Sec. 17b-265g. Health insurer. Duties owed to the state and Commissioner of Social Services.
Sec. 17b-277d. Medicaid payment for maternity services. Regulations.
Sec. 17b-306a. Child health quality improvement program. Purpose and scope. Annual reports.
Sec. 17b-242. (Formerly Sec. 17-313). Payments to home health care agencies and home health aide agencies. Appeals. Hearings. Authorized practitioners. Regulations. (a) The Department of Social Services shall determine the rates to be paid to home health care agencies and 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. 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 modify such fee schedule if such modification is needed to ensure that the conversion to an administrative services organization is cost neutral to home health care agencies and home health aide agencies in the aggregate and ensures patient access. Utilization may be a factor in determining cost neutrality. 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. On and after January 1, 2024, the commissioner shall increase the fee schedule for complex care nursing services provided to individuals over the age of eighteen such that the rate of reimbursement is equal to the rate for such services provided to individuals age eighteen and under. There shall be no differential in fees paid for such services based on the age of the patient. The commissioner may increase any fee payable to a home health care agency or 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 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 posted on the eRegulations System not later than twenty days after the date of implementing the policies and procedures. Such policies and procedures shall be valid for not longer than nine months. For purposes of this subsection, “complex care nursing services” means intensive, specialized nursing services provided to a patient with complex care needs who requires skilled nursing care at home.
(b) The Department of Social Services shall monitor the rates charged by home health care agencies and 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. The commissioner shall monitor Medicaid home health care savings achieved through the implementation of nurse delegation of medication administration pursuant to section 19a-492e. If, by January 1, 2016, the commissioner determines that the rate of savings is not adequate to meet the annualized savings assumed in the budget for the biennium ending June 30, 2017, the department may reduce rates for medication administration as necessary to achieve the savings assumed in the budget. Prior to any rate reduction, the department shall report 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 provider specific cost and utilization trend data for those patients receiving medication administration. Should the department determine it necessary to reduce medication administration rates under this section, it shall examine the possibility of establishing a separate Medicaid supplemental rate or a pay-for-performance program for those providers, as determined by the commissioner, who have established successful nurse delegation programs.
(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 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 home health aide agency.
(f) If the electronic record or signature that has been transmitted to a home health care agency or 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 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) Any order for home health care services covered by the Department of Social Services may be issued by any licensed practitioner authorized to issue such an order pursuant to section 19a-496a. Any Department of Social Services regulation, policy or procedure that applies to a physician who orders such home health care services, including related provisions such as review and approval of care plans for home health care services, shall apply to any licensed practitioner authorized to order such home health care services pursuant to section 19a-496a.
(i) 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; P.A. 11-44, S. 114; 11-61, S. 123; Dec. Sp. Sess. P.A. 12-1, S. 6; P.A. 13-234, S. 78; June Sp. Sess. P.A. 15-5, S. 387; P.A. 19-97, S. 1; P.A. 21-133, S. 1; P.A. 23-204, S. 282.)
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 2% 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”; P.A. 11-44 amended Subsec. (a) by replacing provision allowing commissioner to increase any fee in fee schedule with provision allowing commissioner to modify fee schedule, effective July 1, 2011; P.A. 11-61 amended Subsec. (a) by adding provision excluding utilization as factor in determining cost neutrality, effective July 1, 2011; Dec. Sp. Sess. P.A. 12-1 amended Subsec. (a) to replace “shall not” with “may” and add “for the fiscal year ending June 30, 2013” re utilization as a factor in determining cost neutrality, effective December 21, 2012; P.A. 13-234 amended Subsec. (a) to delete “for the fiscal year ending June 30, 2013.” re utilization as a factor in determining cost neutrality and to make a technical change, effective July 1, 2013; June Sp. Sess. P.A. 15-5 amended Subsec. (c) to add provisions re monitoring of savings achieved through nurse delegation of medication administration and re reduction of rates for medication administration, effective July 1, 2015; P.A. 19-97 replaced “homemaker-home health aide” with “home health aide”, effective July 1, 2019; P.A. 21-133 amended Subsec. (a) by deleting provisions re rates effective prior to July 1, 1994, inserted new Subsec. (h) re authorized practitioners and redesignated existing Subsec. (h) as Subsec. (i), effective July 7, 2021; P.A. 23-204 amended Subsec. (a) by adding provisions concerning complex care nursing services rates, defining “complex care nursing services” and replacing a reference to publication in the Connecticut Law Journal with posting on the eRegulations System, effective January 1, 2024.
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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 individuals with intellectual disabilities, 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 individuals with intellectual disabilities, shall be determined annually by the Commissioner of Developmental Services in accordance with section 17b-244a. For the fiscal year ending June 30, 2008, no facility shall receive a rate that is more than two per cent greater than the rate in effect for the facility on June 30, 2007, except any facility that would have been issued a lower rate effective July 1, 2007, due to interim rate status or agreement with the department, shall be issued such lower rate effective July 1, 2007. For the fiscal year ending June 30, 2009, no facility shall receive a rate that is more than two per cent greater than the rate in effect for the facility on June 30, 2008, except any facility that would have been issued a lower rate effective July 1, 2008, due to interim rate status or agreement with the department, shall be issued such lower rate effective July 1, 2008. For the fiscal years ending June 30, 2010, and June 30, 2011, rates in effect for the period ending June 30, 2009, shall remain in effect until June 30, 2011, except that (1) the rate paid to a facility may be higher than the rate paid to the facility for the period ending June 30, 2009, if a capital improvement required by the Commissioner of Developmental Services for the health or safety of the residents was made to the facility during the fiscal years ending June 30, 2010, or June 30, 2011, and (2) any facility that would have been issued a lower rate for the fiscal year ending June 30, 2010, or June 30, 2011, due to interim rate status or agreement with the department, shall be issued such lower rate. For the fiscal year ending June 30, 2012, rates in effect for the period ending June 30, 2011, shall remain in effect until June 30, 2012, except that (A) the rate paid to a facility may be higher than the rate paid to the facility for the period ending June 30, 2011, if a capital improvement required by the Commissioner of Developmental Services for the health or safety of the residents was made to the facility during the fiscal year ending June 30, 2012, and (B) any facility that would have been issued a lower rate for the fiscal year ending June 30, 2012, due to interim rate status or agreement with the department, shall be issued such lower rate. Any facility that has a significant decrease in land and building costs shall receive a reduced rate to reflect such decrease in land and building costs. The rate paid to a facility may be increased if a capital improvement approved by the Department of Developmental Services, in consultation with the Department of Social Services, for the health or safety of the residents was made to the facility during the fiscal year ending June 30, 2014, or June 30, 2015, only to the extent such increases are within available appropriations. For the fiscal years ending June 30, 2016, and June 30, 2017, rates shall not exceed those in effect for the period ending June 30, 2015, except the rate paid to a facility may be higher than the rate paid to the facility for the period ending June 30, 2015, if a capital improvement approved by the Department of Developmental Services, in consultation with the Department of Social Services, for the health or safety of the residents was made to the facility during the fiscal year ending June 30, 2016, or June 30, 2017, to the extent such rate increases are within available appropriations. For the fiscal years ending June 30, 2016, and June 30, 2017, and each succeeding fiscal year, any facility that would have been issued a lower rate, due to interim rate status, a change in allowable fair rent or agreement with the department, shall be issued such lower rate. For the fiscal years ending June 30, 2018, and June 30, 2019, rates shall not exceed those in effect for the period ending June 30, 2017, except the rate paid to a facility may be higher than the rate paid to the facility for the period ending June 30, 2017, if a capital improvement approved by the Department of Developmental Services, in consultation with the Department of Social Services, for the health or safety of the residents was made to the facility during the fiscal year ending June 30, 2018, or June 30, 2019, to the extent such rate increases are within available appropriations. For the fiscal years ending June 30, 2020, and June 30, 2021, rates shall not exceed those in effect for the fiscal year ending June 30, 2019, except the rate paid to a facility may be higher than the rate paid to the facility for the fiscal year ending June 30, 2019, if a capital improvement approved by the Department of Developmental Services, in consultation with the Department of Social Services, for the health or safety of the residents was made to the facility during the fiscal year ending June 30, 2020, or June 30, 2021, to the extent such rate increases are within available appropriations. For the fiscal years ending June 30, 2022, and June 30, 2023, rates shall be based upon rates in effect for the fiscal year ending June 30, 2021, inflated by the gross domestic product deflator applicable to each rate year, except the commissioner may, in the commissioner's discretion and within available appropriations, provide pro rata fair rent increases to facilities which have documented fair rent additions placed in service in the cost report years ending September 30, 2020, and September 30, 2021, that are not otherwise included in rates issued, or if a rate adjustment for a capital improvement approved by the Department of Developmental Services, in consultation with the Department of Social Services, for the health or safety of the residents was made to the facility during the fiscal year ending June 30, 2022, or June 30, 2023. For the fiscal year ending June 30, 2024, rates shall not exceed those in effect for the fiscal year ending June 30, 2023, except the rate paid to a facility may be higher than the rate paid to the facility for the fiscal year ending June 30, 2023, if a capital improvement approved by the Department of Developmental Services, in consultation with the Department of Social Services, for the health or safety of the residents was made to the facility during the fiscal year ending June 30, 2024, to the extent such rate increases are within available appropriations.
(b) Notwithstanding the provisions of subsection (a) of this section, state rates of payment for the fiscal years ending June 30, 2018, June 30, 2019, June 30, 2020, and June 30, 2021, for residential care homes and community living arrangements that receive the flat rate for residential services under section 17-311-54 of the regulations of Connecticut state agencies shall be set in accordance with section 298 of public act 19-117*. For the fiscal years ending June 30, 2022, and June 30, 2023, rates shall be based upon rates in effect for the fiscal year ending June 30, 2021, inflated by the gross domestic product deflator applicable to each rate year.
(c) For the fiscal year ending June 30, 2024, and each subsequent fiscal year, the commissioner may, in the commissioner's discretion and within available appropriations, provide pro rata fair rent increases to facilities which have documented fair rent additions placed in service in the cost report years that are not otherwise included in rates issued.
(d) The Commissioner of Social Services and the Commissioner of Developmental Services 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; P.A. 07-73, S. 2(b); June Sp. Sess. P.A. 07-2, S. 13; Sept. Sp. Sess. P.A. 09-5, S. 42; P.A. 10-179, S. 37; P.A. 11-44, S. 82; June 12 Sp. Sess. P.A. 12-1, S. 5; P.A. 13-234, S. 106; P.A. 14-143, S. 3; June Sp. Sess. P.A. 15-5, S. 379; June Sp. Sess. P.A. 17-2, S. 41; P.A. 19-117, S. 295, 296; June Sp. Sess. P.A. 21-2, S. 477; P.A. 23-204, S. 273.)
*Note: Section 298 of public act 19-117 is special in nature and therefore has not been codified but remains in full force and effect according to its terms.
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; pursuant to P.A. 07-73 “Commissioner of Mental Retardation” was changed editorially by the Revisors to “Commissioner of Developmental Services”, effective October 1, 2007; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by providing that for fiscal year ending June 30, 2008, a facility shall receive a rate that is 2% greater than the rate in effect for fiscal year ending June 30, 2007, and that for fiscal year ending June 30, 2009, a facility shall receive a rate that is 2% greater than the rate in effect for fiscal year ending June 30, 2008, except any facility that would have been issued a lower rate due to interim rate status or agreement with the department shall be issued such lower rate, effective July 1, 2007; Sept. Sp. Sess. P.A. 09-5 amended Subsec. (a) by adding provision re rates for fiscal years ending June 30, 2010, and June 30, 2011, effective October 5, 2009; P.A. 10-179 amended Subsec. (a) by adding Subdiv. (1) re exception to rate established for fiscal years ending June 30, 2010, and June 30, 2011, when facility makes required capital improvement and by designating existing exception as Subdiv. (2), effective July 1, 2010; P.A. 11-44 amended Subsec. (a) by adding provisions re rates for fiscal years ending June 30, 2012, and June 30, 2013, effective July 1, 2011; June 12 Sp. Sess. P.A. 12-1 amended Subsec. (a) by providing that rate setting provisions formerly applicable to fiscal years ending June 30, 2012, and June 30, 2013, are applicable to fiscal year ending June 30, 2012, making technical changes and adding provision re facility having significant decrease in land and building costs to receive a reduced rate to reflect the decrease in such costs for fiscal year ending June 30, 2013, effective July 1, 2012; P.A. 13-234 amended Subsec. (a) to delete reference to fiscal year ending June 30, 2013, re reduced rate to reflect decreased land and building costs and to add provision re increased rates for fiscal years ending June 30, 2014, and June 30, 2015, for approved capital improvements, effective July 1, 2013; P.A. 14-143 amended Subsec. (a) by replacing “persons with mental retardation” with “individuals with intellectual disabilities”; June Sp. Sess. P.A. 15-5 amended Subsec. (a) to add provisions re rates for fiscal years ending June 30, 2016, and June; June Sp. Sess. P.A. 17-2 amended Subsec. (a) by adding provision re rates for fiscal years ending June 30, 2018, and June 30, 2019, added new Subsec. (b) re facilities that receive flat rates, redesignated existing Subsec. (b) as Subsec. (c) and made a technical change, effective October 31, 2017; P.A. 19-117 amended Subsecs. (a) and (b) to add provisions re rates for fiscal years ending June 30, 2020 and June 30, 2021, effective July 1, 2019, and amended Subsec. (b) by deleting reference to community companion homes and making technical changes, effective January 1, 2020; June Sp. Sess. P.A. 21-2 amended Subsec. (a) by adding rate freeze subject to inflation except for increases for fair rent and certain capital improvements for fiscal years 2022 and 2023 and amended Subsec. (b) by adding rate freeze subject to inflation for fiscal years 2022 and 2023, effective July 1, 2021; P.A. 23-204 amended Subsec. (a) by inserting rate provisions for fiscal year 2024, inserted new Subsec. (c) re fair rent increases and redesignated existing Subsec. (c) as Subsec. (d), effective July 1, 2023.
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Sec. 17b-261. (Formerly Sec. 17-134b). *(See end of section for amended version of subsection (a) and effective date.) Medicaid. Eligibility. Assets. Waiver from federal law. State-funded medical assistance for children regardless of immigration status. *(a) Medical assistance shall be provided for any otherwise eligible person (1) 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 (e) of this section, of the benefit amount paid to a person with no income under the temporary family assistance program, and (2) if such person is an institutionalized individual as defined in Section 1917 of the Social Security Act, 42 USC 1396p(h)(3), 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 household of equal size with no income under the temporary family assistance program. In determining eligibility, the commissioner shall not consider as income Aid and Attendance pension benefits granted to a veteran, as defined in section 27-103, or the surviving spouse of such veteran. Except as provided in section 17b-277 and section 17b-292, the medical assistance program shall provide coverage to persons under the age of nineteen with household income up to one hundred ninety-six per cent of the federal poverty level without an asset limit and to persons under the age of nineteen, who qualify for coverage under Section 1931 of the Social Security Act, with household income not exceeding one hundred ninety-six per cent of the federal poverty level without an asset limit, and their parents and needy caretaker relatives, who qualify for coverage under Section 1931 of the Social Security Act, with household income not exceeding one hundred fifty-five per cent of the federal poverty level without an asset limit. 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. 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 (A) the effect of an assignment or transfer or other disposition of property on eligibility for benefits or assistance, (B) the effect that having income that exceeds the limits prescribed in this subsection will have with respect to program eligibility, and (C) the availability of, and eligibility for, services provided by the Connecticut Home Visiting System, established pursuant to section 17b-751b. For coverage dates on or after January 1, 2014, the department shall use the modified adjusted gross income financial eligibility rules set forth in Section 1902(e)(14) of the Social Security Act and the implementing regulations to determine eligibility for HUSKY A, HUSKY B and HUSKY D applicants, as defined in section 17b-290. Persons who are determined ineligible for assistance pursuant to this section shall be provided a written statement notifying such persons of their ineligibility and advising such persons of their potential eligibility for one of the other insurance affordability programs as defined in 42 CFR 435.4.
(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 a special needs trust, as defined in 42 USC 1396p(d)(4)(A), as amended from time to time. For purposes of determining whether a beneficiary under a special needs trust, who has not received a disability determination from the Social Security Administration, is disabled, as defined in 42 USC 1382c(a)(3), the Commissioner of Social Services, or the commissioner's designee, shall independently make such determination. The commissioner shall not require such beneficiary to apply for Social Security disability benefits or obtain a disability determination from the Social Security Administration for purposes of determining whether the beneficiary is disabled.
(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 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) To the extent permissible under federal law, an institutionalized individual, as defined in Section 1917 of the Social Security Act, 42 USC 1396p(h)(3), shall not be determined ineligible for Medicaid solely on the basis of the cash value of a life insurance policy worth less than ten thousand dollars provided the individual is pursuing the surrender of the policy.
(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. Medical assistance shall also be provided to any child in the behavioral services program operated by the Department of Developmental Services who is not receiving Medicaid benefits, has not yet qualified for Medicaid benefits or is otherwise ineligible for benefits. To the extent practicable, the Commissioner of Children and Families and the Commissioner of Developmental Services shall apply for, or assist such child in qualifying for, the Medicaid program.
(j) The Commissioner of Social Services shall provide Early and Periodic Screening, Diagnostic and Treatment program services, as required and defined as of December 31, 2005, by 42 USC 1396a(a)(43), 42 USC 1396d(r) and 42 USC 1396d(a)(4)(B) and applicable federal regulations, to all persons who are under the age of twenty-one and otherwise eligible for medical assistance under this section.
(k) A veteran, as defined in section 27-103, and any member of his or her family, who applies for or receives assistance under the Medicaid program, shall apply for all benefits for which he or she may be eligible through the United States Department of Veterans Affairs or the United States Department of Defense.
(l) On and after January 1, 2023, and until June 30, 2024, the Commissioner of Social Services shall, within available appropriations, provide state-funded medical assistance to any child twelve years of age and younger, regardless of immigration status, (1) whose household income does not exceed two hundred one per cent of the federal poverty level without an asset limit, and (2) who does not otherwise qualify for Medicaid, the Children's Health Insurance Program, or an offer of affordable, employer-sponsored insurance, as defined in the Affordable Care Act, as an employee or a dependent of an employee. On and after July 1, 2024, the commissioner shall, within available appropriations, provide state-funded medical assistance to any child fifteen years of age and younger, regardless of immigration status, who qualifies pursuant to subdivisions (1) and (2) of this subsection. A child eligible for such assistance under this subsection shall continue to receive such assistance until such child is nineteen years of age, provided the child continues to meet the eligibility requirements prescribed in subdivisions (1) and (2) of this subsection. The provisions of section 17b-265 shall apply with respect to any medical assistance provided pursuant to this subsection.
(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; Oct. 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; P.A. 06-164, S. 3; 06-188, S. 49; 06-196, S. 134, 238, 289; P.A. 07-185, S. 3; June Sp. Sess. P.A. 07-2, S. 7; P.A. 09-8, S. 3; 09-66, S. 1; P.A. 10-179, S. 66; P.A. 11-176, S. 3; P.A. 12-208, S. 5; June 12 Sp. Sess. P.A. 12-1, S. 8; P.A. 13-234, S. 127; P.A. 15-69, S. 17; June Sp. Sess. P.A. 15-5, S. 358, 370; P.A. 16-12, S. 1; 16-176, S. 1; June Sp. Sess. P.A. 17-2, S. 138; P.A. 18-72, S. 29; 18-81, S. 48; P.A. 19-117, S. 316; P.A. 21-172, S. 13; 21-176, S. 1; P.A. 22-118, S. 232, 237; P.A. 23-204, S. 283.)
*Note: On and after October 1, 2024, subsection (a) of this section, as amended by section 302 of public act 23-204, is to read as follows:
“(a) Medical assistance shall be provided for any otherwise eligible person (1) 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 five per cent of the federal poverty level, after any authorized income disregards, and (2) if such person is an institutionalized individual as defined in Section 1917 of the Social Security Act, 42 USC 1396p(h)(3), 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 five per cent of the federal poverty level, after any authorized income disregards. In determining eligibility, the commissioner shall not consider as income Aid and Attendance pension benefits granted to a veteran, as defined in section 27-103, or the surviving spouse of such veteran. Except as provided in section 17b-277 and section 17b-292, the medical assistance program shall provide coverage to persons under the age of nineteen with household income up to one hundred ninety-six per cent of the federal poverty level without an asset limit and to persons under the age of nineteen, who qualify for coverage under Section 1931 of the Social Security Act, with household income not exceeding one hundred ninety-six per cent of the federal poverty level without an asset limit, and their parents and needy caretaker relatives, who qualify for coverage under Section 1931 of the Social Security Act, with household income not exceeding one hundred fifty-five per cent of the federal poverty level without an asset limit. 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. 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 (A) the effect of an assignment or transfer or other disposition of property on eligibility for benefits or assistance, (B) the effect that having income that exceeds the limits prescribed in this subsection will have with respect to program eligibility, and (C) the availability of, and eligibility for, services provided by the Connecticut Home Visiting System, established pursuant to section 17b-751b. For coverage dates on or after January 1, 2014, the department shall use the modified adjusted gross income financial eligibility rules set forth in Section 1902(e)(14) of the Social Security Act and the implementing regulations to determine eligibility for HUSKY A, HUSKY B and HUSKY D applicants, as defined in section 17b-290. Persons who are determined ineligible for assistance pursuant to this section shall be provided a written statement notifying such persons of their ineligibility and advising such persons of their potential eligibility for one of the other insurance affordability programs as defined in 42 CFR 435.4.”
(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; Oct. 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; P.A. 06-164, S. 3; 06-188, S. 49; 06-196, S. 134, 238, 289; P.A. 07-185, S. 3; June Sp. Sess. P.A. 07-2, S. 7; P.A. 09-8, S. 3; 09-66, S. 1; P.A. 10-179, S. 66; P.A. 11-176, S. 3; P.A. 12-208, S. 5; June 12 Sp. Sess. P.A. 12-1, S. 8; P.A. 13-234, S. 127; P.A. 15-69, S. 17; June Sp. Sess. P.A. 15-5, S. 358, 370; P.A. 16-12, S. 1; 16-176, S. 1; June Sp. Sess. P.A. 17-2, S. 138; P.A. 18-72, S. 29; 18-81, S. 48; P.A. 19-117, S. 316; P.A. 21-172, S. 13; 21-176, S. 1; P.A. 22-118, S. 232, 237; P.A. 23-204, S. 283, 302.)
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 6 months for former recipients; P.A. 85-527 amended Subsec. (a) by replacing “the minimum income permissible under federal law” with 120% “of the standard of need”; P.A. 86-363 included children under 18 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 120% to 133%, 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 24 months to 30 months prior to the date of application and 30 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, Sec. 1 required that the medical assistance program provide coverage to persons under the age of 6 and Sec. 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 19 born after September 30, 1983, rather than children under 6, 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 133% of the standard of need established pursuant to Sec. 17b-104 to an income which is not more than 142% 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 133% 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 142% with 143% 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 19 born after September 30, 1983, to persons under the age of 19 born after September 30, 1981, or if possible, within available appropriations, born after June 30, 1980, with family income up to 185% 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 19 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 185% to 150% 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 150% of the federal poverty limit to 100% 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 100% 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 6 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 19 from 100% to 150% of federal poverty level, deleted former Subsec. (f) re ineligibility for medical assistance for parents and needy caretaker relatives with incomes exceeding 100% 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 2 years to 1 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 12 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; P.A. 06-164 amended Subsec. (a) to substitute “Nurturing Families Network” for “Healthy Families Connecticut Program”, insert Subdiv. (1) designator and insert Subdiv. (2) re written statement on services provided by the Nurturing Families Network, effective July 1, 2006; P.A. 06-188 added Subsec. (j) re requirement to provide Early and Periodic Screening, Diagnostic and Treatment program services, as required by federal law, to persons under age 21 who are otherwise eligible for medical assistance, effective July 1, 2006; P.A. 06-196 made a technical change in Subsecs. (a) and (f), effective June 7, 2006, and inserted “and defined as of December 31, 2005,” and made a technical change in Subsec. (j), effective July 1, 2006; P.A. 07-185 amended Subsec. (a) by increasing, except as provided in Sec. 17b-277, family income limits used to determine eligibility for medical assistance for parents and needy caretaker relatives of persons under the age of 19 from 150% of federal poverty level to 185% of federal poverty level, by providing that commissioner shall advise applicants in writing of effect that having income in excess of program limits will have with respect to program eligibility and availability of HUSKY Plan, Part B benefits for persons determined not eligible for medical assistance, and by making conforming changes, effective July 1, 2007; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by requiring that medical assistance coverage be provided to persons under 19 with family income up to 185% of federal poverty level without an asset limit, by deleting provision requiring that commissioner, at the time application for assistance is made, provide a written statement re availability of HUSKY Plan, Part B, health insurance benefits to persons not eligible for assistance, and by adding provision requiring that commissioner provide written statement at the time a person is determined ineligible for assistance, deleted former Subsec. (h) re commissioner's authority to impose cost sharing requirements on parents and needy caretakers with incomes in excess of 100% of federal poverty level, and redesignated existing Subsecs. (i) and (j) as Subsecs. (h) and (i), effective July 1, 2007; P.A. 09-8 made technical changes in Subsec. (a); P.A. 09-66 amended Subsec. (h) by deleting “because of institutional status” and adding provisions re medical assistance to be provided to children in Department of Developmental Services' voluntary services program who are not receiving Medicaid benefits, effective July 1, 2009; P.A. 10-179 amended Subsec. (a) by deleting provision requiring contracts to include provisions for collaboration of managed care organizations with the Nurturing Families Network, effective July 1, 2010; P.A. 11-176 amended Subsec. (c) by adding provisions re determining whether a beneficiary under a special needs trust is disabled, effective July 13, 2011; P.A. 12-208 amended Subsec. (a) to add provision re income disregard for veterans' Aid and Attendance pension benefits, effective July 1, 2012; June 12 Sp. Sess. P.A. 12-1 added Subsec. (j) re responsibility of veteran to apply for benefits through the Veterans' Administration or Department of Defense, effective July 1, 2012; P.A. 13-234 amended Subsec. (a) to change federal statutory citations, added new Subsec. (h) re conditions under which Medicaid eligibility will be granted for persons with certain life insurance policies and redesignated existing Subsecs. (h), (i) and (j) as Subsecs. (i), (j) and (k); P.A. 15-69 amended Subsec. (a) to change “family” to “household”, add reference to Sec. 17b-292, increase income eligibility from 185 per cent to 196 per cent of federal poverty level, add provision re use of modified adjusted gross income financial eligibility rules and add provision re ineligible individuals to be notified of potential eligibility for other programs as defined in 42 CFR 435.4, rather than availability of HUSKY Plan, Part B, effective June 19, 2015; June Sp. Sess. P.A. 15-5 amended Subsec. (i) to replace “voluntary” with “behavioral” re services program, effective July 1, 2015, and amended Subsec. (a) to add provisions re decrease of income limit for parents and needy caretaker relatives from 196 per cent to 150 per cent of federal poverty level and make technical changes, effective August 1, 2015; P.A. 16-12 amended Subsec. (h) to delete former Subdiv. (2) re proceeds of surrendered policy to be used to pay for long-term care and delete Subdiv. (1) designator, effective May 6, 2016; P.A. 16-176 amended Subsec. (c) to add “, as amended from time to time” re references to 42 USC 1396p(d)(4)(A), effective June 6, 2016; June Sp. Sess. P.A. 17-2 amended Subsec. (a) by replacing 150 per cent with 133 per cent re household income for parents and needy caretaker relatives, effective January 1, 2018; P.A. 18-72 amended Subsec. (k) to replace “Veterans' Administration” with “United States Department of Veterans Affairs”; P.A. 18-81 amended Subsec. (a) by increasing maximum household income for parents and needy caretaker relatives eligible under Section 1931 of the Social Security Act from 133 per cent of the federal poverty level to 150 per cent of the federal poverty level, effective July 1, 2018; P.A. 19-117 amended Subsec. (a) by increasing maximum income eligibility for parents and needy caretaker relatives from 150 per cent to 155 per cent of the federal poverty level; P.A. 21-172 amended Subsec. (a)(3) by replacing “Nurturing Families Network” with “Connecticut Home Visiting System”, effective July 1, 2021; P.A. 21-176 added Subsec. (l) re coverage of children regardless of immigration status; P.A. 22-118 amended Subsec. (a) by removing regional temporary family assistance benefit standards in the calculation of medical assistance income eligibility, added new subdivision designators (1) and (2) and redesignated existing Subdivs. (1) to (3) as Subparas. (A) to (C), effective July 1, 2022, and amended Subsec. (l) by increasing the age of children eligible for state-funded medical assistance from 8 to 12 years regardless of immigration status and allowing such eligible children to retain such assistance until age 19, effective May 7, 2022; P.A. 23-204 amended Subsec. (l) by authorizing coverage for eligible children up to age 15 on and after July 1, 2024, subject to the provisions of Sec. 17b-265, effective June 12, 2023, and amended Subsec. (a) by changing the income eligibility threshold from 143 per cent of the program benefit to a person with no income to 105 per cent of the federal poverty level after authorized income disregards and made conforming changes, effective October 1, 2024.
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Sec. 17b-265. (Formerly Sec. 17-134f). Department subrogated to right of recovery of applicant or recipient. Utilization of personal health insurance. Insurance coverage of medical assistance recipients. Limitations. Allocation of child support obligor funds. (a) In accordance with 42 USC 1396k, the Department of Social Services shall be subrogated to any right of recovery or indemnification that an applicant or recipient of medical assistance or any legally liable relative of such applicant or recipient has against an insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, for the cost of all health care items or services furnished to the applicant or recipient, including, but not limited to, hospitalization, pharmaceutical services, physician services, nursing services, behavioral health services, long-term care services and other medical services, not to exceed the amount expended by the department for such care and treatment of the applicant or recipient. In the case of such a recipient who is an enrollee in a care management organization under a Medicaid care management contract with the state or a legally liable relative of such an enrollee, the department shall be subrogated to any right of recovery or indemnification which the enrollee or legally liable relative has against such a private insurer or other third party for the medical costs incurred by the care management organization on behalf of an enrollee. Whenever funds owed to a person are collected pursuant to this section and the person who otherwise would have been entitled to such funds is subject to a court-ordered current or arrearage child support payment obligation in an IV-D support case, such funds shall first be paid to the state for reimbursement of Medicaid funds paid on behalf of such person for medical expenses incurred for injuries related to a legal claim by such person that was the subject of the state's right of subrogation, and remaining funds, if any, shall then be paid to the Office of Child Support Services for distribution pursuant to the federally mandated child support distribution system implemented pursuant to subsection (j) of section 17b-179. Any additional claim of the state to the remainder of such funds, if any, shall be paid in accordance with state law.
(b) An applicant or recipient or legally liable relative, by the act of the applicant's or recipient's receiving medical assistance, shall be deemed to have made a subrogation assignment and an assignment of claim for benefits to the department. The department shall inform an applicant of such assignments at the time of application. Any entitlements from a contractual agreement with an applicant or recipient, legally liable relative or a state or federal program for such medical services, not to exceed the amount expended by the department, shall be so assigned. Such entitlements shall be directly reimbursable to the department by third-party payors. The Department of Social Services may assign its right to subrogation or its entitlement to benefits to a designee or a health care provider participating in the Medicaid program and providing services to an applicant or recipient, in order to assist the provider in obtaining payment for such services. In accordance with subsection (b) of section 38a-472, a provider that has received an assignment from the department shall notify the recipient's health insurer or other legally liable third party including, but not limited to, a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, of the assignment upon rendition of services to the applicant or recipient. Failure to so notify the health insurer or other legally liable third party shall render the provider ineligible for payment from the department. The provider shall notify the department of any request by the applicant or recipient or legally liable relative or representative of such applicant or recipient for billing information. This subsection shall not be construed to affect the right of an applicant or recipient to maintain an independent cause of action against such third-party tortfeasor.
(c) Claims for recovery or indemnification submitted by the department, or the department's designee, shall not be denied solely on the basis of the date of the submission of the claim, the type or format of the claim, the lack of prior authorization or the failure to present proper documentation at the point-of-service that is the basis of the claim, if (1) the claim is submitted by the state within the three-year period beginning on the date on which the item or service was furnished; and (2) any action by the state to enforce its rights with respect to such claim is commenced within six years of the state's submission of the claim.
(d) (1) A party to whom a claim for recovery or indemnification is submitted for an item or service furnished under the Medicaid state plan, or a waiver of such plan, who requires prior authorization for such item or service shall accept authorization provided by the Department of Social Services that the item or service is covered under such plan or waiver as if such authorization were the prior authorization made by such party for the item or service.
(2) The provisions of subdivision (1) of this subsection shall not apply with respect to a claim for recovery or indemnification submitted to Medicare, a Medicare Advantage plan or a Medicare Part D plan.
(e) When a recipient of medical assistance has personal health insurance in force covering care or other benefits provided under such program, payment or part-payment of the premium for such insurance may be made when deemed appropriate by the Commissioner of Social Services. The commissioner shall limit reimbursement to medical assistance providers for coinsurance and deductible payments under Title XVIII of the Social Security Act to assure that the combined Medicare and Medicaid payment to the provider shall not exceed the maximum allowable under the Medicaid program fee schedules.
(f) No self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care plan, or any plan offered or administered by a health care center, pharmacy benefit manager, dental benefit manager, third-party administrator or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, shall contain any provision that has the effect of denying or limiting enrollment benefits or excluding coverage because services are rendered to an insured or beneficiary who is eligible for or who received medical assistance under this chapter. No insurer, as defined in section 38a-497a, shall impose requirements on the state Medicaid agency, which has been assigned the rights of an individual eligible for Medicaid and covered for health benefits from an insurer, that differ from requirements applicable to an agent or assignee of another individual so covered.
(g) The Commissioner of Social Services shall not pay for any services provided under this chapter if the individual eligible for medical assistance has coverage for the services under an accident or health insurance policy.
(h) An insurer or other legally liable third party, upon receipt of a claim submitted by the department or the department's designee, in accordance with the requirements of subsection (c) of this section, for payment of a health care item or service covered under a state medical assistance program administered by the department, shall, not later than sixty days after receipt of the claim or not later than November 30, 2023, whichever is later, (1) make payment on the claim, (2) request information necessary to determine its legal obligation to pay the claim, or (3) issue a written reason for denial of the claim. Failure to pay, request information necessary to determine legal obligation to pay or issue a written reason for denial of a claim not later than one hundred twenty days after receipt of the claim, or not later than January 30, 2024, whichever is later, creates an uncontestable obligation to pay the claim. The provisions of this subsection shall apply to all claims, including claims submitted by the department or the department's designee prior to July 1, 2021.
(i) On and after July 1, 2021, an insurer or other legally liable third party who has reimbursed the department for a health care item or service paid for and covered under a state medical assistance program administered by the department shall, upon determining it is not liable and at risk for cost of the health care item or service, request any refund from the department not later than twelve months from the date of its reimbursement to the department.
(1967, P.A. 759, S. 1(f); P.A. 75-420, S. 4, 6; P.A. 77-614, S. 608, 610; P.A. 83-145; P.A. 84-367, S. 2, 3; P.A. 90-283, S. 1; June Sp. Sess. P.A. 91-8, S. 6, 63; P.A. 93-262, S. 1, 87; 93-381, S. 9, 39; 93-418, S. 32, 41; May Sp. Sess. P.A. 94-5, S. 6, 30; P.A. 95-257, S. 12, 21, 58; 95-305, S. 3, 6; P.A. 99-279, S. 17, 45; June Sp. Sess. P.A. 07-2, S. 20; P.A. 09-8, S. 5; P.A. 10-179, S. 78; P.A. 11-44, S. 84; 11-61, S. 126; P.A. 12-119, S. 5; P.A. 15-247, S. 29; June Sp. Sess. P.A. 15-5, S. 388; June Sp. Sess. P.A. 21-2, S. 334; P.A. 22-118, S. 452; P.A. 23-204, S. 292.)
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. 83-145 made the existing section Subsec. (b) and added Subsec. (a) dealing with subrogation to any right of recovery, assignment of claim for benefits and entitlements and right of action against third party tortfeasors; P.A. 84-367 added Subsec. (c) prohibiting a provision denying or limiting insurance benefits because services are rendered to an insured who is eligible for or received medical assistance and added Subsec. (d) prohibiting the commissioner from paying for services if the individual has coverage under an accident or health insurance policy; P.A. 90-283 in Subsec. (a) subrogated the department to any right of recovery of a legally liable relative of an applicant or recipient of medical assistance and added provisions whereby the department may assign its right of subrogation; June Sp. Sess. P.A. 91-8 amended Subsec. (b) to require a limitation on reimbursement to medical assistance providers for coinsurance and deductible payments to not exceed the maximum allowable under the Medicaid fee schedules, except for those providers licensed by the department of health services; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; P.A. 93-381 replaced commissioner of health services with commissioner of public health and addiction services, effective July 1, 1993; P.A. 93-418 changed reference to insurer to a private insurer or third party and made other technical changes, effective July 1, 1993; May Sp. Sess. P.A. 94-5 amended Subsec. (c) to prevent insurers from imposing requirements on the department of social services which deny or limit benefits which have been assigned pursuant to this section, effective July 1, 1994; Sec. 17-134f transferred to Sec. 17b-265 in 1995; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health, effective July 1, 1995; P.A. 95-305 amended Subsec. (c) by deleting a provision that an insurer, health care center or issuer of any service plan contract for hospital or medical expense coverage shall not impose requirements on the Department of Social Services which limit or deny benefits and adding a provision prohibiting an insurer from imposing certain requirements on the state Medicaid agency, effective July 1, 1995; P.A. 99-279 amended Subsec. (a) to provide that the department shall be subrogated to any right of recovery or indemnification which an enrollee in a managed care organization under a Medicaid managed care contract or legally liable relative has against a private insurer or other third party for the medical costs incurred by the managed care organization on behalf of an enrollee and made technical changes, effective July 1, 1999; June Sp. Sess. P.A. 07-2 amended Subsec. (a) by dividing existing provisions into Subsecs. (a) and (b), amended redesignated Subsec. (a) by deleting “private”, adding “legally liable”, delineating entities deemed an insurer or a legally liable third party, adding “legally responsible for payment of a claim for a health care item or service”, re responsibilities of third party, providing that health care items or services include behavioral health services and long-term care services and making technical changes, amended redesignated Subsec. (b) by adding “In accordance with subsection (b) of section 38a-472” re provider's notice to department of receipt of an assignment, replacing “private insurer” with “health insurer”, adding “legally liable”, and delineating entities deemed a health insurer or a legally liable third party, added new Subsec. (c) re time parameters for submission of claims for recovery or indemnification by department, redesignated existing Subsecs. (b) to (d) as Subsecs. (d) to (f), and amended redesignated Subsec. (e) by redefining types of health insurance plans that shall not contain provisions which have effect of denying or limiting enrollment benefits or excluding coverage because services are rendered to individual who is receiving medical assistance and making a technical change, effective July 1, 2007; P.A. 09-8 made technical changes in Subsec. (b); P.A. 10-179 amended Subsec. (a) by replacing references to managed care with references to care management, effective July 1, 2010; P.A. 11-44 amended Subsec. (d) by adding provision requiring Commissioner of Public Health to limit reimbursement payments to providers whose rates are established under Ch. 368d, effective July 1, 2011; P.A. 11-61 amended Subsec. (d) by deleting provision added by P.A. 11-44, effective July 1, 2011; P.A. 12-119 added references to third-party administrator in Subsecs. (a), (b) and (e) and amended Subsec. (c) to add “the lack of prior authorization”, effective June 15, 2012; P.A. 15-247 amended Subsec. (e) by deleting reference to Sec. 38a-553(c), effective July 10, 2015; June Sp. Sess. P.A. 15-5 amended Subsec. (d) to delete exception re providers whose rates are established pursuant to Ch. 368d, effective July 1, 2015; June Sp. Sess. P.A. 21-2 amended Subsec. (d) by deleting “Effective January 1, 1992,” and added Subsecs. (g) and (h) re deadlines for payments or refunds, effective July 1, 2021; P.A. 22-118 amended Subsec. (a) by inserting provisions re allocation of funds due to persons subject to court-ordered child support payments, effective July 1, 2022; P.A. 23-204 added new Subsec. (d) re prior authorization requirements and exemptions, redesignated existing Subsecs. (d) to (h) as Subsecs. (e) to (i), amended new Subsec. (h) by changing “ninety days” to “sixty days” re after receipt of claim, changing “ninety days after the effective date of this section to” to “November 30, 2023”, and changing “one hundred twenty days after the effective date of this section” to “January 30, 2024” and made technical changes.
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Sec. 17b-265g. Health insurer. Duties owed to the state and Commissioner of Social Services. Any health insurer, including a self-insured plan, group health plan, as defined in Section 607(1) of the Employee Retirement Income Security Act of 1974, service benefit plan, managed care organization, health care center, pharmacy benefit manager, dental benefit manager or other party that is, by statute, contract or agreement, legally responsible for payment of a claim for a health care item or service, and which may or may not be financially at risk for the cost of a health care item or service, shall, as a condition of doing business in the state, be required to:
(1) Provide, with respect to an individual who is eligible for, or is provided, medical assistance under the Medicaid state plan, to all third-party administrators, pharmacy benefit managers, dental benefit managers or other entities with which the health insurer has a contract or arrangement to adjudicate claims for a health care item or service, and to the Commissioner of Social Services, or the commissioner's designee, any and all information in a manner and format prescribed by the commissioner, or commissioner's designee, necessary to determine when the individual, his or her spouse or the individual's dependents may be or have been covered by a health insurer and the nature of the coverage that is or was provided by such health insurer including the name, address and identifying number of the plan;
(2) Accept the state's right of recovery and the assignment to the state of any right of an individual or other entity to payment from the health insurer for an item or service for which payment has been made under the Medicaid state plan;
(3) Respond not later than sixty days after receiving any inquiry from the commissioner, or the commissioner's designee, regarding a claim for payment for any health care item or service that is submitted not later than three years after the date of the provision of the item or service; and
(4) Agree (A) to accept authorization provided by the Department of Social Services that an item or service is covered under the Medicaid state plan, or a waiver of such plan, as if such authorization were the prior authorization made by such health insurer for such item or service, and (B) not to deny a claim submitted by the state solely on the basis of the date of submission of the claim, the type or format of the claim form or a failure to present proper documentation at the point-of-sale that is the basis of the claim, if (i) the claim is submitted by the state or its agent within the three-year period beginning on the date on which the item or service was furnished; and (ii) any legal action by the state to enforce its rights with respect to such claim is commenced within six years of the state's submission of such claim.
(June Sp. Sess. P.A. 07-2, S. 19; P.A. 23-204, S. 293.)
History: June Sp. Sess. P.A. 07-2 effective July 1, 2007; P.A. 23-204 amended Subdiv. (3) by requiring response deadline, amended Subdiv. (4) by adding new Subpara. (A) re acceptance of department authorization, redesignated existing provisions as new Subpara. (B), redesignated existing Subparas. (A) and (B) as Subpara. (B)(i) and (B)(ii) and made technical changes.
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Sec. 17b-277d. Medicaid payment for maternity services. Regulations. (a) To the extent permissible under federal law and within available appropriations, as the single state Medicaid agency designated under sections 17b-2 and 17b-260, the Commissioner of Social Services may implement a bundled payment for maternity services and associated alternative payment methodology for maternity services that the commissioner determines are designed to improve health quality, equity, member experience, cost containment and coordination of care. Such bundled payment may include payment to physicians and other qualified licensed practitioners for the services of doulas and other nonlicensed practitioners. Such bundled payment shall be designed to reduce unnecessary utilization and avoidable costs, ensure access to necessary services, improve outcomes and improve coordination of care. In designing such bundled payment, and prior to implementation, the commissioner shall first consult with health care providers, advocates for consumers of health care and other stakeholders as set forth in subsection (b) of this section.
(b) Consultation shall begin on or after July 1, 2023, and shall include solicitation of input and advice from health care providers, advocates for consumers of health care and other stakeholders covering at least the following topics: (1) The quality measures used to assess the performance of participating practices; (2) reimbursement and financing methods and amounts; and (3) safeguards designed to ensure access and network adequacy. Consultation shall include at least two live, online meeting opportunities for public input noticed at least ten days in advance on the department's Internet web site.
(c) The commissioner shall adopt regulations in accordance with the provisions of chapter 54 to implement the provisions of this section. The commissioner may implement policies and procedures while in the process of adopting such regulations, provided the commissioner publishes notice of intent to adopt regulations on the eRegulations System not later than twenty days after the date of implementation of such policies and procedures. Any policies and procedures implemented pursuant to this section shall be valid until the time final regulations are adopted.
(P.A. 23-204, S. 296.)
History: P.A. 23-204 effective July 1, 2023.
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Sec. 17b-278l. Medical assistance for obesity treatment, surgery. Definitions. State plan amendments. (a)(1) As used in this section, “bariatric surgery” means surgical changes to the digestive system to help a patient with obesity to lose weight;
(2) “Body mass index” means the number calculated by dividing an individual's weight in kilograms by the individual's height in meters squared;
(3) “Medical services” means (A) prescription drugs approved by the Food and Drug Administration for the treatment of obesity on an outpatient basis, and (B) nutritional counseling provided by a registered dietitian-nutritionist certified pursuant to section 20-206n;
(4) “Severe obesity” means a body mass index that is:
(A) Greater than forty; or
(B) Thirty-five or more if an individual has been diagnosed with a comorbid disease or condition, including, but not limited to, a cardiopulmonary condition, diabetes, hypertension or sleep apnea; and
(5) “Obesity” means a body mass index of thirty or higher.
(b) The Commissioner of Social Services shall provide medical assistance for (1) bariatric surgery and related medical services for Medicaid and HUSKY B beneficiaries with severe obesity, and (2) medical services for Medicaid and HUSKY B beneficiaries with a body mass index greater than thirty-five, provided such beneficiaries otherwise meet conditions set by the Centers for Medicare and Medicaid Services for such surgery and medical services. If necessary, the commissioner may amend the Medicaid state plan and the state plan for the Children's Health Insurance Program to implement the provisions of this section.
(P.A. 23-94, S. 1.)
History: P.A. 23-94 effective July 1, 2023.
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Sec. 17b-292. HUSKY B. Eligibility. Expedited eligibility under HUSKY B. Presumptive eligibility under Medicaid. State-funded coverage for certain children not otherwise covered. Postpartum care. (a) A child who resides in a household with household income that exceeds one hundred ninety-six per cent of the federal poverty level but does not exceed three hundred eighteen per cent of the federal poverty level may be eligible for benefits under HUSKY B. Until June 30, 2024, the Commissioner of Social Services shall, within available appropriations, provide state-funded medical assistance to any child twelve years of age and younger, regardless of immigration status, (1) with a household income that exceeds two hundred one per cent of the federal poverty level but does not exceed three hundred twenty-three per cent of the federal poverty level, and (2) who does not otherwise qualify for Medicaid, the Children's Health Insurance Program, or an offer of affordable, employer-sponsored insurance, as defined in the Affordable Care Act, as an employee or a dependent of an employee. On and after July 1, 2024, the commissioner shall, within available appropriations, provide state-funded medical assistance to any child fifteen years of age and younger, regardless of immigration status, who qualifies pursuant to subdivisions (1) and (2) of this subsection. A child eligible for such assistance under this subsection shall continue to receive such assistance until such child is nineteen years of age, provided the child continues to meet the eligibility requirements prescribed in subdivisions (1) and (2) of this subsection. The provisions of section 17b-265 shall apply with respect to any medical assistance provided pursuant to this subsection.
(b) 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 HUSKY B.
(c) To the extent allowed under federal law, the commissioner shall not pay for services or durable medical equipment under HUSKY B if the member has other insurance coverage for such services or equipment. If a HUSKY B member has limited benefit insurance coverage for services that are also covered under HUSKY B, the commissioner shall require such other coverage to pay for the goods or services prior to any payment under HUSKY B.
(d) On or after April 1, 2022, the commissioner shall extend medical assistance for postpartum care for twelve months after birth to a HUSKY B beneficiary, to the extent permissible under federal law. The commissioner shall amend the state plan for the Children's Health Insurance Program in accordance with the American Rescue Plan Act of 2021 to provide federal reimbursement to the state for such postpartum care extension and shall extend such coverage following federal approval. The commissioner shall take any other action necessary under federal law to maintain federal reimbursement for such postpartum coverage. A newborn child who otherwise meets the eligibility criteria for HUSKY B shall be eligible for benefits retroactive to his or her date of birth, provided an application is filed on behalf of the child not later than thirty days after such date. Any uninsured child born in a hospital in this state or in a border state hospital shall be enrolled on an expedited basis in HUSKY B, provided (1) the parent or caretaker relative of such child resides in this state, and (2) the parent or caretaker relative of such child authorizes enrollment in the program. The commissioner shall pay any premium cost such household would otherwise incur for the first four months of coverage.
(e) The commissioner shall implement presumptive eligibility for children applying for Medicaid and may, if cost effective, implement presumptive eligibility for children in households with income not exceeding three hundred eighteen per cent of the federal poverty level applying for HUSKY B. 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 an organization as a qualified entity to grant presumptive eligibility. A qualified entity shall, at the time a presumptive eligibility determination is made, provide assistance to applicants with the completion and submission of an application 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.
(f) In accordance with 42 CFR 435.1110, the commissioner shall provide Medicaid during a presumptive eligibility period to individuals who are determined presumptively eligible by a qualified hospital. A hospital making such a presumptive eligibility determination shall provide assistance to individuals in completing and submitting an application for full Medicaid benefits.
(g) The commissioner shall implement HUSKY B while in the process of adopting necessary policies and procedures in regulation form in accordance with the provisions of section 17b-10.
(Oct. 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; P.A. 06-188, S. 16; P.A. 07-185, S. 6; June Sp. Sess. P.A. 07-2, S. 17; P.A. 09-8, S. 8; P.A. 10-179, S. 62; June Sp. Sess. P.A. 10-1, S. 26; P.A. 11-25, S. 12; P.A. 15-69, S. 25; June Sp. Sess. P.A. 15-5, S. 374; P.A. 21-176, S. 3; June Sp. Sess. P.A. 21-2, S. 336; P.A. 22-118, S. 233; P.A. 23-204, S. 285.)
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 12 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 12 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; P.A. 06-188 amended Subsec. (j) to permit commissioner, to the extent permitted by federal law, to rely on self-declared family income when making program eligibility determinations and to require department to review a random sample of cases to confirm that ineligible clients are not receiving program benefits, effective July 1, 2006; P.A. 07-185 amended Subsecs. (a) and (b) by adjusting family income eligibility limits from 300% to 400% of federal poverty level, amended Subsec. (e) by providing that uninsured child born in a hospital in this state or a border state shall be enrolled in HUSKY Plan, Part B with the commissioner to pay any premium costs for the first two months of coverage, provided the parent or caretaker relative of such child authorizes enrollment and resides in this state, amended Subsec. (g) by requiring commissioner, in consultation with servicer, to establish a centralized unit for processing applications for assistance under HUSKY Plan, Part A and Part B, to ensure that a child determined eligible for benefits has uninterrupted health insurance coverage for as long as the parent or guardian elects to enroll the child for coverage and to electronically transmit both Part A and Part B enrollment and disenrollment data to commissioner, amended Subsec. (i) by requiring servicer to transmit “all applications” to commissioner and deleting language re transmittal of applications where child resides in a home with family income not in excess of 185% of federal poverty level, amended Subsec. (j) by changing from 12 to 10 months the time period for commissioner to make continued eligibility determinations and by requiring that, within existing budgetary resources, commissioner, upon the request of a program participant, electronically transmit application information needed to make continued eligibility determinations beyond the 12 months of initial eligibility, effective July 1, 2007; June Sp. Sess. P.A. 07-2 amended Subsecs. (a) and (b) by adjusting family income eligibility limits from 400% to 300% of federal poverty level, amended Subsec. (e) by replacing “two” with “four” re months that commissioner shall pay premium costs for coverage of uninsured newborn children and made conforming changes in Subsecs. (g) and (j), effective July 1, 2007; P.A. 09-8 made a technical change in Subsec. (j); P.A. 10-179 amended Subsec. (e) by deleting provision re payment of premium costs to managed care organization, amended Subsec. (h) by deleting provision requiring commissioner to develop a contract for managed care enrollment brokerage services, amended Subsec. (i) by replacing provision requiring single point of entry servicer to enroll beneficiaries in managed care plan with provision requiring servicer to enroll beneficiaries in administrative services organization, effective July 1, 2010; June Sp. Sess. P.A. 10-1 amended Subsec. (f) by adding provision permitting commissioner to implement presumptive eligibility for children in families with income under 300% of federal poverty level and by replacing reference to completed application for Medicaid with reference to completed application for benefits, effective June 22, 2010; P.A. 11-25 made technical changes in Subsecs. (i) and (j); P.A. 15-69 changed “family” or “families” to “household”, “HUSKY Plan, Part B” to “HUSKY B” and income eligibility from 185 to 196 per cent and 300 to 318 per cent of federal poverty level throughout, added provision re limited benefit insurance coverage in Subsec. (d), made technical changes in Subsec. (f), deleted former Subsecs. (g) to (j) re single point of entry servicer and eligibility redeterminations, added new Subsec. (g) re presumptive eligibility, redesignated existing Subsec. (k) as Subsec. (h) and deleted former Subsec. (l) re adoption of regulations for income eligibility, residency requirements and eligibility of foreign adoptees, effective June 19, 2015; June Sp. Sess. P.A. 15-5 amended Subsec. (a) by deleting “subsidized”, deleted former Subsec. (b) re unsubsidized HUSKY B benefits for children in households with income over 318 per cent of federal poverty level, redesignated existing Subsecs. (c) to (h) as Subsecs. (b) to (g) and made a technical change in redesignated Subsec. (e), effective August 1, 2015; P.A. 21-176 amended Subsec. (a) by adding state-funded medical assistance for certain children age 8 and under not otherwise qualified for health coverage; June Sp. Sess. P.A. 21-2 amended Subsec. (d) by adding requirement for extension of postpartum care, effective June 23, 2021; P.A. 22-118 amended Subsec. (a) by increasing the age of children eligible for state-funded medical assistance from 8 to 12 years regardless of immigration status and allowing such eligible children to retain such assistance until age 19, effective May 7, 2022; P.A. 23-204 amended Subsec. (a) by replacing “Not later than January 1, 2023, the” with “Until June 30, 2024, the” and by authorizing medical assistance for eligible children up to age 15 on and after July 1, 2024, subject to the provisions of Sec. 17b-265, effective June 12, 2023.
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Sec. 17b-306a. Child health quality improvement program. Purpose and scope. Annual reports. Section 17b-306a is repealed, effective June 12, 2023.
(P.A. 07-185, S. 14; Sept. Sp. Sess. P.A. 09-5, S. 57; P.A. 10-179, S. 69; P.A. 11-44, S. 172; P.A. 15-69, S. 32; P.A. 21-148, S. 4; P.A. 23-204, S. 443.)
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Sec. 17b-307a. Medicaid reimbursement system incentivizing collaboration between primary care providers and behavioral and mental health care providers for HUSKY Health program members. (a) As used in this section:
(1) “Collaborative Care Model” or “CoCM” means the integrated delivery of behavioral health and primary care services by a primary care team that includes a primary care provider, a behavioral care manager, a psychiatric consultant and a database used by the behavioral care manager to track patient progress;
(2) “CoCM codes” means a billing system developed by the Centers for Medicare and Medicaid Services that provide Medicare rates for services provided in the Collaborative Care Model; and
(3) “HUSKY Health” has the same meaning as provided in section 17b-290.
(b) To the extent permissible under federal law, the Commissioner of Social Services shall implement a Medicaid reimbursement system that incentivizes collaboration between primary care providers and behavioral and mental health care providers on an integrated care plan for a HUSKY Health program member. Such reimbursement system shall recognize that multiple providers may be involved in providing care. The commissioner may adopt the Collaborative Care Model to expand access to behavioral and mental health services for HUSKY Health program members and utilize the CoCM codes approved by the Centers for Medicare and Medicaid Services to provide reimbursement to participating providers. The commissioner may take into consideration the potential impact on federal reimbursement when implementing such system.
(P.A. 22-47, S. 59; P.A. 23-195, S. 3.)
History: P.A. 22-47 effective July 1, 2022; P.A. 23-195 amended Subsec. (a)(1) by making a technical change.
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Sec. 17b-307b. Medicaid reimbursement for suicide risk assessments and other mental health evaluations and services provided at school-based health centers or public schools. (a) The Commissioner of Social Services shall provide Medicaid reimbursement, to the extent permissible under federal law, for suicide risk assessments and other mental health evaluations and services provided at a school-based health center or public school.
(b) The Commissioner of Social Services shall (1) amend the Medicaid state plan, if necessary, to provide reimbursement for the suicide risk assessments and mental health evaluations and services described in subsection (a) of this section, and (2) set reimbursement at a level that ensures an adequate pool of providers for such suicide risk assessments and mental health evaluations and services.
(P.A. 23-101, S. 9.)
History: P.A. 23-101 effective July 1, 2023.
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