Substitute Senate Bill No. 637
          Substitute Senate Bill No. 637

              PUBLIC ACT NO. 97-240


AN  ACT  CONCERNING   THE  RECOMMENDATION  OF  THE
MEDICAID MANAGED CARE  COUNCIL  AND EARLY PERIODIC
DENTAL SCREENING.


    Be it enacted  by  the  Senate  and  House  of
Representatives in General Assembly convened:
    Section  1.  Section  17b-28  of  the  general
statutes  is  repealed   and   the   following  is
substituted in lieu thereof:
    (a) There is established a council which shall
advise the Commissioner  of Social Services on the
planning  and  implementation   of   a  system  of
Medicaid  managed  care  and  shall  monitor  such
planning and implementation  and  shall advise the
Waiver     Application    Development     Council,
established  pursuant  to   section   17b-28a,  on
matters including, but not limited to, eligibility
standards, benefits, access and quality assurance.
The council shall  be composed of the chairmen and
ranking members of  the  joint standing committees
of  the  General  Assembly  having  cognizance  of
matters  relating to  human  services  and  public
health, or their  designees;  two  members  of the
General  Assembly, one  to  be  appointed  by  the
president pro tempore  of the Senate and one to be
appointed  by  the   speaker   of   the  House  of
Representatives; the director of the Commission on
Aging,  or  his  designee;  the  director  of  the
Commission  on  Children,  or  his  designee;  two
community  providers  of   health   care,   to  be
appointed by the  president  pro  tempore  of  the
Senate;  two  representatives   of  the  insurance
industry, to be  appointed  by  the speaker of the
House  of  Representatives;   two   advocates  for
persons receiving Medicaid, one to be appointed by
the majority leader  of  the  Senate and one to be
appointed by the  minority  leader  of the Senate;
one  advocate for  persons  with  substance  abuse
disabilities,  to be  appointed  by  the  majority
leader  of  the   House  of  Representatives;  one
advocate    for    persons     with    psychiatric
disabilities,  to be  appointed  by  the  minority
leader  of  the   House  of  Representatives;  ONE
ADVOCATE FOR DEPARTMENT  OF  CHILDREN AND FAMILIES
FOSTER FAMILIES, TO  BE  APPOINTED BY THE MAJORITY
LEADER OF THE  SENATE;  two  members of the public
who are currently  recipients  of Medicaid, one to
be appointed by  the  majority leader of the House
of Representatives and  one to be appointed by the
minority leader of  the  House of Representatives;
two representatives of  the  Department  of Social
Services, to be  appointed  by the Commissioner of
Social  Services;  two   representatives   of  the
Department of Public  Health,  to  be appointed by
the   Commissioner   of    Public    Health;   two
representatives of the Department of Mental Health
and Addiction Services,  to  be  appointed  by the
Commissioner  of  Mental   Health   and  Addiction
Services; TWO REPRESENTATIVES OF THE DEPARTMENT OF
CHILDREN AND FAMILIES,  TO  BE  APPOINTED  BY  THE
COMMISSIONER  OF  CHILDREN   AND   FAMILIES;   TWO
REPRESENTATIVES  OF  THE   OFFICE  OF  POLICY  AND
MANAGEMENT, TO BE  APPOINTED  BY  THE SECRETARY OF
THE  OFFICE  OF   POLICY   AND   MANAGEMENT;   ONE
REPRESENTATIVE  OF  THE   OFFICE   OF   THE  STATE
COMPTROLLER,  TO  BE   APPOINTED   BY   THE  STATE
COMPTROLLER; and the  members  of  the Health Care
Access Board who  shall  be ex-officio members and
who may not  designate  persons  to serve in their
place. The council shall choose a chair from among
its members. [, and the staff of the public health
committee shall provide]  THE  JOINT  COMMITTEE ON
LEGISLATIVE   MANAGEMENT   SHALL    ARRANGE    FOR
administrative support to  such chair. The council
shall convene its first meeting no later than June
1, 1994.
    (b)  The council  shall  make  recommendations
concerning (1) guaranteed  access to enrollees and
effective  outreach  and   client  education;  (2)
available services comparable  to those already in
the   Medicaid   state   plan,   including   those
guaranteed under the  federal  Early  and Periodic
Screening Diagnosis and Treatment Program; (3) the
sufficiency   of  provider   networks;   (4)   the
sufficiency of capitated  rates provider payments,
financing and staff  resources to guarantee timely
access to services;  (5)  participation in managed
care by existing community Medicaid providers; (6)
the   linguistic  and   cultural   competency   of
providers  and  other  program  facilitators;  (7)
quality  assurance;  (8)  timely,  accessible  and
effective   client   grievance   procedures;   (9)
coordination of the  Medicaid  managed  care  plan
with state and  federal  health care reforms; (10)
eligibility levels for  inclusion  in the program;
(11)  cost-sharing  provisions;   (12)  a  benefit
package; and (13)  other  issues pertaining to the
development   of   a    Medicaid    Research   and
Demonstration Waiver under  Section  1115  of  the
Social Security Act.
    (c) The Commissioner  of Social Services shall
seek a federal  waiver  for  the  Medicaid managed
care plan. Implementation  of the Medicaid managed
care plan shall not occur before July 1, 1995.
    (d) [On July  1, 1994, and monthly thereafter,
the] THE Commissioner  of  Social  Services  shall
provide  monthly  reports   on   the   plans   and
implementation of the Medicaid managed care system
to the council.
    (e)  [On  October   1,   1994,  and  quarterly
thereafter,  the] THE  council  shall  report  its
activities and progress  ONCE  EACH QUARTER to the
General Assembly.
    Sec.  2.  Section   17b-266   of  the  general
statutes is amended  by  adding  subsection (e) as
follows:
    (NEW) (e) Providers  of  comprehensive  health
care  under  this  section  shall  report  to  the
Commissioner of Social  Services  all  spending by
service category, as  defined  by the commissioner
and set forth in any contract under subsection (b)
of this section.
    Sec.  3.  (NEW)  The  Commissioner  of  Social
Services, in entering  any  contract  pursuant  to
section 17b-266 of the general statutes concerning
managed care that  covers children, pregnant women
and related coverage  groups  under  the  Medicaid
program,  shall  require  the  following  in  said
contract:
    (1) A specific description of the managed care
organization's  obligation  to  provide  the  full
range of services  required  by the Early Periodic
Screening Detection and Treatment program pursuant
to 42 USC  1396a,  including,  but not limited to:
(A) Case management services, as defined in 42 USC
1396d; (B) assistance with transportation and with
scheduling   appointments;   and    (C)   periodic
screening examinations;
    (2)   Definitions   of   medically   necessary
services  under  the   Early   Periodic  Screening
Detection and Treatment  program  that clarify the
obligations of the  managed  care  organization to
provide services that  maintain  a child's optimal
health regardless of  whether  the services result
in an improvement in health status;
    (3)  Provisions  that  define  procedures  for
prior  authorization,  including  provisions  that
require that any  utilization review of behavioral
health services and  other  specialty services for
children be performed  by  reviewers  with special
training in children's health care needs;
    (4) Provisions that  clarify  the  requirement
that the Early  Periodic  Screening  Detection and
Treatment program includes all medically necessary
services  under  Medicaid,   and  that  limits  on
treatment that are not based on medical necessity,
including upper limits on the amount of particular
types of treatment of any kind, are prohibited;
    (5) A requirement  that  participants  in  the
Medicaid managed care  program  receive notice and
an opportunity to be heard consistent with chapter
54 of the  general statutes prior to the reduction
or  termination  of  any  service  that  has  been
prescribed for them  and  prior  to  the effective
date of the  reduction  or termination of service,
with notice given to the managed care organization
member or the  member's parent or guardian, if the
member is a child;
    (6) A requirement that sets forth time periods
that  the managed  care  organization  must  meet,
including, but not  limited  to,  scheduling:  (A)
Urgent care appointments within twenty-four hours;
(B)   appointments   for   routine   care   within
seventy-two hours; (C)  appointments  for periodic
screening examinations under  the  Early  Periodic
Screening Detection and  Treatment  program within
four weeks; (D)  appointments  for  routine dental
and vision care  services  within  four weeks; (E)
appointments for mental  health  services that are
not  urgent or  emergent  within  two  weeks;  (F)
authorization  for  emergency   care  within  four
hours; (G) authorization  for  urgent  care within
six hours; and  (H)  authorization of routine care
within seventy-two hours;
    (7)   A   requirement    that   a   child   be
automatically  enrolled in  the  mother's  managed
care organization upon birth of the child;
    (8)   A   requirement    that   managed   care
organizations coordinate their  services  with the
following programs by  means  of  a  memorandum of
understanding that sets forth how the managed care
organization will refer  members  to  the program,
how  the program  will  provide  their  respective
services  to  assure   that   services   are   not
duplicated and how  the  managed care organization
will assure that all services received both inside
and  outside the  managed  care  organization  are
coordinated through a  primary  care  provider or,
when necessary because  of  a  child's  mental  or
physical health condition,  through  the provision
of case management  services, as defined at 42 USC
1396d:  (A)  Healthy   Families  Connecticut;  (B)
Healthy Start; (C)  the  Special Supplemental Food
Program for Women,  Infant  and  Child  (WIC); (D)
Birth-to-Three  programs;  (E)  Special  Education
programs; and (F)  other  programs operated by the
Departments  of  Children   and  Families,  Public
Health, Mental Health  and  Addiction Services and
Mental Retardation that  provide services to those
receiving  Medicaid services  under  the  Medicaid
managed care program;
    (9)    Requirements    that    managed    care
organizations  have  the   capacity   to   provide
services to their  members in the members' primary
languages, including the  provision  of  qualified
bilingual, bicultural providers  in their networks
as necessary to meet their members' needs;
    (10)   A   requirement   that   managed   care
organizations  provide  their   members  with  the
following  information upon  the  request  of  the
member: (A) Up  to  date lists of providers in the
managed  care organization's  networks,  including
whether the provider  is  accepting  new patients;
(B) timely access  to  the  members'  own  medical
record  and  other  plan  records;  and  (C)  plan
protocols for confidentiality;
    (11)   A   requirement   that   managed   care
organizations  contract with  school-based  health
centers located in the managed care organizations'
geographic areas for  the  full  range of services
provided by the school-based health centers;
    (12)    Requirements   that    managed    care
organizations include family  members in a child's
treatment     program     unless      specifically
contraindicated,  that  the  organization  provide
family therapy when medically necessary regardless
of whether all family members are part of the plan
and the provision  of transportation to the family
member; and
    (13) Provisions for intermediate and graduated
sanctions for violations  of  the  contract  terms
that are in  addition  to  the  termination of the
entire contract, including:  (A) Corrective action
plans;   (B)   receiverships;    (C)   withholding
capitation  payments; (D)  payment  for  medically
necessary  out of  network  care,  when  medically
necessary  services  within   the   scope  of  the
contract are not provided in a timely fashion; (E)
suspension   or   freezing   of   enrolment;   (F)
adjustment to current enrolment; and (G) fines.
    Sec.  4.  (NEW)   The   Department  of  Social
Services,  in  consultation   with   the  Medicaid
Managed Care Council  and  the  Children's  Health
Council,   shall  develop   model   memoranda   of
understanding, for the purposes of subdivision (8)
of section 3 of this act.
    Sec. 5. (a)  There is established a task force
to study methods  to enhance employer-based health
insurance.
    (b)  The  task  force  shall  consist  of  the
following members:
    (1) An advocate  for  persons  without  health
insurance and a representative of organized labor,
each appointed by  the  speaker  of  the  House of
Representatives;
    (2) A representative  of  companies that offer
health insurance to  small  groups and individuals
and a representative of businesses in Connecticut,
each appointed by the president pro tempore of the
Senate;
    (3) Two small-business  owners, each appointed
by  the  majority   leader   of   the   House   of
Representatives;
    (4)  A  representative   of   a  managed  care
organization, appointed by  the majority leader of
the Senate;
    (5) A representative  of  a  local  chamber of
commerce, appointed by  the minority leader of the
House of Representatives;
    (6)  A  representative   of   a  municipality,
appointed by the  majority  leader of the House of
Representatives;
    (7) A representative  of  organized  medicine,
appointed by the minority leader of the Senate;
    (8) The Secretary  of the Office of Policy and
Management, or his designee;
    (9) The State Comptroller, or his designee;
    (10) The chairpersons  and  ranking members of
the  joint  standing   committee  of  the  General
Assembly having cognizance  of matters relating to
public health, or their designees;
    (11) The chairpersons  and  ranking members of
the  joint  standing   committee  of  the  General
Assembly having cognizance  of matters relating to
insurance and real estate, or their designees;
    (12) The chairpersons  and  ranking members of
the  joint  standing   committee  of  the  General
Assembly having cognizance  of matters relating to
commerce, or their designees;
    (13) The chairpersons  and  ranking members of
the  joint  standing   committee  of  the  General
Assembly having cognizance  of matters relating to
finance, revenue and  bonding, or their designees;
and
    (14) The chairpersons  and  ranking members of
the  joint  standing   committee  of  the  General
Assembly having cognizance  of matters relating to
appropriations, or their designees.
    (c) All appointments  to  the task force shall
be  made no  later  than  thirty  days  after  the
effective date of  this section. Any vacancy shall
be filled by the appointing authority.
    (d)   The   speaker    of    the    House   of
Representatives and the  president  pro tempore of
the Senate shall  select  the  chairpersons of the
task force from  among  the  members  of  the task
force. The chairpersons  shall  schedule the first
meeting of the  task force, which shall be held no
later than sixty  days after the effective date of
this section.
    (e)  The  joint   committee   of  the  General
Assembly having cognizance  of matters relating to
Legislative      Management     shall      provide
administrative staff of the task force.
    (f) Not later  than  January 1, 1998, the task
force shall submit  a  report  on its findings and
recommendations to the  joint  standing committees
of  the  General  Assembly  having  cognizance  of
matters relating to  public  health  and insurance
and real estate, in accordance with the provisions
of section 11-4a of the general statutes. The task
force shall terminate  on the date that it submits
such  report or  January  1,  1998,  whichever  is
earlier.
    Sec. 6. (NEW)  (a) Not later than September 1,
1997, and annually thereafter, the Commissioner of
Public    Health    shall,     within    available
appropriations, provide to  the  Medicaid  Managed
Care  Council  established   pursuant  to  section
17b-28 of the general statutes, as amended by this
act, an inventory  of safety net providers in this
state. To the  extent such information is provided
to  the  commissioner   by   the  contractor,  the
inventory shall include  (1)  a  catalog of direct
and  population-based services  provided  to  both
insured and uninsured  clients  at  each site, (2)
the number of  services provided at each site, and
(3) the payer mix of clients.
    (b)  The commissioner  shall,  to  the  extent
information  is  available   to   him  and  within
available  appropriations,  develop   an   ongoing
monitoring system to  identify safety net provider
reductions in services  including, but not limited
to, medical social  work,  outreach, psychological
testing and home visitation.
    (c)  At  such   time   as   the   commissioner
identifies that a  safety  net provider is at risk
of  closing or  of  reducing  services,  he  shall
convene a public  hearing  at  which  local health
officials  and  any   interested  legislators  and
members of the  public  may  discuss the community
public health impact  of changes to the safety net
and potential solutions.
    (d) For purposes  of this section, "safety-net
provider"   means   community    health   centers,
school-based   health   centers,    local   health
districts, nonprofit visiting  nurse associations,
family planning clinics and public dental clinics.
    Sec.  7.  (NEW)   The   Department  of  Social
Services shall develop  mechanisms  to  streamline
eligibility for the  Medicaid  Expansion  Program,
including, but not  limited to, (1) development of
mail-in  applications,  (2)   collaboration   with
community organizations in  outreach  programs  to
maximize enrolment of  eligible  clients  and  (3)
training of department  staff  in  eligibility for
and  benefits  available  under  Medicaid  managed
care.
    Sec.  8.  (NEW)   (a)   Any  dentist  licensed
pursuant to chapter  379  of  the general statutes
and who participates  in the Medicaid managed care
program  under  section  17b-266  of  the  general
statutes  may  provide   services  exclusively  to
persons eligible for  the Early Periodic Screening
Detection Treatment program  pursuant  to  42  USC
1396d  who  are   qualified  under  said  Medicaid
managed care program.
    (b)  No  person   contracting   with  dentists
pursuant  to the  Medicaid  managed  care  program
shall, as a  requirement for participation require
that a dentist participate in a plan that does not
exclusively provide services  to  persons eligible
for  the  Early   Periodic   Screening   Detection
Treatment program who  are  qualified  under  said
Medicaid managed care program.
    Sec.  9.  (NEW)  The  Commissioner  of  Social
Services  shall develop  a  form  to  be  used  by
managed  care companies  that  contract  with  the
Medicaid managed care  program. Said form shall be
standard for all  such  contracts  and confirm the
credentials of any such managed care company.
    Sec. 10. This  act  shall take effect from its
passage, except that  section  7 shall take effect
October 1, 1997.

Vetoed June 27, 1997