CHAPTER 319v
MEDICAL ASSISTANCE

Table of Contents

Sec. 17b-239. (Formerly Sec. 17-312). Payments to hospitals. Regulations.
Sec. 17b-239b. Chronic disease hospitals. Prior authorization procedures. Regulations.
Sec. 17b-242. (Formerly Sec. 17-313). Payments to home health care agencies and homemaker-home health aide agencies. Appeals. Hearings. Regulations.
Sec. 17b-242a. Medicaid home health services. Prior authorization requirements. Regulations.
Sec. 17b-244. (Formerly Sec. 17-313b). Payments to private facilities providing functional or vocational services for severely handicapped persons and payments for residential care. Establishment of rate. Regulations.
Sec. 17b-244a. Rates for payments to residential facilities for mentally retarded and autistic persons.
Sec. 17b-256e. Reports re potential participants in affordable pharmaceutical drug program.
Sec. 17b-260b. Home and community-based service waivers serving persons with acquired brain injury and persons with mental retardation. Amendments.
Sec. 17b-260c. Medicaid waiver to provide coverage for family planning services.
Sec. 17b-261. (Formerly Sec. 17-134b). Medicaid. Eligibility. Assets. Cost-sharing requirements.
Sec. 17b-261a. Transfer or assignment of assets resulting in the imposition of a penalty period. Regulations.
Sec. 17b-261d. Disease management initiative. Implementation. Annual report.
Sec. 17b-261e. Critical access hospitals: HUSKY and Medicaid coverage.
Sec. 17b-261f. Critical access hospital account established.
Sec. 17b-263a. Amendment to state Medicaid plan to include assertive community treatment teams and community support services.
Sec. 17b-263b. Pilot program for individuals ages nineteen to twenty-one with a mental disorder and chronic health condition. Eligibility.
Sec. 17b-264. (Formerly Sec. 17-134e). Extension of other public assistance provisions.
Sec. 17b-265d. Definition of full benefit dually eligible Medicare Part D beneficiary. Prescription drug coverage under Medicare Part D. Copayment coverage. Commissioner's enrollment authority.
Sec. 17b-265e. Medicare Part D Supplemental Needs Fund.
Sec. 17b-266. (Formerly Sec. 17-134g). Purchase of insurance. Contracts for comprehensive health care on a prepayment or per capita basis. Certification of providers by commissioner. Exception of deadline for payment of capitation claims. Deposit of funds for expenditures for children's health programs and services.
Sec. 17b-267. (Formerly Sec. 17-134h). Use of fiscal intermediaries in connection with medical assistance.
Sec. 17b-272. (Formerly Sec. 17-134m). Personal fund allowance.
Sec. 17b-274. (Formerly Sec. 17-134q). Periodic investigations of pharmacies by Division of Criminal Justice. Brand medically necessary. Procedure for prior approval to dispense brand name drug. Disclosure.
Sec. 17b-274b. Pharmaceutical purchasing initiative. Annual report.
Sec. 17b-274c. Voluntary mail order option for maintenance prescription drugs and drugs covered under the Medicare Part D program.
Sec. 17b-274d. Pharmaceutical and Therapeutics Committee. Membership. Duties. Preferred drug lists. Supplemental rebates. Administrative hearings.
Sec. 17b-277. (Formerly Sec. 17-134u). Medical assistance for needy pregnant women and children. Expedited eligibility. Administrative processing requirements. Biannual reports.
Sec. 17b-279. (Formerly Sec. 17-134aa). Medicaid prescription drug utilization review. Erectile dysfunction drugs. Prior authorization requirement and coverage limitation. Report.
Sec. 17b-280. (Formerly Sec. 17-134bb). Reimbursement rate for legend drugs. Dispensing fee. Reimbursement for over-the-counter drugs and products. Dispensing fee exception. Enhanced dispensing fee.
Sec. 17b-289. Short title: HUSKY and HUSKY Plus Act. HUSKY Plan, Part A and HUSKY Plan, Part B participants.
Sec. 17b-290. Definitions.
Sec. 17b-292. HUSKY Plan Part A and Part B. Eligibility. Presumptive eligibility. Single point of entry services. Managed care enrollment brokerage services. Regulations.
Sec. 17b-295. Cost-sharing requirements under HUSKY Plan, Part B.

      Sec. 17b-239. (Formerly Sec. 17-312). Payments to hospitals. Regulations. (a) The rate to be paid by the state to hospitals receiving appropriations granted by the General Assembly and to freestanding chronic disease hospitals, providing services to persons aided or cared for by the state for routine services furnished to state patients, shall be based upon reasonable cost to such hospital, or the charge to the general public for ward services or the lowest charge for semiprivate services if the hospital has no ward facilities, imposed by such hospital, whichever is lowest, except to the extent, if any, that the commissioner determines that a greater amount is appropriate in the case of hospitals serving a disproportionate share of indigent patients. Such rate shall be promulgated annually by the Commissioner of Social Services. Nothing contained herein shall authorize a payment by the state for such services to any such hospital in excess of the charges made by such hospital for comparable services to the general public. Notwithstanding the provisions of this section, for the rate period beginning July 1, 2000, rates paid to freestanding chronic disease hospitals and freestanding psychiatric hospitals shall be increased by three per cent. For the rate period beginning July 1, 2001, a freestanding chronic disease hospital or freestanding psychiatric hospital shall receive a rate that is two and one-half per cent more than the rate it received in the prior fiscal year and such rate shall remain effective until December 31, 2002. Effective January 1, 2003, a freestanding chronic disease hospital or freestanding psychiatric hospital shall receive a rate that is two per cent more than the rate it received in the prior fiscal year. Notwithstanding the provisions of this subsection, for the period commencing July 1, 2001, and ending June 30, 2003, the commissioner may pay an additional total of no more than three hundred thousand dollars annually for services provided to long-term ventilator patients. For purposes of this subsection, "long-term ventilator patient" means any patient at a freestanding chronic disease hospital on a ventilator for a total of sixty days or more in any consecutive twelve-month period. Effective July 1, 2004, each freestanding chronic disease hospital shall receive a rate that is two per cent more than the rate it received in the prior fiscal year.

      (b) Effective October 1, 1991, the rate to be paid by the state for the cost of special services rendered by such hospitals shall be established annually by the commissioner for each such hospital based on the reasonable cost to each hospital of such services furnished to state patients. Nothing contained herein shall authorize a payment by the state for such services to any such hospital in excess of the charges made by such hospital for comparable services to the general public.

      (c) The term "reasonable cost" as used in this section means the cost of care furnished such patients by an efficient and economically operated facility, computed in accordance with accepted principles of hospital cost reimbursement. The commissioner may adjust the rate of payment established under the provisions of this section for the year during which services are furnished to reflect fluctuations in hospital costs. Such adjustment may be made prospectively to cover anticipated fluctuations or may be made retroactive to any date subsequent to the date of the initial rate determination for such year or in such other manner as may be determined by the commissioner. In determining "reasonable cost" the commissioner may give due consideration to allowances for fully or partially unpaid bills, reasonable costs mandated by collective bargaining agreements with certified collective bargaining agents or other agreements between the employer and employees, provided "employees" shall not include persons employed as managers or chief administrators, requirements for working capital and cost of development of new services, including additions to and replacement of facilities and equipment. The commissioner shall not give consideration to amounts paid by the facilities to employees as salary, or to attorneys or consultants as fees, where the responsibility of the employees, attorneys or consultants is to persuade or seek to persuade the other employees of the facility to support or oppose unionization. Nothing in this subsection shall prohibit the commissioner from considering amounts paid for legal counsel related to the negotiation of collective bargaining agreements, the settlement of grievances or normal administration of labor relations.

      (d) The state shall also pay to such hospitals for each outpatient clinic and emergency room visit a reasonable rate to be established annually by the commissioner for each hospital, such rate to be determined by the reasonable cost of such services. The emergency room visit rates in effect June 30, 1991, shall remain in effect through June 30, 1993, except those which would have been decreased effective July 1, 1991, or July 1, 1992, shall be decreased. Nothing contained herein shall authorize a payment by the state for such services to any hospital in excess of the charges made by such hospital for comparable services to the general public. For those outpatient hospital services paid on the basis of a ratio of cost to charges, the ratios in effect June 30, 1991, shall be reduced effective July 1, 1991, by the most recent annual increase in the consumer price index for medical care. For those outpatient hospital services paid on the basis of a ratio of cost to charges, the ratios computed to be effective July 1, 1994, shall be reduced by the most recent annual increase in the consumer price index for medical care. The emergency room visit rates in effect June 30, 1994, shall remain in effect through December 31, 1994. The Commissioner of Social Services shall establish a fee schedule for outpatient hospital services to be effective on and after January 1, 1995. Except with respect to the rate periods beginning July 1, 1999, and July 1, 2000, such fee schedule shall be adjusted annually beginning July 1, 1996, to reflect necessary increases in the cost of services. Notwithstanding the provisions of this subsection, the fee schedule for the rate period beginning July 1, 2000, shall be increased by ten and one-half per cent, effective June 1, 2001. Notwithstanding the provisions of this subsection, outpatient rates in effect as of June 30, 2003, shall remain in effect through June 30, 2005.

      (e) The commissioner shall adopt regulations, in accordance with the provisions of chapter 54, establishing criteria for defining emergency and nonemergency visits to hospital emergency rooms. All nonemergency visits to hospital emergency rooms shall be paid at the hospital's outpatient clinic services rate. Nothing contained in this subsection or the regulations adopted hereunder shall authorize a payment by the state for such services to any hospital in excess of the charges made by such hospital for comparable services to the general public.

      (f) On and after October 1, 1984, the state shall pay to an acute care general hospital for the inpatient care of a patient who no longer requires acute care a rate determined by the following schedule: For the first seven days following certification that the patient no longer requires acute care the state shall pay the hospital at a rate of fifty per cent of the hospital's actual cost; for the second seven-day period following certification that the patient no longer requires acute care the state shall pay seventy-five per cent of the hospital's actual cost; for the third seven-day period following certification that the patient no longer requires acute care and for any period of time thereafter, the state shall pay the hospital at a rate of one hundred per cent of the hospital's actual cost. On and after July 1, 1995, no payment shall be made by the state to an acute care general hospital for the inpatient care of a patient who no longer requires acute care and is eligible for Medicare unless the hospital does not obtain reimbursement from Medicare for that stay.

      (g) Effective June 1, 2001, the commissioner shall establish inpatient hospital rates in accordance with the method specified in regulations adopted pursuant to this section and applied for the rate period beginning October 1, 2000, except that the commissioner shall update each hospital's target amount per discharge to the actual allowable cost per discharge based upon the 1999 cost report filing multiplied by sixty-two and one-half per cent if such amount is higher than the target amount per discharge for the rate period beginning October 1, 2000, as adjusted for the ten per cent incentive identified in Section 4005 of Public Law 101-508. If a hospital's rate is increased pursuant to this subsection, the hospital shall not receive the ten per cent incentive identified in Section 4005 of Public Law 101-508. For rate periods beginning October 1, 2001, through March 31, 2008, the commissioner shall not apply an annual adjustment factor to the target amount per discharge. Effective April 1, 2005, the revised target amount per discharge for each hospital with a target amount per discharge less than three thousand seven hundred fifty dollars shall be three thousand seven hundred fifty dollars. Effective October 1, 2006, the revised target amount per discharge for each hospital with a target amount per discharge less than four thousand dollars shall be four thousand dollars. Effective October 1, 2007, the revised target amount per discharge for each hospital with a target amount per discharge less than four thousand two hundred fifty dollars shall be four thousand two hundred fifty dollars.

      (1949, 1953, S. 1586d; 1961, P.A. 474, S. 2; 1967, P.A. 726, S. 1; 1969, P.A. 339, S. 1; P.A. 73-117, S. 23, 31; P.A. 77-574, S. 4, 6; P.A. 79-560, S. 26, 39; P.A. 81-472, S. 111, 159; P.A. 84-367, S. 1, 3; P.A. 85-482, S. 1, 2; P.A. 87-27, S. 1; 87-516, S. 1, 5; P.A. 88-156, S. 19; P.A. 89-296, S. 6, 9; June Sp. Sess. P.A. 91-8, S. 13, 43, 63; May Sp. Sess. P.A. 92-16, S. 25, 89; P.A. 93-262, S. 1, 87; May Sp. Sess. P.A. 94-5, S. 2, 30; P.A. 95-160, S. 25, 69; 95-306, S. 1, 7; 95-351, S. 28, 30; P.A. 96-139, S. 12, 13; P.A. 98-131, S. 1, 2; P.A. 99-279, S. 13, 14, 45; June Sp. Sess. P.A. 00-2, S. 15, 53; June Sp. Sess. P.A. 01-2, S. 11, 66, 69; June Sp. Sess. P.A. 01-3, S. 1, 2, 6; June Sp. Sess. P.A. 01-9, S. 119, 120, 121, 129, 131; May 9 Sp. Sess. P.A. 02-7, S. 57; June 30 Sp. Sess. P.A. 03-3, S. 67, 68; P.A. 04-258, S. 1, 3; May Sp. Sess. P.A. 04-2, S. 34; P.A. 05-280, S. 6.)

      History: 1961 act changed technical language, added standard of comparable charges to Subsec. (a), deleted requirement of Subsec. (b) that special services be professional and added Subsec. (c); 1967 act changed term "welfare" to "state" patients, restricted standard of comparable charges in Subsec. (a), made allowances for unpaid bills, working capital requirements and services development costs in determination of "actual cost" in Subsec. (c) and added Subsec. (d); 1969 act allowed alternative rates in Subsec. (a) based on charges for ward or semiprivate facilities and placed limit on rate for outpatient clinic visit in Subsec. (d); P.A. 73-117 replaced hospital cost commission with committee established in accordance with Sec. 17-311; P.A. 77-574 included allowances for costs associated with collective bargaining agreements in Subsec. (c); P.A. 79-560 replaced committee with commissioner of income maintenance; P.A. 81-472 made technical changes; P.A. 84-367 changed the basis of the rate from "actual" to "reasonable" cost and added Subsec. (e) setting rates for the inpatient care of patients who no longer require acute care; P.A. 85-482 amended Subsec. (d) by substituting "one hundred sixteen" per cent for "one hundred fifty" per cent of combined average fee of general practitioner and specialist for office visit as maximum rate for an outpatient clinic visit; P.A. 87-27 amended Subsec. (c) to exclude from "reasonable cost" amounts paid to employees, attorneys or consultants due to unionization disputes; P.A. 87-516 allowed the commissioner to establish a rate cap if he receives approval for a disproportionate share exemption pursuant to federal regulations; P.A. 88-156 added freestanding chronic disease hospitals providing services to persons aided or cared for by the state for routine services furnished to state patients and gave the commissioner the discretion to set a higher rate for hospitals serving a disproportionate share of indigent patients; P.A. 89-296 amended Subsec. (d) to prohibit the state from paying a hospital for services in excess of the charges made by the hospital for comparable services to the public, added a new Subsec. (e) requiring the commissioner to adopt regulations establishing criteria for defining emergency and nonemergency visits to hospital emergency rooms and relettered former Subsec. (e) as Subsec. (f); June Sp. Sess. P.A. 91-8 amended Subsec. (b) to add a provision re payment by the state of charges in excess of charges made when comparable service is rendered to the general public and amended Subsec. (d) re rates paid by the state for outpatient clinic, services, emergency room visits and outpatient hospital services paid on the basis of a ratio of cost to charges; May Sp. Sess. P.A. 92-16 amended Subsec. (d) by providing that emergency room visit rates in effect on June 30, 1991, shall remain in effect through June 30, 1993, except that those which would decrease on July 1, 1992, shall decrease; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; May Sp. Sess. P.A. 94-5 amended Subsec. (d) to add a formula concerning outpatient hospital services paid on the basis of a ratio of cost to charges and required the commissioner to establish a fee schedule for outpatient hospital services, effective July 1, 1994; Sec. 17-312 transferred to Sec. 17b-239 in 1995; P.A. 95-160 amended Subsec. (a) by adding a provision for rates to be paid to freestanding chronic disease hospitals, effective July 1, 1995; P.A. 95-306 amended Subsec. (f) by prohibiting payment to an acute care general hospital for inpatient care of a patient if such patient is no longer in need of such care and is eligible for Medicare, unless Medicare reimbursement is not received for such care, effective July 1, 1995; P.A. 95-351 amended Subsec. (a) by providing that the commissioner use the "actual charge based on utilized service" instead of the "cost of service" when determining rates paid to freestanding chronic disease hospitals, effective July 1, 1995; P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; P.A. 98-131 added new Subsec. (g) requiring commissioner to establish hospital inpatient rates, effective July 1, 1998; P.A. 99-279 amended Subsec. (d) to eliminate annual increases in the fee schedule for outpatient hospital services for the rate periods beginning July 1, 1999, and July 1, 2000, and amended Subsec. (g) to provide an exception for the rate period beginning October 1, 1998, from the application of the three per cent annual adjustment factor to the target amount per discharge, to prohibit the commissioner from applying an annual adjustment factor for succeeding rate periods, and to make a technical change, effective July 1, 1999; June Sp. Sess. P.A. 00-2 amended Subsec. (a) by deleting provisions re rates paid to freestanding chronic disease hospitals on and after July 1, 1995, and inserting provisions re rates paid to freestanding chronic disease hospitals and freestanding psychiatric hospitals, beginning July 1, 2000, and thereafter, effective July 1, 2000; June Sp. Sess. P.A. 01-2 amended Subsec. (a) to make a technical change for the purpose of gender neutrality, to require commissioner to use the rate of the highest-paid freestanding chronic disease hospital for any freestanding chronic disease hospital having more than an average of fifteen per cent of its inpatient days utilized as long-term ventilator patient days beginning for the rate period ending in 2001, in lieu of rate paid for period when determining rates paid on and after July 1, 2001, notwithstanding provisions of subsection, and to define term "long-term ventilator patient", effective July 1, 2001, and further amended Subsec. (a) to remove discretion of commissioner re determination of appropriate amount in the case of hospitals serving a disproportionate number share of indigent patients and to replace provisions re rates paid to freestanding chronic disease hospitals and freestanding psychiatric hospitals for rate period beginning July 1, 2001, effective July 2, 2001; June Sp. Sess. P.A. 01-3 amended Subsec. (d) by deleting provisions re rate for outpatient clinic visit and rate cap for outpatient clinics upon approval of disproportionate share exemption and adding provision re increase of fee schedule for rate period beginning July 1, 2001, and amended Subsec. (g) by deleting former provisions and adding provisions re establishment of inpatient hospital rates, effective July 1, 2001; June Sp. Sess. P.A. 01-9 amended Subsec. (d) to make ten and one-half per cent increase applicable to rate period beginning July 1, 2000, and effective June 1, 2001, and amended Subsec. (g) to make June 1, 2001, the date by which the commissioner is to establish inpatient hospital rates, effective July 1, 2001, and revised effective date of June Sp. Sess. P.A. 01-2 but without affecting this section; May 9 Sp. Sess. P.A. 02-7 amended Subsec. (a) by delaying from July 1, 2002, to January 1, 2003, a two per cent rate increase to a free standing chronic disease hospital and a free standing psychiatric hospital and maintaining effectiveness of existing rate until December 31, 2002, effective August 15, 2002; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (d) to provide that outpatient rates in effect as of June 30, 2003, shall remain in effect through June 30, 2005, and amended Subsec. (g) by replacing "and October 1, 2002," with" through September 30, 2005," re period of time during which commissioner shall not apply an annual adjustment factor to target amount per discharge, effective August 20, 2003; P.A. 04-258 amended Subsec. (a) by providing that each freestanding chronic disease hospital shall receive a rate that is two per cent more than the rate it received in the prior fiscal year and amended Subsec. (g) by substituting September 30, 2004, for September 30, 2005, re time period during which the commissioner shall not apply an annual adjustment factor to the target amount per discharge and adding provisions re revised target amount per discharge for the periods commencing April 1, 2005, April 1, 2006, and April 1, 2007, effective July 1, 2004; May Sp. Sess. P.A. 04-2 amended Subsec. (g) by substituting March 31, 2008, for September 30, 2004, effective July 1, 2004; P.A. 05-280 amended Subsec. (g) by changing effective date for the four-thousand-dollar revised target amount per discharge from April 1, 2006, to October 1, 2006, and changing effective date for the four-thousand-two-hundred-fifty-dollar revised target amount per discharge from April 1, 2007, to October 1, 2007, effective July 1, 2005.

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      Sec. 17b-239b. Chronic disease hospitals. Prior authorization procedures. Regulations. The Commissioner of Social Services shall establish prior authorization procedures under the Medicaid program for admissions and lengths of stay in chronic disease hospitals. The Commissioner of Social Services may contract with an entity for administration of any aspect of such prior authorization or may expand the scope of an existing contract with an entity that performs utilization review services on behalf of the Department of Social Services. The commissioner, pursuant to section 17b-10, may implement policies and procedures necessary to administer the provisions of this section while in the process of adopting such policies and procedures as regulation, provided the commissioner prints notice of intent to adopt regulations in the Connecticut Law Journal not later than twenty days after the date of implementation. Policies and procedures implemented pursuant to this section shall be valid until the time final regulations are adopted.

      (P.A. 05-209, S. 2.)

      History: P.A. 05-209 effective July 1, 2005.

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      Sec. 17b-242. (Formerly Sec. 17-313). Payments to home health care agencies and homemaker-home health aide agencies. Appeals. Hearings. Regulations. (a) The Department of Social Services shall determine the rates to be paid to home health care agencies and homemaker-home health aide agencies by the state or any town in the state for persons aided or cared for by the state or any such town. For the period from February 1, 1991, to January 31, 1992, inclusive, payment for each service to the state shall be based upon the rate for such service as determined by the Office of Health Care Access, except that for those providers whose Medicaid rates for the year ending January 31, 1991, exceed the median rate, no increase shall be allowed. For those providers whose rates for the year ending January 31, 1991, are below the median rate, increases shall not exceed the lower of the prior rate increased by the most recent annual increase in the consumer price index for urban consumers or the median rate. In no case shall any such rate exceed the eightieth percentile of rates in effect January 31, 1991, nor shall any rate exceed the charge to the general public for similar services. Rates effective February 1, 1992, shall be based upon rates as determined by the Office of Health Care Access, except that increases shall not exceed the prior year's rate increased by the most recent annual increase in the consumer price index for urban consumers and rates effective February 1, 1992, shall remain in effect through June 30, 1993. Rates effective July 1, 1993, shall be based upon rates as determined by the Office of Health Care Access except if the Medicaid rates for any service for the period ending June 30, 1993, exceed the median rate for such service, the increase effective July 1, 1993, shall not exceed one per cent. If the Medicaid rate for any service for the period ending June 30, 1993, is below the median rate, the increase effective July 1, 1993, shall not exceed the lower of the prior rate increased by one and one-half times the most recent annual increase in the consumer price index for urban consumers or the median rate plus one per cent. The Commissioner of Social Services shall establish a fee schedule for home health services to be effective on and after July 1, 1994. The commissioner may annually increase any fee in the fee schedule based on an increase in the cost of services. The commissioner shall increase the fee schedule for home health services provided under the Connecticut home-care program for the elderly established under section 17b-342, effective July 1, 2000, by two per cent over the fee schedule for home health services for the previous year. The commissioner may increase any fee payable to a home health care agency or homemaker-home health aide agency upon the application of such an agency evidencing extraordinary costs related to (1) serving persons with AIDS; (2) high-risk maternal and child health care; (3) escort services; or (4) extended hour services. In no case shall any rate or fee exceed the charge to the general public for similar services. A home health care agency or homemaker-home health aide agency which, due to any material change in circumstances, is aggrieved by a rate determined pursuant to this subsection may, within ten days of receipt of written notice of such rate from the Commissioner of Social Services, request in writing a hearing on all items of aggrievement. The commissioner shall, upon the receipt of all documentation necessary to evaluate the request, determine whether there has been such a change in circumstances and shall conduct a hearing if appropriate. The Commissioner of Social Services shall adopt regulations, in accordance with chapter 54, to implement the provisions of this subsection. The commissioner may implement policies and procedures to carry out the provisions of this subsection while in the process of adopting regulations, provided notice of intent to adopt the regulations is published in the Connecticut Law Journal within twenty days of implementing the policies and procedures. Such policies and procedures shall be valid for not longer than nine months.

      (b) The Department of Social Services shall monitor the rates charged by home health care agencies and homemaker-home health aide agencies. Such agencies shall file annual cost reports and service charge information with the department.

      (c) The home health services fee schedule shall include a fee for the administration of medication, which shall apply when the purpose of a nurse's visit is limited to the administration of medication. Administration of medication may include, but is not limited to, blood pressure checks, glucometer readings, pulse rate checks and similar indicators of health status. The fee for medication administration shall include administration of medications while the nurse is present, the pre-pouring of additional doses that the client will self-administer at a later time and the teaching of self-administration. The department shall not pay for medication administration in addition to any other nursing service at the same visit. The department may establish prior authorization requirements for this service. Before implementing such change, the Commissioner of Social Services shall consult with the chairpersons of the joint standing committees of the General Assembly having cognizance of matters relating to public health and human services.

      (d) The home health services fee schedule established pursuant to subsection (c) of this section shall include rates for psychiatric nurse visits.

      (e) The Department of Social Services, when processing or auditing claims for reimbursement submitted by home health care agencies and homemaker-home health aide agencies shall, in accordance with the provisions of chapter 15, accept electronic records and records bearing the electronic signature of a licensed physician or licensed practitioner of a healthcare profession that has been submitted to the home health care agency or homemaker home-health aide agency.

      (f) If the electronic record or signature that has been transmitted to a home health care agency or homemaker-home health aide agency is illegible or the department is unable to determine the validity of such electronic record or signature, the department shall review additional evidence of the accuracy or validity of the record or signature, including, but not limited to, (1) the original of the record or signature, or (2) a written statement, made under penalty of false statement, from (A) the licensed physician or licensed practitioner of a health care profession who signed such record, or (B) if such licensed physician or licensed practitioner of a health care profession is unavailable, the medical director of the agency verifying the accuracy or validity of such record or signature, and the department shall make a determination whether the electronic record or signature is valid.

      (g) The Department of Social Services, when auditing claims submitted by home health care agencies and homemaker-home health aide agencies, shall consider any signature from a licensed physician or licensed practitioner of a health care profession that may be required on a plan of care for home health services, to have been provided in timely fashion if (1) the document bearing such signature was signed prior to the time when such agency seeks reimbursement from the department for services provided, and (2) verbal or telephone orders from the licensed physician or licensed practitioner of a health care profession were received prior to the commencement of services covered by the plan of care and such orders were subsequently documented. Nothing in this subsection shall be construed as limiting the powers of the Commissioner of Public Health to enforce the provisions of sections 19-13-D73 and 19-13-D74 of the regulations of Connecticut state agencies and 42 CFR 484.18(c).

      (h) For purposes of this section, "licensed practitioner of a healthcare profession" has the same meaning as "licensed practitioner" in section 21a-244a.

      (1957, P.A. 539; P.A. 73-117, S. 24, 31; P.A. 78-264, S. 2, 4; P.A. 91-406, S. 5, 29; June Sp. Sess. P.A. 91-8, S. 20, 63; May Sp. Sess. P.A. 92-16, S. 26, 89; P.A. 93-262, S. 1, 20, 87; 93-418, S. 24, 41; 93-435, S. 59, 95; May Sp. Sess. P.A. 94-5, S. 22, 30; P.A. 95-257, S. 39, 58; 95-351, S. 14, 30; P.A. 96-268, S. 5, 34; P.A. 99-130; June Sp. Sess. P.A. 00-2, S. 16, 53; P.A. 02-101, S. 13; P.A. 03-2, S. 8; June 30 Sp. Sess. P.A. 03-6, S. 197; P.A. 05-118, S. 1; 05-272, S. 44.)

      History: P.A. 73-117 replaced hospital cost commission with committee established under Sec. 17-311; P.A. 78-264 replaced public health nursing agencies with home health care and homemaker-home health aide agencies and replaced previous rate provisions with statement that rate to be determined by commission on hospitals and health care; P.A. 91-406 corrected an internal reference; June Sp. Sess. P.A. 91-8 amended the section by replacing "state" with the specific departments, by specifying the rates paid by the state to home health care agencies and homemaker-home health aide agencies and by adding provisions re the appeal of a rate determination; May Sp. Sess. P.A. 92-16 provided that rates in effect on February 1, 1992, shall remain in effect through June 30, 1993; P.A. 93-262 removed the references to departments of income maintenance, human resources and aging and provided that the department of social services shall determine rates to be charged home health care agencies and homemaker-home health aide agencies, made technical changes and added provisions requiring commissioner to adopt regulations, effective July 1, 1993; P.A. 93-418 added provisions regarding rates effective July 1, 1993, which are determined by the commission on hospitals and health care and authorizing income maintenance commissioner to establish fee schedule on and after July 1, 1994, effective July 1, 1993; P.A. 93-435 authorized the Revisors to substitute social services commissioner for income maintenance commissioner in P.A. 93-418, effective June 28, 1993; May Sp. Sess. P.A. 94-5 allowed the fee schedule to be phased in over a two-year period and allowed the commissioner to increase any fee payable to a home health care agency or homemaker-home health aide agency if there are extraordinary costs, effective July 1, 1994; Sec. 17-313 transferred to Sec. 17b-242 in 1995; P.A. 95-257 replaced Commission on Hospitals and Health Care with Office of Health Care Access, effective July 1, 1995; P.A. 95-351 added Subdiv. (4) allowing the commissioner to increase any fee payable for extraordinary costs relating to extended hour services, effective July 1, 1995 (Revisor's note: In the first sentence the phrase "rates to be charged by home health care agencies and the rates to be paid" was changed editorially by the Revisors to read "rates to be charged by home health care agencies and homemaker-home health aide agencies and the rates to be paid" to correct a clerical error in the preparation of the 1995 General Statutes); P.A. 96-268 added reference to homemaker-home health aide agencies, effective July 1, 1996; P.A. 99-130 designated existing language as Subsec. (a), eliminating the responsibility of the department to determine rates to be charged by home health care agencies and homemaker-home health aide agencies and added Subsec. (b) requiring the department to monitor the rates charged by such agencies, requiring such agencies to file annual cost reports and service charge information with the department, and made technical changes; June Sp. Sess. P.A. 00-2 amended Subsec. (a) by deleting provision re phasing in the fee schedule over a two-year period and inserting provision requiring the commissioner to increase by two per cent the fee schedule for home health care services provided under the Connecticut home-care program for the elderly, effective July 1, 2000; P.A. 02-101 amended Subsec. (a) to make a technical change, effective July 1, 2002; P.A. 03-2 added Subsec. (c) re establishment of home health services fee schedule applicable when purpose of nurse's visit is limited to administration of medication, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-6 added Subsec. (d) re rates for psychiatric nurse visits, effective August 20, 2003; P.A. 05-118 added Subsec. (e) allowing for submission of electronic records and records bearing electronic signatures by agencies to department with respect to the processing and auditing of claims for reimbursement and Subsec. (f) re the timely signature of a health care professional on a plan of care for home health services submitted to department; P.A. 05-272 amended Subsec. (e) by requiring department to accept electronic records and signatures of licensed physicians or licensed health care practitioners that have been submitted to an agency, rather than signatures of "an individual duly authorized by any such agency to submit records to the department", added new Subsec. (f) re process for reviewing and validating illegible electronic records or signatures transmitted to home health care agencies or homemaker-home health aide agencies, redesignated existing Subsec. (f) as Subsec. (g), designating provisions therein re document bearing signature as Subdiv. (1) and replacing "provided to such agency" with "signed", added Subsec. (g)(2) re timeliness of signatures from licensed physicians or licensed practitioners of a health care profession in cases involving verbal or telephone orders and re Department of Public Health's powers to enforce specified state and federal regulations concerning patients' care plans and medication administration are not limited by Subsec. (g), and added Subsec. (h) defining "licensed practitioner of a healthcare profession".

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      Sec. 17b-242a. Medicaid home health services. Prior authorization requirements. Regulations. The Commissioner of Social Services shall establish prior authorization procedures under the Medicaid program for home health services, such that prior authorization shall be required for skilled nursing visits that exceed two per week. Unless there are revisions to the prior authorization received during the month, providers shall not be required to submit prior authorization requests more than once a month. The Commissioner of Social Services may contract with an entity for administration of any such aspect of prior authorization or may expand the scope of an existing contract with an entity that performs utilization review services on behalf of the department. The commissioner, pursuant to section 17b-10, may implement policies and procedures necessary to administer the provisions of this section while in the process of adopting such policies and procedures as regulation, provided the commissioner prints notice of intent to adopt regulations in the Connecticut Law Journal not later than twenty days after the date of implementation. Policies and procedures implemented pursuant to this section shall be valid until the time final regulations are adopted.

      (P.A. 05-280, S. 46.)

      History: P.A. 05-280 effective July 1, 2005.

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      Sec. 17b-244. (Formerly Sec. 17-313b). Payments to private facilities providing functional or vocational services for severely handicapped persons and payments for residential care. Establishment of rate. Regulations. (a) The room and board component of the rates to be paid by the state to private facilities and facilities operated by regional education service centers which are licensed to provide residential care pursuant to section 17a-227, but not certified to participate in the Title XIX Medicaid program as intermediate care facilities for persons with mental retardation, shall be determined annually by the Commissioner of Social Services, except that rates effective April 30, 1989, shall remain in effect through October 31, 1989. Any facility with real property other than land placed in service prior to July 1, 1991, shall, for the fiscal year ending June 30, 1995, receive a rate of return on real property equal to the average of the rates of return applied to real property other than land placed in service for the five years preceding July 1, 1993. For the fiscal year ending June 30, 1996, and any succeeding fiscal year, the rate of return on real property for property items shall be revised every five years. The commissioner shall, upon submission of a request by such facility, allow actual debt service, comprised of principal and interest, on the loan or loans in lieu of property costs allowed pursuant to section 17-313b-5 of the regulations of Connecticut state agencies, whether actual debt service is higher or lower than such allowed property costs, provided such debt service terms and amounts are reasonable in relation to the useful life and the base value of the property. In the case of facilities financed through the Connecticut Housing Finance Authority, the commissioner shall allow actual debt service, comprised of principal, interest and a reasonable repair and replacement reserve on the loan or loans in lieu of property costs allowed pursuant to section 17-313b-5 of the regulations of Connecticut state agencies, whether actual debt service is higher or lower than such allowed property costs, provided such debt service terms and amounts are determined by the commissioner at the time the loan is entered into to be reasonable in relation to the useful life and base value of the property. The commissioner may allow fees associated with mortgage refinancing provided such refinancing will result in state reimbursement savings, after comparing costs over the terms of the existing proposed loans. For the fiscal year ending June 30, 1992, the inflation factor used to determine rates shall be one-half of the gross national product percentage increase for the period between the midpoint of the cost year through the midpoint of the rate year. For fiscal year ending June 30, 1993, the inflation factor used to determine rates shall be two-thirds of the gross national product percentage increase from the midpoint of the cost year to the midpoint of the rate year. For the fiscal years ending June 30, 1996, and June 30, 1997, no inflation factor shall be applied in determining rates. The Commissioner of Social Services shall prescribe uniform forms on which such facilities shall report their costs. Such rates shall be determined on the basis of a reasonable payment for necessary services. Any increase in grants, gifts, fund-raising or endowment income used for the payment of operating costs by a private facility in the fiscal year ending June 30, 1992, shall be excluded by the commissioner from the income of the facility in determining the rates to be paid to the facility for the fiscal year ending June 30, 1993, provided any operating costs funded by such increase shall not obligate the state to increase expenditures in subsequent fiscal years. Nothing contained in this section shall authorize a payment by the state to any such facility in excess of the charges made by the facility for comparable services to the general public. The service component of the rates to be paid by the state to private facilities and facilities operated by regional education service centers which are licensed to provide residential care pursuant to section 17a-227, but not certified to participate in the Title XIX Medicaid programs as intermediate care facilities for persons with mental retardation, shall be determined annually by the Commissioner of Mental Retardation in accordance with section 17b-244a.

      (b) The Commissioner of Social Services and the Commissioner of Mental Retardation shall adopt regulations in accordance with the provisions of chapter 54 to implement the provisions of this section.

      (1971, P.A. 560, S. 1; P.A. 73-117, S. 26, 31; P.A. 79-227; 79-560, S. 28, 39; June Sp. Sess. P.A. 83-39, S. 1, 2, 18; P.A. 84-546, S. 54, 173; P.A. 88-71; P.A. 89-325, S. 14, 26; June Sp. Sess. P.A. 91-8, S. 15, 63; June Sp. Sess. P.A. 91-11, S. 11, 25; May Sp. Sess. P.A. 92-16, S. 28, 89; P.A. 93-262, S. 1, 87; May Sp. Sess. P.A. 94-5, S. 11, 30; P.A. 95-160, S. 65, 69; P.A. 96-139, S. 12, 13; 96-188, S. 1, 2; June 30 Sp. Sess. P.A. 03-3, S. 81; P.A. 05-256, S. 11.)

      History: P.A. 73-117 replaced hospital cost commission with committee established under Sec. 17-311; P.A. 79-227 replaced committee with commissioner of income maintenance, included payments to community residences and changed Association for Retarded Children to Association for Retarded Citizens; P.A. 79-560 deleted reference to Sec. 17-311; June Sp. Sess. P.A. 83-39 provided for payment to private nonprofit facilities providing functional and vocational services for severely handicapped persons and to private facilities operated by regional education service centers providing residential care and added Subsec. (b) re establishment of separate rate (Revisor's note: Subsec. (c) was added editorially by the Revisors); P.A. 84-546 confirmed Revisors' action in editorially adding Subsec. (c) re adoption of regulations; P.A. 88-71 substantially rewrote section to empower commissioner of mental retardation to establish service component of rates where previously commissioner of income maintenance had set all rates and commissioner of mental retardation had performed a consultative role; P.A. 89-325 allowed rates in effect April 30, 1989, to remain in effect through October 31, 1989, and also deleted language re rates to be paid to private nonprofit facilities in Subsec. (a); June Sp. Sess. P.A. 91-8 amended Subsec. (a) re rates paid by the state to private facilities providing functional or vocational services for severely handicapped persons and clients of residential care facilities; June Sp. Sess. P.A. 91-11 amended Subsec. (a) to prohibit the department of income maintenance from considering any grants, gifts, fund-raising or endowment income used during the preceding year for payment of operating costs by a private facility in determining the facility's rates for fiscal year 1992-93; May Sp. Sess. P.A. 92-16 amended Subsec. (a) by providing that for the fiscal year ending June 30, 1993, the inflation factor used to determine rates shall be two-thirds of the gross national product percentage increase from the midpoint of the cost year to the midpoint of the rate year (Revisor's note: In Subsec. (a) in the sentence beginning "For the fiscal year ending June 30, 1992," the words "period between the" were inserted before the word "midpoint" and the words "cost year through the midpoint of the" were inserted before the words "rate year" editorially by the Revisors to reinstate existing language omitted through clerical error); P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; May Sp. Sess. P.A. 94-5 amended Subsec. (a) to establish a formula for rates of return for real property for facilities with real property other than land placed in service prior to July 1, 1991, effective July 1, 1994; Sec. 17-313b transferred to Sec. 17b-244 in 1995; P.A. 95-160 amended Subsec. (a) by adding a provision that for fiscal years ending June 30, 1996, and June 30, 1997, no inflation factor shall be applied in determining rates, effective June 1, 1995; P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; P.A. 96-188 provided that the commissioner shall allow, upon request of a facility, actual debt service whether higher or lower than allowed property costs, provided that, in the case of facilities financed through the Connecticut Housing Finance Authority, the commissioner shall allow actual debt service whether higher or lower than allowed property costs, provided such debt service terms and amounts are determined by the commissioner at the time the loan is entered into to be reasonable in relation to the useful life and base value of the property and made a technical change, effective May 31, 1996; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (a) to add provision re allowance of fees associated with mortgage refinancing provided such refinancing results in state reimbursement savings, effective August 20, 2003; P.A. 05-256 amended Subsec. (a) to include reference to Sec. 17b-244a, effective July 1, 2005.

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      Sec. 17b-244a. Rates for payments to residential facilities for mentally retarded and autistic persons. In determining the service component of the rates to be paid by the state under sections 17b-244 and 17b-246 to private facilities and facilities operated by regional education service centers that are licensed to provide residential care pursuant to section 17a-227, but not certified to participate in the Title XIX Medicaid programs as intermediate care facilities for persons with mental retardation, the Commissioner of Mental Retardation shall consider for each facility the actual wage and benefit costs for services and service providers, adjusted for inflation, and said commissioner shall not establish a single fixed amount for wage and benefit costs that is applicable to all such facilities.

      (P.A. 05-256, S. 10.)

      History: P.A. 05-256 effective July 1, 2005.

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      Sec. 17b-256e. Reports re potential participants in affordable pharmaceutical drug program. Section 17b-256e is repealed, effective July 1, 2005.

      (P.A. 03-166, S. 2; P.A. 05-272, S. 45.)

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      Sec. 17b-260b. Home and community-based service waivers serving persons with acquired brain injury and persons with mental retardation. Amendments. The Commissioner of Social Services may amend the federal home and community-based service waivers serving persons with acquired brain injury and persons with mental retardation to enable such persons eligible for or receiving medical assistance under section 17b-597 to receive the services provided under such federally-approved waivers.

      (P.A. 05-44, S. 3.)

      History: P.A. 05-44 effective July 1, 2005.

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      Sec. 17b-260c. Medicaid waiver to provide coverage for family planning services. The Commissioner of Social Services shall apply for a Medicaid waiver, pursuant to Section 1115 of the Social Security Act, for the purpose of providing coverage for family planning services to adults in households with income that does not exceed one hundred eighty-five per cent of the federal poverty level and who are not otherwise eligible for Medicaid services.

      (P.A. 05-120, S. 1.)

      History: P.A. 05-120 effective July 1, 2005.

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      Sec. 17b-261. (Formerly Sec. 17-134b). Medicaid. Eligibility. Assets. Cost-sharing requirements. (a) Medical assistance shall be provided for any otherwise eligible person whose income, including any available support from legally liable relatives and the income of the person's spouse or dependent child, is not more than one hundred forty-three per cent, pending approval of a federal waiver applied for pursuant to subsection (d) of this section, of the benefit amount paid to a person with no income under the temporary family assistance program in the appropriate region of residence and if such person is an institutionalized individual as defined in Section 1917(c) of the Social Security Act, 42 USC 1396p(c), and has not made an assignment or transfer or other disposition of property for less than fair market value for the purpose of establishing eligibility for benefits or assistance under this section. Any such disposition shall be treated in accordance with Section 1917(c) of the Social Security Act, 42 USC 1396p(c). Any disposition of property made on behalf of an applicant or recipient or the spouse of an applicant or recipient by a guardian, conservator, person authorized to make such disposition pursuant to a power of attorney or other person so authorized by law shall be attributed to such applicant, recipient or spouse. A disposition of property ordered by a court shall be evaluated in accordance with the standards applied to any other such disposition for the purpose of determining eligibility. The commissioner shall establish the standards for eligibility for medical assistance at one hundred forty-three per cent of the benefit amount paid to a family unit of equal size with no income under the temporary family assistance program in the appropriate region of residence, pending federal approval, except that the medical assistance program shall provide coverage to persons under the age of nineteen up to one hundred eighty-five per cent of the federal poverty level without an asset limit. Said medical assistance program shall also provide coverage to persons under the age of nineteen and their parents and needy caretaker relatives who qualify for coverage under Section 1931 of the Social Security Act with family income up to one hundred fifty per cent of the federal poverty level without an asset limit, upon the request of such a person or upon a redetermination of eligibility. Such levels shall be based on the regional differences in such benefit amount, if applicable, unless such levels based on regional differences are not in conformance with federal law. Any income in excess of the applicable amounts shall be applied as may be required by said federal law, and assistance shall be granted for the balance of the cost of authorized medical assistance. All contracts entered into on and after July 1, 1997, pursuant to this section shall include provisions for collaboration of managed care organizations with the Healthy Families Connecticut Program established pursuant to section 17a-56. The Commissioner of Social Services shall provide applicants for assistance under this section, at the time of application, with a written statement advising them of the effect of an assignment or transfer or other disposition of property on eligibility for benefits or assistance.

      (b) For the purposes of the Medicaid program, the Commissioner of Social Services shall consider parental income and resources as available to a child under eighteen years of age who is living with his or her parents and is blind or disabled for purposes of the Medicaid program, or to any other child under twenty-one years of age who is living with his or her parents.

      (c) For the purposes of determining eligibility for the Medicaid program, an available asset is one that is actually available to the applicant or one that the applicant has the legal right, authority or power to obtain or to have applied for the applicant's general or medical support. If the terms of a trust provide for the support of an applicant, the refusal of a trustee to make a distribution from the trust does not render the trust an unavailable asset. Notwithstanding the provisions of this subsection, the availability of funds in a trust or similar instrument funded in whole or in part by the applicant or the applicant's spouse shall be determined pursuant to the Omnibus Budget Reconciliation Act of 1993, 42 USC 1396p. The provisions of this subsection shall not apply to special needs trust, as defined in 42 USC 1396p(d)(4)(A).

      (d) The transfer of an asset in exchange for other valuable consideration shall be allowable to the extent the value of the other valuable consideration is equal to or greater than the value of the asset transferred.

      (e) The Commissioner of Social Services shall seek a waiver from federal law to permit federal financial participation for Medicaid expenditures for families with incomes of one hundred forty-three per cent of the temporary family assistance program payment standard.

      (f) To the extent permitted by federal law, Medicaid eligibility shall be extended for one year to a family that becomes ineligible for medical assistance under Section 1931 of the Social Security Act due to income from employment by one of its members who is a caretaker relative is employed or due to receipt of child support income. A family receiving extended benefits on July 1, 2005, shall receive the balance of such extended benefits, provided no such family shall receive more than twelve additional months of such benefits.

      (g) An institutionalized spouse applying for Medicaid and having a spouse living in the community shall be required, to the maximum extent permitted by law, to divert income to such community spouse in order to raise the community spouse's income to the level of the minimum monthly needs allowance, as described in Section 1924 of the Social Security Act. Such diversion of income shall occur before the community spouse is allowed to retain assets in excess of the community spouse protected amount described in Section 1924 of the Social Security Act. The Commissioner of Social Services, pursuant to section 17b-10, may implement the provisions of this subsection while in the process of adopting regulations, provided the commissioner prints notice of intent to adopt the regulations in the Connecticut Law Journal within twenty days of adopting such policy. Such policy shall be valid until the time final regulations are effective.

      (h) The Commissioner of Social Services shall, to the extent permitted by federal law, or, pursuant to an approved waiver of federal law submitted by the commissioner, in accordance with the provisions of section 17b-8, impose the following cost-sharing requirements under the HUSKY Plan, on all parent and needy caretaker relatives with incomes exceeding one hundred per cent of the federal poverty level: (1) A twenty-five-dollar premium per month per parent or needy caretaker relative; and (2) a copayment of one dollar per visit for outpatient medical services delivered by an enrolled Medicaid or HUSKY Plan provider. The commissioner may implement policies and procedures necessary to administer the provisions of this subsection while in the process of adopting such policies and procedures as regulations, provided the commissioner publishes notice of the intent to adopt regulations in the Connecticut Law Journal not later than twenty days after implementation. Policies and procedures implemented pursuant to this subsection shall be valid until the time final regulations are adopted.

      (i) Medical assistance shall be provided, in accordance with the provisions of subsection (e) of section 17a-6, to any child under the supervision of the Commissioner of Children and Families who is not receiving Medicaid benefits, has not yet qualified for Medicaid benefits or is otherwise ineligible for such benefits because of institutional status. To the extent practicable, the Commissioner of Children and Families shall apply for, or assist such child in qualifying for, the Medicaid program.

      (1967, P.A. 759, S. 1(b); 1969, P.A. 730, S. 8; P.A. 78-192, S. 4, 7; P.A. 80-50; P.A. 81-214, S. 6; P.A. 85-505, S. 14, 21; 85-527; P.A. 86-363, S. 3; P.A. 87-390, S. 1, 4; P.A. 89-317, S. 1, 2; P.A. 92-233, S. 1; P.A. 93-262, S. 1, 87; 93-289, S. 1-3; 93-435, S. 59, 95; May Sp. Sess. P.A. 94-5, S. 16, 30; P.A. 95-194, S. 30, 33; 95-351, S. 22, 30; P.A. 96-251, S. 9; P.A. 97-288, S. 3, 6; June 18 Sp. Sess. P.A. 97-2, S. 70, 165; October 29 Sp. Sess. P.A. 97-1, S. 19, 23; P.A. 99-279, S. 16, 45; June Sp. Sess. P.A. 00-2, S. 18, 53; June Sp. Sess. P.A. 01-2, S. 3, 69; June Sp. Sess. P.A. 01-9, S. 129, 131; P.A. 03-2, S. 10; 03-28, S. 2; 03-268, S. 7; June 30 Sp. Sess. P.A. 03-3, S. 63; P.A. 04-16, S. 6; P.A. 05-1, S. 1; 05-24, S. 1; 05-43, S. 1; 05-280, S. 1.)

      History: 1969 act deleted varying income limits and exclusions dependent upon marital status and number of dependents, referring instead to income limits under federal law; P.A. 78-192 added provisions re increases in eligibility standards; P.A. 80-50 added Subsec. (b); P.A. 81-214 added provisions re effect of transfer of property on eligibility for benefits in Subsec. (a); P.A. 85-505 amended Subsec. (a) to allow the extension of benefits for six months for former recipients; P.A. 85-527 amended Subsec. (a) by replacing "the minimum income permissible under federal law" with "one hundred twenty per cent of the standard of need"; P.A. 86-363 included children under eighteen years of age who are living with their parents and are blind or disabled in group for which parental income shall be considered under Subsec. (b); P.A. 87-390 changed the limit from one hundred "twenty" to one hundred "thirty-three", added language on division of property and transfer of the interest in a house between spouses, and added requirement for a written statement advising applicants of the effect of an assignment, transfer or other disposition of property on eligibility; P.A. 89-317 amended Subsec. (a) to require that a person be institutionalized, as defined in the Social Security Act, to be eligible for medical assistance, changed the time from which a transfer of assets will be permitted from "twenty-four" months to "thirty" months prior to the date of application and "thirty" months prior to the date of institutionalization and to require treatment of any disposition of assets in accordance with Section 1917 (c) of the Social Security Act, 42 U.S.C. 1396p (c); P.A. 92-233 amended Subsec. (a) by adding provisions re attribution of property disposed of on behalf of an applicant or his spouse by a guardian, conservator or authorized representative and disposition of property ordered by a court; P.A. 93-262 and 93-435 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; P.A. 93-289, S. 1 required that the medical assistance program provide coverage to persons under the age of six and S. 2 was added editorially by the Revisors as Subsec. (c) requiring the department of income maintenance to submit a report, effective July 1, 1993; May Sp. Sess. P.A. 94-5 removed the time limit on transfers of assets and extended coverage to children under the age of nineteen born after September 30, 1983, rather than children under six, effective July 1, 1994; Sec. 17-134b transferred to Sec. 17b-261 in 1995; P.A. 95-194 amended Subsec. (a) by changing the eligibility for medical assistance from an income which is not more than one hundred thirty-three per cent of the standard of need established pursuant to section 17b-104 to an income which is not more than one hundred forty-two per cent of the benefit amount paid to a person with no income under the AFDC program in the appropriate region of residence and by requiring the commissioner to establish the standards for eligibility for medical assistance at one hundred thirty-three per cent of the benefit amount paid to a family unit of equal size with no income under the AFDC program in the appropriate region of residence, added Subdiv. (d) requiring the commissioner to seek a waiver to permit federal financial participation for Medicaid expenditures and made technical changes, effective July 1, 1995; P.A. 95-351 replaced "one hundred forty-two" with "one hundred forty-three" as the highest allowable percentage of income for the provision of medical assistance and made a technical change, effective July 1, 1995; P.A. 96-251 amended Subsec. (c) by requiring that on and after October 1, 1996, reports be submitted to the legislative committee on human services and to legislators upon request and by adding provisions re submission of report summaries to legislators; P.A. 97-288 amended Subsec. (a) to require that contracts entered into after July 1, 1997, include provisions for collaboration of managed care organizations with the program established under Sec. 17a-56, effective July 1, 1997; June 18 Sp. Sess. P.A. 97-2 amended Subsec. (a) by extending Medicaid coverage, on and after July 1, 1998, from persons under the age of nineteen born after September 30, 1983, to persons under the age of nineteen born after September 30, 1981, or if possible, within available appropriations, born after June 30, 1980, with family income up to one hundred eighty-five per cent of the federal poverty level without an asset limit, replaced references to aid to families with dependent children with temporary family assistance, and made technical and conforming changes, effective July 1, 1997; Oct. 29 Sp. Sess. P.A. 97-1 amended Subsec. (a) to provide that on and after January 1, 1998, the medical assistance program shall provide coverage to persons under the age of nineteen and deleted reference to "born after June 30, 1981, or if possible within available appropriations, born after June 30, 1980", effective October 30, 1997; P.A. 99-279 amended Subsec. (a) to require extension of coverage under the medical assistance program to parents of children enrolled in the HUSKY Plan, Part A and to their needy caretaker relatives who qualify for coverage under Section 1931 of the Social Security Act and made technical changes, effective July 1, 2000; June Sp. Sess. P.A. 00-2 amended Subsec. (a) by deleting "born after September 30, 1981," changing "July 1, 2000," to "January 1, 2001," changing the family income level for eligibility for medical assistance from one hundred eighty-five to one hundred fifty per cent of federal poverty level, and adding provision re providing coverage upon the request of a person or upon a redetermination of eligibility, effective July 1, 2000; June Sp. Sess. P.A. 01-2 made technical changes for purposes of gender neutrality in Subsec. (b), added new Subsecs. (c) and (d) re availability and transfer of assets, and redesignated existing Subsecs. (c) and (d) as Subsecs. (e) and (f), effective July 1, 2001; June Sp. Sess. P.A. 01-9 revised effective date of June Sp. Sess. P.A. 01-2 but without affecting this section; P.A. 03-2 amended Subsec. (a) by making a technical change and changing family income eligibility limit for parents and needy caretaker relatives who qualify for medical assistance program coverage under Section 1931 of the Social Security Act from one hundred fifty per cent of the federal poverty limit to one hundred per cent of the federal poverty limit, and added new Subsec. (g), redesignated by the Revisors as new Subsec. (f), re ineligibility on or after April 1, 2003, of all parent and needy caretaker relatives with incomes exceeding one hundred per cent of the federal poverty level, effective February 28, 2003; P.A. 03-28 added new Subsec. (g) re extended Medicaid eligibility; P.A. 03-268 deleted former Subsec. (e) re submission of annual report to General Assembly re children receiving Medicaid services and doctors and dentists participating in state or municipally-funded programs and redesignated existing Subsec. (f) as Subsec. (e); June 30 Sp. Sess. P.A. 03-3 added new Subsec. (h) requiring an institutionalized spouse applying for Medicaid, who has a spouse living in the community, to divert income to the community spouse so as to raise the community spouse's income to the level of the minimum monthly needs allowance described in Section 1924 of the Social Security Act, effective August 20, 2003; P.A. 04-16 amended Subsec. (g) by adding "one of its members who is a caretaker relative is" re extended Medicaid eligibility and making a technical change; P.A. 05-1 added Subsec. (i) which extended transitional Medicaid benefits until June 30, 2005, for certain individuals who were to lose coverage between March 31, 2005, and May 31, 2005, effective March 10, 2005; P.A. 05-24 added new Subsec. (i) re provision of Medicaid coverage to a child under the supervision of the Commissioner of Children and Families, effective July 1, 2005; P.A. 05-43 amended Subsec. (g) by eliminating "or a family with an adult who, within six months of becoming ineligible under Section 1931 of the Social Security Act becomes employed", effective July 1, 2005; P.A. 05-280 amended Subsec. (a) by increasing family income limit re eligibility determinations for medical assistance for parents and needy caretakers of persons under the age of nineteen from one hundred per cent to one hundred fifty per cent of federal poverty level, deleted former Subsec. (f) re ineligibility for medical assistance for parents and needy caretaker relatives with incomes exceeding one hundred per cent of federal poverty level, redesignated Subsecs. (g) and (h) as Subsecs. (f) and (g), amended redesignated Subsec. (f) to reduce period of transitional medical assistance from two years to one year, add provision re extension of assistance to family that becomes ineligible "due to income from employment by" one of its members and provide that family receiving extended benefits "shall receive the balance of such extended benefits, provided no such family shall receive more than twelve additional months of such benefits", deleted former Subsec. (i) which had extended transitional medical assistance to June 30, 2005, for certain individuals and added new Subsec. (h) re cost sharing requirements under the HUSKY Plan, effective July 1, 2005.

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      Sec. 17b-261a. Transfer or assignment of assets resulting in the imposition of a penalty period. Regulations. (a) Any transfer or assignment of assets resulting in the imposition of a penalty period shall be presumed to be made with the intent, on the part of the transferor or the transferee, to enable the transferor to obtain or maintain eligibility for medical assistance. This presumption may be rebutted only by clear and convincing evidence that the transferor's eligibility or potential eligibility for medical assistance was not a basis for the transfer or assignment.

      (b) Any transfer or assignment of assets resulting in the establishment or imposition of a penalty period shall create a debt, as defined in section 36a-645, that shall be due and owing by the transferor or transferee to the Department of Social Services in an amount equal to the amount of the medical assistance provided to or on behalf of the transferor on or after the date of the transfer of assets, but said amount shall not exceed the fair market value of the assets at the time of transfer. The Commissioner of Social Services, the Commissioner of Administrative Services and the Attorney General shall have the power or authority to seek administrative, legal or equitable relief as provided by other statutes or by common law.

      (c) The Commissioner of Social Services may waive the imposition of a penalty period when the transferor (1) in accordance with the provisions of section 3025.25 of the department's Uniform Policy Manual, suffers from dementia at the time of application for medical assistance and cannot explain transfers that would otherwise result in the imposition of a penalty period; or (2) suffered from dementia at the time of the transfer; or (3) was exploited into making such a transfer due to dementia. Waiver of the imposition of a penalty period does not prohibit the establishment of a debt in accordance with subsection (b) of this section.

      (d) The Commissioner of Social Services, pursuant to section 17b-10, shall implement the policies and procedures necessary to carry out the provisions of this section while in the process of adopting such policies and procedures in regulation form, provided notice of intent to adopt regulations is published in the Connecticut Law Journal not later than twenty days after implementation. Such policies and procedures shall be valid until the time final regulations are effective.

      (June Sp. Sess. P.A. 01-2, S. 4, 69; June Sp. Sess. P.A. 01-9, S. 129, 131; June 30 Sp. Sess. P.A. 03-3, S. 62; P.A. 04-16, S. 7; P.A. 05-209, S. 4; 05-280, S. 40.)

      History: June Sp. Sess. P.A. 01-2 effective July 1, 2001; June Sp. Sess. P.A. 01-9 revised effective date of June Sp. Sess. P.A. 01-2 but without affecting this section; June 30 Sp. Sess. P.A. 03-3 designated existing provisions as Subsec. (a), added Subsec. (b) providing that transfer of assets resulting in imposition of a penalty period is presumed to be made with intent of allowing transferor to remain eligible for medical assistance, added Subsec. (c) re transfers resulting in imposition of a penalty period creating a debt due and owing to the department, added Subsec. (d) permitting commissioner to grant financial relief to nursing facility that demonstrates severe financial hardship due to imposition of transfer of assets penalties, added Subsec. (e) permitting commissioner to waive transfer of assets penalty period when transferor suffers from dementia or was exploited into making transfer, added Subsec. (f) providing that department, when determining medical assistance eligibility, shall review transfers of assets involving real property occurring in the sixty months preceding the date the individual applied for medical assistance and that federal law governs transfers of assets not involving real property, added Subsec. (g) permitting commissioner to establish threshold limits re annual asset transfers not subject to penalty and added Subsec. (h) requiring commissioner to implement policies and procedures necessary to carry out purposes of section while in the process of adopting regulations, effective August 20, 2003; P.A. 04-16 made technical changes in Subsec. (h); P.A. 05-209 deleted former Subsec. (a) re authority of commissioner to seek waiver of federal law for establishing penalty period for transfers of assets for less than fair market value, deleted former Subsec. (d) re commissioner's authority to grant financial relief to nursing homes experiencing severe financial hardship due to imposition of revised transfer of asset penalty period, deleted former Subsec. (e) re commissioner's authority to waive penalty period when transferor suffers from dementia, deleted former Subsec. (f) re sixty month penalty period for transfers of assets involving real property, deleted former Subsec. (g) re commissioner's authority to set threshold limits for transfers not subject to imposition of penalty period, and redesignated existing Subsecs. (b), (c) and (h) as new Subsecs. (a), (b) and (c), respectively, effective July 6, 2005; P.A. 05-280 added new Subsec. (c) re commissioner's authority to waive penalty period when transferor suffers from dementia and redesignated existing Subsec. (c) as new Subsec. (d), effective July 13, 2005.

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      Sec. 17b-261d. Disease management initiative. Implementation. Annual report. The Commissioner of Social Services may design and implement a care enhancement and disease management initiative, if such initiative is determined to be cost effective by the commissioner. The initiative shall provide for an integrated and systematic approach for managing the health care needs of high cost Medicaid recipients. Notwithstanding any provision of the general statutes, the commissioner may contract with an entity to effectuate the purposes of this section, provided such entity has an established and demonstrated capability in the design and implementation of a disease management initiative. If implemented, the commissioner shall report annually on the status of the care enhancement and disease management initiative to the joint standing committees of the General Assembly having cognizance of matters relating to appropriations and the budgets of state agencies and human services.

      (June 30 Sp. Sess. P.A. 03-3, S. 51; P.A. 05-209, S. 1.)

      History: June 30 Sp. Sess. P.A. 03-3 effective August 20, 2003; P.A. 05-209 substituted "may" for "shall" re commissioner's design and implementation of care enhancement and disease management initiative, added "if such initiative is determined to be cost effective by the commissioner" and added "if implemented" with respect to annual reports re the status of initiative, effective July 1, 2005.

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      Sec. 17b-261e. Critical access hospitals: HUSKY and Medicaid coverage. The Commissioner of Social Services shall provide coverage for isolation care and emergency services provided by the state's critical access hospital to persons participating in the HUSKY Plan Part A and Part B and fee for services Medicaid programs under this chapter.

      (P.A. 05-280, S. 66.)

      History: P.A. 05-280 effective July 1, 2005.

      See Sec. 19a-490 for definition of "critical access hospital".

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      Sec. 17b-261f. Critical access hospital account established. There is established a critical access hospital account which shall be a separate, nonlapsing account within the General Fund. Moneys in the account shall be used by the Department of Social Services to fund the operations of the critical access hospital in the event of an activation. The account shall contain all moneys required by law to be deposited in the account.

      (P.A. 05-280, S. 62.)

      History: P.A. 05-280 effective July 1, 2005.

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      Sec. 17b-263a. Amendment to state Medicaid plan to include assertive community treatment teams and community support services. (a) On or before December 31, 2006, the Commissioner of Social Services, in consultation with the Commissioner of Mental Health and Addiction Services and the Community Mental Health Strategy Board, established under section 17a-485b, shall take such action as is necessary to amend the Medicaid state plan to include assertive community treatment teams and community support services within the definition of optional adult rehabilitation services. Such community treatment teams shall provide intensive, integrated, multidisciplinary services to adults with severe psychiatric disabilities, including, but not limited to, persons who are homeless, persons diverted or discharged from in-patient programs or nursing homes and persons diverted or released from correctional facilities, or who are at risk of incarceration, and such teams shall provide intensive community care management through case managers, nurses and physicians and shall include, but not be limited to, vocational, peer and substance abuse specialists. The Commissioner of Social Services shall adopt regulations, in accordance with the provisions of chapter 54, for purposes of establishing the services specified in this subsection. The Commissioner of Social Services may implement policies and procedures for purposes of establishing such services while in the process of adopting such policies or procedures in regulation form, provided notice of intention to adopt the regulations is printed in the Connecticut Law Journal no later than twenty days after implementation and any such policies and procedures shall be valid until the time the regulations are effective.

      (b) For purposes of this section, the Commissioner of Social Services shall enter into a memorandum of understanding with the Department of Mental Health and Addiction Services that delegates responsibility to the Commissioner of Mental Health and Addiction Services for the clinical management of adult rehabilitation services provided to adults eighteen years of age or older who are otherwise receiving mental health services from said department. For purposes of this section, the term "clinical management" describes the process of evaluating and determining the appropriateness of the utilization of behavioral health services, providing assistance to clinicians or beneficiaries to ensure appropriate use of resources and may include, but is not limited to, authorization, concurrent and retrospective review, discharge review, quality management, provider certification and provider performance enhancement. The Commissioner of Social Services and the Commissioner of Mental Health and Addiction Services shall jointly develop clinical management policies and procedures for purposes of this section. The Commissioner of Social Services may implement policies and procedures necessary to carry out the purposes of this section, including any necessary changes to existing behavioral health policies and procedures concerning utilization management, while in the process of adopting such policies and procedures in regulation form, in accordance with the provisions of chapter 54, provided the commissioner publishes notice of intention to adopt the regulations in the Connecticut Law Journal not later than twenty days after implementing such policies and procedures. Policies and procedures implemented pursuant to this subsection shall be valid until the earlier of the time such regulations are effective, or December 1, 2006.

      (P.A. 05-280, S. 84.)

      History: P.A. 05-280 effective July 13, 2005.

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      Sec. 17b-263b. Pilot program for individuals ages nineteen to twenty-one with a mental disorder and chronic health condition. Eligibility. The Commissioner of Social Services shall develop and implement a two-year pilot program for up to one hundred individuals who: (1) Are ages nineteen to twenty-one; (2) reside with a parent or a relative caregiver; (3) have been diagnosed with one or more mental disorders as defined in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders"; (4) have a significant chronic health condition; (5) have a substantial functional impairment as a result of the mental disorder or chronic health condition; and (6) are ineligible for medical assistance under the state-administered general assistance program due to parent or relative caregiver income. An individual who is eligible for benefits under this program, shall cooperate in establishing such individual's eligibility for Medicaid coverage based on disability. For purposes of this section "mental disorder" shall not include mental retardation, learning disorders, motor skill disorder, communication disorders, caffeine-related disorders, relational problems and additional conditions that may be a focus of clinical attention that are not otherwise defined as mental disorders in the most recent edition of the American Psychiatric Association's "Diagnostic and Statistical Manual of Mental Disorders".

      (P.A. 05-280, S. 11.)

      History: P.A. 05-280 effective July 1, 2005.

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      Sec. 17b-264. (Formerly Sec. 17-134e). Extension of other public assistance provisions. All of the provisions of sections 17b-22, 17b-75 to 17b-77, inclusive, 17b-79 to 17b-103, inclusive, and 17b-600 to 17b-604, inclusive, are extended to the medical assistance program except such provisions as are inconsistent with federal law and regulations governing Title XIX of the Social Security Amendments of 1965 and sections 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, and 17b-357 to 17b-361, inclusive.

      (1967, P.A. 759, S. 1(e); June 18 Sp. Sess. P.A. 97-2, S. 71, 165; P.A. 05-280, S. 23.)

      History: Sec. 17-134e transferred to Sec. 17b-264 in 1995; June 18 Sp. Sess. P.A. 97-2 made technical changes, effective July 1, 1997; P.A. 05-280 substituted reference to Sec. 17b-361 for reference to repealed Sec. 17b-362, effective July 1, 2005.

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      Sec. 17b-265d. Definition of full benefit dually eligible Medicare Part D beneficiary. Prescription drug coverage under Medicare Part D. Copayment coverage. Commissioner's enrollment authority. (a) As used in this section, "full benefit dually eligible Medicare Part D beneficiary" means a person who has coverage for Medicare Part D drugs and is eligible for full medical assistance benefits pursuant to section 17b-261, under any category of eligibility.

      (b) On and after the effective date of the Medicare Part D program established pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, no Medicaid prescription drug coverage shall be provided to a Medicaid recipient eligible for Medicare Part D for Medicare Part D drugs, as defined in said act. Medicaid coverage shall be provided to a full benefit dually eligible Medicare Part D beneficiary for prescription drugs that are not Medicare Part D drugs, as defined in said act.

      (c) The department shall be responsible for payment on behalf of a full benefit dually eligible Medicare Part D beneficiary of any Medicare Part D prescription drug copayments imposed pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

      (d) To the extent permitted under federal law, the Commissioner of Social Services may be the authorized representative of a full benefit dually eligible Medicare Part D beneficiary for the purpose of enrolling the beneficiary in a Medicare Part D plan.

      (P.A. 05-280, S. 19; Nov. 2 Sp. Sess. P.A. 05-2, S. 1; Nov. 2 Sp. Sess. P.A. 05-3, S. 1.)

      History: P.A. 05-280 effective July 1, 2005; Nov. 2 Sp. Sess. P.A. 05-2 added new Subsec. (a) defining "full benefit dually eligible Medicare Part D beneficiary", redesignated existing provisions as Subsec. (b) and made technical changes therein, and added Subsec. (c) re department's responsibility for payment of Medicare Part D prescription drug copayments on behalf of a full benefit dually eligible Medicare Part D beneficiary, effective December 1, 2005; Nov. 2 Sp. Sess. P.A. 05-3 added Subsec. (d) re authority of Commissioner of Social Services to act as the authorized representative of a full benefit dually eligible Medicare Part D beneficiary for purposes of enrolling the beneficiary in a Medicare Part D plan, effective December 1, 2005.

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      Sec. 17b-265e. Medicare Part D Supplemental Needs Fund. There is established a fund to be known as the "Medicare Part D Supplemental Needs Fund" which shall be an account within the General Fund under the Department of Social Services. The Commissioner of Social Services shall, within available appropriations, designate moneys to said fund. Moneys available in said fund shall be utilized by the Department of Social Services to provide financial assistance to Medicare Part D beneficiaries who are enrolled in the ConnPACE program or who are full benefit dually eligible Medicare Part D beneficiaries, as defined in section 17b-265d, and who lack the financial means to obtain medically necessary nonformulary prescription drugs. A beneficiary requesting such financial assistance from the department shall be required to make a satisfactory showing of the medical necessity of obtaining such nonformulary prescription drug to the department. The department may require as a condition of receiving such financial assistance that a beneficiary establish, to the satisfaction of the department, that the beneficiary has made good faith efforts to: (1) Enroll in a Medicare Part D plan recommended by the commissioner or the commissioner's agent; and (2) utilize the exception process established by the prescription drug plan in which the beneficiary is enrolled. The department shall expeditiously review all requests for financial assistance pursuant to this section and shall notify the beneficiary as to whether the request for financial assistance has been granted not later than two hours after receiving the request from the beneficiary. The commissioner shall implement policies and procedures to administer the provisions of this section and to ensure that all requests for, and determinations made concerning financial assistance available pursuant to this section are expeditiously processed.

      (Nov. 2 Sp. Sess. P.A. 05-2, S. 2.)

      History: Nov. 2 Sp. Sess. P.A. 05-2 effective December 1, 2005.

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      Sec. 17b-266. (Formerly Sec. 17-134g). Purchase of insurance. Contracts for comprehensive health care on a prepayment or per capita basis. Certification of providers by commissioner. Exception of deadline for payment of capitation claims. Deposit of funds for expenditures for children's health programs and services. (a) The Commissioner of Social Services may, when the commissioner finds it to be in the public interest, fund part or all of the cost of benefits to any recipient under sections 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, 17b-357 to 17b-361, inclusive, 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session*, through the purchase of insurance from any organization authorized to do a health insurance business in this state or from any organization specified in subsection (b) of this section.

      (b) The Commissioner of Social Services may require recipients of Medicaid or other public assistance to receive medical care on a prepayment or per capita basis, in accordance with federal law and regulations, if such prepayment is anticipated to result in lower medical assistance costs to the state. The commissioner may enter into contracts for the provision of comprehensive health care on a prepayment or per capita basis in accordance with federal law and regulations, with the following: (1) A health care center subject to the provisions of chapter 698a; (2) a consortium of federally-qualified community health centers and other community-based providers of health services which are funded by the state; (3) other consortia of providers of health care services established for the purposes of this subsection; or (4) an integrated service network providing care management and comprehensive health care on a prepayment or per capita basis to elderly and disabled recipients of Medicaid who may also be eligible for Medicare.

      (c) Providers of comprehensive health care services as described in subdivisions (2), (3) and (4) of subsection (b) of this section shall not be subject to the provisions of chapter 698a or, in the case of an integrated service network, sections 17b-239 to 17b-245, inclusive, 17b-281, 17b-340, 17b-342 and 17b-343. Any such provider shall be certified by the Commissioner of Social Services in accordance with criteria established by the commissioner, including, but not limited to, minimum reserve fund requirements.

      (d) The commissioner shall pay all capitation claims which would otherwise be reimbursed to the health plans described in subsection (b) of this section in June, 1997, no later than July 31, 1997.

      (e) On or after May 1, 2000, the payment to the Commissioner of Social Services of (1) any monetary sanction imposed by the commissioner on a managed care organization under the provisions of a contract between the commissioner and such organization entered into pursuant to this section or sections 17b-289 to 17b-304, inclusive, or (2) any sum agreed upon by the commissioner and such an organization as settlement of a claim brought by the commissioner or the state against such an organization for failure to comply with the terms of a contract with the commissioner or fraud affecting the Department of Social Services shall be deposited in an account designated for use by the department for expenditures for children's health programs and services.

      (1967, P.A. 759, S. 1(g); P.A. 75-420, S. 4, 6; P.A. 77-614, S. 608, 610; P.A. 83-51; P.A. 93-262, S. 1, 87; May Sp. Sess. P.A. 94-5, S. 27, 30; P.A. 95-160, S. 26, 69; P.A. 96-139, S. 12, 13; June 18 Sp. Sess. P.A. 97-2, S. 112, 165; P.A. 98-239, S. 23, 35; June Sp. Sess. P.A. 00-2, S. 19, 53; P.A. 02-89, S. 31; P.A 03-278, S. 62; P.A. 05-280, S. 24.)

      *Note: Section 16 of public act 97-1 of the October special session is special in nature and therefore has not been codified but remains in full force and effect according to its terms.

      History: P.A. 75-420 replaced welfare commissioner with commissioner of social services; P.A. 77-614 replaced commissioner of social services with commissioner of income maintenance, effective January 1, 1979; P.A. 83-51 added Subsec. (b) allowing the commissioner to enter into contracts for comprehensive health care on a prepayment or per capita basis and allowing recipients to receive medical care on such basis; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; May Sp. Sess. P.A. 94-5 specified with whom the commissioner may contract for the provision of comprehensive health care, allowed comprehensive health care providers not to be subject to chapter 698a and required the health care providers to be certified by the commissioner, effective July 1, 1994; Sec. 17-134g transferred to Sec. 17b-266 in 1995; P.A. 95-160 added Subsec. (d) requiring the commissioner to pay all capitation claims to be reimbursed to health plans in June, 1997, no later than July 31, 1997, effective July 1, 1995; P.A. 96-139 changed effective date of P.A. 95-160 but without affecting this section; June 18 Sp. Sess. P.A. 97-2 authorized the commissioner to enter into comprehensive health care contracts with integrated service networks and exempted such networks from the provisions of chapter 698a or sections 17b-239 to 17b-245, inclusive, 17b-281, 17b-340 or 17b-342 to 17b-344, inclusive, effective July 1, 1997; (Revisor's note: New Subsec. (e) added by vetoed P.A. 97-240 and reprinted in Sec. 112 of June 18 Sp. Sess. P.A. 97-2 is void and was therefore not codified); P.A. 98-239 amended Subsec. (a) to allow the Commissioner of Social Services to fund part or all of the health care insurance costs for recipients of the HUSKY Plan, Part B through the purchase of insurance from any organization authorized to conduct a health insurance business in this state or from any organization specified in Subsec. (b), effective June 8, 1998; June Sp. Sess. P.A. 00-2 added Subsec. (e) re payments made to the commissioner of certain monetary sanctions or settlements deposited in account designated for use for expenditures for children's health programs and services, effective June 21, 2000; P.A. 02-89 amended Subsec. (c) to replace reference to Sec. 17b-344 with reference to Sec. 17b-343, reflecting the repeal of Sec. 17b-344 by the same public act; P.A. 03-278 made technical changes in Subsec. (c), effective July 9, 2003; P.A. 05-280 amended Subsec. (a) by making a technical change for purposes of gender neutrality and substituting reference to Sec. 17b-361 for reference to repealed Sec. 17b-362, effective July 1, 2005.

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      Sec. 17b-267. (Formerly Sec. 17-134h). Use of fiscal intermediaries in connection with medical assistance. (a) If any group or association of providers of medical assistance services wishes to have payments as provided for under sections 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, and 17b-357 to 17b-361, inclusive, to such providers made through a national, state or other public or private agency or organization and nominates such agency or organization for this purpose, the Commissioner of Social Services is authorized to enter into an agreement with such agency or organization providing for the determination by such agency or organization, subject to such review by the Commissioner of Social Services as may be provided for by the agreement, of the payments required to be made to such providers at the rates set by the hospital cost commission, and for the making of such payments by such agency or organization to such providers. Such agreement may also include provision for the agency or organization to do all or any part of the following: With respect to the providers of services which are to receive payments through it, (1) to serve as a center for, and to communicate to providers, any information or instructions furnished to it by the Commissioner of Social Services, and to serve as a channel of communication from providers to the Commissioner of Social Services; (2) to make such audits of the records of providers as may be necessary to insure that proper payments are made under this section; and (3) to perform such other functions as are necessary to carry out the provisions of sections 17b-267 to 17b-271, inclusive.

      (b) The Commissioner of Social Services shall not enter into an agreement with any agency or organization under subsection (a) of this section unless (1) he finds (A) that to do so is consistent with the effective and efficient administration of the medical assistance program, and (B) that such agency or organization is willing and able to assist the providers to which payments are made through it in the application of safeguards against unnecessary utilization of services furnished by them to individuals entitled to hospital insurance benefits under section 17b-261 and the agreement provides for such assistance, and (2) such agency or organization agrees to furnish to the Commissioner of Social Services such of the information acquired by it in carrying out its agreement under sections 17b-267 to 17b-271, inclusive, as the Commissioner of Social Services may find necessary in performing his functions under said sections.

      (c) An agreement with any agency or organization under subsection (a) of this section may contain such terms and conditions as the Commissioner of Social Services finds necessary or appropriate, may provide for advances of funds to the agency or organization for the making of payments by it under said subsection (a), and shall provide for payment by the Commissioner of Social Services of so much of the cost of administration of the agency or organization as is determined by the Commissioner of Social Services to be necessary and proper for carrying out the functions covered by the agreement.

      (1971, P.A. 431, S. 1; P.A. 75-420, S. 4, 6; P.A. 77-614, S. 608, 610; P.A. 93-262, S. 1, 87; P.A. 05-280, S. 25; 05-288, S. 70.)

      History: P.A. 75-420 replaced welfare commissioner with commissioner of social services; P.A. 77-614 replaced commissioner of social services with commissioner of income maintenance, effective January 1, 1979; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; Sec. 17-134h transferred to Sec. 17b-267 in 1995; P.A. 05-280 amended Subsec. (a) by substituting reference to Sec. 17b-361 for reference to repealed Sec. 17b-362, effective July 1, 2005; P.A. 05-288 made technical changes in Subsecs. (b) and (c), effective July 13, 2005.

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      Sec. 17b-272. (Formerly Sec. 17-134m). Personal fund allowance. Effective July 1, 1998, the Commissioner of Social Services shall permit patients residing in nursing homes, chronic disease hospitals and state humane institutions who are medical assistance recipients under sections 17b-260 to 17b-262, inclusive, 17b-264 to 17b-285, inclusive, and 17b-357 to 17b-361, inclusive, to have a monthly personal fund allowance of fifty dollars. Effective July 1, 1999, the commissioner shall increase such allowance annually to reflect the annual inflation adjustment in Social Security income, if any.

      (P.A. 81-320; P.A. 84-354, S. 1, 2; P.A. 85-367, S. 1; P.A. 87-367, S. 1, 2; June Sp. Sess. P.A. 91-8, S. 7, 63; P.A. 93-262, S. 1, 87; June 18 Sp. Sess. P.A. 97-2, S. 151, 165; P.A. 98-239, S. 3, 35; P.A. 05-280, S. 26.)

      History: P.A. 84-354 increased the allowance from twenty-eight to thirty dollars; P.A. 85-367 increased the allowance from thirty to thirty-five dollars; P.A. 87-367 increased the allowance from "thirty-five" to "forty" dollars and added the language re adjustments beginning July 1, 1988; June Sp. Sess. P.A. 91-8 reduced the allowance to an amount equal to the minimum permitted under Title XIX, beginning October 1, 1991, and deleted the previous forty-dollar allowance and the language re adjustments; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; Sec. 17-134m transferred to Sec. 17b-272 in 1995; June 18 Sp. Sess. P.A. 97-2 added a provision effective July 1, 1998, requiring the commissioner to increase personal fund allowance annually to reflect any annual inflation adjustment in Social Security income, effective July 1, 1997; P.A. 98-239 substituted "July 1, 1998" for "October 1, 1991" as applicable date and increased the allowance to fifty dollars, deleting reference to "a level equal to the minimum permitted under Title XIX of the Social Security Act" and substituted "July 1, 1999" for "July 1, 1998" as applicable date for annual increases, effective July 1, 1998; P.A. 05-280 substituted reference to Sec. 17b-361 for reference to repealed Sec. 17b-362, effective July 1, 2005.

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      Sec. 17b-274. (Formerly Sec. 17-134q). Periodic investigations of pharmacies by Division of Criminal Justice. Brand medically necessary. Procedure for prior approval to dispense brand name drug. Disclosure. (a) The Division of Criminal Justice shall periodically investigate pharmacies to ensure that the state is not billed for a brand name drug product when a less expensive generic substitute drug product is dispensed to a Medicaid recipient. The Commissioner of Social Services shall cooperate and provide information as requested by such division.

      (b) A licensed medical practitioner may specify in writing or by a telephonic or electronic communication that there shall be no substitution for the specified brand name drug product in any prescription for a Medicaid, state-administered general assistance, or ConnPACE recipient, provided (1) the practitioner specifies the basis on which the brand name drug product and dosage form is medically necessary in comparison to a chemically equivalent generic drug product substitution, and (2) the phrase "brand medically necessary" shall be in the practitioner's handwriting on the prescription form or, if the prohibition was communicated by telephonic communication, in the pharmacist's handwriting on such form, and shall not be preprinted or stamped or initialed on such form. If the practitioner specifies by telephonic communication that there shall be no substitution for the specified brand name drug product in any prescription for a Medicaid, state-administered general assistance, or ConnPACE recipient, written certification in the practitioner's handwriting bearing the phrase "brand medically necessary" shall be sent to the dispensing pharmacy within ten days. A pharmacist shall dispense a generically equivalent drug product for any drug listed in accordance with the Code of Federal Regulations Title 42 Part 447.332 for a drug prescribed for a Medicaid, state-administered general assistance, or ConnPACE recipient unless the phrase "brand medically necessary" is ordered in accordance with this subsection and such pharmacist has received approval to dispense the brand name drug product in accordance with subsection (c) of this section.

      (c) The Commissioner of Social Services shall implement a procedure by which a pharmacist shall obtain approval from an independent pharmacy consultant acting on behalf of the Department of Social Services, under an administrative services only contract, whenever the pharmacist dispenses a brand name drug product to a Medicaid, state-administered general assistance, or ConnPACE recipient and a chemically equivalent generic drug product substitution is available. The length of authorization for brand name drugs shall be in accordance with section 17b-491a. In cases where the brand name drug is less costly than the chemically equivalent generic drug when factoring in manufacturers' rebates, the pharmacist shall dispense the brand name drug. If such approval is not granted or denied within two hours of receipt by the commissioner of the request for approval, it shall be deemed granted. Notwithstanding any provision of this section, a pharmacist shall not dispense any initial maintenance drug prescription for which there is a chemically equivalent generic substitution that is for less than fifteen days without the department's granting of prior authorization, provided prior authorization shall not otherwise be required for atypical antipsychotic drugs if the individual is currently taking such drug at the time the pharmacist receives the prescription. The pharmacist may appeal a denial of reimbursement to the department based on the failure of such pharmacist to substitute a generic drug product in accordance with this section.

      (d) A licensed medical practitioner shall disclose to the Department of Social Services or such consultant, upon request, the basis on which the brand name drug product and dosage form is medically necessary in comparison to a chemically equivalent generic drug product substitution. The Commissioner of Social Services shall establish a procedure by which such a practitioner may appeal a determination that a chemically equivalent generic drug product substitution is required for a Medicaid, state-administered general assistance, or ConnPACE recipient.

      (P.A. 83-52, S. 1, 2, 4; P.A. 84-217, S. 1, 2; P.A. 89-111, S. 1; P.A. 93-262, S. 1, 87; P.A. 95-264, S. 46; P.A. 96-169, S. 13; June Sp. Sess. P.A. 00-2, S. 38, 53; May 9 Sp. Sess. P.A. 02-7, S. 50; P.A. 03-2, S. 52; June 30 Sp. Sess. P.A. 03-3, S. 84; P.A. 04-76, S. 16; P.A. 05-280, S. 16.)

      History: P.A. 84-217 removed language that limited payment of fee to the period from July 1, 1983, to June 30, 1984, and increased fee from twenty-five to fifty cents; P.A. 89-111 added a new Subsec. (c) containing provisions for when there is to be no substitute for the specified brand name drug product; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; Sec. 17-134q transferred to Sec. 17b-274 in 1995; P.A. 95-264 made technical changes; P.A. 96-169 amended Subsec. (b) to require the Commissioner of Social Services to cooperate and provide information as requested by the Division of Criminal Justice; June Sp. Sess. P.A. 00-2 amended Subsec. (c) to apply provisions to state-administered general assistance, general assistance and ConnPACE recipients, to require specification of the basis of medical necessity and to add provision re approval to dispense, added new Subsec. (d) requiring the Commissioner of Social Services to establish a procedure for approval of dispensing brand name drug products and added new Subsec. (e) re disclosure of the basis of medical necessity, effective July 1, 2000; May 9 Sp. Sess. P.A. 02-7 deleted former Subsec. (a) re fifty cent per prescription dispensing fee, redesignated existing Subsecs. (b) to (e) as Subsecs. (a) to (d) and amended Subsec. (c) by changing "shall establish a procedure" to "shall implement a procedure" and adding requirement that pharmacist not dispense any initial maintenance drug prescription for less than fifteen days for which there is a chemically equivalent generic substitution without obtaining prior authorization from the department, such prior authorization not required for atypical antipsychotic drugs currently used by individuals at the time pharmacist receives prescription, effective August 15, 2002; P.A. 03-2 amended Subsec. (c) to add provision that chemically equivalent generic drug product substitution be available "at a lower cost" as condition precedent to requiring prior authorization for dispensing brand name drug product, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (c) to delete "at a lower cost" and add provision re dispensing of brand name drug in cases where the brand name drug is less costly than the generic drug when factoring in manufacturers' rebates, effective August 20, 2003; P.A. 04-76 amended Subsecs. (b) to (d), inclusive, by deleting references to "general assistance"; P.A. 05-280 amended Subsec. (c) by deleting provision specifying that prior authorization procedure shall not require approval other than initial prescriptions for brand name drug products and adding requirement that length of authorization for brand name drugs shall be in accordance with Sec. 17b-491a, effective July 1, 2005.

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      Sec. 17b-274b. Pharmaceutical purchasing initiative. Annual report. Section 17b-274b is repealed, effective July 1, 2005.

      (May 9 Sp. Sess. P.A. 02-1, S. 123; May 9 Sp. Sess. P.A. 02-7, S. 56; P.A. 04-76, S. 18; P.A. 05-280, S. 104.)

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      Sec. 17b-274c. Voluntary mail order option for maintenance prescription drugs and drugs covered under the Medicare Part D program. (a) The Commissioner of Social Services may establish a voluntary mail order option for any maintenance prescription drug covered under the Medicaid, state-administered general assistance, ConnPACE or Connecticut AIDS drug assistance programs.

      (b) Notwithstanding any provision of the general statutes or regulations adopted pursuant thereto, the Commissioner of Social Services may provide a voluntary mail order option, regardless of a mail order pharmacy's location, for any prescription drug covered under the Medicare Part D program established pursuant to Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

      (May 9 Sp. Sess. P.A. 02-1, S. 120; P.A. 04-76, S. 19; Nov. 2 Sp. Sess. P.A. 05-2, S. 5.)

      History: May 9 Sp. Sess. P.A. 02-1 effective July 1, 2002; P.A. 04-76 deleted reference to "general assistance"; Nov. 2 Sp. Sess. P.A. 05-2 designated existing provisions as Subsec. (a) and added Subsec. (b) authorizing commissioner to provide a voluntary mail order option for any prescription drug covered under the Medicare Part D program, effective December 1, 2005.

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      Sec. 17b-274d. Pharmaceutical and Therapeutics Committee. Membership. Duties. Preferred drug lists. Supplemental rebates. Administrative hearings. (a) Pursuant to 42 USC 1396r-8, there is established a Pharmaceutical and Therapeutics Committee within the Department of Social Services.

      (b) The Pharmaceutical and Therapeutics Committee shall be comprised as specified in 42 USC 1396r-8 and shall consist of fourteen members appointed by the Governor. Five members shall be physicians licensed pursuant to chapter 370, including one general practitioner, one pediatrician, one geriatrician, one psychiatrist and one specialist in family planning, four members shall be pharmacists licensed pursuant to chapter 400j, two members shall be visiting nurses, one specializing in adult care and one specializing in psychiatric care, one member shall be a clinician designated by the Commissioner of Mental Health and Addiction Services, one member shall be a representative of pharmaceutical manufacturers and one member shall be a consumer representative. The committee may, on an ad hoc basis, seek the participation of other state agencies or other interested parties in its deliberations. The members shall serve for terms of two years from the date of their appointment. Members may be appointed to more than one term. The Commissioner of Social Services, or the commissioner's designee, shall convene the committee following the Governor's designation of appointments. The administrative staff of the Department of Social Services shall serve as staff for said committee and assist with all ministerial duties. The Governor shall ensure that the committee membership includes Medicaid participating physicians and pharmacists, with experience serving recipients of medical assistance.

      (c) Committee members shall select a chairperson and vice-chairperson from the committee membership on an annual basis.

      (d) The committee shall meet at least quarterly, and may meet at other times at the discretion of the chairperson and committee membership. The committee shall comply with all regulations adopted by the department, including notice of any meeting of the committee, pursuant to the requirements of chapter 54.

      (e) The Department of Social Services, in consultation with the Pharmaceutical and Therapeutics Committee, may adopt preferred drug lists for use in the Medicaid, state-administered general assistance and ConnPACE programs. The Department of Social Services, upon entering into a contract for the provision of prescription drug coverage to medical assistance recipients receiving services in a managed care setting as provided by section 17b-266a, shall in consultation with the Pharmaceutical and Therapeutics Committee, expand the preferred drug list for use in the HUSKY Plan, Part A and Part B. To the extent feasible, the department shall review all drugs included on the preferred drug lists at least every twelve months, and may recommend additions to, and deletions from, the preferred drug lists, to ensure that the preferred drug lists provide for medically appropriate drug therapies for Medicaid, state-administered general assistance and ConnPACE patients. For the fiscal year ending June 30, 2004, such drug lists shall be limited to use in the Medicaid and ConnPACE programs and cover three classes of drugs, including proton pump inhibitors and two other classes of drugs determined by the Commissioner of Social Services. Not later than June 30, 2005, the Department of Social Services, in consultation with the Pharmaceutical and Therapeutic Committee shall expand such drug lists to include other classes of drugs, except as provided in subsection (f) of this section, in order to achieve savings reflected in the amounts appropriated to the department, for the various components of the program, in the state budget act.

      (f) Nonpreferred drugs in the classes of drugs included on the preferred drug lists shall be subject to prior authorization. If prior authorization is granted for a drug not included on a preferred drug list, the authorization shall be valid for one year from the date the prescription is first filled. Mental-health-related and antiretroviral classes of drugs shall not be included on the preferred drug lists.

      (g) The Department of Social Services shall publish and disseminate the preferred drug lists to all Medicaid providers in the state.

      (h) The department may negotiate supplemental rebate agreements with manufacturers that are in addition to those required under Title XIX of the Social Security Act. The committee shall ensure that the pharmaceutical manufacturers agreeing to provide a supplemental rebate pursuant to 42 USC 1396r-8(c) have an opportunity to present evidence supporting inclusion of a product on the preferred drug lists unless a court of competent jurisdiction, in a final decision, determines that the Secretary of Health and Human Services does not have authority to allow such supplemental rebates, provided the inability to utilize supplemental rebates pursuant to this subsection shall not impair the committee's authority to maintain preferred drug lists. Upon timely notice, the department shall ensure that any drug that has been approved, or had any of its particular uses approved, by the United States Food and Drug Administration under a priority review classification, will be reviewed by the Pharmaceutical and Therapeutics Committee at the next regularly scheduled meeting. To the extent feasible, upon notice by a pharmaceutical manufacturer, the department shall also schedule a product review for any new product at the next regularly scheduled meeting of the Pharmaceutical and Therapeutics Committee.

      (i) Factors considered by the department and the Pharmaceutical and Therapeutics Committee in developing the preferred drug lists shall include, but not be limited to, clinical efficacy, safety and cost effectiveness of a product.

      (j) The Pharmaceutical and Therapeutics Committee may also make recommendations to the department regarding the prior authorization of any prescribed drug.

      (k) A recipient who is denied a nonpreferred drug may request an administrative hearing in accordance with section 17b-60.

      (l) The Commissioner of Social Services may contract with a pharmacy benefits organization or a single entity qualified to negotiate with pharmaceutical manufacturers for supplemental rebates, available pursuant to 42 USC 1396r-8(c), for the purchase of drugs listed on the preferred drug lists established pursuant to subsection (e) of this section.

      (May 9 Sp. Sess. P.A. 02-1, S. 121; May 9 Sp. Sess. P.A. 02-7, S. 52; P.A. 03-2, S. 19; 03-278, S. 63; June 30 Sp. Sess. P.A. 03-3, S. 83; P.A. 04-258, S. 8, 43; May Sp. Sess. P.A. 04-2, S. 41; P.A. 05-280, S. 18; 05-288, S. 71.)

      History: May 9 Sp. Sess. P.A. 02-1 effective July 1, 2002; May 9 Sp. Sess. P.A. 02-7 amended Subsec. (h) by adding provision re implementation of supplemental rebate program subject to determination by a court of competent jurisdiction re federal authority to allow such rebates, effective August 15, 2002; P.A. 03-2 amended Subsec. (a) to require committee to convene on or before March 31, 2003, amended Subsec. (e) to require Department of Social Services to adopt preferred drug list on or before July 1, 2003, to replace provision re department's adoption of preferred drug list upon recommendation of committee with provision re adoption of preferred drug list in consultation with committee, and to substitute "department" for "committee" re review of drugs included in the preferred drug list, and amended Subsec. (i) to add "the department and" re development of the preferred drug list, effective February 28, 2003; P.A. 03-278 made technical changes in Subsec. (h), effective July 9, 2003; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (b) to increase size of committee from eleven to fourteen members, to further specify the professional qualifications required of the committee membership, and to add provisions re committee may seek participation of other state agencies and interested parties, and re committee to convene after Governor's designation of appointments, amended Subsec. (e) to add references to the Medicaid and ConnPACE programs re use of preferred drug list, to provide that for fiscal year ending June 30, 2004, preferred drug list is limited to proton pump inhibitors and two other classes of drugs to be determined by commissioner and to add provision re notice to legislative committees, amended Subsec. (j) to add "in accordance with the plan developed and implemented pursuant to section 17b-491a" and added new Subsec. (l) re application of section to state-administered general assistance program, effective August 20, 2003; P.A. 04-258 amended Subsec. (a) by deleting provision re date by which committee was to convene, amended Subsecs. (e) through (i), inclusive, by replacing "preferred drug list" with "preferred drug lists" and making conforming changes, amended Subsec. (e) by providing that use of preferred drug list would be expanded to HUSKY Plan, Part A and Part B upon the Department of Social Services entering into a contract for the provision of prescription drug coverage pursuant to Sec. 17b-266a, adding provision re use of preferred drug lists for the fiscal year ending June 30, 2004, only in the Medicaid and ConnPACE programs, deleting provision re notification by commissioner by January 1, 2004, of classes of drugs on preferred drug list and adding provision re expansion of drug lists by June 30, 2005, to include other classes of drugs, amended Subsec. (f) by adding "medications used to treat diabetes, asthma or cancer" to the types of drugs not subject to prior authorization requirements, moved provision in former Subsec. (l) re application of section to state-administered general assistance program to Subsec. (e), and added new Subsec. (l) re commissioner's authority to negotiate with pharmaceutical manufacturers for supplemental rebates for drugs on preferred drug lists, effective July 1, 2004; May Sp. Sess. P.A. 04-2 amended Subsec. (f) by deleting "medications used to treat diabetes, asthma or cancer" re the types of drugs not subject to prior authorization requirements, effective July 1, 2004; P.A. 05-280 amended Subsecs. (a), (b), (e) and (h) to (j), inclusive, to delete "Medicaid" from the name of the Pharmaceutical and Therapeutics Committee, amended Subsec. (b) to substitute "recipients of medical assistance" for "all segments of the Medicaid population", amended Subsec. (e) by substituting "may" for "shall" re adoption of preferred drug lists, amended Subsec. (f) by providing that nonpreferred drugs in the classes of drugs included on the preferred drug lists shall be subject to prior authorization, specifying that the length of prior authorization shall be for one year from the date the prescription is first filled and exempting mental-health-related and antiretroviral classes of drugs from inclusion on the preferred drug lists, amended Subsec. (h) by providing that department may negotiate supplemental rebate agreements with manufacturers that supplement those required by Title XIX of the Social Security Act, amended Subsec. (j) by removing provision that limited committee's recommendation to drugs covered by Medicaid in accordance with the plan developed pursuant to Sec. 17b-491a, and replaced former Subsec. (k) re Medicaid recipients appeal of preferred drug list determinations utilizing Medicaid fair hearing process with new Subsec. (k) providing that a recipient denied a nonpreferred drug may request an administrative hearing in accordance with Sec. 17b-60, effective July 1, 2005; P.A. 05-288 made a technical change in Subsec. (f), effective July 13, 2005.

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      Sec. 17b-277. (Formerly Sec. 17-134u). Medical assistance for needy pregnant women and children. Expedited eligibility. Administrative processing requirements. Biannual reports. (a) The Commissioner of Social Services shall provide, in accordance with federal law and regulations, medical assistance under the Medicaid program to needy pregnant women and children up to one year of age whose families have an income up to one hundred eighty-five per cent of the federal poverty level.

      (b) The commissioner shall expedite eligibility for appropriate pregnant women applicants for the Medicaid program. The process for making expedited eligibility determinations concerning needy pregnant women shall ensure that emergency applications for assistance, as determined by the commissioner, shall be processed no later than twenty-four hours after receipt of all required information from the applicant, and that nonemergency applications for assistance, as determined by the commissioner, shall be processed no later than five calendar days after the date of receipt of all required information from the applicant.

      (c) The commissioner shall submit biannual reports to the council, established pursuant to section 17b-28, on the department's compliance with the administrative processing requirements set forth in subsection (b) of this section.

      (P.A. 88-217, S. 1, 2; P.A. 90-134, S. 4, 28; P.A. 93-262, S. 1, 87; June 18 Sp. Sess. P.A. 97-2, S. 72, 165; P.A. 05-280, S. 8.)

      History: P.A. 90-134 added Subsec. (b) re presumptive eligibility; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; Sec. 17-134u transferred to Sec. 17b-277 in 1995; June 18 Sp. Sess. P.A. 97-2 made technical changes, effective July 1, 1997; P.A. 05-280 amended Subsec. (b) by replacing provisions re presumptive eligibility for pregnant women with respect to Medicaid program with provisions re expedited eligibility and requiring that emergency applications be processed no later than twenty-four hours after receipt of all required information and that nonemergency applications be processed no later than five calendar days after the date of receipt of all required information, and added new Subsec. (c) requiring commissioner to submit biannual reports to Medicaid managed care council, effective July 1, 2005.

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      Sec. 17b-279. (Formerly Sec. 17-134aa). Medicaid prescription drug utilization review. Erectile dysfunction drugs. Prior authorization requirement and coverage limitation. Report. The Commissioner of Social Services shall verify the propriety and reasonableness of payments to providers for drugs provided to Medicaid recipients through field audit examinations and other reasonable means to the extent possible within available appropriations. To the extent permitted by federal law, the commissioner shall require prior authorization for coverage of drugs for the treatment of erectile dysfunction. To the extent permitted by federal law, the commissioner may limit or exclude coverage for drugs for the treatment of erectile dysfunction for persons who have been convicted of a sexual offense who are required to register with the Commissioner of Public Safety pursuant to chapter 969. The commissioner shall document financial and utilization statistics as to drugs provided to Medicaid recipients by therapeutic category and shall outline problems encountered in the administration of prescription drug utilization in the Medicaid program, suggested solutions and any recommendations for improvement.

      (P.A. 89-296, S. 1, 9; P.A. 91-190, S. 1, 9; P.A. 93-262, S. 1, 87; May 9 Sp. Sess. P.A. 02-7, S. 88; P.A. 03-268, S. 8; P.A. 05-280, S. 15.)

      History: P.A. 91-190 amended Subsec. (a) to eliminate advisory panel to review prescription drug utilization in the Medicaid program and repealed Subsec. (b) requiring commissioner to study feasibility of (1) implementing a limited formulary of high volume drugs for medical assistance recipients and (2) a rebate to the state from a pharmaceutical manufacturer or direct distributor of a percentage of total sales to the state, and to report results to general assembly committees by February 15, 1990; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; Sec. 17-134aa transferred to Sec. 17b-279 in 1995; May 9 Sp. Sess. P.A. 02-7 deleted ", including the generic incentive dispensing fee", effective September 1, 2002; P.A. 03-268 deleted requirement that commissioner submit annual report to human services and appropriations committees; P.A. 05-280 required commissioner to implement prior authorization for coverage of drugs for the treatment of erectile dysfunction under the Medicaid program and permitted commissioner to limit or exclude coverage for such drugs for persons who have been convicted of a sexual offense who are required to register with the Commissioner of Public Safety pursuant to chapter 969, effective July 1, 2005.

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      Sec. 17b-280. (Formerly Sec. 17-134bb). Reimbursement rate for legend drugs. Dispensing fee. Reimbursement for over-the-counter drugs and products. Dispensing fee exception. Enhanced dispensing fee. (a) The state shall reimburse for all legend drugs provided under the Medicaid, state-administered general assistance, ConnPACE and Connecticut AIDS drug assistance programs at the lower of (1) the rate established by the Centers for Medicare and Medicaid Services as the federal acquisition cost, (2) the average wholesale price minus fourteen per cent, or (3) an equivalent percentage as established under the Medicaid state plan. The commissioner shall also establish a professional fee of three dollars and fifteen cents for each prescription to be paid to licensed pharmacies for dispensing drugs to Medicaid, ConnPACE and Connecticut AIDS drug assistance recipients in accordance with federal regulations; and on and after September 4, 1991, payment for legend and nonlegend drugs provided to Medicaid recipients shall be based upon the actual package size dispensed. Effective October 1, 1991, reimbursement for over-the-counter drugs for such recipients shall be limited to those over-the-counter drugs and products published in the Connecticut Formulary, or the cross reference list, issued by the commissioner. The cost of all over-the-counter drugs and products provided to residents of nursing facilities, chronic disease hospitals, and intermediate care facilities for the mentally retarded shall be included in the facilities' per diem rate. Notwithstanding the provisions of this subsection, no dispensing fee shall be issued for a prescription drug dispensed to a ConnPACE or Medicaid recipient who is a Medicare Part D beneficiary when the prescription drug is a Medicare Part D drug, as defined in Public Law 108-173, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

      (b) The Department of Social Services may provide an enhanced dispensing fee to a pharmacy enrolled in the federal Office of Pharmacy Affairs Section 340B drug discount program established pursuant to 42 USC 256b or a pharmacy under contract to provide services under said program.

      (P.A. 89-296, S. 2, 9; June Sp. Sess. P.A. 91-8, S. 9, 63; May 9 Sp. Sess. P.A. 02-1, S. 122; P.A. 03-2, S. 11; June 30 Sp. Sess. P.A. 03-3, S. 52; P.A. 04-76, S. 20; 04-258, S. 10; May Sp. Sess. P.A. 04-2, S. 85; P.A. 05-280, S. 4.)

      History: June Sp. Sess. P.A. 91-8 divided the subsection into Subdivs., substituted "Medicaid" for "medical aid" and June 30 Sp. Sess. P.A. 03-3 relettered existing provision as Subsec. (a), provision amended to provide effective October 1, 2003 professional dispensing fee paid to pharmacies lowered from three dollars and sixty cents to three dollars and thirty cents, added new Subsec. (b) to allow commissioner to provide an enhanced dispensing fee to a pharmacy enrolled in, or under contract to provide services, under the federal Office of Pharmacy Affairs drug discount program, effective August 20, 2003, added a new Subdiv. (2) re payment for legend and nonlegend drugs and basing the payment on the actual package size dispensed, limitation on the reimbursement of over-the-counter drugs as of October 1, 1991, and the inclusion in the rate of the cost of over-the-counter drugs for nursing facilities, chronic disease hospitals and the intermediate care facilities for the mentally retarded; Sec. 17-134bb transferred to Sec. 17b-280 in 1995; May 9 Sp. Sess. P.A. 02-1 amended Subdiv. (1) to provide that reimbursement for legend drugs applies to the Medicaid, state-administered general assistance, general assistance, ConnPACE and Connecticut AIDS drug assistance programs and that, effective September 1, 2002, the dispensing fee paid to licensed pharmacists is three dollars and eighty-five cents per prescription, effective July 1, 2002; P.A. 03-2 deleted "Notwithstanding any provision of the regulations of Connecticut state agencies concerning payment for drugs provide to Medicaid recipients (1) effective July 1, 1989", provided that effective March 1, 2003, the dispensing fee is three dollars and sixty cents per prescription and made technical changes, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-3 designated existing provisions as Subsec. (a) and, effective October 1, 2003, lowered professional dispensing fee paid to pharmacies from three dollars and sixty cents to three dollars and thirty cents and added new Subsec.(b) re enhanced dispensing fee to pharmacy enrolled in, or under contract to provide services under, the federal Office of Pharmacy Affairs drug discount program, effective August 20, 2003; P.A. 04-76 amended Subsec. (a) by deleting references to "general assistance"; P.A. 04-258 amended Subsec. (a) by deleting "Effective October 1, 2003," and by lowering the professional dispensing fee paid to pharmacies from three dollars and thirty cents to three dollars and fifteen cents, effective July 1, 2004; May Sp. Sess. P.A. 04-2 amended Subsec. (a) to delete "state-administered general assistance" from the list of programs for which commissioner pays a professional fee to licensed pharmacies for dispensing drugs to program recipients, effective July 1, 2004; P.A. 05-280 amended Subsec. (a) by substituting "Centers for Medicare and Medicaid Services" for "Health Care Finance Administration", providing that reimbursement rate for legend drugs shall be the lower of rate established by said Centers, the average wholesale price minus fourteen per cent or an equivalent percentage as established under the Medicaid state plan, deleting language re commissioner's authority to establish and periodically revise estimated acquisition cost in accordance with federal regulations, and providing that no dispensing fee shall be issued for prescription drugs dispensed to a ConnPACE or Medicaid recipient who is a Medicare Part D beneficiary when the prescription drug is a Medicare Part D drug, effective July 1, 2005.

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      Sec. 17b-289. Short title: HUSKY and HUSKY Plus Act. HUSKY Plan, Part A and HUSKY Plan, Part B participants. (a) Sections 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session* shall be known as the "HUSKY and HUSKY Plus Act".

      (b) Children, caretaker relatives and pregnant women receiving assistance under section 17b-261 or 17b-277 shall be participants in the HUSKY Plan, Part A and children receiving assistance under sections 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session* shall be participants in the HUSKY Plan, Part B. For purposes of marketing and outreach, both parts shall be known as the HUSKY Plan.

      (October 29 Sp. Sess. P.A. 97-1, S. 1, 23; P.A. 05-44, S. 1.)

      *Note: Section 16 of public act 97-1 of the October 29 special session is special in nature and therefore has not been codified but remains in full force and effect according to its terms.

      History: Oct. 29 Sp. Sess. P.A. 97-1 effective October 30, 1997; P.A. 05-44 amended Subsec. (b) to include caretaker relatives and pregnant women receiving assistance under Sec. 17b-261 or Sec. 17b-277 as participants in HUSKY Plan, Part A, effective July 1, 2005.

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      Sec. 17b-290. Definitions. As used in sections 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session*:

      (1) "Applicant" means an individual over the age of eighteen years who is a natural or adoptive parent or a legal guardian; a caretaker relative, foster parent or stepparent with whom the child resides; or a noncustodial parent under order of a court or family support magistrate to provide health insurance, who applies for coverage under the HUSKY Plan, Part B on behalf of a child and shall include a child who is eighteen years of age or emancipated in accordance with the provisions of sections 46b-150 to 46b-150e, inclusive, and who is applying on his own behalf or on behalf of a minor dependent for coverage under such plan;

      (2) "Child" means an individual under nineteen years of age;

      (3) "Coinsurance" means the sharing of health care expenses by the insured and an insurer in a specified ratio;

      (4) "Commissioner" means the Commissioner of Social Services;

      (5) "Copayment" means a payment made on behalf of an enrollee for a specified service under the HUSKY Plan, Part B;

      (6) "Cost sharing" means arrangements made on behalf of an enrollee whereby an applicant pays a portion of the cost of health services, sharing costs with the state and includes copayments, premiums, deductibles and coinsurance;

      (7) "Deductible" means the amount of out-of-pocket expenses that would be paid for health services on behalf of an enrollee before becoming payable by the insurer;

      (8) "Department" means the Department of Social Services;

      (9) "Durable medical equipment" means durable medical equipment, as defined in Section 1395x(n) of the Social Security Act;

      (10) "Eligible beneficiary" means a child who meets the requirements specified in section 17b-292, except a child excluded under the provisions of Subtitle J of Public Law 105-33 or a child of any municipal employee eligible for employer-sponsored insurance on or after October 30, 1997, provided a child of such a municipal employee may be eligible for coverage under the HUSKY Plan, Part B if dependent coverage was terminated due to an extreme economic hardship on the part of the employee, as determined by the commissioner;

      (11) "Enrollee" means an eligible beneficiary who receives services from a managed care plan under the HUSKY Plan, Part B;

      (12) "Family" means any combination of the following: (A) An individual; (B) the individual's spouse; (C) any child of the individual or such spouse; or (D) the legal guardian of any such child if the guardian resides with the child;

      (13) "HUSKY Plan, Part A" means assistance provided to children, caretaker relatives and pregnant women pursuant to section 17b-261 or 17b-277;

      (14) "HUSKY Plan, Part B" means the health insurance plan for children established pursuant to the provisions of sections 17b-289 to 17b-303, inclusive, and section 16 of public act 97-1 of the October 29 special session*;

      (15) "HUSKY Plus programs" means two supplemental health insurance programs established pursuant to section 17b-294 for medically eligible enrollees of the HUSKY Plan, Part B whose medical needs cannot be accommodated within the basic benefit package offered to enrollees. One program shall supplement coverage for those medically eligible enrollees with intensive physical health needs and the other program shall supplement coverage for those medically eligible enrollees with intensive behavioral health needs;

      (16) "Income" means income as calculated in the same manner as under the Medicaid program pursuant to section 17b-261;

      (17) "Managed care plan" means a plan offered by an entity that contracts with the department to provide benefits to enrollees on a prepaid basis;

      (18) "Parent" means a natural parent, stepparent, adoptive parent, guardian or custodian of a child;

      (19) "Premium" means any required payment made by an individual to offset or pay in full the capitation rate under the HUSKY Plan, Part B;

      (20) "Preventive care and services" means: (A) Child preventive care, including periodic and interperiodic well-child visits, routine immunizations, health screenings and routine laboratory tests; (B) prenatal care, including care of all complications of pregnancy; (C) care of newborn infants, including attendance at high-risk deliveries and normal newborn care; (D) WIC evaluations; (E) child abuse assessment required under sections 17a-106a and 46b-129a; (F) preventive dental care for children; and (G) periodicity schedules and reporting based on the standards specified by the American Academy of Pediatrics;

      (21) "Primary and preventive health care services" means the services of licensed physicians, optometrists, nurses, nurse practitioners, midwives and other related health care professionals which are provided on an outpatient basis, including routine well-child visits, diagnosis and treatment of illness and injury, laboratory tests, diagnostic x-rays, prescription drugs, radiation therapy, chemotherapy, hemodialysis, emergency room services, and outpatient alcohol and substance abuse services, as defined by the commissioner;

      (22) "Qualified entity" means any entity: (A) Eligible for payments under a state plan approved under Medicaid and which provides medical services under the HUSKY Plan, Part A, or (B) that is a qualified entity, as defined in 42 USC 1396r-1a, as amended by Section 708 of Public Law 106-554 and that is determined by the commissioner to be capable of making the determination of eligibility. The commissioner shall provide qualified entities with such forms as are necessary for an application to be made on behalf of a child under the HUSKY Plan, Part A and information on how to assist parents, guardians and other persons in completing and filing such forms;

      (23) "WIC" means the federal Special Supplemental Food Program for Women, Infants and Children administered by the Department of Public Health pursuant to section 19a-59c.

      (October 29 Sp. Sess. P.A. 97-1, S. 2, 23; P.A. 99-279, S. 18, 45; P.A. 00-196, S. 53; P.A. 01-137, S. 2, 9; June 30 Sp. Sess. P.A. 03-3, S. 73; P.A. 05-44, S. 2.)

      *Note: Section 16 of public act 97-1 of the October 29 special session is special in nature and therefore has not been codified but remains in full force and effect according to its terms.

      History: Oct. 29 Sp. Sess. P.A. 97-1 effective October 30, 1997; P.A. 99-279 amended Subdiv. (10) to provide that a child of a municipal employee may be eligible for coverage under the HUSKY Plan, Part B if dependent coverage was terminated due to an extreme economic hardship on the part of the employee, as determined by the commissioner, effective July 1, 1999; P.A. 00-196 made technical changes in Subdivs. (21) and (22); P.A. 01-137 amended Subdiv. (22) to redefine "qualified entity" by deleting language contained in the federal definition of term and adding reference to such federal definition, effective July 1, 2001 (Revisor's note: In Subdiv. (22), the word "that" was inserted editorially by the Revisors after "(B)" for proper form); June 30 Sp. Sess. P.A. 03-3 amended introductory language to add reference to Sec. 17b-261f, effective August 20, 2003; P.A. 05-44 amended Subdiv. (13) to redefine "HUSKY Plan, Part A" to include assistance provided to caretaker relatives and pregnant women pursuant to Sec. 17b-261 or 17b-277, effective July 1, 2005 (Revisor's note: An erroneous reference to Sec. 17b-261f was deleted editorially by the Revisors to correct a codification error).

      See Sec. 17b-261e re HUSKY and Medicaid coverage for isolation care and emergency services provided by the state's critical access hospital.

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      Sec. 17b-292. HUSKY Plan Part A and Part B. Eligibility. Presumptive eligibility. Single point of entry services. Managed care enrollment brokerage services. Regulations. (a) A child who resides in a household with a family income which exceeds one hundred eighty-five per cent of the federal poverty level and does not exceed three hundred per cent of the federal poverty level may be eligible for subsidized benefits under the HUSKY Plan, Part B.

      (b) A child who resides in a household with a family income over three hundred per cent of the federal poverty level may be eligible for unsubsidized benefits under the HUSKY Plan, Part B.

      (c) Whenever a court or family support magistrate orders a noncustodial parent to provide health insurance for a child, such parent may provide for coverage under the HUSKY Plan, Part B.

      (d) To the extent allowed under federal law, the commissioner shall not pay for services or durable medical equipment under the HUSKY Plan, Part B if the enrollee has other insurance coverage for the services or such equipment.

      (e) A newborn child who otherwise meets the eligibility criteria for the HUSKY Plan, Part B shall be eligible for benefits retroactive to his date of birth, provided an application is filed on behalf of the child within thirty days of such date.

      (f) The commissioner shall implement presumptive eligibility for children applying for Medicaid. Such presumptive eligibility determinations shall be in accordance with applicable federal law and regulations. The commissioner shall adopt regulations, in accordance with chapter 54, to establish standards and procedures for the designation of organizations as qualified entities to grant presumptive eligibility. Qualified entities shall ensure that, at the time a presumptive eligibility determination is made, a completed application for Medicaid is submitted to the department for a full eligibility determination. In establishing such standards and procedures, the commissioner shall ensure the representation of state-wide and local organizations that provide services to children of all ages in each region of the state.

      (g) The commissioner shall enter into a contract with an entity to be a single point of entry servicer for applicants and enrollees under the HUSKY Plan, Part A and Part B. The servicer shall jointly market both Part A and Part B together as the HUSKY Plan. Such servicer shall develop and implement public information and outreach activities with community programs. Such servicer shall electronically transmit data with respect to enrollment and disenrollment in the HUSKY Plan, Part B to the commissioner.

      (h) Upon the expiration of any contractual provisions entered into pursuant to subsection (g) of this section, the commissioner shall develop a new contract for single point of entry services and managed care enrollment brokerage services. The commissioner may enter into one or more contractual arrangements for such services for a contract period not to exceed seven years. Such contracts shall include performance measures, including, but not limited to, specified time limits for the processing of applications, parameters setting forth the requirements for a completed and reviewable application and the percentage of applications forwarded to the department in a complete and timely fashion. Such contracts shall also include a process for identifying and correcting noncompliance with established performance measures, including sanctions applicable for instances of continued noncompliance with performance measures.

      (i) The single point of entry servicer shall send an application and supporting documents to the commissioner for determination of eligibility of a child who resides in a household with a family income of one hundred eighty-five per cent or less of the federal poverty level. The servicer shall enroll eligible beneficiaries in the applicant's choice of managed care plan. Upon enrollment in a managed care plan, an eligible HUSKY Plan Part A or Part B beneficiary shall remain enrolled in such managed care plan for twelve months from the date of such enrollment unless (1) an eligible beneficiary demonstrates good cause to the satisfaction of the commissioner of the need to enroll in a different managed care plan, or (2) the beneficiary no longer meets program eligibility requirements.

      (j) Not more than twelve months after the determination of eligibility for benefits under the HUSKY Plan, Part A and Part B and annually thereafter, the commissioner or the servicer, as the case may be, shall determine if the child continues to be eligible for the plan. The commissioner or the servicer shall mail an application form to each participant in the plan for the purposes of obtaining information to make a determination on eligibility. The determination of eligibility shall be coordinated with health plan open enrollment periods.

      (k) The commissioner shall implement the HUSKY Plan, Part B while in the process of adopting necessary policies and procedures in regulation form in accordance with the provisions of section 17b-10.

      (l) The commissioner shall adopt regulations, in accordance with chapter 54, to establish residency requirements and income eligibility for participation in the HUSKY Plan, Part B and procedures for a simplified mail-in application process. Notwithstanding the provisions of section 17b-257b, such regulations shall provide that any child adopted from another country by an individual who is a citizen of the United States and a resident of this state shall be eligible for benefits under the HUSKY Plan, Part B upon arrival in this state.

      (October 29 Sp. Sess. P.A. 97-1, S. 4, 23; P.A. 01-137, S. 1, 3, 4, 9; P.A. 03-2, S. 7; June 30 Sp. Sess. P.A. 03-3, S. 56; P.A. 04-16, S. 10; P.A. 05-280, S. 5, 9.)

      History: Oct. 29 Sp. Sess. P.A. 97-1 effective October 30, 1997; P.A. 01-137 amended Subsec. (h) to require servicer to electronically transmit enrollment and disenrollment data re HUSKY Plan, Part B to commissioner who may transmit such data to Children's Health Council and amended Subsec. (k) to require the commissioner or servicer, as the case may be, to determine if a child continues to be eligible for benefits under the HUSKY Plan, Part A or Part B, to mail an application form to each participant in the plan and to rely upon information provided in the application form by the participant in determining eligibility for benefits under the plan with respect to family income unless the commissioner or servicer has reason to believe that such information is inaccurate or incomplete, effective July 1, 2001, and amended Subsec. (m) to require regulations providing that any child adopted from another country by a U.S. citizen and state resident shall be eligible for benefits under the HUSKY Plan, Part B upon arrival in this state, effective June 28, 2001; P.A. 03-2 deleted former Subsec. (d) which provided for twelve months of continuous eligibility under the HUSKY Plan, Part A or Part B, from the date that a child was determined eligible for the program and redesignated existing Subsecs. (e) to (m), inclusive, as Subsecs. (d) to (l), inclusive, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (a) to provide that the services and cost-sharing requirements under HUSKY Plan, Part B shall be substantially similar to those afforded to state residents by the largest commercially available health plan offered by a managed care organization, deleted former Subsecs. (f) and (h) re granting of presumptive eligibility under HUSKY Plan, Part A, redesignated existing Subsec. (g) as Subsec. (f) and deleted reference therein re transmittal of data to Children's Health Council, and redesignated existing Subsecs. (i) to (l) as Subsecs. (g) to (j), effective August 20, 2003; P.A. 04-16 made a technical change in Subsec. (a); P.A. 05-280 amended Subsec. (a) to delete provision that required HUSKY Plan, Part B services and cost-sharing requirements to be substantially similar to those of the largest commercially available health plan offered by a managed care organization, added new Subsec. (f) re implementation of presumptive eligibility for children applying for Medicaid and requiring commissioner to adopt regulations re standards and procedures for the designation of organizations that shall act as qualified entities to grant presumptive eligibility, redesignated existing Subsec. (f) as new Subsec. (g), added new Subsec. (h) re development of new contract for single point of entry services and managed care enrollment brokerage services, redesignated existing Subsecs. (g) to (j), inclusive, as new Subsecs. (i) to (l), inclusive, amended redesignated Subsec. (i) to require HUSKY Plan, Part A or Part B beneficiaries, enrolled in managed care plan, to remain enrolled in such plan for twelve months unless beneficiary demonstrates good cause to enroll in a different plan or no longer meets program eligibility requirements and amended redesignated Subsec. (j) to eliminate mandate that commissioner rely on family income information provided by participant in determining eligibility for benefits under the HUSKY Plan, Part A and Part B, effective July 1, 2005.

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      Sec. 17b-295. Cost-sharing requirements under HUSKY Plan, Part B. (a) The commissioner shall impose cost-sharing requirements including the payment of a premium or copayment in connection with services provided under the HUSKY Plan, Part B, to the extent permitted by federal law, and in accordance with the following limitations:

      (1) On and after July 1, 2005, the commissioner may increase the maximum annual aggregate cost-sharing requirements provided that such cost-sharing requirements shall not exceed five per cent of the family's gross annual income. The commissioner may impose a premium requirement on families whose income exceeds two hundred thirty-five per cent of the federal poverty level, as a component of the family's cost-sharing responsibility, provided: (A) The family's annual combined premiums and copayments do not exceed the maximum annual aggregate cost-sharing requirement, and (B) premium requirements shall not exceed the sum of thirty dollars per month per child, with a maximum premium of fifty dollars per month per family. The commissioner shall not impose a premium requirement on families, whose income exceeds one hundred eighty-five per cent of the federal poverty level but does not exceed two hundred thirty-five per cent of the federal poverty level; and

      (2) The commissioner shall require each managed care plan to monitor copayments and premiums under the provisions of subdivision (1) of this subsection.

      (b) (1) Except as provided in subdivision (2) of this subsection, the commissioner may impose limitations on the amount, duration and scope of benefits under the HUSKY Plan, Part B.

      (2) The limitations adopted by the commissioner pursuant to subdivision (1) of this subsection shall not preclude coverage of any item of durable medical equipment or service that is medically necessary.

      (October 29 Sp. Sess. P.A. 97-1, S. 7, 23; P.A. 98-8, S. 2, 5; June 30 Sp. Sess. P.A. 03-3, S. 55; P.A. 05-280, S. 7; Nov. 2 Sp. Sess. P.A. 05-1, S. 1.)

      History: Oct. 29 Sp. Sess. P.A. 97-1 effective October 30, 1997; P.A. 98-8 amended Subdiv. (3) of Subsec. (a) to require each managed care plan, rather than its health care providers, to monitor copayments and premiums, effective April 7, 1998; June 30 Sp. Sess. P.A. 03-3 amended Subsec. (a) to require commissioner to impose cost-sharing requirements in connection with services provided under the HUSKY Plan, Part B to the extent permitted by federal law, to delete "may require" re payment of premiums and copayments, to delete former Subdivs. (1) and (2) re maximum annual cost-sharing for families and add new Subdiv. (1) providing that on and after October 1, 2003, commissioner may increase maximum annual cost-sharing for families in an amount not to exceed five per cent of the family's gross annual income, and authorizing commissioner to impose a premium on families with income exceeding one hundred eighty-five per cent of the federal poverty level as a component of the family's cost-sharing responsibility provided family's combined premiums and copayments do not exceed the maximum annual cost-sharing requirement, and to redesignate former Subdiv. (3) redesignated as Subdiv. (2); P.A. 05-280 amended Subsec. (a)(1) by substituting July 1, 2005, for October 1, 2003, and changing "may" to "shall" re commissioner increasing maximum annual cost-sharing requirements, by requiring the commissioner to impose a premium requirement that does not exceed the maximum annual aggregate cost-sharing requirement on families whose income exceeds one hundred eighty-five per cent of the federal poverty level but does not exceed two hundred thirty-five per cent of the federal poverty level and by increasing the premium requirement on families whose income exceeds two hundred thirty-five per cent of the federal poverty level but does not exceed three hundred per cent of the federal poverty level, effective July 1, 2005; Nov. 2 Sp. Sess. P.A. 05-1 amended Subsec. (a)(1) by changing "shall" to "may" re commissioner's authority to increase maximum annual cost-sharing requirements, by providing that commissioner shall not impose premium requirements on families whose income exceeds one hundred eighty-five per cent but does not exceed two hundred thirty-five per cent of federal poverty level, by removing provision that required commissioner to increase premium requirements on families whose income exceeds two hundred thirty-five per cent but does not exceed three hundred per cent of federal poverty level, and by providing that commissioner may impose premium requirements on families whose income exceeds two hundred thirty-five per cent of federal poverty level, not exceeding thirty dollars per month per child, with a maximum of fifty dollars per month per family, effective November 3, 2005.

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