General Assembly File No. 386
January Session, 1999 Substitute House Bill No. 7030
House of Representatives, April 22, 1999
The Committee on Labor and Public Employees reported through REP. DONOVAN of
the 84th Dist., Chairperson of the Committee on the part of the House, that
the substitute bill ought to pass.
An Act Concerning Access to Health Care for Working Families.
Be it enacted by the Senate and House of Representatives in General Assembly
convened:
Section 1. (NEW) This act shall be known and may be cited as the "Connecticut
Health Care Insurance Act".
Sec. 2. (NEW) There shall be a Connecticut Health Care Trust, referred to in
this act as "the trust", in the Department of Social Services. The trust shall
not be subject to the supervision or control of said department or of any board,
bureau, department or other agency of this state, except as specifically
provided by this act.
Sec. 3. (NEW) The Connecticut Health Care Trust shall have the following powers:
(1) To make, amend and repeal by-laws, rules and regulations for the management
of its affairs;
(2) To adopt an official seal;
(3) To sue and be sued in its own name;
(4) To make contracts and execute all instruments necessary or convenient to
carry out the purposes of said trust;
(5) To acquire, own, hold, dispose of and encumber personal, real or
intellectual property of any nature or any interest therein;
(6) To enter into agreements or transactions with any federal, state or
municipal agency or other public institution or with any private individual,
partnership, firm, corporation, association or other entity;
(7) To appear on its own behalf before boards, commissions, departments or other
agencies of federal, state or municipal government;
(8) To appoint officers and to engage and hire employees, including legal
counsel, consultants, agents and advisors and prescribe their duties and fix
their compensation;
(9) To establish advisory boards;
(10) To procure insurance against any losses in connection with property of the
trust in such amounts and from such insurers, as may be necessary or desirable;
(11) To invest any funds held in reserves or sinking funds, or any funds not
required for immediate disbursement, in such investments as may be lawful for
fiduciaries in the state of Connecticut;
(12) To accept, hold, use, apply and dispose of any and all donations, grants,
bequests and devises, conditional or otherwise, of money, property, services or
other things of value which may be received from the United States, any agency
of the United States or any other governmental agency, institution, person, firm
or corporation, whether public or private. Such donations, grants, bequests and
devises shall be held, used, applied or disposed of for any or all of the
purposes specified in this act and in accordance with the terms and conditions
of any such donation, grant, request or devise. The trust shall detail receipt
of each such donation, grant, request or devise in the annual report of the
trust, which shall include the identity of the donor and the lender, the nature
of the transaction and any conditions attached to the donation or grant;
(13) To do any and all other things necessary and convenient to carry out the
purposes of this act;
(14) To set or establish methods for setting rates, fees and prices for the
Connecticut health care system and reviewing the sufficiency of such rates, fees
and prices;
(15) To establish timely and simplified reimbursement systems for the
Connecticut health care system;
(16) To establish standards of care and staffing for the Connecticut health care
system;
(17) To establish health care guidelines for the treatment and prevention of
specific illnesses under the Connecticut health care system;
(18) To review health care providers based on the guidelines established in
subdivision (17) of this section;
(19) To ensure that all existing laws regarding patient confidentiality are
enforced;
(20) To approve or reject any health care capital expenditure by the Connecticut
health care system in excess of five hundred thousand dollars;
(21) To arbitrate grievances arising under the Connecticut health care system;
(22) To establish an enrolment system for all persons eligible to participate in
the Connecticut health care system;
(23) To establish a formula for and develop global health care budgets and other
system budgets for the Connecticut health care system;
(24) To use bulk purchasing power to lower costs of the Connecticut health care
system;
(25) To adopt a medical benefits package for the Connecticut health care system;
(26) To establish and fund the trust's administrative structure;
(27) To administer Connecticut Health Care Trust revenues;
(28) To recommend, in conjunction with the Department of Revenue Services and
subject to the approval of the General Assembly, the imposition of taxes to fund
the trust;
(29) To negotiate the transfer of funds from this state and the federal
government for health care and administrative duties previously performed by
these governments and transferred to the trust;
(30) To administer funds to support the trust; and
(31) To institute global budgets for health care institutions.
Sec. 4. (NEW) (a) The Connecticut Health Care Trust shall be governed by a
seventeen-member board of trustees appointed as follows: One member shall be the
Commissioner of Social Services; one member shall be the Commissioner of Revenue
Services; one member shall be the Commissioner of Public Health; two members
shall be the chairpersons of the joint standing committee of the General
Assembly having cognizance of matters relating to public health and twelve
members shall be appointed by the Governor, one of whom shall represent
state-wide organizations whose primary purpose is to advocate universal health
care, one of whom shall represent an organization of Connecticut senior
citizens, one of whom shall represent a state-wide organization that defends the
rights of children, one of whom shall represent organizations that provide
services to low income clients, one of whom shall represent state-wide labor
organizations, one of whom shall be a health care economist, one of whom shall
represent state-wide organizations of physicians licensed to practice in
Connecticut, one of whom shall represent state-wide organizations of Connecticut
nurses, one of whom shall represent state-wide organizations of health care
providers, one of whom shall represent state-wide organizations of Connecticut
hospitals and health care facilities, one of whom shall represent the business
community and one of whom shall represent the self-employed. The Governor shall
make these appointments from nominations submitted by relevant state
organizations. Qualifying organizations shall submit nominations to the Governor
not later than one month after the effective date of this act, or not later than
one month after a vacancy on the board due to resignation, removal or completion
of term. There shall be at least three nominations for each appointment. The
Governor shall make appointments from the list of nominations not later than two
months after receiving said list.
(b) Each member shall serve a term of five years, except that for the initial
appointments, four members shall serve three-year terms, four members shall
serve four-year terms and four members shall serve five-year terms. Any person
appointed to fill a vacancy on the board shall serve the unexpired portion of
the vacated term. Any trustee shall be eligible for reappointment. The Governor
may remove any trustee for cause.
(c) Eight trustees shall constitute a quorum and the affirmative vote of a
majority of the trustees present and eligible to vote at a meeting shall be
necessary for any action to be taken by the board. The board of trustees shall
meet at least ten times each year and have final authority over the activities
of the trust. The Commissioner of Social Services shall serve as chairperson.
The gubernatorial appointees shall annually elect a vice chairperson from among
the appointed members of the board of trustees. The trustees shall serve without
compensation, but shall be reimbursed for actual and necessary expenses incurred
in the performance of their duties.
Sec. 5. (NEW) (a) The board of trustees shall hire a health care provider to
serve as the executive director of the trust. The executive director shall be
the executive and administrative head of the Connecticut Health Care Trust and
shall be responsible for administering and enforcing all provisions of law
relating to the trust.
(b) The executive director may, as said director deems necessary for the
effective administration and proper performance of the duties of the trust and
subject to the approval of the board of trustees:
(1) Adopt, amend, alter, repeal and enforce all reasonable rules, regulations
and orders as may be necessary to carry out the provisions of this act; and
(2) Appoint and remove employees and consultants, provided at least one employee
shall be hired to serve as director of each of the divisions of the trust
created by this act, subject to the availability of funds in the trust.
(c) The executive director, in consultation with the directors of each division
of the trust, shall:
(1) Negotiate or establish terms and conditions for the provision of health care
services and rates of reimbursement for such services on behalf of Connecticut
residents, which terms shall include provisions to assure that Connecticut
residents are entitled to use their health insurance benefits in other states
and countries for acute care while visiting such other states and countries;
(2) Negotiate or establish manufacturer discounts and rebates for covered
prescription drugs and other health care products;
(3) Develop prospective and retrospective reimbursement systems for covered
services to provide prompt and fair payment to eligible providers;
(4) Oversee preparation of annual operating and capital budgets for the
state-wide delivery of health care services in accordance with the budgetary
constraints provided in section 13 of this act;
(5) Oversee preparation of annual benefits reviews to determine the adequacy of
covered services; and
(6) In collaboration with the Department of Revenue Services and subject to the
approval of the General Assembly, establish alterations in the methods of
payment for the Connecticut Health Care Trust provided such changes are
consistent with the guidelines established by this act.
Sec. 6. (NEW) (a) There shall be a planning, development and research division
of the Connecticut Health Care Trust which shall be under the supervision of a
director. The director of the division of planning, development and research
shall be appointed by the executive director with the approval of the board of
trustees, and may be removed by the executive director with the approval of said
board.
(b) Subject to the direction, control and supervision of the executive director,
the director of planning, development and research shall be responsible for:
(1) Recommending to the executive director, in conjunction with the consumer,
professional and health care organization advisory councils, a standard benefits
package which shall include (A) diagnostic tests, treatments, including, but not
limited to, mental health services, general medical services, emergency medical
care, hemodialysis, midwifery and pediatric services, medicinals and durable
medical equipment prescribed by licensed health care providers, (B) preventive
and rehabilitative services, (C) inpatient, partial hospitalization and
residential treatment services for medical and mental health disorders, (D)
hospice care, (E) home-based and office-based services by individual providers,
(F) long-term care and treatment, (G) prenatal, perinatal and mastery care,
family planning, fertility and reproductive health care, and (H) dental care.
The director of planning, development and research shall review and update the
benefits package on an annual basis.
(2) Recommending to the executive director, after consultation and negotiation
with the professional, health care and consumer advisory councils, fees for
providers covering all billable procedures. Such fees shall not be less than
standard federal Medicare fees for providers in the state of Connecticut and
shall be renegotiated on an annual basis.
(3) Recommending to the executive director, in consultation with the
professional advisory council, guidelines for the treatment and prevention of
medical and mental illnesses.
(4) Following negotiations with the health care organizations and consumer
advisory councils, recommending to the executive director fees for health care
facilities. In recommending such fees, the director shall give consideration to
establishing capitated global operating budgets and prospective payment
mechanisms for all free-standing health care facilities that provide
nonoutpatient services for Connecticut residents. If prospective payment
schedules are developed, the trust shall provide for retrospective adjustment of
payments to eligible health care facilities. Such payments shall be adjusted
yearly.
(5) In consultation with the consumer, health care organizations and
professional advisory councils, recommending an annual operating budget, with
the understanding that any increases in the budget shall not exceed any increase
in national expenditures for health care for the preceding year and within the
budgetary constraints provided in section 13 of this act.
(6) Making recommendations as to how the annual global operating budget shall be
funded from the following sources: (A) Money transferred to the trust equivalent
to the funds the state would have paid to provide health care to indigent
residents under Title XIX of the Social Security Act, (B) money transferred to
the trust from the federal government that would have been used to pay Medicare,
Title XIX or other health care costs for Connecticut residents, (C) gifts,
grants and donations, (D) copayments from outpatient provider visits, (E) taxes
on items which have been shown to contribute to illness such as tobacco
products, alcohol, gasoline and air and water polluting businesses, (F) a health
care payroll tax, (G) a graduated health care insurance income tax, (H)
investments, (I) unutilized money from the tobacco settlement, (J) money
transferred to the trust that would have been utilized by the state to
administer health care administrative functions that are transferred to the
trust, and (K) general appropriations transferred to the trust by the General
Assembly in response to requests from the executive director of the trust.
(7) In consultation with the consumer, professional and health care
organizations advisory councils, making recommendations concerning current and
future health needs by studying under-utilization and over-utilization of the
state health system in various parts of the state, unnecessary duplication of
services, outcome measurements of treatment, innovations in training, the need
for, or overabundance of, particular types of health care workers in particular
areas of the state, needed capital expenses and ongoing research into the best
means to prevent and treat disease in consultation with the consumer,
professional and health care organizations advisory councils.
(8) Recommending research-based changes in the Connecticut health care system to
the executive director and delineating the cost of such recommended changes.
(9) Assisting and coordinating research efforts with the division of quality
assurance in efforts to evaluate the efficacy of health care providers or health
care institutions, as well as their overall compliance with the treatment
guidelines developed by the division of planning, development and research.
Sec. 7. (NEW) (a) There shall be a benefits division of the Connecticut Health
Care Trust which shall be under the supervision of a director. The executive
director, with the approval of the board of trustees, shall appoint the director
of the benefits division of the trust. The executive director may, with like
approval, remove said director.
(b) The director of the benefits division shall be responsible for:
(1) In consultation with the consumer, professional and health care
organizations advisory councils, making prompt payments to providers for covered
services;
(2) In conjunction with the director of the division of quality assurance and
the director of the division of planning, development and research and in
consultation with the consumer, professional and health care organizations
advisory councils, developing information management systems necessary for
provider payment and utilization review; and
(3) In consultation with the consumer advisory council, investing trust fund
assets consistent with state law.
Sec. 8. (NEW) (a) There shall be a quality assurance division within the
Connecticut Health Care Trust which shall be under the supervision and control
of a director. The executive director, with the approval of the board of
trustees, shall appoint the director of the quality assurance division. The
executive director may, with like approval, remove said director.
(b) The quality assurance director, subject to the direction, control and
supervision of the executive director, shall be responsible for:
(1) In consultation with the consumer, professional and health care
organizations advisory councils, studying the utilization patterns of all health
care providers and health care organizations and the quality of the services
they provide. In fulfilling this responsibility, the quality assurance division
shall investigate all situations of possible billing fraud by individuals or
institutions and investigate providers whose patterns of billing are
inconsistent with the guidelines developed by the trust for the treatment of
specific diseases.
(2) In consultation with the consumer advisory council, investigating consumer
fraud that results from accessing the Connecticut health care system illegally.
(3) Certifying, licensing and recertifying all health care providers in this
state.
(4) In consultation with the consumer, professional and health care
organizations advisory councils, responding to complaints on the part of
consumers, health care providers and health care organizations concerning
inadequate, unprofessional, impaired or prejudicial treatment on the part of a
health care provider or health care organization.
(5) In consultation with the consumer, professional and health care
organizations advisory councils, instituting reeducation, treatment, supervision
requirements and restricting or terminating the licensure of health care
providers or institutions that are found to be deficient in their quality or
manner of providing health care.
(6) In consultation with the consumer and professional advisory councils,
establishing and enforcing continuing education requirements for specified
health care workers in this state.
(7) In consultation with the consumer advisory council, responding to and
arbitrating disagreements between providers and consumers or providers and the
state concerning eligibility for treatment eligibility for reimbursement under
the Connecticut health care system or any other disagreement the director deems
worthy of arbitration.
(8) In consultation with the consumer and health care organizations advisory
councils, establishing procedures for enforcing standards of care and staffing.
Sec. 9. (NEW) (a) There shall be a consumer division within the Connecticut
Health Care Trust which shall be under the supervision and control of a
director. The director of the consumer division shall be appointed by the
executive director of the trust with the approval of the board of trustees, and
may be removed by the executive director with the approval of the board of
trustees.
(b) The consumer division director shall, subject to the direction, control and
supervision of the executive director, be responsible for:
(1) Establishing a reasonable number of regional offices located throughout the
state. Each office shall be staffed to respond to questions and complaints from
consumers and providers, to perform local outreach and informational functions
and to hold hearings to determine unmet health care needs in consultation with
the consumer advisory council.
(2) To promote preventative and ameliorative public health among the residents
of the state of Connecticut through education and the establishment of consumer
groups to promote healthy behavior in consultation with the consumer advisory
council.
Sec. 10. (NEW) (a) There shall be a state-wide consumer advisory council for the
trust, which shall consist of twenty-one members. The Governor shall make
appointments to the advisory council from nominations provided by organizations
that have been supporting or advocating a universal health care system on or
before January 1, 1995. Eligible organizations shall submit nominees to the
Governor not later than one month after the effective date of this act, or
within one month of a vacancy on the council due to resignation, removal or
completion of term. There shall be at least three nominations for each
appointment. The Governor shall make appointments from the list of
recommendations within two months of receiving such nominations. In making
appointments, the Governor shall consider geographic and demographic diversity.
(b) Each member shall serve a term of five years, provided in making the initial
appointments, seven members shall serve three-year terms, seven members shall
serve four-year terms and seven members shall serve five-year terms. Any person
appointed to fill a vacancy on the advisory council shall serve for only the
unexpired term of the member such person replaces. Any member shall be eligible
for reappointment. Any member may be removed by the Governor for cause. Eleven
members shall constitute a quorum and the affirmative vote of a majority of
council members present and eligible to vote at a meeting shall be necessary for
any action to be taken by the advisory council. The members shall annually elect
a chairperson.
(c) The state-wide consumer advisory council shall serve as an independent
oversight body, which shall:
(1) Work with the director of the planning, development and research division to
make recommendations to the executive director concerning benefits packages and
payment schedules for provider and health care organizations and capital
expenditures;
(2) Work with the director of the consumer division to promote consumer
education and healthy behavior among consumers;
(3) Work with the director of the quality assurance division to develop
procedures and investigate professional providers and health care organizations
that are not in compliance with the guidelines for the prevention and treatment
of disease in the state of Connecticut or the staffing and quality of care
standards established by the Connecticut health care system;
(4) Work with the director of the quality assurance division to develop
procedures and investigate consumer fraud that results from accessing the
Connecticut health care system illegally;
(5) Work with the director of the quality assurance division to develop and
enforce continuing education requirements for health care providers in this
state;
(6) Work with the director of the quality assurance division to assure that
grievances by consumers, health care providers and health care organizations
concerning the Connecticut health care system are appropriately investigated and
resolved with recommended changes;
(7) Work with the director of the benefits division to assure that trust money
is appropriately invested and timely and efficient payment mechanisms are
utilized to pay health care providers and health care organizations.
(d) The advisory council may expend its budget in whatever manner it determines
best serves the interests of health care consumers and the Connecticut health
care system. The advisory council shall submit a budget proposal to the
executive director each year and may alter said proposal from time to time
throughout the year. The executive director shall, from time to time,
requisition from the trust such amounts as the executive director deems
necessary to meet the current obligations of the advisory council, provided such
amounts shall not exceed, in the aggregate, five hundred thousand dollars per
year.
(e) Each advisory council member shall serve without compensation but shall be
reimbursed for actual and necessary expenses incurred in the performance of the
member's duties.
Sec. 11. (NEW) (a) There is hereby created a state-wide professional advisory
council which shall work with the director of planning, development and research
of the Connecticut Health Care Trust to:
(1) Recommend to the executive director consensus guidelines to be used by
health care providers for the treatment and prevention of disease in the state
of Connecticut.
(2) Recommend to the executive director a benefits package for residents of the
state of Connecticut, which shall be administered by the trust.
(3) Recommend to the executive director fee schedules for procedures covered
under the benefits package.
(b) The professional advisory council shall work with the director of the
quality assurance division of the trust to:
(1) Recommend to the executive director a method for evaluating the compliance
of health care professionals with the consensus guidelines for the treatment and
prevention of disease in the state of Connecticut.
(2) Recommend to the executive director appropriate consequences for health care
professionals who fail to comply with the consensus guidelines for the treatment
and prevention of disease in the state of Connecticut.
(c) The professional advisory council shall work with the director of the
benefits division to develop information management systems and insure timely
payment to health care providers.
(d) The professional advisory council shall consist of one member from each
licensed category of health care professionals, to be elected or appointed by
their state-wide professional organizations for two to five-year terms at the
discretion of the state-wide professional organizations and seven physicians
licensed to practice in this state, one of whom shall represent primary care
physicians, one of whom shall represent pediatricians, one of whom shall
represent internal medicine specialists, one of whom shall represent
obstetricians and gynecologists, one of whom shall represent surgeons, one of
whom shall represent psychiatrists and one of whom shall represent other
physician specialists.
(e) Each council member shall serve without compensation from the trust, but
shall be reimbursed for actual and necessary expenses incurred in the
performance of the member's duties. Professional advisory council members may be
compensated for their work by their respective professional organizations at the
discretion of that organization.
Sec. 12. (NEW) (a) There is hereby created a state-wide health care
organizations advisory council. The health care organizations advisory council
shall be composed of one member of each category of health care organizations
recognized by the state. These members shall be selected by their respective
professional organizations.
(b) Members of the state-wide health care organizations advisory council shall
be elected or appointed for two to five-year terms at the discretion of their
respective professional organizations. Members shall serve without compensation
from the trust, but shall be reimbursed for actual and necessary expenses
incurred in the performance of the member's duties. Members of the health care
organization advisory council may be reimbursed by their respective professional
organizations for their services on the council at the discretion of their
respective professional organizations.
(c) The health care organizations advisory council shall work with the director
of the planning, development and research division to:
(1) Make recommendations to the executive director concerning services and
procedures offered by health care organizations which should be covered by the
trust.
(2) Make recommendations to the executive director of the trust concerning
payments to health care organizations for covered services.
(3) Make recommendations to the executive director concerning new capital
expenditures in the state and the coordination or consolidation of health care
services among health care organizations.
(d) The health care organizations advisory council shall work with the director
of the quality assurance division of the trust to:
(1) Make recommendations to the executive director of the trust concerning
methods for evaluating the compliance of health care organizations with the
guidelines for the treatment and prevention of disease adopted by the trust.
(2) Make recommendations to the executive director concerning appropriate
consequences to those health care organizations that are not in compliance with
the guidelines for the treatment and prevention of disease adopted by the trust.
(3) Make recommendations to the executive director of the trust concerning
standards of care and staffing requirements.
Sec. 13. (NEW) Any Connecticut resident who meets the following requirements
shall be eligible for covered services under the Connecticut health care system:
(1) Any person (A) who has been a legal resident of this state for at least one
year, (B) whose employer has paid all health care trust fund premium payroll
taxes for such person for at least six months, (C) who has paid all
self-employment health care trust fund premium taxes for a period of at least
six months, or (D) who is the dependent of a person who meets the requirements
of subparagraphs (A), (B) or (C) of this subdivision.
(2) A Connecticut resident eligible for benefits under this section is further
eligible for long-term care upon showing any of the following: (A) That such
resident is and has been employed full-time for two years, or a correspondingly
greater number of months of part-time employment, by an employer who has for the
entire time made all required payments to the trust; (B) resided in Connecticut
and made all required payments of personal and payroll health taxes to the trust
for a period of two years; (C) is entitled under federal laws to such benefits;
or (D) has for two years been a dependent of an eligible Connecticut resident.
(3) Any individual who is not eligible for long-term care under the provisions
of subdivision (2) of this section shall be eligible for long-term care to the
same extent and under the same condition as such individual would have been
under any program existing prior to the effective date of this act.
Sec. 14. (NEW) Initial funding for the Connecticut Health Care Trust shall be
provided from funds received by the state from the Master Settlement Agreement
executed November 23, 1998. Such funds shall be used by the trust to:
(1) Establish and carry out the functions of the trust as provided in this act
until such time that the benefits provided for by this act can be initiated, not
to exceed two years. This provision shall specifically include the development
of information systems to facilitate billing and payment, outcome studies and
utilization review, as well as the development of guidelines for the treatment
and prevention of specific disorders, the establishment of a benefits package
and a payment schedule for providers and institutions with regard to procedures
which will be covered by the benefits package.
(2) Educate providers and consumers about the Connecticut health care system.
(3) Establish enrolment in the Connecticut health care system.
(4) Accomplish baseline studies on the current Connecticut health care system in
terms of its cost and effectiveness.
(5) Make a recommendation to the General Assembly concerning an initial budget
and appropriate sources of funding.
(6) Invest unutilized funds in a manner consistent with state policy.
(7) Obtain grants from the federal government and other funding sources to help
establish the Connecticut Health Care Trust and study its cost and
effectiveness.
(8) Seek all necessary waivers, exemptions, agreements or legislation, so all
current federal and state payments for health care shall be paid directly to the
trust at the starting date of the trust, which shall then assume responsibility
for all benefits and services previously paid for by such federal and state
payments for health care.
(9) Establish provisions for the retraining and assistance in finding suitable
employment for those insurance and health care workers who are displaced by the
enactment of the benefits package of the trust. Provisions for such retraining
and assistance shall be made in the initial budget, not to exceed one per cent
of such initial budget, and shall be considered in subsequent budgets up to
three years after the beginning of the trust.
Sec. 15. (NEW) (a) There is hereby established the Connecticut Health Care Trust
Fund. Funding for the Connecticut Health Care Trust Fund shall be obtained from
the following sources:
(1) The Connecticut Health Care Trust shall seek to maximize all sources of
federal financial support for health care services in this state. The executive
director of the trust shall obtain waivers, exemptions or legislation, if
needed, so that all current federal payments for health care, including
Medicare, shall be paid directly to the fund.
(2) The state of Connecticut shall pay into the fund the moneys it currently
pays for health care services and all administrative functions to be assumed by
the trust currently carried out by the state of Connecticut. The total
appropriation for these health and administrative services shall be altered
yearly through negotiations between the executive director of the trust, the
director of the budget and the General Assembly.
(3) Taxes shall be imposed on items that contribute to increased health care
costs. Surtaxes, to be determined by the General Assembly, in conjunction with
the executive director of the trust, are imposed on tobacco products, alcohol,
gasoline and facilities operating in the state of Connecticut that generate air
or water pollution. These products and facilities may be taxed to the extent
that they can be reasonably determined to contribute to the health care costs of
the residents of the state of Connecticut.
(4) All employers shall pay a trust fund premium, based on their payroll,
starting with the enactment of the benefit plan of the trust, as determined by
the trust and the Department of Revenue Services. The amount of this premium
shall be in line with, or less than, the average contributions that employers
make toward employee health benefits as of the effective date of this act,
adjusted to a rate less than national health care inflation or deflation.
(5) Families or individuals receiving covered benefits under the Connecticut
health care system shall contribute premiums on a sliding scale as determined by
the trust in consultation with the Department of Revenue Services. The premium
shall be collected through the current state income tax system. There shall be
no premiums for families of individuals with income below one hundred
eighty-five per cent of federal poverty level guidelines. The premium for
employed workers shall be negotiated to be less than the amount such an
individual or family would pay through an employer or private insurance plan for
a comparable benefits package. Premiums for Medicare-eligible individuals shall
be limited to less than the cost of private insurance to cover those services
which are benefits of the trust but not of the federal Medicare program.
(6) The trust shall seek grants from all appropriate and available sources to
fund research and administration relevant to the Connecticut health care system.
(7) The trust shall retain: (A) Any charitable donations, gifts, grants or
bequests made to it from whatever source consistent with state and federal laws;
(B) any rebates negotiated or established; and (C) income from the investment of
trust assets, including any remainder from the state tobacco settlement,
consistent with state law.
(8) Any additional funds the state of Connecticut shall distribute to the trust
through a general appropriation enacted by the General Assembly in response to a
funding request by the executive director of the trust.
(b) Amounts credited to the fund shall be used for the following purposes:
(1) To reimburse eligible health care providers and health care facilities for
covered services rendered to eligible patients;
(2) To pay for preventative educational and outreach programs, as well as
related health care activities, not to exceed three per cent of the trust income
in any fiscal year;
(3) To supplement other sources of financing for approved capital investments in
excess of five hundred million dollars for eligible health care providers and
facilities, not to exceed three per cent of trust income in any fiscal year;
(4) To supplement other sources of financing for medical education and research,
not to exceed three per cent of trust income in any fiscal year;
(5) To fund training and retraining programs for workers in the health care
sector displaced as a result of administrative streamlining gained by moving
from a multipayer to a single payer health care system, not to exceed one per
cent of trust income in any fiscal year provided, such funding shall terminate
June thirtieth of the third year following full implementation of this act;
(6) To fund a reserve account to finance potential budgetary shortfalls,
epidemics and other extraordinary events, not to exceed more than one per cent
of the trust income in any fiscal year;
(7) To pay for the benefits division of the trust, not to exceed three per cent
of trust income in any fiscal year;
(8) To pay for the general administration of the trust, including the office of
the executive director and the divisions of planning, development and research
and quality assurance, not to exceed three per cent of trust income in any
fiscal year, not including moneys transferred to the trust from the state of
Connecticut to fund those quality assurance activities that will be taken over
by the trust which were previously carried out by the Department of Public
Health;
(9) To pay the administrative costs of the state-wide consumer advisory council,
not to exceed five hundred thousand dollars in any fiscal year, adjusted for
inflation or deflation;
(10) To pay the administrative costs of the state-wide health care organizations
advisory council, not to exceed one hundred thousand dollars in any fiscal year,
adjusted for inflation or deflation; and
(11) To pay the administrative costs of the state-wide health care organizations
advisory council, not to exceed one hundred thousand dollars in any fiscal year,
adjusted for inflation or deflation.
(c) Unexpended trust assets shall not be deemed to be surplus funds, but shall
be retained in the fund for investment purposes. These funds shall be addressed
and accounted for in determining appropriate funding for the trust.
Statement of Legislative Commissioners: In section 2, the first sentence was
rewritten for consistency with the general statutes; in section 3, subdivisions
(14) to (25), inclusive, were revised to clarify that the exercise of the powers
specified in said subdivisions relate to the Connecticut health care system; in
subsection (c) of section 4, "directors" was changed to "trustees" for
consistency throughout section 4; in section 6, the first sentence of subsection
(b)(2) was rewritten for clarity and in subsection (b)(7) "provider" was changed
to "professional" for consistency throughout the bill; in subsection (b)(1) of
section 8, "in terms of their patterns of utilization" was deleted to avoid
redundancy; in section 10, references to "director of the administrative
division" and "director of administration" were changed to "director of the
benefits division" for accuracy and consistency throughout the bill; in section
12 "representatives" was changed to "members" for consistency throughout the
bill; and in subdivision (7) of section 14, "sites" was changed to "sources" for
accuracy.
LABCommittee Vote:Yea9Nay5JFS
The following fiscal impact statement and bill analysis are prepared for the
benefit of members of the General Assembly, solely for the purpose of
information, summarization, and explanation, and do not represent the intent
of the General Assembly or either House thereof for any purpose:
OFA Fiscal Note
State Impact:See Explanation Below
Affected Agencies:Various
Municipal Impact:Potential Savings
Explanation
State Impact:
This bill creates the Connecticut Health Care Trust within the Department of
Social Services designed to finance and regulate the cost of all health care
services delivered to the citizens of Connecticut. This trust is a quasi-public
entity with the authority to: set provider rates; administer a reimbursement
system; establish health care standards and guidelines; develop a client
enrollment system; adopt a medical benefits package; establish a global budget
and revenue structure to finance health care; and provide and fund an
administrative structure to carryout its authority. A seventeen-member board of
trustees governs the operations of the quasi-public trust. The bill also creates
three statewide councils to advise the trust.
This trust would finance health care services to any person, or dependent, who
has been a legal resident of Connecticut for at least one year; whose employer
has paid all necessary payroll taxes for at least six months; or to an
individual who has paid all necessary self-employed premium taxes for at least
six months. The trust would also pay for long term care for those currently
eligible for such benefits and to those who have been legal residents for at
least two years and meet certain criteria.
This bill would require the creation of a large administrative structure
necessary for the operations of the Health Care Trust. There would be
significant costs associated with the creation and maintenance of this
administrative structure. However, the bill also provides for potential savings
associated with its authority to set provider rates, establish global health
care budgets, and determine the medical benefits package it will deliver. The
trust would use funds collected from a variety of taxes and premiums to finance
the health care system. Due to the complexity involved in implementing such a
large-scale shift in health care policy, the size of the administrative
structure needed to carryout the provisions of the bill, and the economic
implications of creating a single-payer health care system for the entire state,
a net fiscal impact to the state cannot be determined.
Health Care in Connecticut
The new Connecticut Health Care Trust would be responsible for paying for all
health care costs incurred by the 3.25 million residents of Connecticut. The
Office of Fiscal Analysis estimates that health care costs for all residents of
Connecticut totaled approximately $16.2 billion in fiscal year 1998. Of this
total, the state paid approximately $2.59 billion, including expenditures for
the Medicaid program, state employee benefits, and a variety of other
state-funded health programs. The Federal government paid approximately $2.44
billion, including Medicare expenditures and benefits for Federal employees. The
remaining health care expenditures were funded under private entities: $4.54
billion under self-funded ERISA plans; $4.36 billion under private insurance;
and $2.27 billion from consumer's out-of-pocket expenditures. This new entity
would be responsible for the administration of an insurance plan encompassing
all these health care expenditures.
Major Functions of the Trust
The bill creates four major divisions: planning, research and development;
benefits; quality assurance; and consumer issues.
The planning, research and development (PRD) division will be most directly
responsible for the fiscal aspects of the new Health Care Trust. The PRD
division is be charged with making recommendations concerning the funding of the
global operating budget, including identifying all revenue sources. The
potential revenue for the trust will be discussed in a later section. The bill
set a limit on the annual increase in the global health care budget to the
increase in national expenditures for health care in the previous year.
The PRD division also has the responsibility for the development of the health
benefits package that will be provided to residents of the state. The bill
requires that the package include diagnostic tests, preventive and
rehabilitative care, inpatient and residential treatment, hospice services,
individuals provider services, long term care, prenatal care, dental care and a
variety of other services. The services included in the final benefits package
will greatly impact the cost of operations.
The PRD division is also responsible for the development of a fee schedule for
all billable medical procedures. These fees may not be less than the standard
Medicare fees developed for Connecticut.
The bill establishes a benefits division that is responsible for processing
claims and making all reimbursements and payments to providers. The benefits
division is also responsible for the development of any information management
systems necessary to make these payments and to perform utilization reviews. The
establishment of the benefits division will result in a significant increased
cost to the state. Whether the Health Care Trust contracts for the payment
function or directly hires state employees, the Trust must create a large
administrative capacity to process the millions of claims that will be made on
the Connecticut health care system. The cost of this division may not exceed
three percent of the Trust income in any one fiscal year, estimated at $420
million based upon current health care expenditures.
The bill creates a quality assurance division to study utilization patterns,
investigate consumer fraud, certify and license all health care providers,
investigate and respond to complaints, produce and enforce licensing, staffing
and education standards, and settle disputes concerning eligibility. A large
administrative structure will be necessary to carry out the mandates of the
benefits division. These functions appear to supercede several current functions
of the Department of Public Health, the Department of Insurance, and the Office
of Health Care Access. In addition, the state Medicaid program would also be
administered by this entity. However, as the bill does not repeal the existing
statutory obligations upon these agencies, a duplication of services would be
created. A significant additional cost would be incurred due to the hiring of
staff to perform the functions not currently performed by other state agencies.
The bill also creates a consumer division with regional offices throughout the
state. This division will respond to complaints from consumers and providers,
perform outreach and public hearing functions, and promote preventative and
ameliorative public health. These functions appear to supercede several core
public health functions of the Department of Public Health, as well as certain
responsibilities of the Department of Insurance and the Office of Health Care
Access. As the bill does not repeal the existing statutory obligations upon
these agencies, a duplication of services is created.
Sources of Revenue for the Trust
The Connecticut Health Care Trust will utilize several funding streams to
finance the provision of health care in Connecticut. The tobacco settlement
funds received under the Master Settlement Agreement will be used as the initial
funding for the Trust. These funds will be used in the first two years of the
Trust's operation to set up and plan for all aspects of the new health care
system. These aspects include developing information and billing systems,
enrolling residents, seeking all necessary waivers, exemptions, agreements and
legislative changes, performing studies, and recommending a budget and
appropriate funding. The Trust is also expected to establish provisions for
retraining and assistance for all displaced workers currently employed in the
state's health insurance industry resulting from the enactment of this
legislation. Connecticut is expected to receive a total of approximately $300
million from the tobacco settlement by the end of FY01.
After the initial two-year set up period, the ongoing operations of the Trust
are to be funded through the redirection of all current health care funding
streams, both public and private. These streams include all current state-funded
health care ($2.59 billion) and all Federal health care funds ($2.44 billion).
The Trust would receive a premium on all private payrolls, which would correlate
to the contributions that employers currently make toward health care benefits.
This provision would apply to all employers in the state, including those who
self-insure under ERISA plans. Medicare would also be part of the trust's
financial operations. These latter two provisions would require a federal waiver
and possibly federal legislation as well.
Families and individual with incomes over 185% of the Federal poverty guidelines
will also pay for health care premiums on a fee-based sliding scale. This scale
will be determined by the Trust in consultation with the Department of Revenue
Services. This fee will be collected through the current state income tax
system. These individual or family premiums will not be higher than those paid
under the current system as a contribution towards a private or employer based
health plan.
The state will also transfer to the Trust all state funds currently used for
health care services. This will include all or part of the current budgets for
the Departments of Social Services, Public Health, Insurance, Mental Health and
Addiction Services, Mental Retardation, Children and Families, and the Office of
Health Care Access. The disposition of the University of Connecticut Health
Center is unclear under the language of this bill.
The Trust may also receive taxes, if approved by the General Assembly, on
tobacco products, alcohol, gasoline and any facilities in the state that
generate air or water pollution. These taxes are to levied to the extent that
these products and facilities can be reasonably be determined to contribute to
the state health care costs.
The Trust may also receive gifts, grants, rebates and any income from the
investment of Trust assets. The bill is not clear as to whether the Trust will
continue to receive funds from the tobacco settlement after the initial two-year
set up period. The executive director of the Trust may also request a general
appropriation from the General Assembly.
It should be noted that unexpended Trust assets are not deemed to be surplus
funds for the General Fund. Rather, any such funds are to be retained by the
Trust for investment purposes.
Municipal Impact:
This bill represents potential savings for municipalities. All current municipal
expenditures for health care for municipal employees would be assumed by the
Trust. The municipalities would have to pay the general employee premium to the
Trust for the health care services of municipal employees. To the extent that
the Trust succeeds in lowering these premiums below what the municipalities now
pay through the bulk purchasing of health care services, significant savings for
municipalities may result.
OLR Bill Analysis
sHB 7030
An Act Concerning Access to Health Care for Working Families
SUMMARY: This bill establishes the Connecticut Health Care Trust (the "Trust")
to provide health care, including long-term care, for eligible state residents.
A resident and his dependents are eligible if he has lived in the state for at
least one year and he, or his employer, has paid all required taxes. The bill
creates new health care payroll and income taxes. It also creates the
Connecticut Health Care Trust Fund (the "fund") to pay for health care services
and other specified items.
The bill places the Trust in the Department of Social Services (DSS) for
administrative purposes only. It (1) specifies the Trust's powers and
responsibilities (see COMMENT); (2) establishes a board of trustees to govern
it; (3) requires the board to appoint an executive director; (4) establishes
four divisions (planning, development, and research; consumer; benefits; and
quality control); and (5) establishes three statewide advisory councils
(consumer, professional, and health care organizations (HCOs).
EFFECTIVE DATE: October 1, 1999
FURTHER EXPLANATION
Eligibility for Services
General Health Benefits Eligibility. Under the bill, an individual and his
dependents are eligible for health benefits if: (1) he has resided in
Connecticut for at least one year, (2) his employer has paid its required
payroll taxes for him for at least six months, and (3) he has paid any required
self-employment health care taxes for at least six months.
Long-Term Care Eligibility. The bill makes a state resident and his dependents
of at least two years eligible for long-term care (a term that the bill does not
define) if he is able to show that: (1) he has been employed full-time for two
years (or part-time for more than two years) by an employer that has paid all
required payroll taxes; (2) he has lived in the state and paid all required
payroll and income taxes for at least two years; or (3) he is eligible for
long-term care under Medicaid or Medicare, or any other federal law.
The bill specifies that individuals who are not eligible for long-term care
under its provisions may still be eligible for care to the same extent that they
would have been before its enactment.
Connecticut Health Care Trust Fund
List of Funding Sources. The bill establishes a Connecticut Health Care Trust
Fund. Apparently the fund will be within the Trust. It must be funded with state
funds currently spent on health care through the Medicaid program, indigent care
payments, and state health care-related administrative costs; taxes imposed on
items that contribute to increased health care costs; employer, family, and
individual taxes; grants; donations, gifts, and bequests; rebates; fund
investment income; any remaining state tobacco settlement funds; and General
Assembly appropriations.
Federal Financial Support. The bill requires the Trust to maximize all federal
funding sources for health care services. The executive director must obtain any
needed waivers, exemptions, or legislation so that all current federal payments
for health care, including Medicare, are paid directly to the fund. (Medicare is
a purely federal program that makes payments to providers, hospitals, and
individuals. The state receives no payments under it.)
State Funding. The bill requires the state to pay the fund the amount it
currently pays for health care services and administrative functions that the
Trust assumes under the bill. It specifies that the cost is annually altered
through negotiations between the executive director, the director of the budget
(although the bill does not identify who this is), and the General Assembly.
Taxes on Certain Items. The bill requires surtaxes to be imposed on tobacco
products, alcohol, gasoline, and facilities operating within the state that
generate air or water pollution (the bill does not define what levels constitute
air or water pollution). The General Assembly must determine taxes, in
conjunction with the executive Trust's director. The identified items may be
taxed to the extent that they can reasonably be determined to contribute to
health care costs.
Premiums. The bill requires all employers to pay premiums, in the form of a
health care payroll tax. Taxes begin with the enactment of the Trust's benefit
plan. Presumably the Department of Revenue Services (DRS) determines when the
enactment begins. Premiums must be similar to, or less than, the average
contributions that employers make toward their employees' health benefits as of
the bill's effective date, but must be adjusted to a rate less than the national
health care inflation or deflation.
Families or individuals receiving benefits must pay premiums collected through
the state income tax and the tax amount must be determined on a sliding scale
basis as determined by the Trust in consultation with the DSS. However, families
and individuals earning less than 185% of the federal poverty level do not pay
health care income or payroll taxes.
Workers' premiums must be less than the amount they would pay through an
employer or private insurance plan for comparable benefits.
Medicare-eligible individuals' premiums must be less than the cost of private
insurance for non-Medicare covered services.
Permissible Use of Fund
Unspent amounts must stay in the fund. The bill requires the fund to be used
for:
1. reimbursing eligible medical providers and health care facilities for
covered services provided to eligible patients;
2. paying up to 3% of any fiscal year's Trust income (which the bill does
not define) for preventative, educational, and outreach programs and
unspecified health care activities;
3. supplementing, by up to 3% of any fiscal year's Trust income, other
unspecified sources of financing for approved capital investments in excess
of $500 million for eligible medical providers and facilities;
4. supplementing, by up to 3% of any fiscal year's Trust income, other
sources of financing for medical education and research;
5. funding, by up to 1% of any fiscal year's Trust income, training and
re-training programs for health care workers who are displaced as a result
of administrative streamlining;
6. funding, by up to 1% of any fiscal year's Trust income, a reserve account
to finance potential budgetary shortfalls, epidemics and other extraordinary
events;
7. paying for the Trust's Benefits Division with up to 3% of any fiscal
year's Trust income;
8. paying for the Trust's general administration with up to 3% of any fiscal
year's Trust income;
9. paying, up to $500,000, in any fiscal year, adjusted for inflation or
deflation, the administrative costs of the Statewide Consumer Advisory
Council; and
10. paying the administrative costs of the statewide HCO advisory council,
up to $100,000 in any fiscal year, adjusted for inflation or deflation.
Initial Funding
The bill requires the Trust's initial funding to come from the tobacco
settlement. It must be used to:
11. establish and carry out Trust functions required in the bill until the
Trust is providing health benefits up to a maximum period of two years;
12. educate providers and consumers about the new health care system;
13. establish enrollment procedures;
14. accomplish baseline studies apparently on the current health care
system's cost and effectiveness;
15. make a recommendation to the General Assembly concerning an initial
budget and appropriate funding sources;
16. invest unused funds in a manner consistent with state policy;
17. obtain grants from the federal government or other sources to establish
the trust and study its cost and effectiveness;
18. seek all necessary waivers, exemptions, agreements, or legislation, so
that all current federal and state payments for health care are paid
directly to the Trust; and
19. establish provisions for retraining and assistance in finding employment
for insurance and health care workers who lose their jobs as a result of the
bill. (The initial amount used for this purpose cannot exceed 1% and must be
considered in subsequent budgets for up to three years.).
Trust Powers
The bill gives the Trust typical agency powers including the right to sue and be
sued; to make contracts; to acquire, own, hold, dispose of, and encumber
personal, real, or intellectual property; and to appoint officers and to engage
and hire employees. In addition, it authorizes the Trust to:
20. to invest any funds held in reserves or sinking funds or any funds not
required for immediate disbursement;
21. establish ways for setting rates, fees, and prices and evaluating their
sufficiency;
22. establish timely and simplified reimbursement systems;
23. establish standards of care and staffing;
24. establish health care treatment and illness prevention guidelines;
25. review medical health care providers based on guidelines established in
the bill;
26. ensure all laws concerning patient confidentiality are enforced;
27. approve or reject any health care capital expenditure over $500,000;
28. arbitrate grievances;
29. establish an enrollment system for all eligible individuals;
30. establish a formula for, develop, and institute global health care
budgets for health care institutions (the bill does not define this term)
and other system budgets;
31. use bulk purchasing power to lower system costs;
32. adopt a medical benefits package;
33. administer funds to support the Trust;
34. recommend, along with DRS and subject to General Assembly approval,
taxes to fund the Trust; and
35. negotiate the transfer of funds from the state and federal government
for health care and administrative duties they previously performed.
Board of Trustees
The bill establishes a board of trustees to oversee the Trust. It specifies that
the board has final authority over Trust activities. The board consists of 17
members, which must include the departments of Social Services, Revenue
Services, and Public Health commissioners and the Public Health Committee
chairmen. The governor appoints the remaining 12 members and may remove them for
cause. The appointments must include one representative of:
36. a statewide organization that primarily advocates universal health care,
37. a senior citizen organization,
38. a statewide organization that defends childrens' rights,
39. organizations that provide services to low-income clients,
40. statewide labor organizations,
41. health care economists,
42. a statewide organization of licensed physicians,
43. a statewide organization of nurses,
44. a statewide organization of health care providers,
45. a statewide organization of hospitals and health care facilities,
46. the business community, and
47. self-employed people.
The bill requires the governor to make his selections from nomination lists
provided by relevant state organizations. The organizations must submit the
lists to him by November 1, 1999 or within one month of a vacancy, and the
governor has two months in which to make an appointment. Lists must include at
least three nominations for each appointment.
Members serve five-year staggered terms. If a member is appointed as a result of
a vacancy, he may only serve the term's remainder. Members serve without
compensation, but may be reimbursed for necessary expenses.
The bill requires the DSS commissioner to serve as chairman. The gubernatorial
appointments must annually elect a vice-chairman. The bill requires the board to
meet at least 10 times annually. It establishes that eight directors constitute
a quorum and in order for any action to be valid, it must receive a majority
vote of present trustees who are eligible to vote.
Executive Director
The bill requires the board to hire a health care provider to serve as an
executive director for the Trust and to administer and enforce all Trust-related
laws. It allows the director to (1) adopt, amend, repeal, and enforce all
reasonable rules, regulations, and orders to carry out the bill's provisions and
(2) appoint and remove employees and consultants. Each of the Trust's divisions
must be headed by a director if it is financially feasible. The executive
director appoints the division directors, with the Trustees' approval, and may
remove them.
The bill requires the executive director, after he has consulted with each
division director, to:
48. establish terms and conditions for providing health care and
reimbursement rates,
49. include in the terms and conditions a provision that covered state
residents may receive acute care in other states and countries that they are
visiting,
50. establish discounts and rebates for covered prescription drugs and other
health care products,
51. develop a prospective and retrospective reimbursement system for covered
services so providers are paid promptly,
52. oversee the annual operating and capital budgets for health care
services provided under the bill,
53. oversee an annual benefits review to determine whether covered services
are adequate, and
54. in collaboration with DRS and subject to General Assembly approval,
establish alterations in payment methods if the changes are consistent with
guidelines developed under the bill.
Planing, Development, and Research (PDR) Division
The PDR director is responsible for recommending to the executive director:
55. a standard benefits package that includes (a) diagnostic tests, (b)
treatments, including mental health services, general medical services,
emergency medical care, hemodialisis, midwifery, pediatric services,
medicinals, and durable medical equipment prescribed by a licensed medical
provider, (c) preventive and rehabilitative services, (d) inpatient, partial
hospitalization, and residential treatment services for medical and mental
health disorders, (e) hospice care, (f) home-based and office-based services
by individual providers, (g) long-term care and treatment, (h) prenatal,
perinatal and mastery care, family planning, fertility and reproductive
health care, and (i) dental care (he makes these recommendations only after
he has consulted with the three statewide advisory councils);
56. provider fees, on an annual basis, that are at least equal to standard
Medicare fees for Connecticut providers (He must recommend these fees after
consulting with the consumer advisory council and negotiating with
unspecified professional and health care organizations.);
57. treatment and prevention guidelines, after consulting with the
Professional Advisory Council;
58. health care facility fees, after negotiating with health care
organizations and the consumer advisory council (The director must consider
establishing capitated global operating budgets and prospective payment
mechanisms for all free-standing health care facilities that provide only
outpatient services. If prospective payment schedules are developed the
Trust must allow retrospective, annually adjusted adjustment of payments to
eligible facilities.);
59. an annual operating budget within available funding, after consulting
with the three statewide councils and consumer and health care organizations
(but budgetary increases cannot exceed the annual increase in national
health care expenditures);
60. how the annual global operating budget is funded from the sources
described above ("List of Funding Services");
61. about current and future health needs, after consulting with the three
statewide councils and provider and health care organizations and by
studying under- and over-utilization of the state health system in various
parts of the state, duplication of services, outcome measurements of
treatment, innovations in training, the need for, or overabundance of,
particular types of health care workers in particular areas of the states,
needed capital expenses and ongoing research into the best disease
prevention and treatment methods; and
62. research-based changes and identifying their costs.
The PDR director must also assist and coordinate research efforts with the
Quality Assurance Division in medical provider efficiency and compliance
evaluation efforts.
Benefits Division
The division director is responsible for:
63. making prompt provider payments, after consulting with the three
statewide councils in doing this),
64. in conjunction with the quality assurance and PDR directors and the
three statewide councils developing information management systems necessary
for provider payment and utilization review, and
65. investing trust fund assets in consultation with the consumer advisory
council.
Quality Assurance Division
The division director, under the direction, control, and supervision of the
executive director, is responsible for:
66. in consultation with the three statewide councils studying all medical
provider and health care organization utilization patterns and quality of
service and investigating (a) situations of possible billing fraud and (b)
providers whose patterns of billing are inconsistent with developed
guidelines;
67. investigating consumer fraud relating to ineligible individuals
receiving treatment, in consultation with the consumer advisory council;
68. certifying, licensing, and re-certifying all medical providers;
69. responding to, in consultation with the three statewide councils,
complaints about inadequate, unprofessional, impaired, or prejudicial
treatment by a provider or health care organization;
70. establishing re-education, treatment, and supervision requirements and
restricting or terminating the licensure of providers or institutions that
are deficient in their quality or manner of providing health care;
71. enforcing continuing education requirements for unspecified health care
workers in consultation with the consumer and professional advisory
councils;
72. in consultation with the consumer advisory council responding to and
arbitrating disagreements between providers and consumers or providers and
the state concerning treatment or reimbursement eligibility and any other
disagreement he deems worthy of arbitration; and
73. establishing enforcement procedures for standards of care and staffing
standards, in consultation with the consumer and HCO advisory councils.
Consumer Division
The division director, under the direction, control, and supervision of the
executive director, has two responsibilities. First, he must establish a
reasonable number of regional offices located throughout the state. Each office
must be staffed to respond to questions and complaints from consumers and
providers, to perform outreach and informational functions, and to hold hearings
to determine unmet health care needs, in consultation with the consumer advisory
council.
Second, he must promote preventative and ameliorative public health through
education and the establishment of consumer groups to promote healthy behavior,
in consultation with the consumer advisory board.
Statewide Consumer Advisory Council
Membership. The Statewide Consumer Advisory Council consists of 21
gubernatorially-appointed members who serve without compensation (although they
must be reimbursed for expenses). The members annually elect a chairperson. The
governor must select members from nomination lists provided by organizations
that have been supporting a universal health care system since at least January
1, 1995. The organizations must submit lists of at least three nominations by
November 1, 1999 or within one month of a vacancy. The governor must make the
selections within two months of receiving the list. He must consider geographic
and demographic diversity when selecting.
Each member serves a five-year term. However, the initial terms are staggered.
Any member appointed to fill a vacancy serves the unexpired term. Members may be
re-appointed. The governor may remove any member for cause. The bill specifies
that 11 members constitute a quorum.
Funding. The bill allows the council to receive up to $500,000 annually from the
Trust to use in the manner the council determines best serves the interest of
health care consumers and the state's health care system. The council must
annually submit a budget to the executive director and can alter it throughout
the year.
Responsibilities. The bill requires the council to work with:
74. the PDR director to make recommendations to the executive director about
benefit packages and provider and managed care organization payment
schedules;
75. the consumer director to promote consumer education and healthy
behavior;
76. the quality assurance director to create (unspecified) procedures and to
investigate medical providers and health care organizations that are not
complying with Connecticut disease prevention and treatment guidelines or
with staffing and quality of care standards that are developed by the
"Connecticut health care system" (the bill does not define this term);
77. the quality assurance division to (a) develop unspecified procedures;
(b) investigate consumer fraud; (c) develop and enforce medical provider
continuing education requirements; (d) ensure that consumer, provider, and
HCO grievances are investigated and resolved; and
78. the administrative division (which the bill does not establish) director
to ensure (a) trust money is appropriately invested and (b) providers and
HCOs are promptly paid.
Statewide Professional Advisory Council
Membership. The Statewide Professional Advisory Council consists of one
representative of each licensed category of health care profession (appointed or
elected by the statewide professional organization) and seven
Connecticut-licensed physicians (the bill does not specify how these members are
appointed). The physicians must consist of one primary care physician, one
pediatrician, one internist, one obstetrician and gynecologist, one surgeon, one
psychiatrist, and one other unspecified specialist.
The nonphysical representatives serve for between two and five years. The bill
does not specify how long the physicians serve. All serve without compensation
but must be reimbursed for related expenses, and they may be compensated by
their respective professional organizations.
Responsibilities. The bill requires the council to work with:
79. the PDR director to recommend (a) consensus guidelines (which the bill
does not define) that providers must use; (b) a benefit package for state
residents that the Trust administers; and (c) fee schedules;
80. the quality assurance director to recommend provider guideline
compliance evaluation methods and penalties for noncompliance; and
81. the administration director (The bill does not establish an
administration division.) to develop information management systems and
insure timely provider payments.
Statewide Health Care Organizations Advisory Council
Membership. The statewide HCO advisory council that consists of one member of
each category of health care organization recognized by law. Members are
selected by their respective professional organizations.
Members serve for between two and five years, at the discretion of their
professional organization. They serve without compensation but are reimbursed
for related expenses, and they may be compensated by their respective
professional organization.
Responsibilities. The bill requires the council to make recommendations to the
Trust executive director about:
82. services and procedures that HCOs must cover,
83. HCO payments for covered services,
84. new capital expenditures,
85. coordination or consolidation of services among HCOs,
86. methods of evaluating HCO compliance with treatment guidelines and
disease prevention,
87. penalties for HCOs not in compliance with the guidelines, and
88. standards of care and staffing requirements.
COMMENT
Trust Powers and Responsibilities
The bill authorizes the Trust to perform functions that are currently performed
by DSS, the Department of Public Health, and the Office of Health Care Access,
but it does not eliminate the statutory responsibility of these agencies.
COMMITTEE ACTION
Labor and Public Employees Committee
Joint Favorable Substitute
Yea9Nay5
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