the Commissioners testimony, and I don't want to put words in his mouth, but it seemed like he was speaking about the infrastructure not changing by reducing beds, 10 here and five there and eight here and that the only way that the state was going to get cost savings was for buildings to close. Well, we all know how that's worked for the last fifteen years. There's been a lot of buildings that have been closed and every single community has spent two or three years fighting every single closure as there are important resources within the community that they do business and I'm not so sure that I want to see a whole list of people laid off to close one building of 150 beds, when that might be 10 beds in 15 different buildings that would improve the care in 15 buildings. That's what makes sense to me. The overhead cost for any Medicaid rate adjustments would only be for those fixed things. Let's face it. If you reduce 10 beds, the mortgage doesn't change, okay? Some of your costs that is related to staffing that you can adjust for the number of meals you're making, the amount of laundry you're doing, can be adjusted. But some of that fixed cost would have to be rebased with in the system.

So a facility that might reduce their beds 10 percent might get a three percent Medicaid rate increase. Well, that three percent might be something that will keep them going that otherwise they wouldn't. It's either that or you go out and close 10 nursing homes altogether and who is going to make that decision? Are we going to leave that to the Commissioner of Social Services to decide if it's your town that's losing 100 beds or your town or your town or your town?

SENATOR MARKLEY: Well, and it might be argued that these bed reductions spread out among many homes to some extent start to address the very subject we were just talking about which is the staffing levels without putting people out of work but rather giving them a chance to improve the level of care they're providing.

I want to say finally, Dennis, that I think both of us agree that a 45 year old is not a particularly old anything in my opinion. I think I've known you that long. Thank you very much Madam Chair and thank you.

SENATOR SLOSSBERG: Thank you. Are there further questions? All right. Thank you gentlemen. Look forward to continuing to work with you. Our next speaker is Deborah Chernoff.

Good afternoon.

DEBORAH CHERNOFF: Good afternoon everyone. For the record, my name is Deborah Chernoff. I'm the public policy director for New England Health Care Employees Union District 1199.

As you know, our union represents more than 6,000 caregivers in Connecticut nursing homes and we have frequently advocated for the need to improve minimum staffing levels in those facilities. Our members have testified often and eloquently in the past about the impact that short staffing has on resident care, about the corners that got cut because there's a limit to one person can do in an eight hour day, the call bells that don't get answered, the baths that don't get given, the meals that are served late, the incontinent care delayed, the list goes on.

As nursing home residents have gotten frailer and older and hospitals discharge patients sooner, resident needs have increased but minimum staffing levels have not. Therefore, any public measure that moves us in the direction of doing that, of improving staffing deserves our support.

We continue to believe that there may be a better way to do that which is by setting minimum staff to resident ratios which is far easier to monitor than hours of care per day and that is the position that is taken by most of the research in this area and by the leading advocacy organizations. But while that might be the preferable reproach, staffing levels desperately need updating any legislation that moves us in that direction should be seriously considered.

I'm also speaking to Senate Bill 253, which we believe would assist in the state's current efforts to rebalance the long term care system in a thoughtful and deliberate manner. I've testified in the past that the contraction of nursing homes beds over the last ten years or more has been anything but thoughtful. Instead relying on a kind of financial Darwinism whereby nursing homes fail and beds disappear due to bankruptcy receivership and without regard to the needs of residents, communities or workers. Achieving bed reduction that way is the worst sort of laissez faire public policy that puts our economy and our elderly at risk. These closures are traumatic for our members who are faced with the loss of their jobs after long years of service, but even more so for the residents in the nursing homes who are evicted from their homes and displaced from their communities. Given the current financial insecurity in a long term care industry and a historically inadequate reimbursement rates, this seems to us a worthwhile approach that will assist in the efforts to rebalance while providing modest rate relief to those facilities that do cut bed numbers. We do need to keep in mind that they Silver Tsunami is already breaking over us. No matter how serious our efforts to rebalance our system of long term care may be, the demographics tell us that the percentage of the population that will need nursing home care at some point will keep growing and we need to be able to respond. Therefore on behalf of our nursing home members, I must uncomfortably say that I have to agree with the industry on this one.

SENATOR SLOSSBERG: Okay, thank you for your testimony.

DEBORAH CHERNOFF: You know, every so often our worlds collide.

SENATOR SLOSSBERG: It's a good thing. We like that. Are there any questions? No. Thank you very much. Appreciate it.

Our next bill is House Bill 5442 and our first speaker is Jane McNichol.

JANE MCNICHOL: Good afternoon. I'm Jane McNichol. I'm the Director of the Legal Assistance Resource Center of Connecticut, the advocacy and support center for the legal services programs for in the state. We represent the interests of very low-income residents of the state.

I'm going-- I'm going to try to be very brief. The specific piece we're concerned about in 5442 is I think in Sections I and II, the elimination of the SAGA cash program for families.

The Department believes these provisions are obsolete and we don't. I mean its not I think that they want to close the program if people were benefiting from it and we know it's not used very much at the moment, but we do believe there are some categories of families with kids who don't at the moment qualify for TFA and this is their cash assistance. It's a small band of people, but more importantly, the processing time for SAGA is significantly shorter than the processing time for TFA and when DSS is operating correctly in getting people on when they should, it has been an important bridge for very needy families to have some income for a month or so before they can get on TFA. So, at some point we're going to be back in the situation where that will be an important bridge. I mean, I'm basically confused by the fact that the monthly reports of assistance units that I get show three families who are actually on this assistance program. They may be miscoded, I don't know, it's not a lot of families, but it's -- if we're only getting rid of it because it's obsolete we're just not convinced it's obsolete. And if federal rules change, and families don't continue to be eligible for TFA we would not want them not to have SAGA available so that is our concern with 5442.

And then I was, but I don't have to now so much, going to speak about Senate Bill 251 which we believe as written is an important way of helping the system right now be more client friendly at DSS without overburdening DSS. I didn't get a chance to read the Commissioner's testimony because - I think that his concerns are not what the intent of the bill was. It wasn't to add a whole lot of more processes, but just to make it more user friendly right now but I completely agree with the people who said there are more systemic things we should be doing particularly looking at changing the redetermination default option so that people who have done what they're supposed to do and are -- should just remain eligible. They don't have to make nine phone calls to find out that in fact they really are eligible and that their documents really are in and it would move the system along faster in addition to being much better for people.

Thank you.

SENATOR SLOSSBERG: Thank you for your testimony. Can you -- would you be able to provide to the committee, you said you get a monthly report that shows you've got three families on this currently now. If you don't mind, obviously deidentified--

JANE MCNICHOL: It's just numbers, it's a document they put out publically.

SENATOR SLOSSBERG: We just want to make sure we're not violating anybody's confidentiality but I would be-- I think that would be useful for us to see. We'll be similarly asking for the Department to produce reports that confirm that there aren't actually people on there. So, thank you very much for your testimony.


SENATOR SLOSSBERG: Okay, moving right along. Senate Bill 253. Our first speaker is Patricia Quinn.

Good afternoon.

PATRICIA QUINN: Good afternoon. Senator Slossberg and Representative Abercrombie and distinguished Members of the Health Services Committee. I'm privileged to be here. My name is Patricia Quinn. I have been born, raised and continue to reside in Terryville, Connecticut, and I am here this afternoon to ask the Human Services Committee members to support Senate Bill Number 253 AN ACT CONCERNING TEMPORARY NURSING HOME BED REDUCTIONS.

This bill is being advanced by the Connecticut Association of Health Care Facilities of which Genesis HealthCare is a member of. Genesis HealthCare is a multi-faceted stilled nursing and rehabilitation company and we operate and manage 20 skilled nursing homes in Connecticut.

This legislation will accelerate the state's long term care rebalancing goals while improving resident care and maintaining the viability to skilled nursing facilities facing low census.

I particularly want to address those centers with low census. One of which Genesis owns and operates is Kimberly Hall South. It's located in Windsor Connecticut and it was built and opened up in 1968, and as I believe Mr. Cleary eluded to and a gentleman that -- Representative Case mentioned about 45 year old aging buildings. At the time Kimberly opened up it was state of the art. And imagine, it was -- a majority of the beds were semi-private rooms. Beautiful. And we were very fortunate to have a very high occupancy. Approximately about 10 to 15 years ago, assistive living communities have sprung up all around Windsor, Connecticut, and they've been providing safety and care to many of our residents that we used to take care of back in the 1970s.

Currently, we're admitting very complex patients at Kimberly Hall South and many of you would be astonished that a lot of our patients that we care for have certain infections and a number of infections that cannot be comingled with other frail elderly and therefore, residents are requiring private rooms in order to properly care for their infections. In addition to these types of residents, we also care for residents that have a lot of equipment. Not only wheelchairs, but oxygen, pi-pap, c-pap, nebulizers. They require certain safe handling equipment that takes up room, again, requiring private rooms. We also take care of patients that have behavioral issues and challenges and with less stimulation the resident has a better-improved quality of life and our staff is better able to care for them, again, in a private room.

So, our 180 bed skilled nursing home, Kimberly Hall South, now has a majority of our patients in private rooms. Therefore, this is reasoning why we're looking for your to support the rebalancing bill that is in -- you're learning about today. The policy advanced-- the policy advanced in the bill would allow facilities to temporarily remove licensed beds from service. The beds must remain unlicensed for at least a minimum of six months. The beds would be available for transfer or sale in accordance with existing Connecticut laws. In order for the beds to be temporarily delicensed or surrendered, and have a facility qualify for a rate increase, the facilities utilization and overall utilization in a specific geographic area must be able to absorb the reduction with current vacancies. Would allow Kimberly Hall South to operate more efficiently and cost effectively, thereby assuring stability in the quality of delivery of skilled nursing care that we provide our elderly in the Windsor community. Our state can accelerate our rebalancing goals with this bill while establishing a clear policy that provides an organized and stable approach to delivery of high quality nursing facility services with fewer beds.

Thank you very much. I appreciate being heard today.

SENATOR SLOSSBERG: Thank you very much for being here and for your testimony. Are there questions? Seeing none. Thank you.


SENATOR SLOSSBERG: Our next speaker is Dennis Cleary. Dennis, you coming back up? You're done? Matt, you done? Okay, loving you guys. All right, that takes care of that bill.

Our next bill is Senate Bill 254 and Laurie Julian. Where's Laurie? There's Laurie. And Mag, you're on deck.

LAURIE JULIAN: Good afternoon. Thank you for staying. Laurie Julian with the Alzheimer's Association, Connecticut Chapter, Director of Public Policy and I speak on support of the presumptive Medicaid eligibility bill and as we heard today it's one of the most cost effective nursing home diversion programs. It is estimated that as high as one-third of the recipients in category three, that's the Medicaid nursing home level care, in the program have a cognitive impairment.

Alzheimer's is a progressive degenerative disease and implementing and administering the presumptive eligibility will help stabilize this already fragile population in the community. Seventy percent live in the community with caregiver support and those individuals with Alzheimer's and dementia are most at risk for transition to skilled nursing care. So, it is crucial in terms of client's health and condition for the need for these supports, and due to these eligibility delays, they can often reenter critical care in hospital or nursing facility.

The recent report of the Task Force on Alzheimer's disease, which many of you, thank you very much co-sponsored, made recommendation supporting enhancing the rebalancing initiatives that focus on diversion. Now, this is important because unlike the Money Follows the Person, we're talking about not transitioning from but not transitioning to, in the first place. With our fragile population it's most important to catch them up front, put the resources up front which this program does, or excuse me, which this presumptive eligibility would do.

So, we heard earlier today about the 20 percent error rate versus a two percent and my colleague-- I was hoping she was going to testify today with the areas on aging, Marie Allen, because as I recall last year, she did have the data and I don't know if she submitted testimony, but even -- because of the diversion program brings in federal monies that this would -- even the error rate would set off those amounts. So, again, another reason to maybe look at -- have a closer inspection.

That's basically all I wanted to say in support of this bill.

SENATOR SLOSSBERG: Okay great. Thank you Laurie. We appreciate your testimony here and being here. We like the bill, too.

Any questions from the members? Seeing none. Thank you.

Next speaker is Mag Morelli.


MAG MORELLI: Hello. Thank you Senator Slossberg, Representative Abercrombie and members of this committee. My name is Mag Morelli and I'm the President of LeadingAge Connecticut, a statewide membership organization representing over 130 mission-driven and non-for-profit provider organizations serving older adults across the continuum of long term care, services and supports and including senior housing. On behalf of LeadingAge Connecticut, I would like to testify on four bills that are before you today.

And beginning with Senate Bill 254, AN ACT CONCERNING PRESUMPTIVE ELIGIBILITY. Thank you for raising this bill which would immediately address the eligibility determination backlog in the Connecticut Home care program for elders by elders by implementing a system of presumptive eligibility for applicants to the program -- yes I have. The delay in processing the long term care Medicaid applications as we've heard all day today, for this segment of the vulnerable elderly population is preventing individuals in the community from receiving needed services in a timely manner, and placing them at risk and we strongly support a resolution to the situation.

Now, while this specific bill addresses the Home Care Program for Elders, the problems with eligibility system are affecting individuals throughout the entire continuum of care and services. I've attached a joint statement of LeadingAge Connecticut, CAHCF, CSMS, the Connecticut Hospital Association and Connecticut Health Care at Home, urging your immediate attention to the situation system wide.

On Senate Bill 253, AN ACT CONCERNING TEMPORARY NURSING HOME BED REDUCTION, you know, part of the state's rebalancing effort is the nursing home rightsizing initiative which is aimed at adjusting and redistributing the number of nursing home beds in the state to meet the changing consumer demand for nursing home care. And toward that goal, we have been advocating for a collaborative and flexible regulatory and reimbursement environment for all nursing home providers so as to encourage nursing homes to adjust modernize and diversify their models of care. We believe that a regulatory environment that is adaptive and receptive to individual providers forward thinking ideas will encourage creative nursing home rightsizing initiatives.

While this specific bill is not our proposal, it does fit into this model of a collaborative and flexible regulatory environment. It could be one element in a variety of initiatives to existing nursing home providers and adapting to the current consumer demand while preserving the opportunity to adjust for future demand. This proposal could indeed be an opportunity to help appropriately adjust the nursing home bed supply and move us forward in our rebalancing plan.

On 325, on the complex medical needs, LeadingAge Connecticut supports this legislative proposal to the extent that it will protect the rights of nursing home residents with complex needs to access the complex rehabilitation technology that will meet their needs. Medicaid reimbursement policies that limit a nursing home residents mobility or deny them access by denying them access to a motorized wheelchair, or that endanger a residents physical condition and or skin integrity by limiting their access to a customized wheelchair, threatens the rights of nursing home residents and may prevent nursing homes from being able to provide the level of care and services that is required. We therefore support if clarification of the Medicaid policy that would ensure nursing home residents the access to the complex rehabilitation technology that is needed.

And finally, on 5322, AN ACT CONCERNING NURSING HOME FACILITY MINIMUM STAFFING LEVELS. LeadingAge Connecticut does not oppose the intent of this bill, which is to raise the minimum staffing requirements for nursing homes that are currently outlined on the public health code. But we also do not see a critical for the legislation since both the public health code and federal requirements for nursing homes require that nursing homes staff to meet the needs of residents and already authorized the Department of Public Health to assess penalties in certain cases when facilities fall short of staffing requirements and fail to employ sufficient staff to meet the residents needs.

Now, we do have a concern with the specific bill as proposed because it merges the staffing requirements of two distinct levels of nursing home care that are currently recognized in state licensure and regulation. State nursing home licensure and the public health code currently differentiate between a chronic and convalescent nursing home level of care, and a rest home with nursing supervision level of care, with the latter having a lower staffing requirement because the residents have a lower level of care need. The bill is proposing to bring the staffing requirements of the rest home with nursing supervision up to the level of the chronic and convalescent nursing home. We are concerned that this increase would require most rest homes with nursing supervision to increase their staffing even if they are currently staffing to meet the needs of those residents. The effect on the rest home with nursing supervision units, and it's usually a unit within another nursing home, so there are skilled beds and there are ICF beds and they are two different units. So, when you see the numbers on nursing homes compared, they're usually staffed above level of - above average because they're combining, their staffing so well on the chronic and convalescent unit that it merges with the ICF level and you don't see that the ICF level might not be coming up to these requirements that would be in the public health code.

Now, this may have been an unintended consequence of the drafting of the bill, and if the bill moves forward we hope to work with the proponents of the bill to modify the proposal to reflect the current differentiation in the requirements.

So, thank you for this opportunity to testify and I'd be happy to answer any question.

SENATOR SLOSSBERG: Thank you, Mag. Appreciate it. Madam Co-Chair.

REP. ABERCROMBIE: Just a quick question on the staffing levels, right? So, our understanding is that it only affects two nursing homes. Do you know which level those two nursing -- first of all, do you know which nursing homes they are and secondly, do you know which level it would affect?

MAG MORELLI: I think Brian mentioned the two nursing homes and I don't want to repeat them because I can't remember but if you go on Nursing Home Compare, you can go to staffing levels and rank all the nursing homes according to how they staff because they have, must report their staffing levels. It may not be exactly the way that it's required here, but it does not -- you cannot report people that are not working that day. So, in other words, if the State walks in to your facility and your Director of Nursing happens to be on vacation, those numbers don't count. Your staffing levels and things like that.

But if you go on Nursing Home Compare you can rank them and most people in that 24 hour number on Nursing Home Compare, and that's why I use it in my testimony and when I'm kind of demonstrating the ICF problem, are staffing above those levels for a 24 hour period and the only difference would be those who had ICF units, if you were to pull out the ICF unit, that might not be reaching -- I know in particular one, and I speak of it in my testimony. One particular nursing home, it's a smaller nursing home, has ICF level beds which is the rest home beds and it has SNF level, which is the convalescent. They have high quality marks on Nursing Home Compare, they're a four star facility, but if you -- and their staffing is five star. But if you were to pull out the ICF unit, you'd see -- and it talks about these new levels -- they would have to raise, they'd have to put -- I think they said nine hours of staff a week.

So, it adds nursing hours there. Now, they probably would not pull that off of the convalescent and bring it over, they would probably add additional staff. But even though they are meeting the level, there's no care needs on that ICF level right now. So, it will have an impact and maybe that was the intent of this and we would discuss it with the proponents of the bill, but it may not have been the intent. You know to raise that level but maybe not to the level that the chronic and convalescent is. And there aren't that many ICFs that are out there.

There was a movement several years ago on the part of DSS to get people to convert their ICF level of care to chronic and convalescent. And if you have and ICF level of care you do have to staff up if you-- you have to increase your level of care if someone comes back on a Medicare stay to that bed. There are some left and usually it's on a campus. Several of them are my members because my members tend to provide a variety of services, so they'll have housing, they'll have ICF, they'll have maybe assisted living and then they'll have SNF. So, it's usually a smaller unit and it's -- but it is there and it is licensed in the state and it would be just one area we'd like to see addressed.

REP. ABERCROMBIE: Thank you. Thank you Madam chair.

SENATOR SLOSSBERG: Okay, thank you. Are there further questions? Seeing none. Thank you.

MAG MORELLI: Thank you.

SENATOR SLOSSBERG: Moving on to House Bill 5324. Laurie Julian do you want to come back?

LAURIE JULIAN: (Inaudible.)

SENATOR SLOSSBERG: Okay, terrific. Our next speaker is Jack Reardon.

JACK REARDON: Good afternoon, Senator Slossberg, Representative Abercrombie and members of the committee. Thank you for allowing me the opportunity to speak to you today. I'd also like to thank Representative Miller for the great work he does for my hometown of Essex, Connecticut.

I am here. My name is Jack Reardon. I am speaking to you on behalf of the Connecticut Chapter of the National Academy of Elder Law Attorneys. NAELA is a nonprofit association whose mission is to provide legal advocacy, information and education to attorneys, bar associations and others who deal with the many specialized issues involving the elderly and individuals with special needs.

I am here to state our support for House Bill 5324. H.B. 5324 provides process the collect the necessary data to analyze the true fiscal impact of increasing the community spouse protected amount the maximum allowed under federal law in Connecticut. CTNAELA has advocated for a law permitting the well spouse of a person receiving long term care to keep the maximum assets permitted under federal law and the reason for this is that such a law helps the well spouse pay for such things as uncovered medical expenses, personal expenses, taxes and insurance, and ultimately it helps them remain self sustaining and independent rather than becoming impoverished themselves and becoming a person dependent on the states Medicaid plan for their own medical care.

Fiscal notes on passed bills to increase the community spouse protected amount are based upon assumptions that are unsupported by hard data. House Bill 5324 would provide a set of data to help identify the potential fiscal impact ahead of time and enhance the ability to provide a solution with minimal budgetary impact to the state.

I ask that you please support this proposal to enhance the quality of life for seniors and provide accountability for the state's Medicaid program.

Thank you. That is all I'd like to add today and if you have any questions I'd be happy to answer.

SENATOR SLOSSBERG: Thank you very much for your testimony and for being here and for staying with us for the day. We appreciate it and I don't have any questions. Okay, Representative Abercrombie.

REP. ABERCROMBIE: Just a quick question. Would you know the percentage of our population that has to spend down? Would you say that you know -- right-- because the whole idea of this is to be able to keep the surviving spouse in the home as long as possible, right? So, if we keep it at the lower amount, which it is right now, which is what --

JACK REARDON: The minimum amount is $23,441.00 --

REP. ABERCROMBIE: -- $23,000.00, right. So would you say that the majority of them have to spend down?

JACK REARDON: I can -- I don't have -- a percentage of that, but I can say from speaking with colleagues that it is a regular occurrence that once the community spouse has spent down all their assets, and they no longer have enough resources remaining to keep themselves in the community, which in turn causes the ill spouse, if they're receiving home care, to end up in a nursing home, in addition to the community spouse ultimately having to go into a nursing home themselves in order to pay for their necessities of living.

REP. ABERCROMBIE: Okay, thank you.

SENATOR SLOSSBERG: Any other questions? Seeing -- yes? No? Okay, thank you very much for your testimony.

That is all we have for signed up speakers. So, at this time I will ask if anyone who has not had an opportunity to speak, here you are going once. Anyone like to speak? And for the third and final time, would anyone like to speak on the bills on our public hearing agenda? Seeing none.

This public hearing is closed. Thank you.