Sec. 17b-192. (Formerly Sec. 17b-257). Medical assistance component of state-administered general assistance program. Eligibility. Medical services provided. Enrollment in federally qualified communit - Connecticut Statutes

      Sec. 17b-192. (Formerly Sec. 17b-257). Medical assistance component of state-administered general assistance program. Eligibility. Medical services provided. Enrollment in federally qualified community health centers. Pharmacy services. Reimbursement to providers. Federal waiver application. Regulations. (a) The Commissioner of Social Services shall implement a state medical assistance component of the state-administered general assistance program for persons ineligible for Medicaid. Eligibility criteria concerning income shall be the same as the medically needy component of the Medicaid program, except that earned monthly gross income of up to one hundred fifty dollars shall be disregarded. Unearned income shall not be disregarded. No person who has family assets exceeding one thousand dollars shall be eligible. No person shall be eligible for assistance under this section if such person made, during the three months prior to the month of application, an assignment or transfer or other disposition of property for less than fair market value. The number of months of ineligibility due to such disposition shall be determined by dividing the fair market value of such property, less any consideration received in exchange for its disposition, by five hundred dollars. Such period of ineligibility shall commence in the month in which the person is otherwise eligible for benefits. Any assignment, transfer or other disposition of property, on the part of the transferor, shall be presumed to have been made for the purpose of establishing eligibility for benefits or services unless such person provides convincing evidence to establish that the transaction was exclusively for some other purpose.

      (b) Each person eligible for state-administered general assistance shall be entitled to receive medical care through a federally qualified health center or other primary care provider as determined by the commissioner. The Commissioner of Social Services shall determine appropriate service areas and shall, in the commissioner's discretion, contract with community health centers, other similar clinics, and other primary care providers, if necessary, to assure access to primary care services for recipients who live farther than a reasonable distance from a federally qualified health center. The commissioner shall assign and enroll eligible persons in federally qualified health centers and with any other providers contracted for the program because of access needs. Each person eligible for state-administered general assistance shall be entitled to receive hospital services. Medical services under the program shall be limited to the services provided by a federally qualified health center, hospital, or other provider contracted for the program at the commissioner's discretion because of access needs. The commissioner shall ensure that ancillary services and specialty services are provided by a federally qualified health center, hospital, or other providers contracted for the program at the commissioner's discretion. Ancillary services include, but are not limited to, radiology, laboratory, and other diagnostic services not available from a recipient's assigned primary-care provider, and durable medical equipment. Specialty services are services provided by a physician with a specialty that are not included in ancillary services. Ancillary or specialty services provided under the program shall not exceed such services provided under the state-administered general assistance program on July 1, 2003, except for nonemergency medical transportation and vision care services which may be provided on a limited basis within available appropriations. Notwithstanding any provision of this subsection, the commissioner may, when determined cost effective, provide or require a contractor to provide home health services or skilled nursing facility coverage for state-administered general assistance recipients being discharged from a chronic disease hospital.

      (c) Pharmacy services shall be provided to recipients of state-administered general assistance through the federally qualified health center to which they are assigned or through a pharmacy with which the health center contracts. Recipients who are assigned to a community health center or similar clinic or primary care provider other than a federally qualified health center or to a federally qualified health center that does not have a contract for pharmacy services shall receive pharmacy services at pharmacies designated by the commissioner. The Commissioner of Social Services or the managed care organization or other entity performing administrative functions for the program as permitted in subsection (d) of this section, shall require prior authorization for coverage of drugs for the treatment of erectile dysfunction. The commissioner or the managed care organization or other entity performing administrative functions for the program may limit or exclude coverage for drugs for the treatment of erectile dysfunction for persons who have been convicted of a sexual offense who are required to register with the Commissioner of Public Safety pursuant to chapter 969.

      (d) The Commissioner of Social Services shall contract with federally qualified health centers or other primary care providers as necessary to provide medical services to eligible state-administered general assistance recipients pursuant to this section. The commissioner shall, within available appropriations, make payments to such centers based on their pro rata share of the cost of services provided or the number of clients served, or both. The Commissioner of Social Services shall, within available appropriations, make payments to other providers based on a methodology determined by the commissioner. The Commissioner of Social Services may reimburse for extraordinary medical services, provided such services are documented to the satisfaction of the commissioner. For purposes of this section, the commissioner may contract with a managed care organization or other entity to perform administrative functions, including a grievance process for recipients to access review of a denial of coverage for a specific medical service, and to operate the program in whole or in part. Provisions of a contract for medical services entered into by the commissioner pursuant to this section shall supersede any inconsistent provision in the regulations of Connecticut state agencies. A recipient who has exhausted the grievance process established through such contract and wishes to seek further review of the denial of coverage for a specific medical service may request a hearing in accordance with the provisions of section 17b-60.

      (e) Each federally qualified health center participating in the program shall enroll in the federal Office of Pharmacy Affairs Section 340B drug discount program established pursuant to 42 USC 256b to provide pharmacy services to recipients at Federal Supply Schedule costs. Each such health center may establish an on-site pharmacy or contract with a commercial pharmacy to provide such pharmacy services.

      (f) The Commissioner of Social Services shall, within available appropriations, make payments to hospitals for inpatient services based on their pro rata share of the cost of services provided or the number of clients served, or both. The Commissioner of Social Services shall, within available appropriations, make payments for any ancillary or specialty services provided to state-administered general assistance recipients under this section based on a methodology determined by the commissioner.

      (g) On or before January 1, 2008, the Commissioner of Social Services shall seek a waiver of federal law for the purpose of extending health insurance coverage under Medicaid to persons with income not in excess of one hundred per cent of the federal poverty level who otherwise qualify for medical assistance under the state-administered general assistance program. The provisions of section 17b-8 shall apply to this section.

      (h) The commissioner, pursuant to section 17b-10, may implement policies and procedures to administer the provisions of this section while in the process of adopting such policies and procedures as regulation, provided the commissioner prints notice of the intent to adopt the regulation in the Connecticut Law Journal not later than twenty days after the date of implementation. Such policy shall be valid until the time final regulations are adopted.

      (May Sp. Sess. P.A. 92-16, S. 21, 89; P.A. 93-262, S. 1, 87; P.A. 93-418, S. 7, 41; P.A. 95-351, S. 8, 30; P.A. 96-268, S. 23, 34; P.A. 97-143, S. 1, 4; June 18 Sp. Sess. P.A. 97-2, S. 68, 165; June Sp. Sess. P.A. 01-2, S. 59, 69; June Sp. Sess. P.A. 01-9, S. 129, 131; May 9 Sp. Sess. P.A. 02-7, S. 19; P.A. 03-2, S. 18; June 30 Sp. Sess. P.A. 03-3, S. 43; P.A. 04-16, S. 5; 04-258, S. 9; May Sp. Sess. P.A. 04-2, S. 87; P.A. 05-280, S. 13; P.A. 07-185, S. 2; June Sp. Sess. P.A. 07-2, S. 14; June Sp. Sess. P.A. 07-4, S. 118.)

      History: 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. 93-418 changed the date for implementing program from July 1, 1994, to July 1, 1996, effective July 1, 1993; Sec. 17-12ii transferred to Sec. 17b-257 in 1995; P.A. 95-351 changed the implementation date for the state medical program from July 1, 1996, to July 1, 1998, and provided that such program shall be implemented in the towns in which the fourteen regional or district offices of the Department of Social Services are located on or before April 1, 1997, effective July 1, 1995; P.A. 96-268 added a provision requiring the commissioner, effective July 1, 1997, to implement a managed care program for medical services for the state medical assistance program, except for services provided pursuant to Sec. 17a-453a, effective July 1, 1996; P.A. 97-143 changed the implementation date for the managed care program from July 1, 1997, to on or after April 1, 1997, and added a provision allowing the commissioner to enter into contracts including purchase of service agreements, effective June 13, 1997; June 18 Sp. Sess. P.A. 97-2 replaced a reference to aid to families with dependent children with temporary family assistance and made technical changes, effective July 1, 1997; June Sp. Sess. P.A. 01-2 added exception for nonemergency medical transportation, effective July 1, 2001; June Sp. Sess. P.A. 01-9 changed effective date of June Sp. Sess. P.A. 01-2 from July 1, 2001, to August 1, 2001; May 9 Sp. Sess. P.A. 02-7 added eye care, optical hardware and optometry care, podiatry, chiropractic, natureopathy and home health care as exceptions to services covered under the state medical assistance program, effective August 15, 2002; P.A. 03-2 designated existing provisions as Subsec. (a), making a technical change therein, and added Subsec. (b) re cost-sharing requirements for recipients of medical assistance, effective February 28, 2003; June 30 Sp. Sess. P.A. 03-3 replaced former Subsecs. (a) and (b) with new Subsec. (a) requiring commissioner to implement a state medical assistance component of the state-administered general assistance program with eligible persons receiving medical care through federally qualified health centers or other providers with whom commissioner contracts, new Subsec. (b) providing that recipients of town-operated general assistance programs shall also receive medical services through federally qualified health centers or other providers with whom the commissioner contracts, new Subsec. (c) re pharmacy services being provided to eligible persons through federally qualified health centers or a pharmacy with which the health center contracts, new Subsec. (d) imposing copayment of $1.50 for prescriptions, new Subsec. (e) re payments by commissioner to entities providing medical services to eligible state-administered general assistance recipients, new Subsec. (f) requiring federally qualified health centers participating in program to enroll in federal drug discount program, new Subsec. (g) re payments by commissioner for inpatient hospital services, specialty services and ancillary services provided to eligible recipients, and new Subsec. (h) requiring commissioner to seek waiver of federal law that would permit extension of health insurance coverage under Medicaid to recipients of medical assistance under the state-administered general assistance program, effective August 20, 2003; P.A. 04-16 made a technical change in Subsec. (a); P.A. 04-258 amended Subsec. (a) by adding ineligibility provision for those persons, who during the three months prior to the date of application for medical assistance, assigned, transferred or otherwise disposed of property for less than fair market value, and by adding provisions re calculating time period of ineligibility and evidentiary standard used in connection with review of such property dispositions, deleted former Subsec. (d) re prescription drug copayment, redesignated existing Subsecs. (e) to (h), inclusive, as Subsecs. (d) to (g), inclusive, and added new Subsec. (h) re authority of commissioner to implement policies and procedures relative to section while in the process of adopting such policies and procedures as regulation, effective July 1, 2004; May Sp. Sess. P.A. 04-2 amended Subsec. (d) to permit commissioner to contract with a managed care organization or other entity with respect to the state-administered general assistance grievance process and to operate the program in whole or in part, and to provide that a program recipient who has exhausted the grievance process with respect to denial of coverage for a specific medical service may request a hearing in accordance with Sec. 17b-60, effective May 12, 2004; Sec. 17b-257 transferred to Sec. 17b-192 in 2005; P.A. 05-280 amended Subsec. (c) to allow commissioner, a managed care organization or other entity performing administrative functions for the program to require prior authorization for coverage of drugs for treatment of erectile dysfunction and to permit them to limit or exclude coverage for such drugs for persons who have been convicted of a sexual offense who are required to register with Commissioner of Public Safety pursuant to chapter 969, effective July 1, 2005; P.A. 07-185 amended Subsec. (a) by dividing existing provisions into Subsecs. (a) and (b) and deleting "Not later than October 1, 2003" therein, further amended Subsec. (a) by adding provisions re eligibility for assistance, deleted former Subsec. (b) re former general assistance program, amended Subsec. (c) by deleting "On and after October 1, 2003," and deleting "Prior to said date, pharmacy services shall be provided as provided under the Medicaid program.", and amended Subsec. (g) to extend time period, from March 1, 2004, to January 1, 2008, by which commissioner is to seek a federal waiver to extend health care coverage under Medicaid to persons with income not in excess of 100% of federal poverty level who otherwise qualify for medical assistance under state-administered general assistance program, effective July 1, 2007; June Sp. Sess. P.A. 07-2 amended Subsec. (b) by adding exception to requirement that ancillary or specialty services not exceed services provided under the state-administered general assistance program on July 1, 2003, for nonemergency medical transportation and vision care services provided for a limited duration, and by providing that notwithstanding provisions of subsection commissioner may, when determined cost effective, provide or require a contractor to provide home health services or skilled nursing facility coverage to an assistance recipient being discharged from a chronic disease hospital, effective July 1, 2007; June Sp. Sess. P.A. 07-4 amended Subsec. (b) by replacing "limited duration" with "limited basis within available appropriations" and by making a technical change, effective July 1, 2007.

      See Sec. Sec. 17b-193 re administrative review process for denial, modification or termination of state-administered general assistance cash or medical benefits.