JOINT STANDING COMMITTEE HEARINGS

HUMAN SERVICES PART 6 1678 - 1984

2009 aliheimer's S?S association

Good morning Senator Doyle, Representative Walker, and distinguished members of the Human Services Committee. My name is Heather Sandler and I am a graduate student at UCONN"s School of Social Work and an intern at the Alzheimer's Association of Connecticut as well as a Helpline volunteer.

I am here today to testify in support of Raised Bill No. 989. An Act Concerning the Alzheimer's Respite Care Program.

The Alzheimer's Association is a donor supported, non-profit organization serving the needs of families, health care professionals and those individuals who are affected with Alzheimer's disease and related dementias. The Association provides information and resources, support groups, education and training, and a 24 hour, 7 day a week Helpline.

Currently in Connecticut there are approximately 70,000 residents who have Alzheimer's and related dementias with over 113,000 caregivers. Those caregivers, usually family, provide over 97 million hours of unpaid care that would equal over a billion dollars. The Respite program allows many of these families the time they need to keep their loved one home.

As a graduate student in social work I have been able to research and study the Alzheimer's Respite program. In the course of studying this program I found that it allows more people to remain in their homes for a longer period of time. Allowing the use of Personal Care Assistant services would make the Respite program more flexible to more families. It is a cost effective alternative to the current services covered in Respite, including home health aide, homemaker/companion, skilled nursing care or short term 001679

nursing care. A family using the Personal Care Assistant service will pay approximately $552 per week as compared to $950 a week for a skilled nursing facility, if the person is on Medicaid. Therefore, allowing the use of a Personal Care Assistant can provide a family with a longer period of Respite due to the cost savings. It will allow the average grant size of $3500 to provide approximately six weeks of Respite with Personal Care Assistant Services compared to three and a half weeks of Respite care in a skilled nursing facility.

The Alzheimer's Respite Grant is an important program to families coping with the emotional and physical stress they face everyday. The expansion of services to include Personal Care Assistants is paramount to keep these families from falling apart and their loved one being placed out of the home.

The Alzheimer's Association supports adding Personal Care Assistant services to the Alzheimer's Respite Care Program and Raised Bill 989.

Thank you for your time and attention. I would be willing to answer any questions that you might have for me. 001680

February 27, 2009

Hello Senator Doyle, Representative Walker, and distinguished members of the Human Services Committee. My name is Elaine Zandri I am an Administrative Secretary for a Regional Education Center here in Connecticut and a caregiver for my 95-year-old Mother.

I am writing today in support of Raised Bill No. 989, An Act Concerning the Alzheimer's Respite Care Program. .

My husband and I are caregivers for my Mother who is 95 years old. He is with her during the day as he is retired and I work full time. My Husband had a major heart attack a few years back and the stress of being with my Mom all day every day was taking a toll on our relationship as well as him. When I looked into what was available, I was introduced to the Respite Care Program. My Mom has been attending Adult Day Care 2 days a week, not only is my husband in better spirits as he now has some time to himself, but my Mom is a new person. It has opened her world to new people and she is excited to go and now has something to talk about and look forward to. Her time she is allotted runs out in a week and we are at a crossroads as to what we can do to keep her active in this program.

This Adult Day Program is absolutely wonderful, wish I knew about it sooner not only for our sanity but also for the new life it has given my Mom.

Thank you, Elaine Zandri 438 Derby Milford Road Orange, Ct 06477 001681

alzheimer's \Q association

Good morning, Senator Doyle, Representative Walker, and distinguished members of the Human Services Committee. My name is Maria Tomasetti, and I have been working for the Alzheimer's Association of Connecticut for approximately three years. I am currently the South Central Regional Director for the Association. I am also a former family caregiver for my mother who had dementia of the Alzheimer's type.

I am here today to testify in support of Raised Bill No. 989. An Act Concerning the Alzheimer's Respite Care Program.

The Alzheimer's Association is a donor supported, non-profit organization serving the needs of families, health care professionals, and individuals affected with Alzheimer's disease and related dementias. The Association provides information and resources, support groups, education and training, and a 24-hour, 7 day a week Helpline.

The Connecticut Statewide Respite Care Program is funded by the State Department of Social Services and is operated in partnership with the Alzheimer's Association, Connecticut Chapter and the Connecticut Area Agencies on Aging. The Connecticut Statewide Respite Care Program currently pays for up to $3,500 in respite care services per eligible family, per year. Respite care provides a break, or a time of caregiver relief, from the constant physical and emotional stress of caring for a person with Alzheimer's disease or other forms of dementia. Eligible families may apply for daytime or overnight respite care services including: Adult day center care, home health aide, homemaker/companion, skilled nursing care, or a short-term inpatient facility stay. The individual with dementia must meet income and asset eligibility requirements — with income of no more than $30,000 a year and liquid assets of $80,000 or less. As one of the primary caregivers for my mother who was diagnosed with Alzheimer's disease, I can speak first hand of the daily demands of care giving and the importance of getting a break from care giving responsibilities — both for the caregiver and the person with dementia. Our family utilized personal care assistant services for 3 Vi years on a private 001682

pay basis. The use of personal care assistant services — for help with activities of daily living — gave us the break we needed to continue to care effectively for mom at home. We were able to keep mom home because of these personal care assistant services. Personal care assistant services are not inexpensive. The average cost of a personal care assistant is $13.80 an hour (gross). We were paying over $15.00 an hour. Families with income and/or assets slightly over the current State Respite program limits would not be in a financial position to pay privately for needed respite care services, adding to caregiver stress.

Prior to my new role as the South Central Regional Director, I coordinated the Alzheimer's Association Helpline services for approximately 2 !4 years. I volunteered on the Helpline for nine months prior to joining the Association. During this time, I was able to refer many eligible family caregivers to our Connecticut Statewide Respite Care Program. These family caregivers, often tired and overwhelmed, were relieved and happy to learn about the possibility of a break from care giving responsibilities. While serving our Helpline clients, I encountered other family caregivers, equally tired and overwhelmed, who were initially hopeful about some respite care through the State Respite program and then disappointed and frustrated since their income and/or assets were slightly more than the program's eligibility guidelines. These families were not financially able to pay for needed respite care. There are other families in this same situation who are aware of the financial eligibility guidelines and simply do not inquire or apply.

Lastly, families are most appreciative of the $3,500 in respite care services per family, per year, which is currently allowed under the State Respite program. At the same time, the Area Agency on Aging Respite Care Managers work closely with families and are very aware of families with special needs who are in need of additional services. Some flexibility in the program maximum for these special situations can only increase the effectiveness of the State Respite Program. 001683

The Alzheimer's Association, Connecticut Chapter supports the following changes to the Alzheimer's Respite Care Program so the program can help the families it was designed to help.

Increasing income and asset eligibility limits, which have not changed in 11 years, to reflect cost of living adjustments

Allowing flexibility to increase the respite grant maximum for families with special circumstances through regulation changes

Allowing use of personal care assistants as a respite care option

Thank you. 001681*

alzheimer's association

279 New Britain Road, Suite 5 Kensington, CT. 06037 860-828-2828 Position Statement in support of Raised Bill No. 989, AN ACT CONCERNING THE ALZHEIMER'S RESPITE CARE PROGRAM

By Christine I. Andrew, Esq, Member of the Board of Directors for the Alzheimer's Association Connecticut Chapter

The Alzheimer's Association is a donor supported, non-profit organization serving the needs of families, health care professionals, and those individuals who are affected with Alzheimer's disease and related dementias. The Association provides information and resources, support groups, education and training, and a 24 hour, 7 Day a week Helpline.

Eleven years ago I and three other family caregivers sat around a table with other representatives-of-the Alzheimer's Association and discussed the tremendous stress upon family care givers and what we might do lessen the caregiving burden. Each of us was personally familiar with those burdens and the toll that they had taken upon our lives and our ability to care for our loved ones. Although I wasn't my father's hands-on caregiver, my daily presence kept his anxiety under control without the need for psychotropic drugs and ensured that my father received the quality of care that he so deserved. For that to be possible, I, like so many other family caregivers, had to struggle with the often conflicting demands of my own needs and those of my family member. In my case, I did not take a vacation during the last five years of my father's life and made a series of career choices based solely upon the effect that they would have upon my caregiving responsibilities; another of us had learned that the only way that she could get a full night's sleep was by renting a room in a motel while a paid caregiver stayed with her husband; a third had been forced to leave this distinguished body when her caregiving responsibilities made it impossible for her to continue to serve as a legislator; the fourth 001685

had simply put her own life and needs on hold while she struggled with the conflicting demands of caring for her husband and functioning as a de facto single parent for their college age children. Each of us knew first hand that without a break from care giving responsibilities, be it only for a few hours, even the most dedicated caregiver eventually reaches a breaking point. It was our shared awareness of the need for a safety net and the gaps in existing programs and services that gave birth to the legislation that created the Statewide Alzheimer's Respite Care program.

We recognized that there was a large segment of the caregiving population that lacked the resources to pay for needed respite care yet was too "affluent" to qualify for subsidized home care services. We were especially concerned about those individuals who were struggling to provide 24/7 care for a loved one with dementia while juggling the often competing and equally stressful demands of career and parenting responsibilities. Our objective was to create a program that would provide help for this underserved group of Connecticut citizens...commonly referred to as the "middle class". We investigated respite programs in other states and proposed what we thought at the time to be appropriate asset and income criteria. The criteria that we proposed in February of 1998 - income of $30,000 or less and no more than $80,000 in liquid assets ---are still in effect today, more than eleven years later. Failure to adjust those figures has in effect slowly, but surely, eroded the effective reach of the Alzheimer's Respite Grant program and reduced the options available to the otherwise unserved Connecticut family caregivers that we sought to help.

Raised Bill No. 989 proposes a one-time corrective adjustment that translates the original financial criteria for the Alzheimer's Respite Grant program into their 2009 equivalents and provides for subsequent annual adjustments in order to avoid future erosion. While some might view this bill as an expansion of the statewide respite program, it is, in reality, simply a return to the original concept and objectives of this very important program. To that end, I urge you to support Raised Bill No. 989. 001686

TESTIMONY of John M Whitcomb

Before the Human Services Committee of the

Connecticut General Assembly

March 3, 2009

Chairpersons Doyle, Walker and Honorable Members of the Human

Services Committee; my name is John M Whitcomb. I am here today to testify in support of Raised Bill No. 989 An Act Concerning the Alzheimer's

Respite Care Program

I am here in the role of citizen, taxpayer and as a believer in limited government and fiscal control; also I am a supporter of the Alzheimer's

Association.

My wife suffers from advanced early onset Alzheimer's disease. We are private payers, and not covered under Title XIX, although my wife is disabled under Social Security. We must pay out of our savings for the vast majority of my wife's care. It must come from money that had been planned for retirement living, and will radically affect our futures. It will particularly impact me, since I am expected to live longer and her care will likely use all of my life savings, making me dependent on the state, too. 001687

Testimony of John M Whitcomb Before HSC - March 3, 2009

Her health care also impacts my ability to have any serious gainful employment in a period that should have been peak earning and saving years.

WHEN my wife is forced into nursing home care, our assets will be drained and the state will be faced with serious expenses. Respite care is one way to help delay that inevitability, and is FAR less expensive than the alternative. Raising the asset test as proposed is minimal. A caregiver knows a nursing home will easily use up $100,000 in assets a year. The asset level prescribed is lost money to the disabled person... it just comes down to "how long can nursing home admission be delayed"; which equates to both taxpayer savings and a better quality of life for the disabled.

Likewise, an increase in annual grant size would also save the state a considerable amount of money by permitting caregivers to further delay nursing home care.

It is also necessary to grant latitude for administratively determined special exceptions to the individual cap, WITHIN the budgetary authority. Again, good judgment can actually SAVE expense.

2 001688

Testimony of John M Whitcomb Before HSC - March 3,2009

This economic comparison doesn't even touch on health of the caregiver.

Being a care-giver is very high stress. Health is certainly impacted, as is the caregiver's productivity, and ability to earn wages and pay taxes. We can expect short and long term health care cost ramifications. Since the limited nature of benefits also are likely to force the spouse into eventual dependence on the state, those costs also eventually become costs to the state.

Thank you for listening to reasons that I support this legislation, and thank you for the opportunity to testify before you today. I would be happy to answer any questions at this time and if you have questions or concerns at a future date please do not hesitate to contact me.

John M Whitcomb

Taxpayer

3 0016

Written Testimony for Human Services Committee-March 3, 2009

Good morning Senator Doyle, Representative Walker, and distinguished members of the Human Services Committee. My named is Linda Martin and I submit this written testimony in support of Raised Bill No. 989, An Act Concerning the Alzheimer's Respite Care Program.

My mother, Lillian G. Payne has been living through the mental and physical torments of Alzheimer's disease for the past five years. Three years ago, her states of confusion and fear associated with her condition necessitated my mother moving into our home to live with my husband, daughter and myself.

In June 20071 contacted the Connecticut Chapter of the Alzheimer's Association to learn more about what we would be facing and options for caring for my mother. I read the information but took no action because I believed that we could provide for my mother's care both financially and socially. I retired from work with a plan of caring for my mother along with the assistance of other family members. In November 2009 I realized that the assistance was not as available as promised and our goal of ensuring that mom lives comfortably in her community was slipping out of our grasp and that we needed help with the financial burden of continuing her at the Adult Day Care Program she loves attending. The grant that we were awarded from the Alzheimer's Respite Care Program has extended my mother's specialized care while she continues to live at home and it affords me time to run errands, work at a part-time job and for a short period of time, it allows me to keep a major financial worry at bay.

I implore you to pass the bill to consider an increase the total grant size awarded through the Alzheimer's Respite Care Program from $3500 to $7500 per year for special circumstances to allow more service options.

Respectfully, Linda F. Martin 001690

I am writing in support of Raised Bill No. 989. An Act Concerning the Alzheimer's Respite Care Program.

My name is Laurie Browne and I am the Respite Care Manager at the North Central Area Agency on Aging. The North Central Area Agency on Aging is a private non• profit agency whose mission is to enhance the quality of life for older adults in the north central region by providing them with access to cost effective services.

The Respite care Program offers up to $3,500 for caregivers who are caring for someone with Alzheimer's disease or some type of dementia to allow the caregiver some respite, or some relief from caregiving. Adult day care and Home Health aide services are the most requested services among caregivers who apply for this program. Most clients are awarded the full $3,500 award and typically spend their full grant within 3 to 5 months. New proposed regulations in this bill to increase the grant size up to $7,500 after a demonstrated need is presented would help those caregivers in particularly challenging situations to continue to care for their loves ones at home.

Caregivers are under immense stress because they have to take care of their loved ones; themselves and sometimes, they, have kids they have to take care of as well. When I get calls from caregivers who are stressed out, physically tired and are looking for help, they are usually at the end of their ropes. They are grateful for any help that is given. All they want it to be able to continue to take care of their loved ones at home. With the proper support, caregivers are helping to keep their loves ones at home and out of nursing homes. The Respite Care Program has been a vital source of support for caregivers in our region and they rely heavily on the grant to give them some respite a couple of months a year.

Thank you very much for your support.

Laurie Brown 001691

Written Testimony for Human Services Committee-March 3,2009

Good Morning Senator Doyle, Representative Walker and distinguished members of the Human Service Committee. I am Teresa Hall and am writing to you on behalf of myself and my mother Agnes DelGiudice.

I am writing to support Raised Bill 989-An Act Concerning the Alzheimer's Respite Care Program

My mother has been the primary caregiver of my father for the last seven years. He is now 83 years and in the late stages of Alzheimer's disease. She is now 75 years old and has given up her precious golden years, her hobbies, her health and her livelihood to provide the care my father requires. We struggled with several home care agencies and found out the hard way that are so many unqualified/untrained healthcare employees that really cannot handle or understand the extensive care, burden and frustration that comes along with caring for an Alzheimer's patient. Being exhausted and depressed myself, with not being able to help my mother more with my father's care, I turned to the Alzheimer's Association for advice. On that day we learned about the respite fund. Once the fund became available for my mother, we looked into several options and decided we would try Adult Day Care three times a week for my Dad. The Adult Day Care has been a God Send for us. The respite fund helped us finance a small portion of the enormous amount of cost we are financing for my father's care and medications. We would love to be able to take him there for four or five days a week. However, given today's economic conditions, the cost of living increase and the fact that Medicare or insurance does not cover anything for this long devastating disease, we are not able to do this. This is why we urge you to consider the proposed concept of regulations to provide up to $7500 in special situations and help the caregivers get a little more support which they so much need when caring for a sick loved one. The time my father spends at Adult Day Care, gives my mother some time to rest and recharge for a short while. For her these means taking a breather, a chance to just sit, run an errand or enjoy a cup of coffee. We are thankful for this fund and as caregivers we strongly urge you to support the increase concerning the Alzheimer's Respite Care. Sincerely,

Teresa Hall 001692

Connecticut Association of Centers for Independent Living 151 New Park Ave. Suite 106, Hartford, CT 06106 voice 860-656-0430 fax 860-656-0496 www.cacil.net Coonccttait • The CoDxtitutmo Stale

...Working for the full integration, independence, and civil rights of people with disabilities through Centers for Independent Living

Testimony of Gary Waterhouse, Executive Director

Center for Disability Rights Before the Human Services Committee 764A Campbell Ave March 3,2009 West Haven, CT 06516 V 203-934-7077 TDD 203-934-7079 Raised S.B. No. 991 AN ACT CONCERNING FUNDING FOR CENTERS FOR INDEPENDENT LIVING. Disabilities Network of Eastern CT CACIL SUPPORTS- Raised Senate Bill No. 991 and the continuation of state 238 West Town Street Norwich, CT 06360 funding for Centers for Independent Living (CILs). Centers for Independent V/TDD 860-823-1898 Living are the adrninistrative platforms used to bring supports and services to the disability community sustaining such programs as: Disability Resource Center • Nursing Facility Transition Program of Fairfield County 80 Ferry Boulevard • Money Follows the Person Suite 210 • CT Aging and Disability Resource Centers Stratford, CT 06497 • Nursing Home Diversion Program V 203-378-6977 TDD 203-378-3248 • Connect-Ability Employment Program • Housing for People with Aids

Independence Northwest Centers provide office space, telephone access, internet access, computer use, 1183 New Haven Rd supervision, support staff and ficuciary responsibility for grant programs making Naugatuck, CT 06770 V 203-729-3299 often time limited programs more cost effective and efficient. TDD 203-729-1281 Centers for Independent Living (CILs) receive limited federal funding under the Independence Unlimited (Rehabilitation Act of 1973, as amended, Title VII, Chapter 1, Part C, sees. Suite D 721727; 29 D.S.C. 796f-796f-6) to provide: 151 New Park Avenue Hartford, CT 06106 • Advocacy V/TDD 860-523-5021 • Information and Referral • Independent Living Skills • Peer support Stimulus funding under the "American Recovery and Reinvestment Act of2009 " will not stimulate the economy if staff layoffs are required by state budget cuts.

Centers advocate for people with disabilities (consumers) and teach consumers how to advocate for themselves. Many consumers have difficulty receiving necessary supports and services from state agencies, CILs provide the knowledge skills and abilities to help consumers get the services they need to live and thrive in the community and prevent institutionalization at much greater 001693

! ! CAC1L and Centers for Independent Living

CACIL is a non-profit 501(c)(3) corporation consisting of five (5) Centers for Independent Living (CIL) located in Hartford, Norwich, West Haven, Naugatuck and Stratford. CILs are community based, non• residential, consumer controlled and cross-disability. Each follows the Independent Living Philosophy of serf-help, self-reliance and self-determination.

Each CIL serves a portion of the state. CILs typically serve 25-30 cities and towns. They serve individuals of all ages, with all types of disabilities including but not limited to:

• Physical • Mental Health • Cognitive • Developmental Disability • Vision • Hearing • Multiple Disabilities

Most recent census data listed below shows the number of persons aged 5 and older with Disabilities in Connecticut by region covered by Independent Living Centers. (Fortinsky Study- Univ. of CT Health Center. 2003)

Region 1 DISABILITY RESOURCE CENTER OF FAIRFIELD COUNTY (DRCFC) Persons with Disabilities in Region: 104,831 Sensory 16,354 Mental 21,711 Physical 36,512 80 Ferry Boulevard, Stratford, CT 06615 203-378-6977 Region 2 CENTER FOR DISABILITY RIGHTS (CDR) Persons with Disabilities in Region: 128.918 Sensory 28,458 Mental 31,122 Physical 52,866 764-A Campbell Ave. West Haven, CT 06516 203-934-7077 Region 3 DISABILITIES NETWORK OF EASTERN CONNECTICUT (DNEC) Persons with Disabilities in Region: 64,236 Sensory 12,989 Mental 17,457 Physical 27,363 238 West Town St. Norwich, CT 06360 860-934-1898 Region 4 INDEPENDENCE UNLIMITED (IU) Persons with Disabilities in Region: 159.178 Sensory 27,642 Mental 38,012 Physical 62,137 151 New Park Ave. Hartford, CT 06106 860-523-5021 Region 5 INDEPENDENCE NORTHWEST (IN) Persons with Disabilities in Region: 89,650 Sensory 16,6678 Mental 23,178 Physical 36,469 1183 New Haven Road Naugatuck, CT 06770 203-729-3299

Visit us at www.cacil.net 00 I 69U

C4A

Connecticut Association of Area

Agencies on Aging, Inc.

Testimony - Human Services Committee 3/3/09

Kate McEvoy, Deputy Director Agency on Aging of South Central CT, (203) 785-8533

Positions

> Governor's Bill No. 6365 - An Act Concerning the State Budget for the Biennium Ending June 30,2011 and Governor's Bill 843. An Act Implementing the Governor's Budget Recommendations Concerning Social Services C4A opposes various of the Governor's proposals to reduce appropriations for core, preventative home and community-based long-term care services that permit older adults and individuals with disabilities to live independently in the community and that achieve dramatic cost savings to the State in preventing institutionalization. Related, C4A respectfully urges the Human Services Committee to support continued investment in programs that promote rational and effective use of public and private long-term care resources.

Information and Assistance for Older Adults and Individuals with Disabilities

• C4A opposes the proposal to eliminate funding for the Connecticut Centers for Independent Living (CflVs).

• C4A respectfully urges the Appropriations Committee to renew state funding for the CHOICES program in the amount of SI million.

Home and Community-Based Long-Term Care Services

• C4A opposes the proposal to cut overall funding for the Connecticut Home Care Program for Elders and to restrict participation in the state-funded levels of the program to the caseload in place as of June, 2009 (Section 54 of Governor's Bill 843). 001695

• C4A respectfully urges the Human Services Committee to appropriate renewal funding for the Connecticut Home Care Program for the Disabled and to appropriate funding sufficient to address the wait lists for the Acquired Brain Injury and Personal Care Assistant waivers.

• C4A respectfully urges the Human Services Committee to support increases in reimbursement rates to all long-term care providers.

State Prescription Drug Coverage

• C4A opposes the proposal to drastically restrict participation in the ConnPACE program through more stringent eligibility criteria and increased cost sharing.

• C4A opposes the proposal to eliminate various elements of the state prescription drug "wrap-around'' protection for enrollees of Medicare Part D, including:

• discontinuation of state coverage for dually-eligible individuals of non- formulary drugs (Section 66 of Governor's Bill 843);

• capping of state coverage of Part D co-payments (in 2009, these range from $ 1.10 to $6.00 per prescription), with the result that dually-eligible individuals will be expected to pay up to $20 per month in co-payments (see Section 15 of Governor's Bill 843); and

• requiring dually-eligible individuals and other ConnPACE participants to enroll in a "benchmark" Medicare D plan (eliminating DSS subsidy of higher cost Part D plans) (see Sections 13 and 65 of Governor's Bill 843).

• C4A opposes other proposals to impose cost-sharing on low-income participants of the Medicaid program.

Background

Information and Assistance to Older Adults and Individuals with Disabilities

Older adults and individuals with disabilities need information to help them make informed choices about long-term care. Without assistance, many find the system to be complex and confusing. Connecticut's Program for Health Insurance Assistance, Outreach, Information & Assistance, Counseling & Eligibility Screening (CHOICES), a partnership among DSS, the Connecticut Agencies on Aging, the Center for Medicare Advocacy, and diverse community partners, has been identified as a focal point for information & referral. Further, the Agencies on Aging have developed partnerships with the Connecticut Centers for Independent Living to 1) build on CHOICES and to lay plans for implementing Aging and Disability Resource Centers (ADRC's) in all regions of the state; and 2) work collaboratively in making effective transitions under the Money Follows the Person (MFP) program. 001696

Connecticut's Health Insurance Assistance, Outreach, Information and Referral, Counseling and Eligibility Screening Program (CHOICES) is a collaborative effort among the Connecticut Area Agencies on Aging, the Department of Social Services Aging, Community and Social Work Division, the Center for Medicare Advocacy, and numerous community partners, including senior centers.

CHOICES provides health insurance counseling, information & assistance and benefits screening to older adults, those with disabilities, and caregivers. This service helps people to understand and plan for their long-term care needs. CHOICES provides a sound platform on which to build ADRC's.

In 2008 alone, CHOICES:

• made 36386 contacts with individuals and caregivers to provide information and referral on Medicare, Medicaid, financial assistance, benefits, housing, adult day care and services for people with disabilities • staffed 18 enrollment events at which countless people were screened for and connected with the Medicare Low-Income Subsidy benefit • counseled over 5,500 individuals on the federal Medicaid Savings Programs (QMB, SLMB, QI) • sponsored 364 outreach presentations • provided meaningful volunteer opportunities to 371 trained counselors • provided expert training to social services professionals to help them keep current • used radio, cable television, billboards, local newspapers and expert materials from the Center for Medicare Advocacy and other sources to educate the public

Why should legislators continue to fund CHOICES?

• It saves money for the State of Connecticut! If consumers understand how to make more rational long-term care choices, they will:

o access all available federally-funded benefits including the Medicare D Low- Income Subsidy and the Medicaid Savings Programs (QMB, SLMB, QI) o use their own funds more rationally o be less likely to need Medicaid-funded care in an institution

• It's vital to Connecticut's efforts to "re-balance" long-term care spending. Education of consumers regarding financial planning, the limited scope of public benefits, and available home and community-based options will be a key component of Connecticut's efforts to rationalize and rebalance its long-term care spending.

• Consumers need streamlined access to information. The recently released Connecticut Long-Term Care Needs Assessment endorsed creation of a statewide Single-Point of Entry (SPE) or No Wrong Door (NWD) Long-term Care 001697

Information and Referral program in Connecticut that would serve individuals across all ages and disabilities.

In 2008, federal funding for a new pilot project entitled Choices at Home that was awarded to DSS has permitted DSS, the Agency on Aging of South Central Connecticut and the Center for Disability Rights (West Haven) to collaborate in developing the first Aging and Disability Resource Center (ADRC) in Connecticut, which is serving the south central region. Another such grant will, in the spring of 2009, permit the Western Connecticut Agency on Aging and Northwest Center for Independent Living to open an ADRC in Western Connecticut. This effort reflects a larger scale initiative among Agencies on Aging (AAA's) and Centers for Independent Living (CIL's) to use the regional emphasis and subject matter expertise of both networks to accomplish the goals of implementing ADRC's in all regions of the state and to make effective transitions under the Money Follows the Person Program.

Home and Community-Based Long-Term Care Services

Home and community-based care is often principally described in terms of its cost efficacy. Missing from this analysis, however important, is reference to its human value to older adults and individuals with disabilities. Surveys and anecdotal data show that consumers overwhelmingly prefer to receive needed services at home in the community. Through these services, an individual can 1) preserve the right to live as s/he chooses; 2) assist to the extent of ability in planning the course of his/her care; 3) retain immediate contact with loved ones; and 4) safeguard both health and dignity.

Diverse groups including the State of Connecticut Long-Term Care Planning Committee, the Nursing Home Transitions Work Group, and research institutions have emphasized the many benefits of community-based care. Ongoing efforts to shift both state policy priority and expenditure of Medicaid dollars to care at home reflect these commitments. Ironically however, promotion of these services to meet growing levels of need has put the capacity of the home care industry in Connecticut into sharp relief. Key sources of support for home and community-based services include:

• Connecticut Home Care Program for Elders: In 2008, the Connecticut Home Care Program for Elders (CHCPE) has an active client population of over 15,000 individuals, more than 10,000 of whom received services through the Medicaid Waiver. In the CHCPE Annual Report to the Legislature for SFY 2007, the Department of Social Services documented cost savings to the State in that program year of $91,510,543. Breaking out this figure, average monthly costs per client in 2007 were as follows: Waiver clients: $1,572; State funded clients: $909. In 2007, this compared with an average monthly Medicaid nursing home cost of $5,338. State support has ensured that eligible individuals can access the CHCPE on a rolling basis and that there is no wait list.

• Additional Connecticut Medicaid Waivers: Younger individuals with disabilities have relied on the following waivers to receive needed services:

o the Acquired Brain Injury Waiver, which provides care management and supportive services to individuals with that diagnosis; 001698

o the Department of Developmental Services (DDS) Comprehensive Supports and Individual and Family Supports Waivers, which assist individuals who have been assessed as having mental retardation with care management and an extensive menu of services; and

o the Personal Care Assistance Waiver, which enables individuals who have chronic, severe, permanent disabilities to hire their own assistants for such tasks as bathing and dressing.

• - -Connecticut Home Care Program for Disabled Adults: The Connecticut Home Care Program for Disabled (CHCPDA), a state-funded pilot program, provides services based upon the Connecticut Home Care Program model to up to SO individuals, age 18-64, who have been diagnosed with a neurodegenerative disease. This is currently the only initiative in Connecticut that provides such services to individuals under the age of 65, and is a significant factor in preventing unnecessary institutionalization. Without renewalo f funding, this program will not be able to continue.

Just as important as having sufficient capacity in the above programs is the adequacy of reimbursement to providers of home and community-based long-term care. Data from professional groups including the Connecticut Home Care Association and the Connecticut Association for Adult Day Care indicate that Medicaid reimbursement rates to providers of home and community-based services have not kept pace with increased costs of doing business (e.g. staff recruitment and retention, insurance and quality assurance/ regulatory compliance efforts). Inadequacy of reimbursement has directly contributed to closure of many home care agencies and adult day care centers over the last five years, just when expansion of the available service array is most needed by both older adults and individuals with disabilities. C4A strongly supports measures intended to increase reimbursement rates to its partners in the network. Prescription Drug Coverage

Connecticut should maintain its long-time commitment to older adults, individuals with disabilities and other low-income people by resisting proposals to make extreme cuts in coverage for prescription drugs, including stringent new income and asset eligibility guidelines for ConnPACE, imposition of cost-sharing requirements on those least able to bear these costs, coverage restrictions and reduction of Connecticut's "wrap-around" coverage to the Medicare Part D prescription drug benefit.

ConnPACE has for years represented an essential long-term care benefit for low-income individuals. Further, Connecticut has established valuable "wrap-around" coverage to the Medicare Part D prescription drug benefit, which became effective January 1,2006, for those who receive pharmacy benefits under the ConnPACE and Medicaid programs.

For participants of ConnPACE, the State covers Medicare Part D monthly premiums, formulary drugs needed during the "gap" period under the federal coverage, and most prescription drug costs (co-payments and deductible requirements) over the standard $16.25 co-payment. Additionally, the Legislature provided those who are dually-eligible for Medicare and Medicaid with coverage of the $l-$5 co-payments that they would otherwise have been obligated to pay. Finally, for both ConnPACE and Medicaid 001699

recipients, the Legislature in 2006 appropriated $5 million to provide initial coverage for non-formulary drugs.

Both older adults and individuals with disabilities will be adversely affected by failure to protect low-income individuals who rely on state-funded pharmacy assistance. As a financial frame of reference, an individual applying for "community" Medicaid in most parts of Connecticut must show a monthly income of less than $506.22 per month ($672.10 for a couple). Given their low incomes, Medicaid recipients do not have sufficient income or savings through which they can bear cost-sharing for the services that they receive. Already burdened with significant out-of-pocket expenses, including over-the-counter medical supplies, utilities and food, recipients erode what little they have to live on each time a co-payment is made. The Legislature should reaffirm its commitment to protecting this population from co-payments, which leave those affected exposed to unacceptable barriers to accessing drugs that are desperately needed to enable them to remain safe and stable in the community.

Over and above issues of cost, full coverage of needed drugs is also a critical issue. Due to frailty and compromised health status, this population is heavily dependent on pharmacy coverage. Older Medicaid recipients are predominantly female, widowed and likely to live at home alone. Recipients evidence high incidence of chronic health conditions including congestive heart failure, hypertension, and diabetes that necessitate an evolving array of complementary medications. A significant incidence of clients must also contend with the debilitating effects of Alzheimer's or other dementia. Younger individuals with disabilities face parallel financial and physical constraints as they also subsist on fixed income budgets and require multiple medications to remain physically and psychiatrically stable. For all of these reasons, proposals to restrict coverage and to impose prior authorization requirements on additional classes of drugs are of great concern. OGI 700

STATE OF CONNECTICUT OFFICE OF POLICY AND MANAGEMENT

TESTIMONY PRESENTED TO THE HUMAN SERVICES COMMITTEE March 3, 2009

Robert L. Genuario Secretary Office of Policy and Management

Testimony Supporting House Bill No. 6379

An Act Implementing the Governor's Budget Recommendations Concerning Maximization of Pharmacy Rebates

Senator Doyle, Representative Serra and distinguished members of the Human Services Committee, thank you for the opportunity to offer testimony on House Bill No. 6379, An Act Implementing the Governor's Budget Recommendations Concerning Maximization of Pharmacy Rebates.

The federal Centers for Medicare and Medicaid Services (CMS) clarified last year that .the Department of Social Services cannot require pharmaceutical manufacturers to provide rebates on non-formulary drugs under Medicare Part D based on existing federal Medicaid rebate agreements. As a result, the department was forced to return approximately $3 million in non-formulary rebates. To ensure that DSS could continue to obtain manufacturers' rebates, P.A. 08-1 allowed for the continuation of rebates at the Medicaid level by establishing separate provider agreements with manufacturers similar to the agreements in place under ConnPACE. Based on more recent guidance from CMS, however, DSS is only allowed to require rebates at the Medicaid level for federally qualified state pharmacy assistance programs (i.e., ConnPACE and State Administered General Assistance (SAGA)). Manufacturer rebates for non- federally qualified programs (i.e., HUSKY B and the Charter Oak Health Plan, as well as the portion of the Medicare Part D Supplemental Needs Fund serving persons dually eligible for Medicare and Medicaid) must be at the lower levels stated in this bill.

This bill makes the following changes: Section 1. This section reflects existing practice and clarifies that DSS may enter into contracts with pharmaceutical manufacturers for supplemental rebates. Section 2. This section of the bill clarifies the rebate levels that can be required of pharmacy manufacturers under the Medicare Part D Supplemental Needs Fund based on recent guidance provided by CMS.

450 Capitol Avenue •• Hartford, Connecticut 06106-1308 www.opm.state.ct.us 001701

Section 3. This section is needed to ensure continuation of rebates under DSS' pharmacy carve-out. DSS is responsible for administering the pharmacy benefit under HUSKY A, HUSKY B, SAGA and the Charter Oak Health Plan. Net savings continue to be assumed in the budget based on the expectation that DSS will be able to maximize the level of rebates received from the pharmaceutical manufacturers. For the pharmacy carve-out to be successful, it is critical that this legislation be in place to ensure that manufacturers are required to pay rebates at the levels allowed by the federal government for claims beginning February 1, 2008, which is the effective date of the pharmacy carve-out. In summary this legislation is required to implement the Governor's budget which is predicated on receipt of these rebates. Without passage of this bill, an estimated $6.2 million is at risk in FY 09, which includes retroactive periods, and approximately $2.9 million in FY 10 and $2.0 million in FY 11 would need to be added to DSS' budget

I would like to again thank the committee for the opportunity to present this written testimony. I respectfully request the Committee support this bill and, as always, my staff and I are available at your convenience to answer any questions you may have about this bill. 001702!

STATE OF CONNECTICUT DEPARTMENT OF PUBLIC HEALTH

TESTIMONY PRESENTED BEFORE THE HUMAN SERVICES COMMITTEE March 3, 2009

Jennifer Filippone, Chief, Practitioner Licensing and Investigations, (860)509-7414

House Bill 6522 - An Act Concerning Licensing for Individuals Performing Services Under Agreements with Federally Qualified Health Centers

The Department of Public Health provides the following information on House Bill 6522

.House Bill 6522 would exempt physicians who provide telemedicine services pursuant to any agreement or arrangement with a Federally Qualified Health Center from having to hold a Connecticut license if the individual is not a resident of this state.

• Physicians, who are not licensed in Connecticut, would be authorized to provide diagnostic or treatment services, including primary diagnosis of pathology specimens, slides or images, through electronic communications or interstate commerce, and official written reports of diagnostic evaluation of such images to physicians or patients located in this state.

• Out-of-state physicians who provide such services in other settings are required to hold a Connecticut license.

• The Department of Public Health has concerns that this bill does not specify any form of required current licensure for individuals providing services

• The Department of Public Health has no authority to take disciplinary action against such out-of-state physicians in the event that there is a violation in the standard of care. This is a concern for DPH in ensuring quality care for all Connecticut residents

Thank you for your consideration of the Department's views on this bill

Phone. Telephone Device for the Deaf (860) 509-7191 410 Capitol Avenue - MS # PO Box 340308 Hartford, CT 06134 Affirmative Action IAn Equal Opportunity Employer March 3,2009 Regarding H.B.6523 An Act Concerning Licensing of Adolescent Substance Abuse Treatment Facilities Jeffrey Walter, President and CEO Rushford Center Inc.

My name if Jeffrey Walter and I am President and CEO of Rushford Center, a private, non-profit organization providing residential treatment services to adolescent boys, under contract with the Dept. of Children and Families. I am here to testify in favor of HB 6523. By exempting certain residential programs from requiring a DCF license, this bill would eliminate dual licensure for a small number of residential facilities providing substance abuse services to adolescents in Connecticut.

The problem is that conflicting state law requires our program to hold both DPH and DCF licenses. The requirements of these two licensures are occasionally inconsistent. For example, DPH requires that all medications taken by residential clients either be administered by a registered nurse or be self-administered by the client. DCF does not allow self-administration but provides a certification for child care workers so that these staff can administer medications. DPH does recognize such certification.

This is an important, but not the only, area of conflict.

I would like to add that my organization does not favor licensure by one state department over the other. We do not want to create conflict between state agencies. Our position is simply that we want to be able to comply at all times with all state requirements under which we operate. Dual licensure makes such compliance difficult.

I thank you for your consideration of HB 6523.

Jeffrey Walter Rushford Center Inc. 203-238-6803 001701*

|p Advocacy for Patients _ with Chronic Illness, Inc. 18 Timberline Drive Farming ton, CT 06032 (860) 674-1370 (phone) (860) 674-1378 (fax) (860) 305-9835 (cell) www.advocacyforpatients.org [email protected]

Testimony of Jennifer C. Jaff, Esq. In Opposition To Raised Bill 6524

Thank you for allowing me to testify today in opposition to Raised Bill No. 6524.

This Bill would require the aged, blind and disabled who are dually eligible for Medicaid and

Medicare to choose a Medicaid managed care plan as an alternative to traditional Medicaid.

This is a bad idea for several reasons.

First, one need only have skimmed the newspapers over the past year or so to have heard horror stories about seniors and disableds who have chosen to participate in Medicare

Advantage Plans, which are HMOs for Medicare. These plans have proven to be expensive and confusing to this population. In addition, we have seen far more denials of coverage from Medicare Advantage Plans than we have ever seen from traditional Medicare. These plans cost more, promise the moon, and fail to deliver medically necessary care.

The same reasoning pertains, in our view, to the HUSKY managed care organizations. They are more expensive than traditional Medicaid, they add an additional layer of complexity and confusion, and they administer benefits more narrowly than does traditional Medicaid.

Medicare is confusing enough without adding an additional layer of complexity. The aged, blind and disabled have to enroll In Medicare Part B, and they have to go through the difficult process of selecting a Medicare Part D drug plan. They are aggressively marketed by Medicare Advantage Plans even though they are eligible for Medicaid and, thus, do not 001705

need Medi-gap coverage. To add yet another decision to this annual ritual will just make

the system that much more difficult for them to navigate.

Frankly, in light of the fact that, in both Medicaid and Medicare, managed care has

proven to be more expensive than traditional fee-for-service, we fail to see the benefit of

managed care to this population. Add to this the fact that these plans provide narrower coverage than traditional fee-for-service arrangements, and there simply is nothing to be gained by this proposal. Managed care plans limit the number of providers available to

patients, and capitated care provides an incentive to provide less care. Combine that with the fact that this population of patients is most likely to suffer from multiple, complex

medical conditions, and you have a recipe for nothing short of disaster.

Thus, we strongly oppose Raised Bill No. 6524. Thank you. Vermont Nursing Home Medicaid Expenditures Actual vs Without "Shifting the Balance"

$200,000,000 $192,732,202

$180,000,000 •Actual Spending

$160,000,000 Without Shifting the Balance. (FY83 FY96 avg rate of increase = 8.3%)

$140,000,000

$120,000,000

$100,000,000

$80,000,000

$60,000,000

$40,000,000

$20,000,000

$0 -1 1 1 1 1 1 1 1 r 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Fiscal Year Equal Access = More People Increased HCBS and ERC, Decreased NF

Choices for Care: Total Number of Enrolled Participants October 1.2005 • August 1.2008 "•^-Nursing Facility -Q-Home and Community Based (Highest and High Needs) -^Home and Community Based (Moderate Needs) •'O'Enhanced Residential Care

Lg o* ^ ^ ^ o6" <<& & & ^

o o

oo t t

Home & Community-Based Services include CFC, AAA State funds, Adult Day, Alz/Dementia grants, Commodity Food, Supportive Housing, Flex Funds, ASP, TBI Waiver, Home Modification, Homemaker, Mental Health & Aging, and other. Excludes DS Waiver, High Tech, and Children's Personal Care Services. 001710

canpfa The Connecticut Association of Not-for-profit Providers For the Aging

Testimony to the Human Services Committee Regarding of House Bill 6524, An Act Concerning Managed Care for Certain Medicaid Beneficiaries March 3,2009 Presented by Mag Morelli, CANPFA President Good morning Senator Doyle, Representative Walker, and members of the Human Services Committee. My name is Mag Morelli and I am the President of the Connecticut Association of Not-for-profit Providers for the Aging, (CANPFA), an association of over 150 not-for-profit providers of aging services.

CANPFA is pleased to have the opportunity submit the following testimony regarding House Bill 6524, An Act Concerning Managed Care for Certain Medicaid Beneficiaries.

CANPFA must object to this bill as written as it would require the Commissioner of Social Services to develop a plan to enroll Medicaid beneficiaries who are aged, blind or disabled in managed care by the first of the year.

This proposal is of great concern to us, particularly if the priority and determining factor of accepting such a plan would be the projected cost savings. A managed care system would be a major system change for these Medicaid beneficiaries, and particularly those residing in nursing homes. Rapidly instituting such a change without a comprehensive assessment of its potential impact is inappropriate and inadequate. We strongly suggest that this concept be studied by a representative group of interested parties before any such plan is proposed. We encourage the committee to reject this bill as written.

Thank you for your consideration of this testimony. Mag Morelli, President CANPFA, 1340 Worthtngton Ridge, Berlin, CT 06037 (860) 828-2903 fax (860) 828-8694 [email protected] 00171 I

written testimony of Ms. Cheryl Martone Tues. March 3, 2009 P.O. Box 165 Westbrook, CT. 06498 (860) 301-1274

Pro & Con for Raisari Bill No. 6525. For the Human Services Committee

I'm a Parent of a child who was taken illegally from my care and family due to the irresponsibility of the Department of Children and Families. My child had a life before he was taken by DCF. I would like to see the responsibility of removing children from Families taken out of the DCF's hands and given to someone or a group that is fair, honest and balanced. I would also like to see the Department of Children and Families checkbook, as they are a public agency and the financial record should be public knowledge. The investigators, workers, providers, authorities and anyone affiliated at DCF are very unfair, cruel, inhumane and handle situations unlawfully and in a manner that is not respectful to families. The removing of a child and taking away visits from his or her family just because a false report was sent in, is not the way to take care of children and families, or the way to do things in our life. We have a voice and it should be heard before anything is done in a court. DCF should try to work with people. I would like to see some common decency- socially and morally as I was brought up and I'm trying to raise my child with. What the DCF practices is not decent at all. They have traumatized my child and I on many occasions. My child's life and many other childrens life has been ripped apart due to the Negligence of the Department of Children and Families. I think that changes need to be made immediately due to the fact of my own child who is suffering without me, his mother and his biological family. I would like our group to be heard by this committee/and or Legislation, also the Gov. Jodi Rell.

I'm a Parent that has organized a group with parents and supporters, and we would like to be part of this task force to help with the policies of managing the way families need to be handled. We would like to be heard and be' part of the decisions and recommendations made by the task force. Please call us at anytime, (860) 301-1274

Our group is called: Parents INvestigaton on DCF in CT Team If you or a loved one has been falsely accused or wronged by the Department of Children & Families or the system, we can give you information and guidance reguarding your family. Families and parents haverights and your rights are being violated when they try to force their way into your home, take your child and hold your child(ren) hostage. The system takes in false reports, hides reports, has secret meetings, and makes decisions from false, untrue testimony by the system. Parents and famiies have united to take a stand and not be bullied by the system, please contact us for more information email: [email protected] Respectfully, Responsibly, Ms. Cheryl Martone, Educator, Advocate, Parent of Justin M. 001712

N ASW National Association of Social Workers / Connecticut Chapter

2139 Silas Deane Highway Sherry Ostrout, MSW, CMC, President Suite 205 Stephen A Karp. MSW, Executive Director Rocky Hill, CT 06067 naswct@conversent net (860) 257-8066 • (860) 257-8074 FAX www naswct org Human Services Committee March 3, 2009

My name is Marcia Bok and I am testifying today for the Connecticut Chapter of the National Association of Social Workers in support of HB 6525 - an act to establish a task force to study the reorganization of DCF While often a believer that task forces only delay action when action is needed, in this situation I believe that a task force to study the reorganization of DCF is a sound idea.

We would all agree about how complex the work of DCF is. We would hope that any reorganization would be very thoughtful and would greatly improve the work of DCF. There are many issues that such a task force could address. Most important, of course, are outcomes for children and their families. Certainly one task of the study would be to help establish measurable indicators of desired outcomes. It would be very useful for the task force to study issues of prevention and early intervention, community based vs. residential placements, behavioral health, juvenile justice and child protection, the role of families, siblings, and voluntary services, and foster care, adoption, kinship care, and aging out of the system. Intergovernmental and public-private partnerships should also be addressed.

The composition of the task force is very important as the participants could determine outcomes. Thus, as many stakeholders as possible should be represented. Parents and foster parents, who are immediately impacted by DCF decisions and activities, should certainly be represented. The experiences of parents, and their children, provide the most important commentary on the system. Teenagers and young adults who have participated in the DCF system would also have an important perspective to provide.

I would also strongly recommend that the a member "of the National Association of Social Workers CT. Chapter also be asked to participate on the task force. With its 3600 members in CT., representing many different facets of social work and intimately knowledgeable about DCF, one of our experienced members would bring a wide range of knowledge about the total service delivery system that DCF impacts in its work. This appointed individual would provide both detailed knowledge, as well as a broad understanding, of the experiences and judgments of social workers who have worked m the DCF system - both in the public and non• profit sectors. NASW/CT. also have many members working in other state agencies, whose work impacts on DCF and who the work of DCF also affects, so that this individual would have knowledge about interagency issues, concerns, and needed solutions.

I think the legislature and the people of Connecticut can benefit greatly from the work of the proposed task force. I can hardly think of anything more important than the work of DCF and its partners in the community. Thank you very much for your help. 001713

Legal Assistance Resource Center • of Connecticut. Inc. • 44 Capitol Ave., Suite 301 • Hartford, Connecticut 06106 (860) 278-5688 • FAX (860) 278-2957

H.B. 6543 - Title IV-D child support orders Human Services Committee Public Hearing - March 2,2009 Testimony of Raphael L. Podolsky

Recommended Committee action : AMENDMENT OF THE BILL

This bill, which is sponsored by the Department of Social Services, makes numerous changes in the establishment of child support and the enforcement of orders in Title IV-D cases. We ask the Committee to make two changes in the bill:

* "Neglect and refusal" (Sec. 24, lines 703-708): Connecticut law has long required that a child support order will be issued only if a person obligated to support a child "neglects or refuses" to furnish necessary support. Section 24 of the bill would make proof of neglect or refusal unnecessary "when petitioning" for support. We do not object to this clarification as applied to current support but we think it contradicts an important principle of Connecticut child support law if applied to arrearages. Liability for an arrearage requires both knowledge of the existence of the child and the ability to pay, i.e., it requires that there be a neglect or refusal to support. To make clear that the new language in Section 24 does not change the law as to arrearages, the following should be added at the end of line 708:

..."except with respect to arrearages determined pursuant to subpara• graph (A) of subdivision (7) of this section, as amended by this act, or subparagraph (A) of subdivision (5) of subsecton (a) of section 17b-745 .

* Arrearage collection when the obligor lives with the child (Sec. 29, lines. 812-815): If a parent with an arrearage is living with the child, existing law recognizes that arrearage payments should be suspended or reduced if paying them would have an adverse impact on the current ability to support the child. The existing statute as a result requires the Child Support Guidelines Commission to "consider" exemptions similar to those in the state's Uniform Contribution Scale (UCS), which applies to legally liable relatives repaying the state for benefits received by themselves or family members. The UCS exempts those with incomes below 250% of median income from making payments. The Commission did consider the UCS standard but adopted a more restrictive standard. Section 29 deletes entirely the requirement that the Commissioner consider an exemption "similar to" the UCS. We urge the Committee to insert into line 812 the substance of the language actually adopted by the Commission: "In such cases the guidelines shall require that the payment order be no more than one dollar per week if the obligor's gross income is less than or equal to 250% of the poverty guideline for the obligor's household size or no more than 20% of the imputed current support obligation if the obligor's income is above that amount." oo nu ghla Greater Hartford Legal Aid

Testimony before Human Services Committee March 3, 2009 Submitted by Lucy Potter Greater Hartford Legal Aid

S.B 6543. An Act Concerning Paternity and Support Establishment and Enforcement of Orders in Title IV-D Child Support Orders, oppose specified changesmsections24 and29 " " ".

I am an attorney at Greater Hartford Legal Aid. I have represented low income Hartford area residents for many years. I have also served on the Fatherhood Advisory Council and the last four Child Support Guideline commissions. I submit this testimony on behalf of Greater Hartford Legal Aid's low income clients. This lengthy bill from the Bureau of Child Support Enforcement makes changes to an array of child support statutes. A similar bill was raised last year and this version modifies the previous bill to accommodate some of the concerns that legal services raised last year. I do not object to most of the bill, but remain concerned about two specific changes. As this committee is well aware, there is growing recognition in Connecticut that fairness to both parties is in the best interests of children and families. Connecticut laws have been improved to add some protections for custodial and noncustodial parties vis a vis the interest of the state. For example, changes have been made to assure that child support arrearages reflect ability to pay, to limit orders for those who have documented disabilities, to limit liability during periods when the obligor is institutionalized and allow compromise of arrearages owing to the state for successful participation in fatherhood programs. The following proposals included in this bill could run counter to these enlightened trends of recent years.

Section 24,

This section amends Conn. Gen. Stats. 46b-215, the support petition statute. The IV-D agency (Bureau of Child Support Enforcement) would no longer be required to allege or prove that the defendant "neglected or refused" to support the child, in order to petition for support. We agree that IV-D should not have to prove "neglect or refusal to support" in order to get orders for current support or medical coverage. But we are concerned that this change will also be applied to arrearage orders. We believe it remains important for Connecticut to keep longstanding language that only makes the defendant liable for retroactive support when the defendant knew that he or she was the father of the child, had the ability to pay, and still did not pay. This principle dates back over a century and should be clearly preserved in the statutes. Lathrop v. Lathroo. 78 Conn. 650 (1906)

Greater Hartford Legal Aid, Inc.

999 Asylum Avenue, 3F1 Hartford, CT 06105-2465 • Tel. 860. 541 5000 • Fax 860 541 5050 • TTY 860 541 5069 •

www.ghla.org

'United Way 001715

If this principle does not remain clearly articulated in the statute, it could fundamentally change the nature of retroactive liability, and raise due process concerns in situations where the obligor had no knowledge of the child's existence prior to commencement of the action for support.

Recommendation: add the following language at Line 708. Following "as amended by this act" :

EXCEPT WITH RESPECT TO ARREARAGES DETERMINED PURSUANT TO SUBPARAGRAPH (A) OF SUBDIVISION (7) OF THIS SUBSECTION, AS AMENDED BY THIS ACT, OR SUBPARAGRAPH (A) OF SUBDIVISION (5) OF SUBSECTION (a) OF SECTION 17b-745

Section 29

This section governing the promulgation of child support guidelines, changes the language regarding the treatment of parents who have reunited with their children. The statute recognizes that such parents should be afforded greater leniency in repaying arrearages owing to the state, so that more income is available for the support of the child. This section deletes language requiring the commission to consider the uniform contribution scale from Connecticut General Statutes, which exempts income below 250% of median income. I understand that BCSE believes that the ongoing reference to this provision is confusing because the guideline commission actually adopted a different standard. I would propose that this section be amended to incorporate the current guideline language as follows.

Recommendation: line 812, following "preceding such order." IN SUCH CASES THE GUIDELINES SHALL REQUIRE THAT THE PAYMENT ORDER BE NO MORE THAN ONE DOLLAR PER WEEK IF THE OBLIGOR'S GROSS INCOME IS LESS THAN OR EQUAL TO TWO HUNDRED FIFTY PERCENT OF THE POVERTY GUIDELINE FOR THE OBLIGOR'S HOUSEHOLD SIZE, OR NO MORE THAN 20 % OF THE IMPUTED CURRENT SUPPORT OBLIGATION IF THE OBLIGOR'S INCOME IS ABOVE THAT AMOUNT. 001716

STATE OF CONNECTICUT JUDICIAL BRANCH

EXTERNAL AFFAIRS DIVISION 231 Capitol Avenue Hartford, Connecticut 06106 (860) 757-2270 Fax (860) 757-2215 Testimony of Stephen N. Ment Human Services Committee Public Hearing March 3,2009

House Bill 6543, An Act Concerning Paternity And Support Establishment And Enforcement Of Orders In Title IV-D Child Support Cases

Thank you for the opportunity to submit written testimony on behalf of the

Judicial Branch in support of House Bill 6543, An Act Concerning Paternity and Support Establishment and Enforcement of Orders in Title IV-D Child Support Cases. This bill, proposed by the Department of Social Services (DSS), seeks to make several beneficial changes to our child support statutes.

As members of the Committee may be aware, in IV-D child support cases, the

Judicial Branch's Support Enforcement Services unit is responsible for monitoring child support awards for compliance with financial, medical insurance, and child care orders, as well as initiating court-based enforcement actions such as income withholdings and contempt applications when appropriate. Cases are heard by quasi-judicial officers within the Judicial Branch, Family Support Magistrates.

The Judicial Branch supports several provisions of this bill. More specifically, the

Judicial Branch supports Section 10 of the bill which would increase the number of statutorily-authorized special policemen within DSS' Bureau of Child Support

Enforcement from four to eight. Special policemen serve outstanding warrants against child support obligors, in addition to State Marshals. These warrants — capias mittimus

'- are issued by the court only after repeated attempts to have the obligor come to court to address his or her delinquency have failed. 001717

Increasing the number of special policemen will have a direct effect on child

support collections, and thereby benefit custodial parents and children, because past

statistics have proven that an arrested parent will pay nearly $2000, on average, in child

support after their arrest. In cases without capias execution, however, most families

receive little or no court ordered child support. Thus, we strongly support this

provision.

The Judicial Branch also supports Section 47. This section would grant judicial

marshals the narrow authority to serve a capias mittimus on a child support obligor if

the person is in the custody of the marshal, or the individual is present in the

courthouse. This section does not diminish in any way the jurisdiction of state marshals

who currently serve the majority of capias orders. Rather, it allows for the timely

service of a capias mittimus if an obligor is in the presence of a judicial marshal. With a

backlog of unserved capias mittimus orders pending, any steps that can be taken to

have these orders served more efficiently would aid in ensuring that Connecticut's

families are getting the child support to which they are entitled.

In addition to the two sections highlighted above, the Judicial Branch also

specifically supports:

• Section 23, which makes several amendments to the law regarding income withholdings;

• Section 29, which modifies the charge of the Commission for Child Support Guidelines;

• Lines 1003 -1010"of Section 35, which clarifies and articulates the authority of Family Support Magistrates to order an obligor to participate in educational, training, skill-building, work, rehabilitation, or like programs; and

• Lines 1353-1359 and lines 1428-1429 of Sections 42 and 43, respectively, which clarifies and expands the definition of "issue" in the context of income withholding orders.

While the Judicial Branch is supportive of this bill and urges the Committee to

take favorable action on it, we are opposed to Section 37. This section provides that any order entered in the Family Support Magistrate Division (FSMD) is appealable to the 001718

Superior Court, regardless of whether the order was entered by a family support

magistrate or by a judge trial referee.

By way of background the Chief Court Administrator will, from time-to-time,

ask judge trial referees to hear support matters, augmenting the magistrates. This move

has helped reduce court cancellations and has led to a more expeditious handling of

judicial business. While current law provides that a decision of a family support

magistrate (a quasi-judicial official) may be taken to a Superior Court judge, passage of

this section would create the prospect of a Superior Court judge "overruling" a judge

trial referee; we believe that these matters ought to be heard in the Appellate Court, and

we will work with the proponents of the bill to come to a mutual understanding on this section.

Thank you for the opportunity to submit written testimony. 001719

la Greater Hartford Legal Aid

Testimony before Human Services Committee March 3, 2009 Submitted by Rafael Rodriguez-Cruz Greater Hartford Legal Aid

S.B 6543,i An'Act Concerning Paternity and Support Establishment and Enforcement of Orders in Title'TV-DIChild Support Orders, oppose specified changes in sections 24 and 29 . - ''

I am an attorney at Greater Hartford Legal Aid. I have represented low income Hartford area residents in family and support matters for many years.

There are two important changes that need to be made to this bill. Lucy Potter, has also submitted testimony which makes specific language recommendations.

First, Section 24 clarifies that the Bureau of Child Support does not have to allege and prove that someone has "neglected and refused" to provide support in order to bring a petition for support. While we agree that this is fair with respect to current support, the change could be construed to apply to arrearages also. It has always been the law that there must be a showing of neglect and refusal for the court to order support for periods before the filing of the case in court. It is important that this principle be preserved. The language needs to be clarified so that the "neglect and refusal" standard continues with respect to the determination of arrearages.

And in section 29, we believe it is important to prescribe a standard for setting arrearage payments to the state for parents who reunite with their children, in order to ensure that support for the children is maximized. The proposed language deletes reference to the statute that sets contribution from family members for support of people in institutions, as a possible model. This section amends the statute to merely say that the guideline commission should assure that arrearage orders for reunited families are appropriate. The standard that the guideline commission adopted should be in the statute to assure that the needs of these families are given sufficient priority.

Greater Hartford Legal Aid, Inc.

999 Asylum Avenue, 3FI Hartford, CT 06105-2465 • Tel 860 541 5000 • Fax. 860 541 5050 • TTY. 860. 541 5069 • www.ghla.org 001720

CAHS The Connecticut Association for Human Services Michael Rohde, President 110 Bartholomew Avenue Suite 4030 James P. Horan, Executive Director Hartford, Connecticut 06106 860951.2212 x 235 www cans org 860.951.6511 (fax)

Testimony in favor of H.B. 6544 Human Services Committee

Submitted by Sherry Linton

Good morning Senator Doyle, Representative Walker, and Committee Members. The Connecticut Association for Human Services would first like to thank the Committee for the opportunity to testify in favor of bill 6544, "An Act Simplifying Procedures for Early Care and Education Facilities." This bill addresses the long overdue mandate for increased collaboration and communication between the Departments of Education, Social Services and Public Health as it relates to streamlining procedures of early care facilities. CAHS applauds the intent of this bill to increase the efficiency of the procedures undertaken by early care and education providers. }

Through the convening of early care providers, it has been gleaned that the State Department of Education (SDE), the Department of Public Health (DPH), and the Department of Social Services (DSS) as regulators of early care facilities of ten request duplicative information. In addition, providers report having to adhere to cumbersome procedures in order to meet the requirements governing their funding. For example, an early care facility may depend on multiple funding sources such as a licensed state funded center that has School Readiness and Head Start slots. For licensing, the facility has to adhere to DPH reporting systems, for state funds the facility may also have to adhere to DSS regulations, and for School Readiness funding a facility must abide by the procedures outlined by SDE. Each funding source imposes varying regulations and procedures relating to attendance of participants, credentials of teachers and care givers, and how funds are distributed. Consequently, one facility is often deluged with multiple reporting requirements.

In these economic times, as we seek the best ways to invest our resources, it is imperative that we define the efficiencies that can be achieved in Early Care and Education. This bill represents a step forward in creating a more efficient Early Care and Education system, as opposed to mamtaining silos based on funding streams. The assertion to the Departments to, identify their requirements and recommend simplifications speaks directly to the initial steps necessary to facilitate a more seamless process for providers who depend on multiple funding sources to maintain a quality early care facility.

Thank you again for raising this bill and providing the opportunity for public comment. For more information, I can be reached at,

Sherry Linton, Early Care and Education Policy Analyst, 110 Bartholomew Ave Hartford, CT 06106, (860) 951-2212x233, [email protected]. 001721

Margaret M. O'Shea, Ph.D Chairman of the Board

Thomas P. Gullotta, M.A., M.S.W. Chief Executive Officer

RAISED BILL NO. 6544 An Act Simplifying Procedures for Early Care and Early Education Facilities

Testimony to the Committee on Human Services - March 3.2009

Child and Family Agency of Southeastern Connecticut, a state-licensed child care provider and multi-service behavioral health and social service agency, submits this testimony in favor of Raised Bill No. 6544, "An Act Simplifying Procedures for Early Care and Early Education Facilities". In the era of growing fiscal challenges for all resources involved in early child care, state agencies and private providers alike, this bill's intention to charge the Departments of Social Services, Education and Public Health with the task of conducting a joint study to make recommendations to simplify procedures and requirements for caregivers comes at an extraordinarily helpful time. In particular, Child and Family Agency would like to draw attention to the fact that providers of certain after-school programs for school-aged children up to the age of 16 are currently required to maintain the same staff-to-child ratios (1:10) required for pre-school children (ages 3 - Kindergarten). While after-school "drop-in" programs are not required to be licensed as Child Day Care Providers, after-school programs that serve the same registered children and teens on a daily basis must maintain this licensure. Child and Family Agency encourages the joint committee established under this bill to consider approving more flexible and developmentally appropriate staff-to-child ratios for programs serving school-aged children. While a staff-to-child ratio of 1:10 is certainly prudent and developmentally appropriate for children ages 3-6 (the infant/toddler ratio is 1:4), we are confident that the following ratios would be developmentally appropriate for the following age ranges: ages 7-12: recommend a maximum staff-to-child ratio of 1:12 ages 12-14: recommend a maximum staff-to-child ratio of 1:16 ages 14-16: recommend a maximum staffrto-child ratio of 1:20. If these revised staff-to-child ratios were adopted, licensed private non-profit child day care providers could provide after-school academic, recreational and social support programs for greater numbers of children and teens without incurring prohibitive increased program costs, while maintaining a responsible, developmentally-appropriate level of supervision. To this end, Child arid Family Agency requests that this testimony be forwarded to the Departments of Social Services, Education and Public Health so that it may be considered as the joint committee to be established under this bill does its work.

Thank you,

Richard D. Calvert, LCSW Associate Director of Programs (860) 442-2797, ext. 1213 cahertr@cfapress. org (501722

STATE OF CONNECTICUT OFFICE OF POLICY AND MANAGEMENT

TESTIMONY PRESENTED TO THE HUMAN SERVICES COMMITTEE March 3, 2009

Robert L. Genuario Secretary Office of Policy and Management

Testimony Opposing House Bill No. 6609

AN ACT ESTABLISHING A COMMUNITY PROVIDER RESCUE FUND ACCOUNT AND COMMUNITY-BASED SERVICES COMMISSION

Senator Doyle, Representative Walker and distinguished members of the Human Services Committee thank you for the opportunity to offer testimony on House Bill No. 6609, An Act Establishing a Community Provider Rescue Fund Account and Community-Based Services Commission.

This bill establishes a nonlapsing account within the General Fund to serve as a "community provider rescue fund" and authorizes me to make funds available to the agencies that contract with private providers under purchase of service agreements. The bill also establishes a commission on community-based services that is to study and make recommendations about long-term funding for private providers. The bill specifies the outcome of the commission's recommendations: to provide for increases in provider payments through an indexing methodology, and to develop a budget for implementing the indexing option. Finally, the bill specifies a bonding allocation of $65 million for private provider capital improvements, and makes specific allocations to each agency that contracts with private providers.

Before commenting on the bill, let me state unequivocally that our private providers do a very good job of serving some of the most vulnerable populations in our state; the provider community is an invaluable partner and is essential to the provision of state services. With that said, however, I am not supportive of this bill. As most of you know, I have generally not supported the creation of more off-budget accounts. By their very nature, off-budget accounts are not subject to the scrutiny and review such as that provided annually by the Appropriations Committee, and as a result this leads to less transparency in our budgeting process.

450 Capitol Avenue • Hartford, Connecticut 06106-1379 wwwct.gov/opm 001723

I am also not supportive of the amount of bonding proposed in this bill. The Governor's budget proposes the cancellation of existing bond authorizations in order to help us deal with the amount of debt service that is squeezing out room for discretionary appropriations. While there may be some very real needs on the part of private providers, those needs should be clearly articulated and projects specifically identified for review through the traditional bonding process.

In addition, I am not supportive of the commission envisioned under this bill. If the legislature wishes to engage in a policy discussion about long-term funding for private providers, it should do so in the context of a long-term solution to the state budget, of which provider funding is only one component. There is also no need to establish a commission if the bill specifies the outcome of the commission's work: indexing of provider funding. Any policy discussion about provider funding should consider multiple outcomes of provider funding over the long term, rather than be pre-determined. Finally, and probably most importantly, I think we all need to recognize that budgeting is the process for weighing multiple, competing demands against scarce resources. Indexing and solutions like it limit the authority and discretion of the legislature and the executive branch to make policy choices and to allocate resources accordingly.

I would like to again thank the committee for the opportunity to present this testimony. I respectfully request the Committee oppose this bill and I will be happy to answer any questions you may have. 00 I72U

CT ...tc serve, szrenpther and suppor: Connecticut's NONPROFITS nonprofit community.

Testimony before the Human Services Committee 3.3.09 In support of HB 6609. AA Establishing a Community Provider Rescue Fund Account and Community-Based Services Commission BY: Catnj Zeiner, Board President. Connecticut Associanon of Nonprofit Senator Doyle, Representative Walker and members of the committee, my name is Cathy Zeiner. I am the Execuuve Director of the Women's Center of Southeastern Connecticut and the President of the Board of Directors of the Connecticut Association of Nonprofits I am joined today by our Executive Director Ron Cretaro and our past Board President Dems Geary. Executive Director of the Jewish Association For Community Living We are among the 530 nonprofit organizations represented by Connecticut Associauon of Nonprofits (CT Nonprofits), 300 of whom receive state funding to provide health and human services on the state's behalf

I am urging your support of the concepts raised m HB 6609, AA Establishing a Community Provider Rescue Fund Account and Community-Based Services Commission This bill seeks to address the chronic underfundmg of our state's pnvate nonprofit health and human services providers The average cost-of-living adjustment (COLA) for nonprofit providers stands at 1 1 % over the past 20 years: this does not even begin to keep pace with the inflation that providers have experienced during that time With percentage increases in the double digits for energy and healthcare costs, nonprofits are falling further and further behind with each passing year of inadequate COLAs

HB 6609 contains three important measures designed to assist nonprofits

• It establishes an account within the General Fund that will provide an immediate remedy to budget shortfalls for community providers, as well as a stable funding system and a consistent cost-of-service adjustment to avoid future budget shortfalls • It establishes a commission on community-based services that will study and make recommendations concerning a long-term funding soluuon for community providers • It creates a capitol improvement fund to assist community providers in addressing aging infrastructure We further ask you to consider the creauon of a "Nonprofit Collaborauon Incentive Grant Program'" within the Office of Policy & Management for state contracting nonprofit organizations includmg those funded by the Commission on Culture & Tourism, Department of Labor. Department Education, Department of Mental Health & Addictions, Department of Public Health, Department of Development Services, Department of Children & Families, Department of Social Services, Children's Trust Fund and the Judicial Branch Court Support Services Division This grant program would serve as an mcentive for collaborative and strategic partnerships which may include but are not limited to mergers, jomt purchasing of buildings, facihues. or equipment, refinancing of program or admimstrauve facilities, pooling of administrative functions, creating efficiencies in energy conservation, transportation, technology, etc. These initiatives would ultimately result m the streamlining and consolidation of programs, services or organizauons We fully understand the financial cnsis facmg Connecticut: however, this bill is absolutely critical to the sustainability of Connecucut's private nonprofit providers The health and human services delivery system simply cannot sustain any further mcreases in demand for services without additional funding bemg made available While we do not envy the position that you find yourselves m or the difficult decisions that you must make, we are familiar with them The budget cuts, making every dollar stretch a little further, the DOING MORE WITH LESS is something that nonprofits have been domg for years. We are asking for your support and urge passage of HB 6609. When Connecticut needs us most, this is what we need to be there for Connecticut

Thank you for the opportunity to submit testimom Please do not hesitate to contact me with any questions

90 Brainard Road • Hartford. CT 06114 • Tel 860 525.5080 • Fax 860.525.5088 • www xtnonprofits org 001725

Testimony on HB_MH2.(Commuoity Provider Rescue Fund) and SB 843 Good morning Senator Doyle, Representative Walker and members of the Human Services Committee. My name is Tom Fanning. I am President of Ability Beyond Disability, a non profit provider that has been serving people with disabilities in Connecticut for 55 years.

I am here today to offer comments on two related matters, HB 6609, an attempt to address the overall inadequacy of funding for the private, non profit community and a provision of SB 843 that would freeze rates for Intermediate Care Facilities for the Mentally Retarded.

The inadequacy of funding for the private non profit sector has a history of more than 25 years, during which the State has been turning to us to meet the needs of people with disabilities and then turning away from us when it came time to pay for those services. Over the years, you have heard of the need for a COLA increase, for funds to sustain our infrastructure and for a Rescue Fund. Call it what you will, but you have to come to grips with the fact that those most deserving of State support are in peril because of years of inadequate funding. In spite of these frighteningly challenging times, the State needs to find funding for nonprofits.. .we are the organizations that provide the services to the most fragile among us. Again, call it what you will, but please look at the system and put the dollars where they are needed. Support the Community Provider Rescue Fund.

The second matter I wish to discuss is a subset of the first. Freezing the rates of Intermediate Care Facilities for the Mentally Retarded will have a devastating impact on the care of some of the most fragile people with developmental disabilities. ICFs/MR are group homes licensed by DDS, certified by DPH and funded by DSS. These homes typically serve people who have intense care needs.

On December 11 last year, the Legislative Program Review and Investigations Cornrnittee published a comprehensive report that details the challenges CT faces as our citizens with developmental disabilities live longer. Not only are people living longer...they develop other complications related to aging at an earlier age than the general population...notably Alzheimer's Disease but also other age related conditions such as diabetes, heart problems, the need for personal care and assistance in getting around.

Ability Beyond Disability operates 20 ICFs/MR serving 118 people. The needs of the people who live in these homes are changing dramatically as a direct reflection of the aging of people with disabilities. The people who live in these homes are not a stagnant population. Medical needs are increasing daily. The needs for behavioral supports are increasing. Each new referral is more complex than the last one. We have been grateful to the Department of Social Services for recognizing this trend and providing relief when possible but if the rates of the ICFs/MR are frozen for 2 more years, it will absolutely put the well-being of these people at risk. If section 16 of SB 843 is not amended: I fear that the lives of our aging residents of ICFs/MR homes will literally be put in danger.

Thank you for listening. Please hear us. 601726

Community Providers Association Caring for Connecticut

March 3, 2009

Human Services Committee *H. B. No. 6609 (RAISED^ AN ACT ESTABLISHING A COMMUNITY PROVIDER RESCUE FUND ACCOUNT AND COMMUNITY-BASED SERVICES COMMISSION.

Good morning. My name is Heather Gates and I am the President/CEO of Community Health Resources. We are a community based provider of behavioral health services serving the communities east and north of Hartford. We have sites in clinic Enfield, Windsor, Bloomfield, Manchester, Vernon, and Willimantic as well as residential program throughout the area. We receive funding from DMHAS, DCF, DSS, CSSD, third party insurers, municipalities, United Way, and private donations. We serve over 4000 children, adolescents, families and adults every year.

I am speaking today as a member of the Board of Directors of the Connecticut Community Providers Association and co-chair of CCPA's public policy committee. CCPA represents organizations that provide services and supports to people with disabilities and other significant needs, including children and adults with substance use disorders, mental illness, developmental and physical disabilities.

Community providers are the backbone of Connecticut's human service system. For years, community based providers have collaborated with the state to ensure that critical services are provided to children and adults in a manner that is accessible and affordable, yet maintains the highest standards of quality. We want to continue that partnership, but frankly decades of underfunding coupled with the 0% increase in FY09 and the proposed 0% increase in FY10 and FY 11, we will not be able to continue services at current levels.

CCPA

35 Cold Springs Rd., Suite 522, Rocky Hill, CT 06067-3165 (PJ860-257-7909 • (F]860-257-7777 vvww.ccpa-inc.org 001727

3-3-09 Human Services Committee Heather Gates - Page 2 of 2 Community providers have been under funded for more than 20 years. By every objective measure, budget increases to help our clients have failed to keep pace with inflation. It's not even close. While the Consumer Price Index has risen by nearly 95% in the last twenty years, cost of service increases for private providers have only gone up by about 33%. This disparity is placing increasing strain on our budgets and ultimately our clients - your constituents. This year we are asking for help once again on behalf of those individuals that you represent.

We applaud this Committee for raising HB 6609 and urge your support of AN ACT ESTABLISHING A COMMUNITY PROVIDER RESCUE FUND ACCOUNT AND COMMUNITY-BASED SERVICES COMMISSION. This legislation is designed to: > Provide an immediate fix to shortfalls in the last two budget years > Stabilize the system > Create a new base for future funding growth >. Establish a consistent cost of service adjustment system to avoid future budget shortfalls > Address long-term solutions to the funding structure for community providers. Government acts most decisively when there is a crisis. For years we have been pleading for adequate funding to provide services to the most vulnerable citizens in Connecticut. Please support HB 6609 before this fiscal problem becomes a healthcare crisis for the 500,000 individuals served by the community provider system.

Thank you for your time and attention. 001728

Connecticut Nonprofit Human Services Cabinet

90 Bralnard Road • Hartford, CT 06114 • (860) 525-5080 • (860) 525-5088 (tax) • [email protected]

Children's League of Connecticut Testimony before the Human Services Committee Connecticut AIDS Resource Coalition March 3, 2009

Connecticut Association for HB 6609: AA Establishing a Community Provider Rescue Fund Account and Community Action Community-Based Services Commission

Connecticut Association for Hello Senator Doyle. Representative Walker and members of the Committee, thank you for Human Services the opportunity to testify today. My name is Patrick Johnson, I am Co-Chairman of the CT

Connecticut Association of Area Nonprofit Human Services Cabuiet (the Cabmet) The Cabmet is a statewide coalition Agencies on Aging comprised of 20 nonprofit human service associations and organizations representing approximately 800 providers. Its mission is to advance a strong and unified nonprofit human Connecticut Association of services system to effectively meet community needs The Cabmet has worked with state Nonprofits agencies on critical contracting issues and business practices that impact over 1.900 Purchase of Services (POS) Contracts valued at approximately S2 billion annually Our members play Connecticut Coalition Against a vital role in addressing the cntical health and human services needs that face so many Domestic Violence Connecticut residents - they provide the safety net that anyone can find themselves in need of in the blink of an eve Connecticut Coalition to End Homelessness The Cabmet supports HB 6609. An Act Establishing a Community Provider Rescue Fund Connecticut Community Providers Account and Community-Based Services Commission. Association While members of the Cabmet have varied funding sources, from even.' state agency and the Connecticut Consortium of Legal federal government, one of our top pnonties is across the board COLA funding for all private Services provider POS contracts in the amount of 5.5% for both SFY10 and SFY11 HB 6609 seeks to address the chrome underfunding of private nonprofit providers This bill contains three Connecticut Council of Family Service Agencies importani measures designed to assist nonprofits

Connecticut Sexual Assault Crisis • It establishes an account within the General Fund that will provide an immediate Services remedy to budget shortfalls for community providers, as well as a stable funding system and a consistent cost-of-service adjustment to avoid future budget shortfalls Connecticut Women's Consortium • It establishes a commission on community-based services that will study and make recommendations concerning a long-term funding solution for community providers Easter Seals Connecticut • It creates a capitol improvement fund for community providers

End Hunger Connecticut' Our employees have been loosing purchasing power for years with none receiving wage increases equal to or exceeding the Consumer Pnce Index How long can we continue to Human Services Council survive on the backs of our employees'' Fixed costs contmue to increase for utilities, heating fuel, gasoline, food, health insurance, liability insurance, etc Cuts in human services programs Oak Hill from the least expensive option the state has will not save the state money but our vital programs can not survive with three years of zero on top of 20 years of chrome underfunding •Planned Parenthood of Connecticut The average cost-of-living adjustment (COLA) for pnvate providers over the past 20 years is The Connection, Inc 1.1%. far off pace from inflation While we fully understand the difficult financial situation facing our state, sustamability of our health and human services delivery system is bordering on Wheeler Clinic the impossible. It is akin to reducing food to an already undernourished starving person Our pnvate providers are anorexic organizations Flat funding is equivalent to budget cuts because expenses grow regardless of whether budgets keep pace The funding provided in HB 6609 will supply the influx of dollars needed to prevent the nonprofit human services sector from falling further behind However, a long-term funding solution is desperately Deeded. The Cabmet supports developing a commission to study and make recommendations on this matter 001729

Connecticut Nonprofit Human Services Cabinet Page 2

We urge you to pass HB 6609 and provide nonprofits with the funding needed to serve the state's most vulnerable residents Your attention to this complex and challenging problem is greatly appreciated Please feel free to contact me with any questions or concerns

In addition I want to express my strong opposiuon to SB 843 which would cap rates for ICF-MR facihues. These are facilities serving the most medically fragile people with severe disabilities requiring more robust nursing staff Please do not balance the budget on the backs of the most helpless vulnerable people m the state who literally have no voice of their own1 Thank you

Respectfully submitted, Patrick J Johnson Jr

President of Oak Hill Co-Chairman of CT Non Profit Human Service Cabmet Vice-Chairman of CT Community Providers Associauon 001730

Community Providers Association Caring for Connecticut

Human Services Committee Public Hearing

March 3.2009 *H. B. No. 6609 (RAISED) AN ACT ESTABLISHING A COMMUNITY PROVIDER RESCUE FUND ACCOUNT AND COMMUNITY-BASED SERVICES COMMISSION.

Good morning Senator Doyle, Representative Walker and members of the Human Services Committee. My name is Barry Simon and I am the Executive Director of Gilead Community Services and Board Chair of Connecticut Community Providers Association (CCPA). Gilead Community Services is a mental health provider funded by DMHAS and DCF that serves almost 500 individuals throughout Middlesex County. CCPA represents organizations which provide services and supports for children and adults with disabilities and special needs including people with addictions, mental illness, developmental and physical disabilities.

I am here today to commend this committee for raising HB 6609, AN ACT ESTABLISHING A COMMUNITY PROVIDER RESCUE FUND ACCOUNT AND COMMUNITY-BASED SERVICES COMMISSION. This important legislation recognizes community providers as an integral part of the public/private partnership in the healthcare service delivery system. After more than 20 years of chronic under funding, this legislation proactively addresses needed resources to maintain services, examines the industry to develop a systematic way of funding the cost of services and recognizes neglected infrastructure through bonding allocations.

Community providers deliver services to over 500,000 of the state's most needy residents. Local agencies in your districts continue to witness under funding, yet everyday families and individuals across our state turn to their, local community provider, at increasing rates, for the support they need to lead more productive, healthy and fulfilling lives. Demand continues to grow yet, funding has not kept pace.

The current budget proposal contains no increases for any state funded community provider contracts for FY10 and FY11. We struggle this year to maintain services with a 0% increase for FY09. This lack of funding, coupled with decades of inadequate COLAs, simply does not address our ever increasing operating costs. As healthcare providers our costs continue to rise with inflation. Over the past 20 years the Medical CPI has increased 197% while the state has increased its payments 33% (avg. 1.1% per year).

As a business this is unsustainable; our agency costs have increased dramatically as we maintain 14 buildings, honor an 1199 union contract, pay for fuel, malpractice, workers comp and Health insurance which have increased 42%, 18% and 23% respectively the past fiscal year.

CCPA

35 Cold Springs Rd., Suite 522. Rocky Hill, CT OS067-3165 (PJ860-257-7909 • (F1860-257-7777 www.ccpa-inc.org 001731

March 3, 2009 Human Services Committee Public Hearing Barry Simon, Gilead Community Services and CCPA - Page 2 Programs have closed in the last few years and will continue to do so - this is not a false alarm. As an agency: • We need to manage with nearly 20 vacancies at any given time. • We have reduced hours of operations in programs and have closed a program. • Waiting lists in our group homes and supported apartment programs are growing. • People are waiting longer for services or spend long periods of time in emergency rooms.

We have closed a program and made reductions in others due to the short sighted approach to state budgeting which ultimately will lead to dire consequences for the total community service system.

We recognize and appreciate that the Governor and i Legislature want to invest the limited dollars wisely. In order to get the best return on your investment, it is our belief that funds need to be appropriated to address the comprehensive needs of the system and consumers. If the only investment is in high-end services, the system will create more high-needs consumers. There needs to be support of foundational community-based services and the preventive role that they play in order to create a sustainable system.

This is why we are asking you to support The Community Provider Rescue Fund, to support essential services and protect the people we serve. This legislation creates a fund to help stabilize the system, it creates a path to consistent funding in the future with the formation of a Commission to consider a long term funding strategy and addresses much needed investments in irifrastructure through capital improvement funds.

Such funding creates capacity building in existing community based programs which assures timely access to services; staff to client ratios are improved; intensive levels of community care commensurate with client needs can be developed; and long term solutions to housing and service needs of persons with severe disabilities created. Community Providers are part of the solution for the future of the service delivery system and preserving the investment made in quality, cost effective, community care.

Please help the community human service providers in your community succeed. We urge you to make Community Providers a priority by passing HB 6609.

I thank you for your time and would be happy to answer any questions. 001732

Testimony before the Human Services Committee

HBfifim

March 3,2009

Good morning. My name is Ray Veazie and I am from Norwich, CT. I am here today to testify about the effect of the Medicaid spend down on my healthcare.

I struggled to learn in school and in the community as a child and young adult. When I was 19,1 was in a motorcycle accident resulting in traumatic brain injury. After rehabilitation, I always worked a full-time job and paid into the social security system which I expected to be there when I needed it. I have always had good jobs. It took me longer to learn than most people, but once I learned the job I had it down to a science. My last job involved making airplane engine parts which I did until I couldn't work any longer-'I could no longer lift the heavy parts as required by the job. Since then I have been unable to find a job.

I currently receive $1,025.00 per month in Social Security Disability. After paying all of my monthly bills which includes rent, utilities, car insurance, car taxes, gas, and car maintenance, I have approximately $200.00 to get through the month. With this $200.001 need to buy food. I receive Food Stamp assistance, but this only covers 2/3 of my monthly food needs. I also need to purchase toiletries, clothes, and other necessities.

Every six month, I am subjected to a "spend down" because I am determined to have too much income ($1,025.00 per month). My "spend down" is $2,000.00. This means I need to come up with $2,000.00 worth of medical bills in order to have Medicaid insurance. My monthly medication costs $708.00. I am unable to get my medication when I am on a spend down. I do have Medicare Part D, but the medications I need are not on the approved list. I have tried other medications that are on the list, but they do not work for me. My doctor gives me samples, but they only last a few days. My doctor has tried various programs to get discounted medications from the pharmaceutical companies without success. What's the point of going through all that treatment only to end up back at square one because I cannot afford the medication I need. Before I got into treatment, I self-medicated with drugs and alcohol which led to crime which led to jail and thoughts of suicide. I don't wish that on my worst enemy. I don't want to go down that road again.

When I go without my medications, my comprehension and mood are greatly affected. I also have traumatic brain injury and am supposed to take anti-seizure medications, but have had the same problems with access. I have had seizures which is life-threatening and scary. I know that there are many other people going through this terrible situation too. I am unable to go to any doctor appointments. I can't afford to pay for my medications and still meet all of my monthly basic needs. I also can't live the life I want without the medications and medical care that I need. I have given up trying. I think things are just going to get worse. In fear of not knowing what tomorrow will bring, what will people do? I see this happening in other countries and now I see it getting worse here. I see a lot of people I know give up. They end up turning to drugs and alcohol. All the money I paid into the system for years - where is it? Where did it go?

Thank you for listening. 001733

Written testimony for the Human Services Committee In Favor of HB 6610 March 3, 2009

It's time once again to regurgitate the Medicaid Spend down issue and bring this unfair practice to the forefront. The Legislature is back in session, hopefully to wrestle with this disturbing health conundrum that effects thousands of people in Connecticut. Our Mental Health Advocacy Group from Fellowship Place in New Haven is trying to encourage the passing of legislation to raise the income limit for Medicaid, administered by the State. As it stands now, what an individual makes above the $506.22 monthly cap is called "excess income". The Department of Social Services then does some sort of "hocus pocus" with the difference and comes up with what they call a Spend down. Mine is $2000.00. This means that I would have to "spend down" that much money in paid Doctor bills to be qualified for Medicaid benefits again. This process happens every six months. It is difficult, if not impossible, to get off the "hamster wheel".

As a result many lower income people in Connecticut do not have health insurance. The Spend down is confusing and senseless. I receive about $13,000 in Social Security Disability benefits per year for Bipolar disorder. I guess that makes me among the "rich", and that I could afford to pay for medical care out of pocket.

There are questions to be asked and solutions to be made. I urge the Legislature to look very closely at these issues. Hopefully, citizens of Connecticut will see the light at the end of the proverbial tunnel.

Kristina Zallinger Advocacy Group of Fellowship Place 0 0 I 7 3 U

Testimony presented by Marcia DuFore On behalf of North Central Regional Mental Re: Raised Bill No. 6610 March 2, 2009

Distinguished Senators and Representatives,

My name is Marcia DuFore. I live in Suffield and am on staff with the North Central Regional Mental Health Board. I am here to give testimony on the Medicaid spend down.

The spend down which must be met to receive Medicaid coverage is an unwieldy, difficult obstacle for individuals in recovery from mental illness and/or substance abuse, people with physical and/or cognitive disabilities and low-income older people. They face an overwhelmingly difficult time in understanding how to meet their spend down and in accessing, and receiving critical medical services. We estimate that there are about 10,000 people at any given time who are in spend down status. Of those, only about 3,000 meet their spend down and become active for Medicaid.

In December 2008 our agency conducted a survey with individuals across the state who suffer from a variety of chronic illnesses, disabilities, or are older adults with low-income. Many other agencies including Advocacy Unlimited, the Connecticut Association of Non-Profits, NAMI, the Mental Health and Aging Coalition, and the five Independent Living Centers also identifed individuals affected by Medicaid spend down and helped them complete our survey. 105 individuals responded to the survey. I'd like to share just a few of the stories that people told us who completed that survey.

We heard about their difficulties in meeting a Medicaid spend down on a limited income and still having enough money left over for their living expenses. One person said, "What spend down means to me is that my income is $952 per month. My rent is $650 per month. I receive no help out of the $300 I have left to pay for my food, or utilities and I am told that I am on a spend down because I have excess income. That's what spend down means to me!" One person, whose income is $1113 per month explained that her $2730 (over 6 months) spend down meant that she had to spend 41% of her income on medical expenses before she could qualify for Medicaid coverage. Another whose income was $852 per month said, "I have to pay medical bills that are not covered during the spend down period. I can't go to the dentist or certain doctors because I have no insurance."

We heard from people about the many difficulties they face in obtaining medical care when they are on spend down. These include physicians who will not treat them, medical taxis that will not drive them to their appointments, 00 I 735

visiting nurse and homemaker services that will not provide care or administer medications. For example, this is one person's story: "Many doctor's offices expect payment up front which I don't have, so they refuse me care. I was a patient when my doctor's office first opened up and remained faithful to their practice even when they became a huge conglomeration. When I went on spend down they expected me to pay up front for all services, which I couldn't do, so they refused to see me and eventually let me go as a patient."

Another told us, "I have to pay the 20% that Medicare does not cover and when that happens I have less money for utilities and food. Also, getting dental work done is harder because I haven't met my spend down, and I have to pay for a large part of my home care because I can't meet my spend down." We're talking about a person who makes about $10,000 per year in Social Security benefits. Think about trying to meet all of these expenses out-of-pocket on $10,000 per year. And this is because everything you earn over $500 per month is classified "excess income" when it comes to determining eligibility for Medicaid benefits.

Another person told us, "I lost my nursing services." Another, "I have not seen my doctor. I can't afford it." Another, "I hardly ever meet my spend down and I cannot get medical transportation." Some have given up hope, "I will never meet an $3000 (over 6 months) spend down."

Although a large proportion of individuals receive Social Security benefits and therefore have Medicare coverage, they have difficulty meeting the cumulative co-pay amounts for services covered by Medicare due to their low income, and as a result, lose those services. Also some of the services they need are not covered by Medicare, i.e. the dental services, medical taxis, homemaker services described above.

We also heard from people about the hardships of going without needed medications. 31% of the people we surveyed indicated that they have had to miss their medication due to a spend down issue and 28% reported that they had been denied medication due to a spend down issue. This seems to occur primarily when 1) they cannot afford the co-pay for the prescription, 2) the type of medication or a name brand medication is medically necessary but is outside the formulary covered by Medicare Part D, or 3) the individuals' prescriptions costs have maxed out. Here is one person's story: "When I am on spend down I have to rely on my doctor to give me samples for my medication. My counselor and clinician work arduously to get cheaper medication that will have the same results and will work for my diagnosis. I rely on samples from my psychiatrist as well as patient assistance from major medication suppliers. I am always in jeopardy of missing doses of medications. At one point I had to stop taking Clozaril because I couldn't afford it. After discontinuing the medication, I decompensated and had to be hospitalized." 001736

Another person said, "You cannot pay $700 a month for meds out of the $60 or $70 you have left after your bills are paid." Another, "I had to stop taking my medication - couldn't afford it." Another, "Yes, I missed medication when the doctor's office was out of samples." Another, "Yes, I have missed medication - almost every 6 months, which leads to re-hospitalization."

Unfortunately, in Connecticut low-income elders and people with serious mental and physical disabilities must be much more impoverished than other eligible groups to qualify for Medicaid. Their income limit is 60-80% of the federal poverty level as opposed to 185% for parents and caregivers of children on the HUSKY program. We must raise the income level for these populations in order to restore fairness in our treatment of these groups of people and reduce the number of individuals who have to suffer the hardships of spend- downs, disrupted medical care, and disrupted lives.

I hope that those of you who have heard these stories will consider favorably legislation that is being introduced to raise the income limit for Medicaid eligibility so that it is equitable with other Medicaid recipients. Please support equity in Medicaid eligibility and increase the income limit for the aged, blind, and disabled.

For more info about our survey please contact Marcia DuFore, North Central Regional Mental Health Board at (860) 966-8166 or [email protected].

Thank you. 001737

f\ KEEP THE PROMISE COALITION Community Solutions, Not Institutions! 241 Main Street, 5* Floor, Hartford, CT 06106 Phone: 860-882-0236; 1-800-215-3021, Fax: 860-882-0240 E-Mail: [email protected], Website: www.ctkeepthepromise.org

Testimony before the Human Services Committee In favor of HB 6610 March 3, 2009

Good morning/afternoon Senator Doyle, Representative Walker, and members of the Human Services Committee. My name is Cheri Bragg, Coordinator of the statewide Keep the Promise Coalition. The Coalition is dedicated to the creation and maintenance of a comprehensive, community mental health system in CT.

The Coalition is in favor of HB 6610, An Act concerning Medicaid Income Limits for Aged, Blind, and Disabled persons. It is critical for many of our members to see this bill passed. Currently the income limits to qualify for Medicaid for older adults and people who are blind or disabled remain between 60-80% of the Federal poverty level - less than $500-$600.00 per month. If a person has any kind of work history, as many people with mental illness have, their income is likely to be above this threshold. The person is then subjected to a complex and burdensome process called "spend down" where they have to show evidence of enough medical bills every six months in order to meet their "spend down" and qualify for Medicaid coverage.

It is not uncommon for people to have "spend down" amounts of several thousand dollars. Many people do not incur enough medical bills to get their Medicaid insurance back, resulting in them becoming permanently uninsured. As a whole, this population tends to have the most complex physical and mental health needs. While they are uninsured, many people face the stress of mounting unpaid bills or doctors who refuse to see them due to a lack of insurance or ability to pay. The result is lack of timely health care, the costs of which can be critical for the person and result in spillover costs in emergency 001738

care and unnecessary hospitalizations.

In addition, the advent of Medicare Part D had the unintended consequence of compounding the problem by making it harder to qualify for Medicaid: people can no longer count the costs of prescriptions toward their "spend down". Raising the Medicaid Income Limit, so that fewer people have a "spend down", will help people who are caught in the "Part D trap" and will simplify continuous access to vital health care services.

Several Coalition members have submitted written testimony detailing their personal struggles with the "spend down" process. I urge committee members to read these accounts which reflect the experiences of thousands of people who continue to be left behind when it comes to healthcare. Some have testified in the past about friends who access costly emergency rooms so that they can meet their "spend down". Others choose to forego needed treatment and medications. Some people who have other health concerns such as traumatic brain injury testified about the complexities of keeping track and submitting their medical costs to meet the "spend down". Still others speak about never being able to meet their "spend downs", remaining permanently uninsured.

As many of you know, the Medicaid Income Limit has remained below 80% of the Federal Poverty level since 1990, almost 20 years. We ask that this limit be raised to 185% of the Federal Poverty Level, in equity with adults in the HUSKY program. While we acknowledge the enormity of this task during the present fiscal crisis, we feel that people experiencing these continuous and critical health care needs must not be forgotten. As the state begins to expand access to health care coverage for CT's citizens, we urge you not to leave older adults and people with disabilities behind. Thank you. 001739

National Alliance on Mental Mini 'testimony before the Human Services Committee March 3, 2009 Support for HB 6610 Opposition to HB 6524

Good morning, Senator Doyle, Representative Walker, and members of the Human Services Committee. My name is Alicia Woodsby, and I am the Public Policy Director for the National Alliance on Mental Illness, CT (NAMI-CT). I am here today on behalf of NAMI-CT to testify in strong support of HB 6610. An Act Concerning. Medicaid Income Limits for Aged, Blind, and Disabled Persons. I would also like to express our strong concerns regarding HB 6524, An Act Concerning Managed Care for Certain Medicaid Beneficiaries.

Currently, the Medicaid income limits for people who are aged, blind, or disabled are $491.92 per month or $593.45 for Fairfield County. An increase to the income limit for Medicaid to the elderly and people with physical and mental disabilities is long overdue. The current limits are at approximately 60-70% of the Federal Poverty Guidelines, which leaves thousands of people with very low-incomes and significant health needs grappling with the state's spend-down program. The program requires that they incur enough medical bills within a six month period to "spend down" to qualify for Medicaid. It is extremely complicated and frustrating, and makes it difficult for people to access coordinated cafe. As a further complication, low-income seniors and people with disabilities who receive Medicare Part D prescription drug coverage are no longer able to use the cost of medications covered by the federal program to meet their Medicaid spend-down requirements. As a result, people often go without needed health care and prescriptions, and they also end up with further financial hardship.

These are individuals with very limited resources and serious health conditions. In addition, those who worked for most of their lives but are now disabled are disproportionately impacted by this problem because they receive higher SSDI payments placing them over the current income guidelines. Those with Medicare are losing their Medicaid coverage for critical health care services, such as dental, vision, and transportation, and those with only Medicaid are unable to access any of their health care services with any level of regularity or stability. Connecticut can prevent these onerous consequences by establishing a special income disregard applicable only to aged, blind or disabled individuals and only under the Medicaid program. This will raise the income limit to the same standard that applies to all other adults Medicaid populations in the state.

The current income limits are drastically lower than the income limit for parents and caregivers on the Medicaid HUSKY program, which are currently at 185% of the FPL. How can we justify this discrepancy? Especially when the Department of Social Services has publicly recognized that they are saving more money than they had ever anticipated from the cost shifts to Medicare Part D. They are likely saving even more now as people lose their coverage, and the full state wraparound. SB 528 will correct this perverse outcome and create equity between the income limits for adults on HUSKY and people who are elderly or have disabilities receiving Medicaid coverage.

NAMI-CT 241 Main Street, 5th Floor, Hartford, CT 06106 PHONE: 860-882-0236 FAX: 860-882-0240 www.namict.org 00171*0

We realize that this is a significant investment - but it is an investment in people who are forced to utilize more expensive and acute medical services and whose health will continue to deteriorate if not provided with accessible and stable health care services.

Many people with serious mental illnesses experience decreased access to medical care generally because they are either uninsured or underinsured, have difficulty accessing transportation and primary care providers, and struggle to adhere to medical regimens. People with serious mental illnesses are dying, on average, 25 years earlier than the general population, and the lack of access to appropriate health care is cited as one of the main factors contributing to this serious public health problem. The practical implications of this are that people who can be and are productive in our state, die prematurely due to lack of adequate access to health care (NASMHPD).

This legislation will raise the income limit for Medicaid, thus reducing the reliance on spend-down and preserving health care coverage for people who are "aged, blind, and disabled" in our state.

In addition, HB 6524 would require the Department of Social Services (DSS) to create a plan to involuntarily enroll aged, blind and disabled persons in managed care health insurance plans. The state had to carve out behavioral health services from the Husky HMO's because of their failure to provide "timely, appropriate, and effective care to children with special behavioral health needs" ( May 2005, Commissioner Wilson-Coker, Memo to Appropriations and Human Services Committees). Furthermore, the Commissioner noted that there were "gaps in essential services, care decisions driven by dollars, and a system of services that is confusing and difficult to navigate" and that "the design of the Medicaid Managed Care program may undervalue behavioral health".

HB 6524 would put an even more vulnerable population with significant mental health needs in managed care plans that cannot meet their mental health service needs. Medicare managed care plans should be a lesson to us all about the ineffectiveness of using this model for people who are elderly or have disabilities, "a decade of research has found that enrolled beneficiaries would have cost the program less if they had stayed in the fee-for-service (FFS) sector."1 Every federal study shows that the beneficiaries have a more difficult time accessing services and the plans cost 14% more on average than fee for service.

Thank you for your time and attention to these important issues.

1 Center for Medicare Advocacy, Inc., 2008. "Medicare Overpayments to Pnvate Plans.' 00171*1

30 Bank Street PO Box 350 New Britain, CT 06050-0350 06051 for 30 Bank Street

(860)223-4400 fax (860)223-4488 Testimony of Attorney Julia M. Brown on behalf of Elder Law Section Connecticut Bar Association

In Opposition to sections of SB843 An Act Implementing the Governor's Budget Recommendations Concerning Social Services

Home and Community Based Programs and Services Connecticut Home Care Program for Elders Waivers Money Follows the Person

Human Services Committee March 3,2009

Thank you for the opportunity to provide written testimony on a matter of great importance to the Elder Law Section of the Connecticut Bar Association. There are approximately 500 members in our section and because this matter touches so many of our clients, I am submitting written testimony to highlight its significance. My testimony focuses on our support for home and community based programs and services and efforts to support a rebalancing through the Money Follows the Person Program.

I am an attorney whose practice focuses on the elderly, primarily persons 65 and older, their family members and others with disabilities. I have practiced for over twenty years in this area following my client's preferences for where they want to receive care and services, working hard with them to keep them at home while utilizing the array of services and support available to them. When they have required hospitalization or nursing home care, working to return them to their home at the earliest date possible or helping them find the best care available in our nursing, assisted living and other medical facilities.

My clients all share the desire to make decisions for themselves. They want to express their likes and dislikes and want them considered. They want their family and friends to be involved in helping them remain independent and in receiving the highest quality of care, support and services available and, when possible, they want to pay their own way.

With the exception of the Money Follows the Person program, most of the following programs discussed try to preempt the need for full 24 hour care in a facility by getting care and services in place when it is needed, not having people wait until it is too late, and they require more costly full time 24 hour care.

1

www.ctbar.org 001

While we acknowledge there are conditions and circumstances where 24 hour in-patient care may be the first and the only choice, we also have to acknowledge that as a state we have taken the easier but more costly way of in-patent care as the first and easiest choice rather than fully committing to our home and community based services and waivers. Unfortunately, based on some of the services noted below we seem to retiiming in that way again this session.

Home and Community Based Programs and Services

The Elder Law Section supports legislation that would increase the availability of home and community based services for the elderly and for individuals under 65 whose care is supported thru the many Medicaid waivers in Connecticut. In particular, we ask to eliminate the proposed reductions and caps on spending for 2010 and 2011 to the proposed 2009 limits for the state- funded portion of the program. 1 Funding for the home care services of the home care program was capped in the 1990's and as a result many people did not receive care, their names were waitlisted for a number of years. Some of my clients, as well as many others, were eliminated from the wait list, not by having services provided to them, but by having to be placed into a nursing facility prematurely because they could not receive the lesser amount of care they needed at home that the funded home care program would have provided. Meanwhile, other people just kept under the radar arid somehow "lived" without the care and support.

It takes a number of well-coordinated pieces to keep someone at home in the community. When one of those pieces fails and cannot or is not replaced, that person at home will no longer be able

Governor's Bill 843. An Act Implementing the Governor's Budget Recommendations Concerning Social Services. Sec. 54. Subdivision (1) of subsection (i) of section 17b-342 of the general statutes is repealed and the following is substituted in lieu thereof (Effective July 1,2009): (i) (1) On and after July 1,1992, the Commissioner of Social Services shall, within available appropriations, administer a state-funded portion of the program for persons (A) who are sixty-five years of age and older; (B) who are inappropriately institutionalized or at risk of inappropriate institutionalization; (C) whose income is less than or equal to the amount allowed under subdivision (3) of subsection (a) of this section; and (D) whose assets, if single, do not exceed the minimum community spouse protected amount pursuant to Section 4022.05 of the department's uniform policy manual or, if married, the couple's assets do not exceed one hundred fifty per cent of said community spouse protected amount and on and after April 1,2007, whose assets, if single, do not exceed one hundred fifty per cent of the minimum community spouse protected amount pursuant to Section 4022.05 of the department's uniform policy manual or, if married, the couple's assets do not exceed two hundred per cent of said community spouse protected amount. For the fiscal years ending June 30.2010. and June 30.2011. the caseload for the state-funded portion of the program shall not exceed the caseload level on June 30.2009. (b) The plan developed pursuant to subsection (a) of this section shall detail the structure of the demonstration project, persons served, services to be provided and how they will be provided. The plan shall Include a timetable for implementation of the demonstration project on or after July 1, [2009] 2011. The plan shall ensure that the demonstration project includes, but is not limited to, the provision of the following services through a Medicaid state plan amendment, a new Medicaid waiver or modification of an existing home and community-based Medicaid waiver: Personal care assistance services, twenty-four-hour care, occupational therapy, homemaker services, companion services, meals on wheels, adult day care, transportation, mental health counseling, care management, elderly foster care, minor home modifications, assistive technology and assisted living services. The plan shall ensure that a person participating in the demonstration project receives the level of care and services appropriate to maintain such person in such person's home or community.

2 00 I7U3

to remain there. Their independence is lost, their family and their community lose something, and the cost to the state instantly and dramatically increases. The Connecticut Home Care Program for Elders is one of those critical pieces that we cannot afford to lose or dimmish. We ask you not to limit funding for this program and avoid taking a step backward in the quality of life of our elders; this will not reduce the ultimate cost to our state.

Waivers

Medicaid waiver programs for persons with disabilities under the age of 65 have ongoing waitlists. The Acquired Brain Injury (ABI) waiver is currently on a waitlist and the Personal Care Assistant (PCA) waiver is on a waitlist and has been for a couple years. This means that these individuals either go without services or they must seek costly institutional care. Although the Department of Social Services has requested increases for these programs, no money has been allocated to increase the numbers of residents who would be served by these programs in the community; once again a great loss to the individual, their family and the community.

Money Follows the Person

With respect to efforts to "rebalance" the long-term care system, the Governor's Bill SB843 proposes to significantly limit the number of chronic care transitions under the recently implemented Money Follows the Person. 2

The bill proposes as follows:

• To limit Money Follows the Person transitions of the chronic care waiver population to no more than 2% of the targeted 700 transitions • To defer until July 1. 2011 the proposed timetable for implementation of a demonstration project (known as "MFP 2") to provide the same service array as is being offered under MFP to individuals age 18 and older who are a) institutionalized or at risk of institutionalization; and b) meet CHCPE eligibility criteria 3

Governor's Bill 843. An Act Implementing the Governor's Budget Recommendations Concerning Social Services DSS planned to transition one individual in FY2009,14 individuals in FY2010 and 24 individuals in FY2011 at an average annual cost of $148,260 per year. DSS is projected to spend $2.7 million in year one transition costs for 24 clients in FY2011. Although this represents just underl2% of the approximately 200 transitions anticipated in FY2011 it accounts for over 26% of the costs. To address the extremely costly nature of these clients, DSS states that the operational protocol will be revised to limit the number of transitions under the chronic care waiver to no more than 2% of the 700 clients expected to be transitioned under the demonstration period. By the end of the next biennium, after the bulk of the transitions have occurred under the demonstration period, DSS will reassess this policy to determine where the state's limited resources should best be targeted. 3 Governor's Bill 843. Section 55

3 00 I7UU

• To defer until January 1. 2012 submission by DSS to the legislature of a plan to implement the above demonstration4 • to defer until July 1,2011 establishment of the Long-Term Care Reinvestment Account that was authorized in 20085 • To defer until January 1. 2012 submission by DSS to the legislature of a report on use of the LTC Reinvestment Account funds 6

I thank you for the opportunity to provide written testimony on a matter of great importance to the Elder Law Section of the Connecticut Bar Association. Home and community based programs and services and "rebalancing" through the Money Follows the Person Program are critical not only to our senior members but to those persons with disabilities and to their families and our communities.

The programs we support try to preempt the need for full 24 hour care in a facility and when they cannot eliminate that need to delay that need until it is a necessity not a convenience or a failure of our home based and community supports. Please ensure that we do not lose ground at this time and that we continue to see the costs savings and value of the programs we already have in place.

Thank you.

4 Governor's Bill 843. Section 56 5 Governor's Bill 843. Section 57

6 Governor's Bill 843. Section 58 00171*5

Testimony Human Services Committee Shawn M. Lang 3 March 2009

Senator Doyle, Representative Walker, members of the Committee. I'm Shawn Lang the Director of Public Policy with the CT AIDS Resource Coalition; Connecticut's only statewide organization whose sole focus are the needs of people with HIV/AIDS.

I'm am here to testify against HB6254 and.SB843 which will do untold harm to the \\C>U health of the nearly 11,000 people living with HIV/AIDS across this state; who are among the most medically and socially fragile and vulnerable people in this state.

We work to ensure that the nearly 11,000 people living with HIV/AIDS in our state have the housing, care and supportive services they need in order to live their lives in dignity. I'm here to testify against the draconian health care cuts the Governor is proposing.

In her state of the state speech, the Governor said that "We must care forour most vulnerable." People with HIV/AIDS are among the most medically fragile and vulnerable people and this budget must not and cannot be balanced on their backs!

All of the proposed cuts - dental care, co-pays, eliminating medical interpreters, vision cares and non-emergency medical transportation, the Part D wraparound, eliminating over-the-counter drugs, requiring PA for high cost drugs, etc., will do more to unnecessarily create additional barriers for people living with HIV/AIDS. And when- people face these types of barriers, they get sicker and end up with much higher cost illnesses, unnecessary use of emergency rooms, and longer hospitalizations.

Instituting co-pays has been proposed numerous times and it simply does not work. In a recent research study of people living with HIV/AIDS in AIDS housing programs, the average income was $640 per month.. Many people take anywhere from 5-14 medications per day; some for HIV, others to mitigate the side effects of their HIV medications, and still others for co-occurring disorders. Implementing co-pays means that people won't get their meds simply because they cannot afford to do so. If a person skips even one dose of their HIV meds, their virus can mutate requiring a complete change in their combination therapies which may or may not even exist.

Eliminating all but emergency dental care will be devastating to people with HIV/AIDS. Already difficult to access, in the greater Hartford area there are only two places where people with HIV/AIDS go for dental care — UCONN and the Hartford's Gay and Lesbian Health Collective. The lack of healthy, functioning dental health can interfere with quality of life, complicate the management of medical conditions, and create or exacerbate nutritional and psychosocial problems. Prevention and early detection of oral disease and prompt referrals to dental care providers can often mitigate the debilitating and painful effects of untreated oral disease. 80171*6

Requiring PA for high costs drugs will result in a delay for people getting their meds. As I stated before, that simply cannot be allowed to happen to people living with HIV/AIDS. A couple of quick examples of the cost of HIV meds are $894 for a one month's supply for Truveda; $876 for a month's supply of Reyataz; and $274 for Norvir.

Many people living with HIV/AIDS in our state are also incredibly socially fragile and have poor literacy skills and lack the ability to navigate through an already complicated system of care. And even for those who have the skills face a number of other challenges. As a friend of mine who has been living with HIV/AIDS for many years said to me, "I don't know of any other illness that creates the same level of social stigma, medical crisis and bureaucratic chaos."

All of this will place greater and more unmanageable hoops to navigate not only for people whose health care depends on these programs, but it will add to the hoops that their multiple doctors and pharmacists have to jump through as well; thus, creating an even more burdensome health care system.

I also want to oppose the Governor's "delaying" of the HIV/AIDS Home and Community Based Health Care Waiver. This waiver would SAVE the state $1.2 million over two years, and $4 million in five years. And benefit approximately 100 people. Why delay something that is replicable, evidence-based and will save funds?

Finally, these proposed cuts will cost the state up to $1.3 BILLION in increased Medicaid reimbursement. Health care cuts will only result in intensifying the significant barriers people already face. We urge you to restore these cuts.

Thank you. STATE OF CONNECTICUT HUMAN SERVICES COMMITTEE

SB 843. AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECCOMENDATIONS CONCERNING SOCIAL SERVICES

HB 6379. AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECCOMENDATIONS CONCERNING MAXIMIZATION OF PHARMACY REBATES

March 3, 2009

Statement of the American Society of Consultant Pharmacists

Rep. Walker, Sen. Doyle and members of the Human Services Committee, thank you for the opportunity to speak with you today. My name is Larry Sobel and I am testifying today as the President Emeritus of the American Society of Consultant Pharmacists (ASCP).

ASCP empowers pharmacists to enhance quality of care for over 30,000 of the state's most frail citizens through the appropriate use of medication. Our expertise lies in geriatric pharmacotherapy and the unique medication related needs of seniors and long- term care residents and we are patient-centered advocates for seniors at risk for medication related problems. In essence, we ensure that patients in Connecticut's nursing homes, group homes and other long-term care settings are getting the appropriate medication and care that they deserve.

The Governor's proposed budget for the Department of Social Services proposes severe cuts to pharmacy within the state. These proposed changes lessen the reimbursement rates to pharmacists, lessen the dispensing fees to pharmacists, eliminate coverage for most over-the-counter drugs under Medicaid and offer several other troubling initiatives. For example, eliminated access to Benzodiazepines (Valium, Ativan) will just shift those costs to more expensive alternatives which are covered.

In sum, the following cuts to pharmacy were included in the Governor's proposed budget:

• AWP reimbursement to AWP -15% (from minus 14%) • Dispense fees to $2.15 (from $3.15) • MAC: AWP - 50% (from AWP minus 40%) • Co-pays for Medicaid services (capped at $20 per month for pharmacy services) • Discontinue payment for non-formulary drugs under Medicare Part D • Eliminate coverage of most OTC drugs under Medicaid • Put mental health related drugs on Preferred Drug List • Require Prior Authorization for high cost drugs 00 i 7U8

• Tighten early refill criteria under DSS pharmacy programs

These proposed cuts would be devastating to an industry that has been continuously cut from the state budget for the past decade and has not had a fee increase in over 20 years. Coupled with the increasing cost of doing business within the state, these cuts would put a severe financial strain on many pharmacies. Pharmacists are still the most easily accessible health care professional. However, with fewer dollars there are fewer professionals and therefore fewer services.

I thank you for your time and attention and would be happy to entertain any questions at this time.

Thank you. 00171*9

STATE OF CONNECTICUT OFFICE OF THE CHILD ADVOCATE 999 Asylum Avenue, Hartford, Connecticut 06105 Jeanne Milstein Testimony of Jeanne Milstein, Child Advocate Child Advocate Human Services Committee March 3, 2009

Senator Doyle, Representative Walker, and Members of the Human Services Committee. Thank you for the opportunity to testify about HB 6525, An Act Establishing a Task Force to Study Reorganization of the Department of Children and Families and to testify in opposition to HB 6523, An Act Concerning Licensing of Adolescent Substance Abuse Treatment Facilities..

The bill includes two charges for the task force. The first charge would be to evaluate the department's current policies, practices and procedures including whether DCF may suspend visitation prior to a court hearing. Connecticut General Statutes § 17a-10a currently requires that DCF ensure that any child in the care and custody of the department under an order of temporary custody or an order of commitment is "provided visitation with such child's parents and siblings, unless otherwise ordered by the court." In my view, this language already requires that DCF seek a court order prior to suspending visitation and is the appropriate policy. If the committee's goal is to ensure that visits are not suspended without a court hearing, I would suggest consideration of modification of section 17a-10a of the General Statutes to clarify that such a hearing is required, rather than charging a task force to review the issue.

The second charge of the task force would be to consider changes in the structure of DCF. As I testified at the investigative hearings regarding DCF in October and November, I believe DCF is an agency in peril. I agree that bold action must be taken. I would urge you, however, to move beyond the idea of structural change of the Department and look at whether DCF has the right ... A*. people with the rightskill s in the rightposition s to effect badly needed fundamental change. nw

There are pockets of progress at DCF. Much of this progress, however, has occurred in the context of a crisis or in response to external pressure, rather than as a result of ongoing systematic efforts of self-evaluation and improvement. For example, much of the progress made over the last decade has been in response to the constant scrutiny of the Juan F. Consent Decree and Exit Plan. Last summer, DCF was on the brink of federal receivership because of sustained noncompliance with the Juan F. outcome measures. Only under the threat of receivership did DCF decide to conduct a high level review of all children with no hope of ever living with a family [those with a permanency goal of Another Planned Permanent Living Arrangement (APPLA)] or to finally release a plan to recruit and retain the necessary pool of foster homes. Only under pressure from OCA did DCF close Lake Grove last fall, despite nearly a decade of persistent and known concerns about the health, safety, and well-being of children placed at the facility. And most recently, only in response to the tragic death of Michael B. did DCF take action to stop the practice of keeping paper files on DCF employees accused of abuse rather than entering those cases into the DCF database as required in every other case.

I am gravely concerned about the chronic and substantially similar patterns of deficient leadership and management, inadequate oversight, and poor long-term planning for individual children and for all children and families served by DCF found in investigations and evaluations

Phone (860) 566-2106 • Toll Free (800) 994-0939 • Fax (860) 566-2251 Web Site: www.ct.gov/oca • E-Mail: [email protected] An Affirmative Action / Equal Opportunity Employer 001750

by my office and numerous others including the Office of the Attorney General, and the Legislative ProgTam Review and Investigations Committee.

I am equally troubled by the persistent slow pace of implementation of much needed change. During my tenure as Child Advocate, I investigated the harmful conditions for children at Haddam Hills, the Connecticut Juvenile Training School (CJTS), Riverview Hospital, and more recently at Lake Grove and Stonington Institute, and found that DCF was often aware of these conditions and failed to act to protect children. These investigations reveal repetitive and similar problems and inadequate response. They also confirm that many of the people in leadership positions at DCF during these crises continue to guide the agency in leadership positions today. After seventeen years under the Juan F. Consent Decree, the 2008 CFSR preliminary findings still rate DCF significantly below national standards for, permanency outcomes and raise significant concerns about work quality being driven by individual staff rather than an agency- wide practice model.

During the past two years, OCA has raised concerns about DCF's process related to the implementation of a statewide Differential Response System (DRS) in 2009. DCF initiated its most recent effort in 2006 without a careful look at the reasons for the failure of its citywide DRS pilot in 2003. In 2004, evaluators concluded that the pilot failed and cited changes in leadership related to reorganization at DCF, the lack of clear accountability mechanisms, and inadequate involvement and commitment of community-based providers as reasons contributing to failure. These factors continue to exist today as DCF moves forward with a statewide DRS initiative.

In the three years since DCF's own consultants cited an urgent and compelling need to create a continuum of services for girls, the most tangible girls initiative is a plan for an 18-bed secure facility for delinquent adolescent girls. Almost no planning has gone into developing the continuum of services that is so desperately needed and recommended by numerous experts and stakeholders. Last summer, my office released a report revealing the child welfare to prison pipeline. Over a two year period, 325 girls under age eighteen were admitted to Connecticut's maximum-security prison for adult women. Our investigation found that over 90% of these girls had either current or historical involvement with DCF, a significant number with DCF cases that had been closed within the year prior to incarceration. And nearly 98% of these girls entered and remained in adult prison without ever being convicted of a crime. My staff also discovered that DCF has been noncompliant with its own policies related to incarcerated girls and its memorandum of understanding with the Department of Correction. While Commissioner Lantz promptly responded and sent a detailed action plan for the Department of Correction, DCF's response has been unsatisfactory.

For all of these reasons, I believe that today's DCF is an agency in peril. It has suffered from a chronic lack of effective leadership and management, at all levels and across all bureaus. Until this deficiency is corrected, DCF will continue to struggle to meet the needs of children and families and those children and families will suffer the consequences.

I have great concerns, however, about the bill as written and recommend today, as I did during the investigative hearings in October and November, that the legislature conduct a broad and 001751

deep leadership audit rather than focusing on structural change. I see no reason to believe that structural change alone, including removal of certain statutory mandates, can transform ineffective managers into effective leaders that can execute and sustain fundamental change in outcomes for our children. If anything, separately housing the programs and services needed to assess and address the needs of a "whole" child requires an even greater confidence in leadership talent to communication and collaborate across state agencies. A leadership audit, as outlined in HB 6420. An Act Concerning a Leadership Audit of the Department of Children and Families, would be a focused look at leadership at all levels to ensure that the agency has the right people with the right skills in the right places to bring about the kind of fundamental change that is needed. Rather than focusing on structure, it would focus on making sure those in charge have the skills, training, experience, and talent to get the job done. This kind of analysis of DCF has never, been done and I believe it is the critical next step and the most effective action that we can take to address the agency's long-standing pattern of failure.

I oppose HB 6523, An Act Concerning Licensing of Adolescent Substance Abuse Treatment Facilities. Currently, substance abuse treatment facilities for children and youth are dually licensed, both by the DCF and the Department of Public Health (DPH). This bill as written would exempt such facilities from licensure by DCF but does nothing to transfer the licensing responsibilities currently administered by DCF fromDC F to DPH. Given that the present DPH licensing role is very narrow, the bill as written would leave significant gaps in licensing and oversight, placing children at risk of harm.

In the course of more than one investigation conducted by my office, we have learned that DPH facilities inspectors take a very narrow view of DPH's licensing responsibilities. Our investigation of Stonington Institute is demonstrative. Our investigation revealed serious concerns, including lack of adequate medical care and involuntary intramuscular injections of medication. While DPH took action with regard to some violations, DPH facilities inspectors viewed DPH's role as limited to substance abuse treatment,only. This is significant because substance abuse facilities for children and youth necessarily include components not involving substance abuse treatment as defined by DPH. It is not wise or good policy to remove the present DCF licensing authority without fransferring it to another agency. Given the potential risk of harm to children, I oppose HB 6523.

I would encourage, however, a deeper look at licensing of programs and facilities that provide care and treatment to children. Providers find that they often must obtain a license from more than one agency. Multiple inspectors from different agencies inspect the facilities. Communication between the various inspectors is lacking and inspectors from one agency often presume that inspectors from a different agency are responding to inadequacies outside of their purview. Some inspectors do not have appropriate training, skills, or experience. I would encourage you to consider methods to improve the quality of licensing and oversight; identify areas of overlap and methods to increase efficiency in the licensing process, both from an administrative and provider point of view; and ensure that those charged with licensing have appropriate expertise. I would be happy to work with the Committee on such an endeavor.

Thank you. 001152

COMMISSION OFFICERS Connect/cut General Assembly HONORARY MEMBERS Susan O. Storey, Omr Connie Dice Tanya Meek, Vvs Omr Patricia T. Hendel Adnenne Farrar Hbuel, Seoaoy Patricia Russo Elizabeth Donohue, Tiesurer Permanent Commission on the Status of Women LEGISLATIVE MEMBERS COMMISSIONERS The Slate's leading fane tor women's equality Senator Andrew J. McDonald Yvonne R, Davis Senator John A. Kissel Barbara DeBapaste Representative Michael P. Lawbr Carrie Gallagher Representative Arthur J. O'Neill Melanie OBnen Jean L Rexford EXECUTIVE DIRECTOR Denise Rodosevtch Teresa C Younger Cindy R. Slane Patricia EM Whitcombe Cecilia J. Woods

Testimony of Natasha M. Pierre, JD, MSW Legislative Director The Permanent Commission on the Status of Women Before the Human Services Committee Tuesday, March 3,2009

Re: S.B. 843, AA Implementing the Governor's Budget Recommendations Concerning Social Services .H.B. 6610, AAC Medicaid Income Limits for Aged, Blind and Disabled Persons

Senator Doyle, Representative Walker and members of the committee, thank you for this opportunity to provide testimony on the Governor's recommendations concerning social services, and H.B. 6610. AAC Medicaid Income Limits for Aged, Blind and Disabled Persons. I am also testifying on behalf of the Connecticut Women's Health Campaign (CWHC), a broad coalition of organizations committed to and working for the health and well-being of Connecticut women over their lifespan; and the Young Women's Leadership Program (YWLP), which highlights the concerns of women ages 18 to 35.

S.B. 843, AA Implementing the Governor's Budget Recommendations Concerning Social Services

Once again during a time of economic crisis, a budget is proposed that attempts to solve a significant portion of our state budget problems by reducing or elimmating health care for poor families. The Governor proposes to cut $273 million from health care programs for families and individuals. The proposed cuts would limit access to health care for pregnant women, parents in HUSKY A, children in HUSKY B, senior citizens and others who rely on Medicare Part D for prescription drugs, and recent legal immigrants. Our state budget deficit is everybody's problem, and should not be solved by taking health care away from low-income families and immigrants. GO i 753

PCSW Testimony Before the Human Services Committee March 3,2009 Page 2

Medicaid, the state-federal health coverage program for the poor, provides over 20 million low- income women with basic health and long-term care coverage.1 While often not considered to be a women's health program, women comprise 69% of adult beneficiaries nationally,2 and 71% of adult beneficiaries in Connecticut.3 In 2005,10% of all women and 22% of low-income women had health insurance through Medicaid.4 For these women, Medicaid covers a wide range of health services, including reproductive healthcare, care for chronic conditions and disabilities, and long-term services. In addition, SAGA medical is a lifeline for almost 30,000 residents, and women comprise 40% of those with SAGA medical coverage - or about 12,000 of those with SAGA.

The majority of Medicare, ConnPACE and nursing home residents are also women. Medicare provides a health and financial safety net for virtually all older Americans and for many people with disabilities who are under the age of 65. Because women have longer life expectancies than men, more than half (57%) of those covered by the program are women. By the time women are 85 and older, they account for nearly three-quarters of all beneficiaries.5 The security that Medicare provides through its coverage of health benefits is especially important to women because with their longer lifespans, they are more likely to have multiple chronic conditions. Medicare covers the costs associated with hospital and physician care, and other basic health services, but does not cover the outpatient prescription drugs necessary to manage their conditions. Because of their lower incomes and greater health needs, women on Medicare spend a significant share of their incomes on prescription drugs.

We urge you to reject the following budget cut proposals:

Suspension of Reproductive Health Services The Governor's budget proposes to suspend supplemental payments to FQHC's and hospitals for unreimbursed costs for pregnant women to save $4M over the biennium.

Implementing Co-pays, Premiums, and Access to Prescription Drugs The Governor's budget proposes to implement co-pays and premiums for Medicaid, HUSKY A adults, HUSKY B, and increase the annual enrollment fee for ConnPACE to save approximately $40.2M over the biennium. It also proposes to limit access to prescription drugs by enforcing prior authorization for certain drugs, including mental- health related drugs in the Preferred Drug List System, and eliminating Medicaid coverage for over-the-counter drugs to save $23.9M over the biennium.

1 Kaiser Family Foundation. Medicaid's Role for Women, 2007 Update. 2 Ibid. 1 National Women's Law Center Cuts to Medicaid Will Hurt Connecticut, May 2005. * Kaiser Family Foundation. Medicaid's Role far Women, 2007 Update, s Ibid. DO I75U

PCSW Testimony Before the Human Services Committee March 3,2009 Page 3

Eliminating Health Care for Recent Legal Immigrants

The Governor's budget proposes to eliminate health care for recent legal immigrants to save $48.1M over the biennium. Now is not the time to cut healthcare services. Especially when the federal Children's Health Insurance Program legislation will provide new funding for children and pregnant women in HUSKY A and HUSKY B who are recent legal immigrants.

Implementing the HIV/AIDS Community-Based Services Waiver

The Governor's budget proposes to delay implementation of the HTV/ATDS community- based services waiver for a savings of $5.6M over the biennium. Connecticut ranks ninth in the nation in AIDS cases per capita and in 2005 had the fastest growing rate of AIDS in New England. Since 1980,14,399 people in Connecticut have been diagnosed with AIDS, and there are currently 8,821 people living with HTV/AIDS in the state.6 HTV/AIDS is one of the leading causes of death for women in the state of Connecticut.7 Of the 14,487 reported AIDS cases- 28% are female, 36.7% are Biack, and 25.5% are Hispanic.8 Of the reported new AIDS cases - 35.9% are female, 33% are Black, and 32.6 % are Hispanic.9 Racial and ethnic populations have been disproportionately affected by the HTV/AIDS epidemic in Connecticut. Although Blacks/African-Americans and Hispanics represent 9.1% and 9.4% of Connecticut's population/0 62.3% of reported AIDS cases and 65.9% of reported HTV infections are among these populations.11 Among women, the disparities are even more dramatic, with Black/African-American and Hispanic women representing 70.2% of females with AIDS, and 72.3% of females with HTV infection.12

Eliminating Medicaid Coverage for Medical Interpreters and;

Implementing a Medical Necessity and Appropriateness Definition

The Governor's budget proposes to eliminate Medicaid coverage for medical interpreters for a savings of $11.5M, and implement a medical necessity and appropriateness definition for a savings of $13.5M. The combined effect of eliminating $25M from the Medicaid plan will impact access to healthcare negatively. The Legislature has debated

'Ibid. 7 U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Mortality by State, Rflce/Etfimcify, Gender, Age and Causes, 1999-2002, accessed 9/05 at httrW/www.cdcgov/nchs. 8 Connecticut. Distribution of Reported AIDS Cases. The Henry F. Kaiser Family Foundation accessed 2/07 at www.statehealthfacts org. 'Ibid. ,0 U.S. Census Bureau, Census 2000, Table DP-a Profile of General Demographic Characteristics 11 CT Department of Public Health. CT HIV/AIDS Statistics through December 31, 2004, avadable at www dph.state.ctus/BCHfinfecnousdise/2003/final%20pages/topic index X.htm. accessed on 1/19/06 "Ibid. 001755

PCSW Testimony Before the Human Services Committee March 3,2009 Page 4

these two issues for the past few years, and each year the Appropriations Committee wisely decided not to take the Governor's recommendation. Inability to communicate with a health care provider can result in serious injury or death. An estimated 22,000 Medicaid recipients in Connecticut face an additional barrier to accessing health care due to limited English proficiency. Enforcing a medical necessity and appropriateness definition would also impede access to health care, and deprive Medicaid recipients of medical care that they need to lead healthy and productive lives. Although it may appear to be a technical matter, in actuality it would result in limited access to health care, especially for specialty care and chronic conditions. The administrative hurdles mat are erected for commercial plans may prove insurmountable for clinicians participating in Medicaid. The result would be reduced access to care for the poorest and neediest families in Connecticut. Commercial policies use such "technical" provisions to require pre-approval for on-going medical treatments. The current definition is set up not only to ameliorate medical conditions, but to maintain a patient's health status. There is no commercial equivalent for this and it was designed in order to address chronic needs as well as the special barriers that poverty places on access to health care. Connecticuf s seniors, disabled and low-income individuals cannot pay for the health services that are denied by Medicaid. In the end, it is likely that the state could incur more costs as individuals become sicker and the services more expensive.

Eliminating Non-Emergency Medical Transportation Under SAGA The Governor's budget proposes to eliminate vision care and non-emergency medical transportation in SAGA for a savings of $2.2M over the biennium. This critical benefit is essential to ensuring access to care for the tens of thousands of very low income residents who rely on SAGA for medical care and must travel long distances to avail themselves of partitiparing providers.

Most of these measures have been proposed and rejected many times in the past. Some have been adopted then rejected when their impact became clear. Some have been implemented and then rescinded. Experience has shown that cutting healthcare services in times of economic crisis does not solve the problem.

Adequate health insurance is critical to helping low-wage mothers stay employed. During the state fiscal crisis of the early 2000s, many publicly funded work support programs were either reduced or eliminated, with those working often the first cut from the programs. A study conducted by the Center for Economic and Policy Research examined how patterns of Medicaid and childcare access affect women's employment outcomes.13 It found that less than a quarter of

13 Heather Boushey, Ph.D. The Effects on Employment and Wages When Medicaid and Child Care Subsidies are No Longer Available. Center for Economic and Policy Research, January 26,2005. < http7/wvw.cepr.net/publicahons/Effects_on_employment_wages_without_medicaid_ child_care_subsidies.htm> 001756

PCSW Testimony Before the Human Services Committee March 3; 2009 Page5

women who stopped receiving Medicaid in 2002-2003 went on to receive health coverage from employers. In addition, those who left Medicaid in 2002-2003 were less likely to receive employer-provided health insurance .than those who left in 1997-1998. Further, women who lost Medicaid without receiving employer-provided health insurance were nine times as likely to leave the labor market, compared to women who moved into employer-provided health insurance. Many working families cannot afford to purchase health insurance, and only those who very recently left welfare have any likelihood of receiving public benefits. This creates a hole in the safety net for low-wage working women that do not receive welfare, who are not likely to have access to'employer-provided health insurance or to have sufficient income to purchase health insurance in the market.

Further, The federal government has expanded funding for Connecticut's Medicaid and HUSKY programs by at least $1.3 billion in stimulus payments. The federal government will pay more than half the costs of the Medicaid program by increasing the federal share from 50% to at least 56.2%. If the state decides to use the stimulus money to fill the budget gap, rather than pay for healthcare costs, it should at least maintain benefits for the recipients under Medicaid and other state health insurance programs for low-income residents.

H.B. 6610, AAC Medicaid Income Limits for Aged, Blind and Disabled Persons

PCSW urges passage of H.B. 6610, which would require DSS to exercise existing federal options to permit the use of less restrictive methodology in determining the income limit when making Medicaid eligibility determinations for persons who are aged, blind or disabled.

Women represent 58.9% the total elderly population in the state of Connecticut,14 and 15.13% of women in poverty in the state.15 Women also represent 59% of all people 65 and older in Connecticut who rely on social security benefits; without social security, 46% of elderly women in Connecticut would be poor.16 This limited- or low-income makes it very likely that they will seek services through the Medicaid program.

We urge the Legislature to provide expand eligibility through this bill. We appreciate your attention to these matters.

14 U.S. Census Bureau, 2006 Fact Finder 15 U.S. Census Bureau Current Population Survey, 2004 16 Social Security Administration, Women and Social Security, National Women's Law Center, Social Security Women, Children and the States, 2005. 001757

Connecticut General Assembly

Permanent Commission on the Status of Women

The State's leading force for women's equality

18-20 Trinity St, Hartford, CT 06106 • 860/240-8300 • [email protected] • www.cga.gov/pcsw

Young Women and Reproductive Health

Reproductive health is an important issue to young women ages 18-35. The majority of sexually transmitted infections occur in people under 35. Additionally, during these years many young women decide to start families, making access to reproductive health services critical to a healthy pregnancy. Below are some key facts about young women and reproductive health.

Sexually Transmitted Infections (STIs)

• Of the 18.9 million new cases of STIs each year, 9.1 million (48%) occur among 15-24- year-olds.' • Although 15- to 24-year-olds represent only one-quarter of the sexually active population, they account for nearly half of all new STIs each year." • Human papillomavirus (HPV) infections account for about half of STIs diagnosed among 15- to 24-year-olds each year. HPV is extremely common, often asymptomatic and generally harmless. However, certain types, if left undetected and untreated, can lead to cervical cancer."' • A recentCD C survey found that only 10% of women ages 18 to 26 had received the HPV vaccine as of summer 2007." • Many STIs are "silent," in that they cause few symptoms. Without symptoms, many STIs can be diagnosed only through testing, yet routine screening is not widespread."

Pregnancy

• The average age of a first-time mother is 252." • The average U.S. woman is expected to have 32 pregnancies in her lifetime at current pregnancy rates; black and Hispanic women are expected to have 42 pregnancies each, compared with 2.7 for non-Hispanic white women.™ • 43,017 Connecticut women gave birth over the past 12 months.vm • According to the CDC, nearly 38% of pregnancies in 2004 were to women under age 25, down from nearly 43% in 1990. The proportion of pregnancies among teens under age 20 dropped from 15% in 1990 to 12% in 2004." • The percentage of babies bom premature (before 37 weeks gestation) has increased nationwide by more than 15% between 1995 and 2005, to a high of 12.7%.x

y& llwoxBoaiLjo i tins \A |i«titpoa t Icof^f fillip proflfai 001758

• Women are more likely to have a premature baby if they: have no health insurance, receive no prenatal care, have diabetes or hypertension, are overweight, smoke and/or if they eat poorh/.111 • Premature births cost society more than $26 billion a year. This includes money spent on medical care for short- and long-term health conditions, educational expenditures and lost productivity.1"

Disparities in Reproductive Health

• The rate of chlamydia among black women (1/22 per 100,000) was nearly eight times the rate among white women (227 per 100,000). The rate among African-American men (645 per 100,000) was more than 11 times that of white men (573 per 100,000).™ • African-Americans remain the group most heavily affected by gonorrhea. In 2004, the gonorrhea rate among African-Americans was 19 times the rate among whites.™' • Although African-Americans make up only approximately 13% of the U.S. population, they accounted for one-half of the estimated new HTV/AIDS diagnoses in 2004." • There are racial/ethnic differences in sexual activity rates. African-American high school students are more likely to have had intercourse (67%) compared to White (44%) and Hispanic students (52%). Sixteen percent of African-American high school students and 8% of Latino students initiated sex before age 13 compared to 4% of White students."1 • By age 20,32% of Latinas, 24% of African-American women and 21% of Native Americans have had a birth, compared to 11% of White and 7% of Asian-American women.""

ReamrrBTdadans The Young Women's Leadership Program supports efforts to ensure the right to access and receive comprehensive reproductive health services including proposals to provide sexual assault nurse examiners (SANE's) in hospitals across Connecticut. Additionally, the program supports efforts to address racial and ethnic disparities in reproductive health care.

: Ecooomc Qttnaemtics- 2005-2007 00I759

CONNECTICUT WOMEN'S HEALTH CAMPAIGN E-News January 2009

Permanent Commission on ths Status of Women

Members 2009

Advocacy for Patients with Chronic Illness, Inc. African American Affairs Commission American Heart Association Coalition for Choice Connecticut Association for Human Services Connecticut Commission on Aging Connecticut AIDS Resource Coalition Connecticut Association for Nonprofits Connecticut Breast Cancer Coalition Foundation Connecticut Coalition Against Domestic Violence Connecticut Community Care, Inc. Connecticut Primary Care Association Connecticut Sexual Assault Crisis Services, Inc. Connecticut Voices for Children Connecticut Women's Consortium Connecticut Women's Problem Gambling Project Hartford Gay & Lesbian Health Collective Health Care for All Coalition Latino and Puerto Rican Affairs Commission Legal Assistance Resource Center of CT MATCH Coalition, Inc. NARAL Pro-Choice Connecticut National Council of Jewish Women National Alliance on Mental Illness, CT (NAMI-CT) Permanent Commission on the Status of Women Planned Parenthood of Connecticut, Inc. The Paul and Lisa Program University of Connecticut Health Center, Celebrate Health Programs Witness Project of Connecticut, Inc. Women and Family Life Center of Guilford YWCA Northeast Regional Council 001760

STATE OF CONNECTICUT DEPARTMENT OF CHILDREN AND FAMILIES PUBLIC HEARING TESTIMONY ^^S^J-~< HUMAN SERVICES COMMITTEE MARCH 3, 2009

.S.B. No. 843 AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECOMMENDATIONS CONCERNING SOCIAL SERVICES

The Department of Children and Families supports S.B. No. 843 AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECOMMENDATIONS CONCERNING SOCIAL SERVICES. This bill makes a number of changes to implement the Governor's budget, including a statutory change in section 3 of the bill to reflect the proposed closure of High Meadows, a DCF-operated residential facility in Hamden.

High Meadows currently serves 36 children and is the oldest and smallest of the four DCF facilities. Approximately 20 of the 36 are individuals with developmental disabilities and the staff at High Meadows do an outstanding job in meeting their needs. However, over the last several years, the Department has moved to serve children in their communities rather than in large congregate settings and we have been successful in greatly reducing the number of children who require residential treatment. We anticipate that the downward trend in residential census will continue and we believe that the reduction in utilization is appropriate and will result in better outcomes for the children we serve. The move to close High Meadows is consistent with this trend.

The closure of the facility will result in an annual operating savings of $6 million and a significant cost avoidance of $11.8 million in capital improvements.

H.B. No. 6523 (RAISED) AN ACT CONCERNING LICENSING OF ADOLESCENT SUBSTANCE ABUSE TREATMENT FACILITIES

The Department of Children and Families offers the following comments regarding H.B. No. v . ,< 6523 AN ACT CONCERNING LICENSING OF ADOLESCENT SUBSTANCE ABUSE VD\fl&b TREATMENT FACILITIES.

This bill would amend section 17a-145 of the general statutes to exempt those residential substance abuse treatment facilities that are licensed by the Department of Public Health (DPH) from also being licensed by DCF. Currently, four facilities: the Children's Center of Hamden; Midwestern CT Council on Alcoholism, Inc.; New Hope Manor, Inc.; and Rushford Center, Inc., are dually licensed.

We recognize that potential conflict issues regarding state agencies' licensure role and function have arisen in recent years, and that during these difficult economic times the Legislature is 001761

naturally interested in evaluating any potential redundancies in state agency regulatory activities. We are happy to work with members of the committee and DPH on making the best choices regarding the licensing of these and other programs and services that serve children.

Please note that bill has an incorrect reference to the DPH licensure statute. The correct reference is section 19a-490, not section 19a-491.

H.B. No. 6525 (RAISED) AN ACT ESTABLISHING A TASK FORCE TO STUDY THE REORGANIZATION OF THE DEPARTMENT OF CHILDREN AND FAMILIES

The Department of Children and Families offers the following comments regarding H.B. No. 6525 AN ACT ESTABLISHING A TASK FORCE TO STUDY THE REORGANIZATION OF THE DEPARTMENT OF CHILDREN AND FAMILIES.

This bill would established a task force to study the Department of Children and Families, including: (1) an evaluation of the department's policies, practices and procedures, including, but not limited to,.whether the Commissioner of Children and Families may suspend a child's visitation with his or her parent before an evidentiary hearing has occurred on the issue of visitation; and (2) consideration possible changes in the structure and organization of the department, including whether any functions of the department should be transferred to other departments or agencies.

We understand that this bill is likely intended to serve as a vehicle to address issues raised during the joint hearings of the Select Committee on Children and the Human Services Committee last fall. There are a number of similar bills before the Select Committee on Children, including: S.B. No. 878 An Act Concerning the Prevention Role of the Department of Children and Families; S.B. No. 879 An Act Concerning Oversight and Reorganization of the Department of Children and Families; H.B. No. 6419 An Act Concerning Transparency and Accountability of the Department of Children and Families; ji.B. No. 6420 An Act Concerning a Leadership Audit of the Department of Children and Families. There is also H*B. No. 6352 An Act Concerning Oversight of the Department of Children and Families, which was heard by the Human Services Committee on February 10* and remains before your committee.

The Department appreciates many of the concerns raised by Committee members and looks forward to working collaboratively to achieve consensus on a number of issues. We have already reached out to the leadership of both committees and welcome the continued dialogue.

We recognize that the task force membership in these bills may just serve as a "placeholder," but we believe that if you are to establish a task force or multiple task forces, that they should include individuals with expertise in the subject area and should include both executive and legislative branch appointments.

As you consider the establishment of a new task force, we would also point out that over the past three decades, there have been at least 11 studies conducted by either the Legislative Program Review and Investigations Committee or management consultants regarding the Department of

2 001

Children and Families. In fact, the Department's current organizational structure is, in part, based on prior recommendations from such studies. The following is a brief summary of these studies:

Year Title/Author Key Points 1977 A Critical Review of Agency problems related to: Mandates and • striking gap between department mandates and resources provided Resources in the • transfer of authority incomplete; agency lacks full control over some key Connecticut management functions; no mechanism for resolving interagency conflicts Department of Children • lack of commitment on part of executive and legislature to improve agency and Youth Services by performance the Review Team of the Management issues. DCYS Advisory Council • crisis management operatton; no evidence of commitment to long range planning or improved service delivery • functions not integrated; services remain three largely separate tracks • basic management documents nonexistent; management authority ambiguous and overlapping • staff turnover high, morale low, relationships with providers poor • information systems inadequate, lack information needed for informed decision making, cannot assess worker, contractor performance or client progress

To address management issues recommend- • detailed management plan endorsed by governor, shared with legislature • clear table of organization, comprehensive budget with new categories related to policy, and automated information system capable of monitoring performance • advisory groups be given data to assess agency effectiveness, progress in implementing plan

1978 Study of Juvenile The committee found- Justice in Connecticut • virtually no analysis is done by DCYS to indicate what treatment methods by the Program Review work with what kinds of delinquents and Investigations • DCYS ability to oversee Youth Service Bureaus is questionable Committee • A major problem of the Long Lane School is that of runaways and the Long Lane treatment manual contains no goal statement on the role or importance of maintaining a secure facility • Pnvate agencies play a crucial role m addressing Connecticut's juvenile delmquency problem and are essential to the development of a continuum of needed services • DCYS reimbursement of private providers of juvenile delinquency services is madequate and inefficient • Juvenile needs assessments are lacking • DCYS Office of Evaluation, Research, and Planning has not demonstrated its capacity to effectively evaluate programs • There are few additional standards, beyond licensing, for pnvate providers

To address these issues, the committee recommended. • More analysis of the effectiveness of various programs designed to treat juvenile offenders should be undertake by the department • The Law Enforcement Assistance Administration should provide technical assistance to DCYS to help the agency develop evaluation procedures that could be integrated into the department's system for managing funds • DCYS detention staff job classifications and salaries should be upgraded 001763

• Information about juveniles must be maintained and tracked in a more effective manner • DOC should be utilized by the department to provide technical assistance to Long Lane on security and custody matters • Long Lane's primary role should be limited to the treatment of a small population requiring secure custody • DCYS should articulate, as part of its master plan, clear policy on the use of private resources, including the development of programs equipped to handle difficult cases • DCYS should provide more reasonable cost related payments for pnvate delinquency treatment services • DCYS should exercise aggressive leadership to stimulate the development of family-centered programs in the pnvate sector • DCYS should require private programs to provide transitional aftercare services following release from residential treatment and reimbursement rates should be adjusted to reflect this additional requirement • A written plan should be developed by the DCYS Office of Evaluation, Research, and Planning which establishes pnonties and specifically shows how and when major tasks will be accomplished • DCYS must update licensing standards, hire more qualified workers, and improve workers' training • DCYS must improve its communications with DSS, DMH, DMR, and the Juvenile Courts

1978 DCYS: A Program The committee found. Review by the Program • DCYS managers are unable to effectively manage the operations of the Review and department or to fully comply with statutory mandates Investigations • Management information systems are ineffective Committee • Projections of caseloads and staffing requirements are insufficient • There are deficiencies m the child abuse and neglect reporting system • The timeliness of abuse and neglect investigations is not monitored • One in five cases has no wntten treatment plan and only 68% of those with treatment plans have had a current review • 50-70% of the children m DCYS care are not receiving routine medical examinations or other routme medical services • Many children are in foster care for more than two years without a permanent placement plan • The inadequacy of board and care funds for both foster and other pnvate placements has been caused, m part, by the department's poor forecasting and budget preparation • DCYS has weak oversight, at best, of troubled youths between the ages of 16 and 18 who cannot be forced to stay in a foster home or a group home • DCYS has not fulfilled its prevention mandate

To address these findings, the committee recommended- • DCYS draft a five-year rolling master plan together with a comprehensive budget • Fines be imposed for mandated reporters who intentionally fail to report suspected child abuse or neglect • DCYS implement a manual tracking system to provide more thorough information to supervisors • All DCYS foster care commitments must be limited to two years 90 days before expiration of the commitment, DCYS should be required to file a petition with'the Supenor Court to either- (1) terminate parental nghts, (2) revoke the

4 001761*

commitment, or (3) extend the commitment for an additional two years based on a finding that continued commitment would be in the best interests of the child • DCYS must expedite the recruitment process for foster parents. The Department must recognize that foster parents make a vital contribution to the treatment of DCYS children • DCYS must not only improve its forecasting and budget preparation, but also place children in foster homes and other appropriate settings within the limits of physical, rather than fiscal resources, even if such a policy results in the need for a deficiency appropriation • DCYS must improve its supervision of difficult youth between the ages of 16 and 18

1987 Study of Psychiatric The committee found' Hospital Services for • DCYS has not met its statutory mandate to complete a comprehensive child's Children and mental health plan Adolescents by the • DCYS has not assessed the demand for existing services to determine if Program Review and supply of state beds was appropriately allocated among age groups, treatment Investigations needs, and regions Committee • There is a high demand for hospital services but DCYS hospitals frequently operate under capacity • There is a lack of information on psychiatric hospital services available to children. No state or private agency maintains a centralized directory • Incomplete or sporadic compliance by hospitals with statutory client information reporting requirements is typical • The DCYS database does not provide accurate information on children treated for psychiatric problems in emergency rooms

To address these issues, the committee recommended. • DCYS must meet its statutory mandate and complete a comprehensive child's mental health plan • DCYS must reassess the role of psychiatric hospitals in terms of bed space and regional services • DCYS should utilize psychiatric hospitals to their fullest if demand for psychiatric services is high • DCYS should develop and maintain a statewide telephone clearinghouse on public and private inpatient bed openings • DCYS should establish an emergency psychiatric services program to provide crisis intervention and triage in each region • DCYS should develop a plan to more thoroughly collect psychiatric emergency room information

1989 Study of Juvenile The committee found: Justice in Connecticut • The contents of DCYS treatment plans for committed juveniles are lacking by the Program Review • There is an imbalance in the staff-to-client ratio between aftercare and Long and Investigations Lane staff Committee • There is an increase in the number of escapees from Long Lane and many escapees are serious juvenile offenders • Little new money, high utilization rates, rigid criteria, and lengthy acceptance processes all create a lack of pnvate residential facilities for juvenile delinquents in the state

To address these issues, the committee recommended: • DCYS include specific information in treatment plans and case files • Long Lane allocate a number of its correctional staff to aftercare services

5 001765

• DCYS either make Long Lane a secure facility with a fence or build a medium security unit attached to the existing structure • DCYS monitor treatment and care of committed children and should take care that the automatic review policy does not further constrict limited resources

1991 •Study of DCYS Child The committee found. Protective Services by • The reorganization of DCYS has focused on protective services programs and the Program Review case management and Investigations • There is a need for an independent review of DCYS handling of cases to Committee provide oversight. There are no random audits to ensure that practice follows policy • There are broad variations between regions in case management and an absence of uniform standards in the Department • DCYS does not follow up cases to ensure that treatment and service plans have been implemented. Reviews are only done every 6 months • Staff training is not a top priority and training is inadequate • There are a number of deficiencies in case management • DCYS is deficient in administering and funding community-based programs • DCYS social workers are an untapped resource in the evaluation of community-based programs

To address these issues, the committee recommended: • The DCYS management team must evaluate measurements of program effectiveness • Program evaluations and monitoring of client outcomes should be placed in one division • DCYS create a comprehensive system for managing cases, evaluating client outcomes, and reducing administrative paperwork for social workers • DCYS should develop an independent case audit unit to monitor regional compliance with policy and procedure • DCYS should develop a Staff Development and Training Division • DCYS should reduce the caseloads of workers, particularly new workers • All protective service social workers should, within first 10 years of employment, obtain MSW • DCYS should install an on-line computer system with 24-hour access and develop outcome measures for evaluating the effectiveness of client interventions • DCYS should design a grant processing system that funds proportionate to success in treating clients and allows for the reduction of funds against ineffective programs. The success of programs should be measured against specific criteria Data on program outcome measures should be collected and analyzed • As part of the program evaluation process, social workers and supervisors should be surveyed and asked to gauge program effectiveness • DCYS should develop and maintain a computerized database of all available community service programs

1995 Study of DCF Foster The committee found: Care by the Program • DCF does not sufficiently focus on the placement of children which consumes Review and over half of its resources and is the primary focus of its work Investigations • The DCF practice of matching and placing children does not conform to Committee staff policy. The lack of information about children prohibits appropriate matching to foster homes and hinders foster parents' abilities to care for children • The certification of family relatives for foster care is a questionable practice

6 001766

with no centralized oversight • DCF practice is confusing for staff and providers There is a repetitive effort to maintain two separate investigation units Also, there is no scale of authority for DCF to enforce its investigation recommendations • DCF foster parents typically have a poor working relationship with the Department

As a result of these findings, the committee recommended' • DCF should be reorganized to create divisions responsible for coordinating, licensing, managing, and quality assurance of all placement resources, including those specific to foster care • DCF implement a child-placing portfolio containing all relevant and necessary information and documents to adequately provide foster care to a child A copy should be provided to foster parents • Division of Quality Assurance should have the same responsibilities for relative certification as it does for foster care licensing • There be investigations of abuse and neglect allegations against foster homes conducted by regional staff, and completed within 14 days of referral. There ' should also be an investigation resolution process.

1995 Report on DCF KPMG found: Organization and • There are numerous small divisions and units m DCF's organizational Staffing by KPMG structure which hinder department integration and horizontal communication • The current organization structure ineffectively divides and groups some functions • Some functions currently performed in the central office can be performed more appropriately in the field or on a contracted-out basis • Central Office and staffing have grown substantially • There are a high number of managers/supervisors in central office relative to staff yet the span of control of these managers/supervisors is low • Additional layers of management exist in the functional layers than is necessary • The commissioner's span of control is too great, yet it excludes important areas of the agency such as health and mental health • Too much of the department's functional responsibility is concentrated under the deputy commissioner for programs (DCP). Combining programmatic and administration functions under the deputy commissioner for administration (DCA) may not be optimal • Planning and program development functions are lacking at a high level within DCF's organizational structure

To address these issues, KPMG recommended: • DCF bring together all aspects of research, clinical planning, strategic business planning, program development, and policy development. Closely integrating these with DCF's implementation unit will strengthen DCF's implementation of the consent decree • The number of senior employees reporting directly to the commissioner should be reduced from 9 to 7 and the commissioner should hire an executive assistant. A chief of staff and a public information officer should report directly to the commissioner • DCF should eliminate both deputy commissioner positions and replace them with five equivalent-level senior managers overseeing: child welfare services; health; mental health and education services, administration and finance, program development and planning; and juvenile justice

7 001767

• The chief of staff, public information officer, and executive assistant positions should be created The chief of staff should coordinate external relationships and interaction with the commissioner, as well as internal agency initiatives and responses to events. He/she would also supervise DCF's case investigation unit. The agency ombudsman and legislative liaison should report to the chief of staff rather directly to the commissioner as under the current structure. The public information officer should manage external communications He/she should continue to report directly to the commissioner. The executive assistant to the commissioner should handle administrative tasks such as responding to correspondence and schedulmg

1998 Study of the DCF The consultants found: Bureau of Juvenile • Very little of the Juvenile Justice Reorganization Plan (mandated by PA 95- Justice by Loughran 225) has been implemented, such as the reconfiguration of the Long Lane School and Associates and the development of a full continuum of community programs and parole services • Most of DCF's budget, administrative structure, and support systems are dedicated to its child welfare operations • Parole services, the community case management arm of the Juvenile Justice Bureau, suffers from its disconnection from the rest of DCF

To address these issues, the consultants recommended • The department must better integrate the Juvenile Justice Bureau • The Juvenile Justice Bureau's regional offices should be co-located with those of the Bureau of Child Welfare Services. They should be large enough and have enough computers, phones, and fax and copy machines to accommodate the number of parole officers and support staff assigned to a particular office • Administrative practices must be changed to allow for better integration of the juvenile justice function into the department • The Juvenile Justice Bureau's administration should be transferred to DCF's central office, and the bureau's director should report to the juvenile justice bureau chief rather than to the assistant superintendent of Long Lane

1999 Study of the The committee found: Department of Children • Goals of a consolidated children's agency — leadership and advocacy for and Families by the children's issues and integrated service delivery — have not been fulfilled Program Review and • No overarching policy guides state government efforts to promote well-being Investigations of children and their families Committee staff • No formal structure exists to examine the "big picture" or coordinate services and resources of the many state agencies responsible for children • Major banners to integrated services are categorical funding, lack of a coordinating mechanism, and "turf wars" among programs and agencies; most effective incentive for interagency coordination is financial. • Noncategoncal, flexible funding is more important to integration than organizational structure. • Children and families are best served by integrated, individualized care delivered through community-based systems. • Coordinating resources and services to achieve an integrated care system must be the prionty of a single entity without responsibilities for providing direct services • All three branches of government, not just DCF, have responsibility for prevention, coordmating prevention efforts needs to be one entity's focus. • Leadership and management for child protective services, children's behavioral health, and juvenile justice must be strengthened, each mandate must be an agency's prionty to ensure it receives sufficient attention and resources 001768

• Despite continuous efforts to "fix" DCF, it is plagued by systemic management deficiencies. • DCF's child protective services mandate dominates agency policy and resources; it must be a priority due to dramatic increases in the number and severity of child abuse and neglect cases as well as a federal court consent decree. • Children's behavioral health and juvenile justice mandates have been seriously neglected by DCF and the legislature and only receive attention in response to a crisis. • Separate state agencies can focus on each mandate to ensure leadership and parity; service delivery can be integrated through a statewide coordinating structure and "pooled" resources.

As a result of these findings, the committee recommended- • the creation of a secretary for children responsible for coordinating state efforts to implement the state's policy on children and families. • realigning the responsibilities of DCF as follows: children's mental health and substance abuse shall be transferred to the Department of Mental Health and Addiction Services; juvenile justice shall be transferred to the Connecticut Juvenile Authority (CJA) — a new statutorily created state agency; and protective services for abused, neglected, or abandoned children shall remain within DCF. • that DCF develop an assessment standard and tool to determine which calls require a full investigation response by its staff and which can be referred to a state-contracted community partnership for children for assessment and services. The differential response process shall be fully implemented by the fourth year of the phase-m of community partnerships

2007 Study of DCF The committee found. Monitoring and • little attention has been given to examining DCF as a whole or assessmg how Evaluation by the well the agency is achieving its broad goals of safety, permanency, and well- Program Review and being for all children and families. Investigations • while the department is responsible for carrying out four major mandates, Committee staff monitoring and evaluation is focused primarily on the child protective services mandate, due largely to the ongoing impact of the federal Juan F lawsuit consent decree and requirements of federal agencies - • there is greater emphasis on tracking how services for children and families are delivered rather than on assessmg their end results. While high quality service delivery is important, the crucial indicator of effectiveness is whether programs are making a difference and achieving stated goals. In general, more attention to outcome information is needed throughout the DCF accountability system. • pockets of strength within the system, such as the Juan F. exit plan process and related DCF area office quality improvement processes, the department's licensing procedures, the agency's recently revised special review process, and the activities of on-site facility momtors. • Some major weaknesses were revealed as well. In particular, the agency's contracting process provides little accountability, consequences for poor performance are rare, and working relationships with pnvate providers need improvement. The committee also found ineffective use of some important sources of feedback on services and programs, such as child fatality reviews, OCA investigations, and even the department's own program review reports and contracted evaluations. In pan, these deficiencies are due to both fragmentation of quality improvement efforts withm the agency and the fact that results data are not regularly integrated and analyzed. Both problems are related to the

9 001769

department's information systems, which are themselves fragmented and in some cases inadequate. Another challenge is a lack of department staff with the analytic skills and research experience needed to use results data and information Further, there is no centralized place - like an agencywide strategic plan - where all DCF goals and information about service delivery and outcomes are brought together. • Duplication of external monitoring efforts also was revealed by the program review committee's examination of statutorily required DCF plans and reports The committee determined several mandates could be eliminated without a loss of accountability, as certain documents have become obsolete or been replaced by newer sources of similar information. In addition, reducing the number and clarifying the purpose of reporting mandates could improve the quality of information on department results available to the legislature and the public

As a result of these findings, the committee recommended. • making agency goals explicit; • integrating quality improvement activities and incorporating best practices throughout the agency; • improving the quality and quantity of available data, and • promoting the use of results information to better meet the needs of children and families

10 0017 Legal Assistance Resource Center • of Connecticut Inc. • 44 Capitol Avenue, Suite 301 • Hartford, CT 06106-1764 (860) 278-5688 • FAX (860) 278-2957 Testimony before the Human Services Committee on SB 843 (opposing Sec. 41 and supporting Sec. 43) and supporting HB 6526, AAC Activities of the Council that Monitors the Temporary Family Assistance Program and Employment Services

by Jane McNichol, Executive Director March 3, 2009

I am Jane McNichol, Executive Director of the Legal Assistance Resource Center of Connecticut, the advocacy and support center for legal services programs in the state. We represent the interests of very-low income residents of the state. LARCC also convenes the Welfare Working Group, a group of about 25 advocates on welfare issues. Since 1996, the Welfare Working Group has monitored the federal TANF program and the state's family welfare program and its impact on low-income families with children in the state.

We oppose Sec. 41 of SB 843 would suspend the scheduled Cost of Living Adjustment in the Temporary Family Assistance program. There are three important reasons to provide a COLA to TFA participants.

1. Benefit levels are extremely low. Before 2007, cash assistance levels in the TFA program had not been increased for at least 15 years. Even with two COLAs in 2007 and 2008, a family of three in most of the state receives only $576 a month in cash assistance benefits. COLAs really do make a difference. From 1995 to 2007, the cash assistance amount for a family of three in most of the state was $543 a month. As a result of the two COLAs, these families now receive almost $400 more a year.

2. Cash assistance to low-income people provides an economic stimulus. The additional $24 million in cash assistance grants paid to very low-income people over the next two years will be spent and will go into the local economy.

3. The federal government will probably pay for most of the cost of the COLA through two TANF Contingency Funds which are newly available to Connecticut. For the last 12 years, Connecticut's TANF block grant has been frozen at $267 million, with some occasional and small bonus funds available.

- In October of 2008, for the first time, Connecticut qualified for funds under the existing TANF Contingency Fund as a result of increases in our SNAP (food stamp) caseload. If our SNAP caseload remains high and we can show sufficient state Maintenance of Effort spending, we could qualify to receive up to $50 million (20% of our TANF block grant) in additional TANF funds from the federal government.

- Probably more importantly, in the federal stimulus package, a new Emergency Contingency Fund was established. This fund will pay for 80% of a state's TANF costs related to increased expenditures for basic cash assistance, non-recurrent one-time payments and employment subsidies, up to 50% of the state's family assistance grant amount. 001771

There are undoubtedly details to be worked out in this new program, but it appears that if our TFA cash assistance caseload is rising, as it is, we will qualify for this additional federal money. Once we meet the qualifying threshold, the 80% match is available for all increases in spending on cash assistance, including COLA increases.

The Governor projects a $5 million increase in cash assistance in the coming year without a COLA. Including a 5% COLA would mean an $ 11 million increase in cash assistance, of which the federal government would pay as much as $8.8 million - for a net gain of $2.2 million.

Before making cuts in desperately needed assistance programs, we should carefully explore the new resources available from the federal government and design our programs to maximize federal funds and support for needy families.

We support the provisions of HB 6526, which would streamline the work of the existing TANF Council and provide a structure for developing recommendations from Connecticut on the upcoming federal debate on TANF reauthorization. One of the most helpful functions of the TANF Council has been to provide access to information on the TFA and Jobs First caseloads. Sec. 1(c) of this bill requires quarterly written reports rather than relying on sporadic reports at the Council meetings. The information required on the Jobs First Employment Services program is currently reported in the Department of Labor's At-A-Squint report. The information on the TFA caseload was for the most part reported in the past in the Department of Social Services' TFA Program Summary Report. Publication of this report was discontinued in 2002.

One important but missing element in the list of items to be reported on the TFA caseload is the number of families exempt from time limits and the reasons for these exemptions.

The task assigned to the TANF Council in Sec. 1 (e) seems completely appropriate and members of the Welfare Working Group would be eager to help in organizing the needed informational forums. The September 1 deadline seems somewhat optimistic.

Finally, we welcome and support Sec. 43 of SB 843, which implements the Governor's proposal to pass through an additional $50 to families receiving both cash assistance and child support. This proposal takes advantage of new federal rules, adopted as part of the 2006 Deficit Reduction Act, which reduce the amount of reimbursement required by the federal government. The federal government made this change to encourage states to pass more of the child support it collects on to families receiving cash assistance. Connecticut should accept this incentive from the federal government. Passing more money onto families both encourages non• custodial parents to pay child support and increases the income of struggling families.

Thank you for your attention and for your work on this issue. TO: Members of the HUMAN SERVICES Committee FROM: Sheila B. Amdur, NAMI-CT RE: ffTt 6514? An Act Concerning Managed Care for Certain Medicaid Beneficiaries HB 6610 AN ACT CONCERNING MEDICAID INCOME LIMITS FOR AGED, BLIND AND DISABLED PERSONS S>R. Nn. fi

I testified before you yesterday on the same issue that is contained in HB 6524, to which we are in full opposition. Many bills and proposals are coming before you that presumably would "save money," but which in reality will lead to greater costs and greater misery. Health care is complex, and the approaches to the treatment of chronic illness and particularly to the treatment of serious mental illnesses, for which the etiology and biology and efficacies of treatment are still not well understood, are individualized, and often not standardized.

We should take no steps about moving the sickest, poorest, and most vulnerable populations covered under Medicaid into traditional managed care. Over time, we will see more hospitalizations, emergency room visits, and in all likelihood, higher death rates. We do know that risk based private managed care is a terrible management model for people with serious mental illnesses and other serious illnesses. We already witnessed the disastrous consequences of this model for children, which shifted the cost of behavioral health treatment to the state, with sky rocketing emergency room, inpatient, and residential treatment costs. We do not need to repeat this scenario for the adult seriously mentally ill population.

If we want to look at how to better manage the health care costs of people who are aged, blind or disabled, then let's seriously study this issue with a "study group" that predominantly includes consumer, families, and advocates, the people who know from the ground level what approaches are most efficacious with a seriously disabled population. Let's look at primary care case management models. Let's look at models that promote and support healthy life styles—nutrition, exercise, tobacco cessation. Let's look at models that have primary responsibility focused in a treater and not an anonymous voice in a call center in Iowa. Let's look at models that focus on reducing institutional costs, and address the fact that the mortality of people with severe mental illnesses is 25 years below the rest of the population. This bill will not get us there.

HB 6610 would raise the income disregard for Aged, Blind, and Disabled recipients to the same level as HUSKY adults. In an era of health care reform in which we are working to cover more uninsured Connecticut citizens, this is a population that is at high 001773

risk and for whom federal Medicaid funds would be equal partners in paying for their health care.

SB 843 AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECOMMENDATIONS CONCERNING SOCIAL SERVICES contains very harmful provisions related to people who are poor, elderly, and disabled, and their access to medications. Connecticut has received major financial support from the federal government for CONNPACE and for its own state retiree health insurance plans. The protections put into place when Medicare Part D was implemented were to prevent people who were dually eligible for Medicaid and Medicare fromlosin g access to medications that they had under the traditional Medicaid program. Taking this away from them, requiring co-pays, enrollment in plans that may require them to switch medications that have helped maintained their health and stability is a very poor choice. We know what the outcomes are of restricting access to psychiatric and other medications needed for people with major disabilities and chronic illnesses; let's not go down that route

We thank you for all of your efforts to protect the needs of our most vulnerable citizens. 001771*

I I New England Home Care Taking Advanced Care to the Home

Testimony Before the Human Services Committee on Behalf of New England Home Care, Inc. March 3rd, 2009

Good afternoon Senator Doyle, Representative Walker, and members of the Human Services committee. I am a psychiatric visiting nurse and I am here to speak in opposition to the proposal to require unlicensed personnel to obtain certification for medication administration in residential (-\AQI in

care homes and boarding homes, which you can find in Section 62 of SB 943 AA Implementing JTL? Cr\yj the Governor's Budget Recommendations Concerning Social Services.

This proposal assumes that the administration of medication requires no actual medical care or evaluation. My training as an advanced practice psychiatric nurse and my years of experience in the field has taught me that medication administration is not a static task but rather a dynamic process that requires advanced training and medical evaluation. Complicated medication regimens as well as co-morbid medical and psychiatric illnesses together present clinical challenges that even the best med technicians are ill prepared to evaluate or treat. Often questions or concerns arise, such as whether a patient's change in mental status is related to a psychiatric decompensation or a drug-drug interaction related to the addition of a new medication. It is unclear whether a med tech is even able to evaluate whether or not a change in mental status has occurred. Experience has demonstrated to me time and time again that in rest homes the answer is often, no.

Patients with severe and chronic mental illness residing in rest homes are among the most vulnerable of this patient population. Indeed it is by virtue of their inability to manage independently in the community that they are in rest homes at all. We as nurses who are the most familiar with this population feel it is unfair to them that they be made to cope with a less than optimal system of care, as would be the case were this proposal to be approved.

The psychiatric population is already largely de-institutionalized as you know, and we are happy to be providing what we feel is essential care in order to allow individuals with such illnesses to remain in the community. As we see more proposals to move individuals in other settings out of institutions and into the community, it is imperative that the broad spectrum of home care is funded in a way that supports the system and enhances the infrastructure thatis currently quite fragmented. We urge you to keep this under consideration as you discuss'this difficult budget, and to reject a proposal that would be a cut to one of the system's most important safety nets.

Thank you for your time and consideration.

JoinS Cothmim atari 36 Berlin Road 370 James Street 433 South Main Street 525 Wolcott Street 1077 Bridgeport Awe. rornivell.CT 06416 New Haven, CT 06513 W. Hartford, CT 06110 Waterbury, CT 06705 Shelton. CT 06484 Connecticut Licensed ^203 874-6667 tel860.313.5448 tel203.573.8232 tel203.925 5929 JCAHOAccredited * 860.635.9717 fax 203.862.7170 fax 860.313.5458 fax 203.S96.7902 fax 203.225.6081 Medicare/MedicaidCertified Testimony of Brenda Kelley, AARP CT State Director SB 843 & HB. 6524 " Human Services Committee Public Hearing, 3/3/2009

Good Morning. Thank you for the opportunity to testify today about the Governor's budget proposal for human services and other proposed legislation. My name is Brenda Kelley and I am the State Director for AARP Connecticut. AARP is a nonprofit, non-partisan membership organization for people age 50 and over. We have more than 40 million members nationwide and over 629,000 in Connecticut.

Older residents in Connecticut have been among the hardest hit by the economic crisis. Often living on fixed incomes, they have seen their retirement savings drastically reduced, making it even harder for them to afford the high costs of health and long term care. AARP believes that we should not balance the budget on the backs of our most vulnerable residents with disproportionatej cuts to the health and human services parts of the budget. We also should beware of potentially attractive short-term savings that exposes the state to greater liability and costs in the long run.

SB 843, An Act Implementing the Governor's Budget Recommendations Concerning Social Services, makes significant cuts to the health and long term care safety net and, if implemented, will very negatively impact vulnerable older adults and other vulnerable CT residents. I want to thank you for rejecting most of these proposed cuts in the recent deficit mitigation plan for SFY 09 adopted by the General Assembly on 2/25/2009. AARP hopes that you will be able to sustain this decision as you work to adopt a state budget for the next two fiscal years. We also are concerned about HB 6524. An Act Concerning Managed Care for Certain Medicaid Beneficiaries, especially at this point in time.

1 001776

Thank you for Opposing Devastating Cuts to ConnPACE! Please sustain these decisions as you work to adopt a budget for FY 10-11!

AARP is deeply concerned with proposals contained in SB 843 that would decimate the Connecticut Pharmaceutical Assistance Contract to the Elderly and Disabled (ConnPACE) program by slashing funding for the program and implementing changes that will make it more difficult, if not impossible, for the vast majority of those currently eligible for the program to qualify. Since it was created in 1986, the ConnPACE program has provided a lifeline to many people with disabilities and low-income elderly who otherwise could not afford costly prescription drugs.

The proposal in SB 843 to apply the federal low-income subsidy asset test to the ConnPACE program (i.e. $12,510 for individuals and $25,010 for married couples in 2009), would essentially destroy the program and irreparably harm a significant number of the more than 30,000 people with disabilities and elderly Connecticut residents that rely on this program to pay for costly prescription drugs.

Like major state prescription drug programs in other states, ConnPACE has been based on income alone and has never been the subject of an asset test. And for good reason: no one should have to choose between paying their rent, buying groceries, or paying for prescription drugs. Applying an asset limit to ConnPACE unfairly punishes those who have saved over the years and harms those who need the modest income generated by their savings to pay for food, housing and medical care.

Suspending COLA increases in income, as SB 843 proposes, would also reduce the number of people eligible for ConnPACE. For example, if Social Security benefits increase during this period people's incomes may increase just enough to make them ineligible for ConnPACE. This is exactly what happened when the state tried this several years ago. Connecticut realized back then that there would have to be a mechanism to automatically adjust ConnPACE income limits to match any increases in Social Security payments, or risk disqualifying many seniors every time a minor Social Security increase took effect.

2 001777

Similarly, an open enrollment period would add a significant obstacle to seniors trying to get access to the prescription drug program. If a senior is unable to come up with the annual enrollment fee in December, he or she would be locked out of ConnPACE for the year rather than simply delaying his/her enrollment until they had enough money to cover the enrollment fee.

This legislation also would discontinue state coverage of drugs not on a ConnPACE and/or dually- eligible individuals' Medicare Part D Plan drug formulary to allow time for DSS to file an appeal on their behalf with their Part D plan or to work with the individual's doctor to secure a prescription for an equally effective drug that is on the formulary. This program has been very effective in ensuring that individuals do not stop taking drugs that are necessary for their health because of a restrictive Part D formulary.

A ConnPACE asset test and other changes that would significantly reduce eligibility & benefits may be penny-wise, but they are definitely pound-foolish. Instead, AARP supports usmg the proposal outlined in H. B. 5056, An Act Concerning Eligibility for the Medicare Savings Programs, as a way to maximize federal funds, save money on ConnPACE, and assist more low-income Medicare beneficiaries in paying their Medicare Part B premium and, in many cases, also reducing other Medicare and prescription drug costs. We were very pleased that you included the provisions of this legislation in the budget deficit mitigation plan for SFY 2009 passed on 2/25/09. When similar legislation was considered during last year's legislative session, it was estimated that Connecticut's low-income Medicare beneficiaries (seniors and people with disabilities) could have saved some $47 million per year in co-pays and premiums while saving the state money at the same time. So by your vote last week you have protected ConnPACE beneficiaries, provided them with an economic stimulus of over $40 million per year once this is implemented, and also saved Connecticut over 4 million dollars. This is exactly the creative thinking that will help us get through this devastating fiscal crisis. Again, congratulations and thank you! We hope you will sustain this wise decision as you work to adopt a budget for the next 2 years.

3 DO I 778

Thank you for Opposing Reductions to the CT Home Care Program for Elders! Please sustain these decisions as you work to adopt a budget for FY 10-11! And please ensure that the Money Follows the Person initiative and other vital programs have the resources they need to support people in receiving quality long term care.

AARP also opposes the proposed cuts for home and community based long-term care services under the Home Care Program for Elders. According to the Governor's Budget, approximately 15,000 clients receive services based on their financialeligibilit y and functional impairments under state funded and Medicaid waiver portions of the CT Home Care Program. As of December 2008, approximately 36% of the participants, or an estimated 5,400 seniors, are receiving services under the state funded component. The state funded portion of the Connecticut Home Care Program helps very vulnerable Connecticut seniors receive basic care at home (including visiting nurse services, home health aides, chore assistance, homemakers, adult day care, home delivered meals, companion services, respite care, transportation, and emergency response systems) - and prevents or delays the need for expensive nursing homes, resulting in cost savings to both the state and the taxpayer in the long-run.

The Governor has recommended capping this program, so there will be no additional funding. This decision comes at the same time that there is swelling need for long-term care services because of Connecticut's aging population. Flat funding for the program during a time of increased need means that the program will operate under a waiting list for the first time since 1997! Seniors unable to get services under the state funded program will be denied relatively low-cost care in the community, and instead be at greater nsk of needing Medicaid or even costly nursing home care. That's because a senior, who cannot get services under the state funded portion, would need to lower their asset and income levels and meet a higher level of physical impairment before they qualify for services under the Medicaid portion of the Connecticut Home Care Program. This, in turn, makes it much more difficult for them to remain independent in the community. Again you rejected capping the state-funded Home Care Program for Elders in the recent deficit mitigation plan for SFY 2009. Please continue to do so as a budget gets adopted for FY 10 & 11.

4 001779

AARP also is concerned about provisions in SB 843 that would delay implementation of Money Follows the Person legislation adopted in 2008. We believe this threatens to erode Connecticut's efforts to rebalance our long-term care system. The Governor's budget would delay the establishment of the legislatively-mandated Long Term Care Trust fund, which was to be funded through the enhanced federal match on Money Follows the Person. The Long Term Care Trust Fund is necessary to build Connecticut's long term care infrastructure and give people more options to age in place in their own homes and communities. In addition, the Governor recommends delaying Money Follows the Person II, a demonstration project passed by the General Assembly in 2008 to allow people who have not been institutionalized for 6 months to access home and community based services without first entering a nursing home.

We also are very concerned about provisions to shift all of the funding for the Centers for Independent Living to federal funding and a portion of the funding for the LTC Ombudsman Program to federal funding as well! We urge you to ensure that these vital programs have sufficient resources to support people in remaining independent in the community and to protect them when they received long term care in a nursing or assisted living facility.

Connecticut already ranks near the bottom of states when looking at the percentage of Medicaid dollars spent on home and community based services. AARP's recent Public Policy Report, "A Balancing Act, State Long-Term Care Reform" ranks Connecticut #42 out of 50 states with regard to the percentage of 2006 Medicaid expenditures going to Home and Community Based Services for older people and adults with physical disabilities. The University of CT's Long Term Care Needs Assessment found similar results ranking Connecticut #34 in 2007 (down ten spots from Connecticut's ranking in 2005 by UConn). Today, AARP will be releasing another report with information on how states, including Connecticut, are doing rebalancing their long term care systems. Shortly we will be sharing this additional information with you and ask that you consider it as you develop plans to address Connecticut's large and growing fiscal deficit.

5 001780

Thank you for Opposing Barriers to Health Care Assess! Please sustain these decisions as you work to adopt a budget for FY 10-11!

AARP is concerned with portions of the Governor's plan that restrict access to health care services including changes to Medicaid and HUSKY cost sharing, changes in the medical necessity definition, reduction in dental care, eliminating state-funded non-emergency medical care for non- citizens and eliminating medical interpreting services. These recommendations will add significant barriers to health care access to our most vulnerable populations. Now is not the time to add barriers or restrict access to necessary health care services to Connecticut residents. AARP opposes any efforts to rollback progress we have made in the last few years to expand health care quality and access.

Please oppose HB 6524. An Act Concerning Managed Care for Certain Medicaid Beneficiaries!

AARP is very concerned about HB_6Jt24.that would require the Commissioner of DSS to develop a plan to enroll Medicaid beneficiaries who are aged, blind or disabled in managed care. The aged, blind and disabled are among the most vulnerable people in Connecticut. We need to proceed very cautiously in moving them involuntarily to a managed care system that may be unable to meet their diverse and complex needs. We are very concerned that HB 6524 calls for a cost-benefit analysis but does not require an analysis of how quality of care will be improved and how the needs of vulnerable people will be protected under such a system. While DSS would be required to submit this plan to the Human Services Committee by 1/1/2010, it does not appear that the Human Services Committee would have any way to offer meaningful input or to reject the plan if it does not appear to be in the best interest of the aged, blind and disabled Medicaid beneficiaries and/or the State of Connecticut. We also do not see a process for other stakeholders & consumers to be included in the planning of such a major change in the way that health care is delivered to this very high risk group of people. AARP believes that much more inclusive planning, careful review, approval and oversight should be required when changes to health care systems for Connecticut's most vulnerable citizens are being contemplated. We ask you to oppose HB 6524

6 001181

Conclusion

Connecticut has seen how artificial cost savings in the short term often jeopardize the health and quality of life for our most vulnerable citizens, and also result in greater cost to the state over time. Many of the proposed cuts that I discussed today have been tried before and were later reversed because they hurt vulnerable people and did not result in real cost savings.

AARP understands the need to make budget adjustments during these difficult times and we recognize and respect the difficult decisions that the General Assembly and the Governor will need to make. Again, we thank you for not including most of the cuts that I discussed today in the SFY 09 deficit mitigation plan recently adopted. We ask that you sustain these decisions moving forward. AARP is committed to working in a bipartisan fashion to find ways to address CT's budget crisis while minimizing the budget's impact on health care coverage and long-term care services for Connecticut's most vulnerable residents!

7 001782

Testimony Before the Human Services Committee

S. B. No. 843 AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECOMMENDATIONS CONCERNING SOCIAL SERVICES.

H. B. No. 6379 AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECOMMENDATIONS CONCERNING MAXIMIZATION OF PHARMACY REBATES.

H.B.Nn 6543 fRAISF.lTl AN ACT CONCERNING PATERNITY AND SUPPORT ESTABLISHMENT AND ENFORCEMENT OP ORDERS IN TITLE IV-D CHILD SUPPORT CASES.

H. B. No. 6524 (RAISED) AN ACT CONCERNING MANAGED CARE FOR CERTAIN MEDICAID BENEFICIARIES.

H. B.No. 6610 (RAISED) AN ACT CONCERNING MEDICAID INCOME LIMITS FOR AGED, BLIND AND DISABLED PERSONS.

H. B. No. 6544 (RAISED) AN ACT SIMPLIFYING PROCEDURES FOR EARLY CARE AND EARLY EDUCATION FACILITIES

,H. B. No. 6526 (RAISED) AN ACT CONCERNING ACTIVITIES OF THE COUNCIL THAT MONITORS THE TEMPORARY FAMILY ASSISTANCE PROGRAM AND EMPLOYMENT SERVICES PROGRAM.

fS. B. No. 989,(RAISED) AN ACT CONCERNING THE ALZHEIMER'S RESPITE CARE PROGRAM.

S. B. No. 1060 (RAISED) AN ACT ESTABLISHING AN ACCOUNT FOR THE BENEFIT OF SUPPORTED LIVING DM GROUPS HOMES

Claudette Beaulieu Deputy Commissioner for Programs March 3,2009 001783

Good morning Senator Doyle, Representative Walker and members of the Human Services Committee. My name is Claudette Beaulieu and I am the deputy commissioner for programs of the Department of Social Services. I am pleased to be here this morning to present testimony on two bills introduced at the request of Governor Rell implementing features of the Governor's biennial budget recommendation to the Connecticut General Assembly. I am also happy to have this opportunity to testify on the merits of child support enforcement legislation raised by the committee at the request of Commissioner Starkowski. My testimony includes written remarks on several other bills on the agenda.

As we indicated in our testimony before the Appropriations Committee in support of Governor Rell's budget recommendation for the Department of Social Services, these are extraordinary times of economic adversity. We are seeing economic problems that are well beyond the scope of recent downturns:

• residents across the state are trying make ends meet with reduced wages or hours of work • others have lost their jobs • businesses are scaling back, or in some cases closing • home foreclosures are up • people fortunate enough to have been able to save for retirement or other needs have seen the value of those nest eggs drop dramatically • the price of food, fuel, and clothing and just about everything else has gone in the opposite direction—only getting higher • people are curtailing spending and looking to find ways to do more with less.

And virtually everywhere we look, we see the same across the country. The national economic outlook will take some time to improve, even with the efforts being made in Washington by the President and Congress to intervene and reverse the economic decline.

All these forces are coming to bear on state budgets, and Connecticut is no exception.

• As Connecticut workers lose jobs or have their hours reduced, demand for services of the Department of Social Services has risen o As just one example, applications for the Supplemental Nutrition Assistance Program (formerly known as Food Stamps) were up 30% in the October to December 2008 quarter, compared to the same time in 2007. • We are facing a projected budget deficit in SFY 2009 of over $922 million.

• Over the biennium, this shortfall is estimated by the Office of Policy and Management to increase to over $6 billion.

• Other states are facing problems of even larger magnitudes, and may not have the benefit of having "rainy day funds" to help offset the deficit.

1 001781*

Understanding that DSS expenditures of over $5 billion equate to 28.1% of the overall SFY 2010 budget, the Department must be a significant part of any effort to balance the budget.

Just as Connecticut families are scaling back and tightening their budgets, so must we.

The Governor's recommended budget for DSS, while it does contain reductions, allows us to maintain our core functions and services to those most in need. Unlike what is happening in some other states, the Governor's recommended budget protects that which is most important and in some critical areas even expands benefits. Significantly, the Governor's recommended budget provides for expected caseload increases in vital programs as more Connecticut residents apply for services. And the Governor's budget also protects recent eligibility-level expansions in HUSKY for parents, relative caregivers and pregnant women.

The combined total of the Governor's recommended changes in the DSS appropriation result in current service reductions of $382 million in SFY 2010 and $438 million in SFY 2011, for a total reduction over the bienmum of $820 million.

Governor Rell stated in her budget address that none of the proposed cuts were easy to make and that they are not inconsequential, but that they do represent a return to a level of government spending that is affordable in these times. The Governor's proposed budget, which incorporates the federal economic stimulus package, allows us to hold our core services in place until the economy recovers.

I'd like now to turn to a discussion of the details of the Governor's bills before the committee.

S. B..No. 843 AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECOMMENDATIONS CONCERNING SOCIAL SERVICES.

I will be remarking on the sections of the bill pertaining to DSS.

Sections 1 and 8 - Provide non-citizens with emergency health care services only

Under federal rules, non-citizens who have been in the country for more than five years are eligible for Medicaid and their costs are federally reimbursable. States have the option of providing coverage to non-citizens who have been in the country for less than five years, but the costs are 100% state funded. Connecticut is one of only fourteen states providing coverage for non-citizens through state-only funds. The Governor recommends that the state-funded Medicaid be eliminated and that DSS only provide non-citizens with emergency health care services, which are federally reimbursed. This change is expected to save $23.6 million in FY 2010 and $24.5 million in FY 2011.

2 &0I 785

Sections 4-7,9-12 - Community and Social Services Block Grant and Employment Services Block Grant

The Governor's budget calls for the creation of a Community and Social Services Block Grant and an Employment Services Block Grant. Under these provisions, funding from certain non-entitlement programs within DSS are reallocated into block grants and distributed according to a plan developed by regional planning councils, subject to review and approval by DSS, OPM and legislative committees of cognizance. This is consistent with the theme of regionalism in the Governor's budget. The combined savings from these initiatives is expected to be $3 million in both FY 2010 and FY 2011.

Sections 13,15,17, 65,66, 68 - Medicare Part D and ConnPACE Changes

Some adjustments to programs are proposed where necessary to reflect either new programs or funding available at the federal level. The maturation of the Medicare Part D pharmacy benefit has allowed Connecticut to rethink the necessity of the state's Medicare Part D Supplemental Needs Fund, as prescription drug plans are required to cover those drugs that are medically necessary. In line with the benefits provided by other states, Connecticut will no longer provide coverage of non-formulary drugs under Medicare Part D, as prescription drug plans are required to cover all medically necessary drugs.

Both dually eligible clients (those who are eligible for both Medicare and Medicaid), and ConnPACE clients will be required to enroll in one of the 12 basic benchmark plans under Medicare Part D. It has been found that the current enhanced plans do not provide any additional benefits over the lower costing basic plans. With no lock-in, dually eligible clients have the ability to switch plans on a regular basis as their drug regimens change. Other states do not do this. For ConnPACE clients, pharmacists will provide that upfront assistance to make sure the client is enrolled in the most appropriate plan that meets their needs.

Like the vast majority of states, Connecticut will no longer cover all of the Medicare Part D co-pays charged to dually eligible (Medicare and Medicaid) clients under the federal prescription drug assistance program, resulting in savings of $3.7 million in FY 2010 and $4.0 million in FY 2011. To ensure that these co-pay provisions are not overly burdensome, clients will not be responsible for pharmacy co-pays of more than $20 per month.

The Governor's budget also calls for a number of modifications to ConnPACE and the other pharmacy programs. Given the significant expenditures made by DSS each year for pharmaceuticals ($564.3 million on FY 2009), program revisions are proposed which would save $86.0 million in FY 2010 and $94.5 million in FY 2011. A large portion of these savings are related to the elimination of non-formulary coverage for Part D enrollees ($26.2 million in FY 2010 and $28.7 million in FY 2011) and the restructuring of the ConnPACE program ($25.0 million in FY 2010 and $27.5 million in FY 2011). Savings initiatives include adding mental health related drugs to the preferred drug list, requiring prior authorization on certain high cost drugs, reducing pharmacy

3 001786

reimbursement levels, eliminating coverage of most over-the-counter drugs to the extent allowed under federal law, and adding co-pay requirements (up to $20 per month).

Changes under the ConnPACE program include increasing the annual enrollment fee from $30 to $45, freezing income eligibility levels over the biennium, and instituting an open enrollment period similar to commercial plans and the Medicare Part D program. In addition, by adopting the same asset test used to determine eligibility for the federal low- income subsidy under Medicare Part D, ConnPACE benefits will be targeted to those most in need.

Currently, persons dually eligible for Medicare and Medicaid, and ConnPACE recipients in Medicare Part D may enroll in any Part D prescription drug plan of their choice. CMS pays the monthly benchmark premium ($31.74 in calendar year 2009) for those individuals receiving the federal Part D low-income subsidy, but when clients enroll in a plan costing more than the benchmark amount, DSS pays the difference. Of the 47 prescription drug plans available to enrollees in program year 2009, 26 are enhanced plans, with premiums ranging as high as $111.30. Clients are increasingly enrolling in enhanced plans, although generally there are no substantive benefits to the higher costing plans.

The Governor recommends requiring all dually eligible and ConnPACE recipients participating in Medicare Part D to enroll in one of the 12 benchmark plans. Limiting enrollment to benchmark plans will simplify the coordination of benefits and premium payment and plan reconciliation. This proposal is expected to save $900,000 in FY 2010 and $ 1.8 million in FY 2011.

Section 14 - Study SAGA waiver

This provision requires DSS to study the impact of implementing a waiver to extend Medicaid coverage to individuals with income up to 100% of the federal poverty level who would otherwise qualify for medical assistance under SAGA. By moving forward with a study, the cost-effectiveness of this approach can first be determined prior to resources being devoted to the development and submission of a full blown waiver proposal.

Sections 16,22, 50-53 - Nursing Home, ICF-MR and Residential Care Home Rate

The budget includes a proposal to eliminate the rebasing of nursing home rates that would have resulted in a 9.64% increase in FY 2010 and a 3% inflationary adjustment in FY 2011 resulting in savings of $115.3 million in FY 2010 and $166.4 million in FY 2011.

We are proposing to move one-half of the June 2010 payment for nursing homes to July 2010, with this delay continuing in subsequent years. This would result in a one-time savings of $53.1 million in FY 2010.

4 001787

The proposed budget eliminates the rate add for Intermediate Care Facilities for the Mentally Retarded. Elimination of the 4.7% and 4.9% increases in FY 2010 and FY 2011, respectively, for ICFs for those with developmental disabilities would result in savings of $2.9 million in FY 2010 and $6.2 million in FY 2011.

In addition, to control future costs, the budget proposes a cap on the total number of beds under 'small house nursing home" projects. Further development is restricted by capping the number of beds at 280 through the biennium.

Section 18 - Over-the-Counter Drugs

The Governor recommends eliminating coverage of over-the-counter drugs, with the exception of insulin and insulin syringes, under the department's pharmacy programs. This change is consistent with the current policy under the ConnPACE program. To comply with federal rules, Connecticut will continue to provide coverage of over-the- counter drugs to all children under the age of 21 under the HUSKY A program. This change is expected to save $7 million in FY 2010 and $7.7 million in FY 2011.

Sections 19 - 20,48 Copayments, Premiums and Self Declaration

Given the high cost of health care, cost sharing is proposed as an alternative to restricting eligibility under a number of DSS programs. Many states - up to 44 - already have some form of cost-sharing in their Medicaid programs. Co-payments and premiums are introduced under Medicaid (to include HUSKY A), and client financial participation is increased under the. HUSKY B program as an alternative to reducing or eliminating eligibility. Cost sharing will be required under Medicaid not to exceed 5% of family income on allowable medical services (excluding hospital inpatient, emergency room, home health, laboratory and transportation services), resulting in savings of $8.5 million in FY 2010 and $10.5 million in FY 2011.

Consistent with federal rules, children under age 21, individuals at or below 100% of the federal poverty level, SSI recipients, pregnant women, women being treated for breast or cervical cancer and persons in institutional settings are exempt from the cost-sharing requirement.

The Governor is also proposing to establish monthly premiums for HUSKY-eligible adults, not to exceed federal maximum levels, for savings of $8.8 million in FY 2010 and $9.3 million in FY 2011. Premium amounts will be determined on a sliding scale.

Finally, under HUSKY B, individuals with income between 236% and 300% of the federal poverty level will be required to pay higher premium amounts, which will result in savings of $1.5 million in FY 2010 and $1.6 million in FY 2011. Through these cost sharing measures, critical health care programs can be maintained and eligibility restrictions avoided.

5 001788

In addition to the establishment of premiums for HUSKY A adults and modifications to premium payment requirements under HUSKY B, the budget eliminates self-declaration of income under HUSKY A, resulting in estimated savings of $2 million in both FY 2010 and FY 2011 through a tightening of eligibility screening.

Section"21 - Hospital Never Events

This legislation is not expected to be needed as this authority was included in the recent deficit mitigation legislation, HB 6602, which has been transmitted to the Governor for signature.

The Governor's budget includes implementation of provisions to deny Medicaid payment to hospitals for 'never events.' These are serious and costly errors in the provision of health care services that should never happen. This proposal mirrors the Medicare policy on non-payment for these types of errors. The savings estimated as a result of this initiative is $1.7 million in FY 2010 and $1.8 million in FY 2011.

Sections 23 - 39 - False Claims

The federal Deficit Reduction Act of 2005 authorizes the state to bring a civil action against any individual or entity who engages in fraud against the state of Connecticut. This proposal includes 'qui tam' provisions allowing individuals to initiate claims and allowing the Attorney General to substitute the state of Connecticut for such individual's civil action. The federal government will provide financial incentives to states that adopt this qui tam law for purposes of recovering Medicaid funds in such actions.

Section 40 - Interpreter Services

In the 2007 session, the legislature provided funds to implement a statewide medical interpreting service under the Medicaid program, effective April 1, 2008. The Governor recommends that DSS not amend the Medicaid state plan to include foreign language interpreter services as a covered service under the Medicaid fee-for- service program with the expectation that providers will continue to provide interpreter services for individuals with limited English proficiency, for a savings of $5.5 million in FY 2010 and $6 million in FY 2011.

Sections 41 -42 - Payments Standard Freeze

Under current law, effective July 1, 2009 and July 1, 2010, recipients of Temporary Family Assistance, State Administered General Assistance, and the Aid to the Aged, Blind and Disabled programs are scheduled to receive a state-funded cost of living adjustment based on the percentage increase in the Consumer Price Index - Urban (CPI- U), assumed to be 6.0% in FY 2010 and 3.5% in FY 2011. These increases total $7.7 million in FY 2010 and $11.8 million in FY 2011.

6 001789

Additionally, under current statute, DSS is required to annually deterrnine rates for various boarding homes. Per DSS regulations, boarding home rate increases are based on actual cost reports submitted by facilities, barring any legislation to remove rate increases for a particular fiscal year. These increases total $4.5 million in FY 2010 and $9.3 million in FY 2011.

The Governor recommends eliminating these statutory increases.

Section 43 - Child Support Disregard

The Governor's budget also proposes an increase in the amount of child support recoveries paid to families. This proposal increases from $50 to $100 the amount of the current child support payment that is disregarded and passed through to families receiving Temporary Family Assistance. Increasing the disregard provides families with additional financial support and a greater incentive to cooperate in securing child support for their children. Since October 2008, the Deficit Reduction Act no longer requires states to reimburse the federal government for 50% of child support payments collected and disregarded. As a result of this change in federal law, the child support pass-through can be increased to $100 at no cost to the state.

Sections 44 - 45 - Dental limitations

Other program reductions or eliminations are necessary to deal with the fiscal crisis. Adult dental benefits under the Medicaid and SAGA programs will provide emergency services only, coverage similar to that offered by most other states. According to the National Academy of State Health Policy (October 2008), only 16 states (including Connecticut, MA, NY, NJ) currently provide comprehensive adult dental services. Most states provide only emergency or partial adult dental services; 6 do not provide any adult dental services at all.

Section 47 - Pharmacy Reimbursement

The Governor recommends reducing the dispensing fee paid to pharmacy providers for each prescription filled under the department's pharmacy programs from $3.15 to $2.15. This change will save $4.1 million in FY 2010 and $4.5 million in FY 2011. In addition, The Governor recommends reducing the reimbursement level to pharmacy providers from the average wholesale price (AWP) minus 14% to AWP minus 15%. This change is expected to save $6.5 million in FY 2010 and $7.1 million in FY 2011.

Section 54 - Maintain Home care caseload levels

The Governor proposes capping the caseload under the state-funded Connecticut Home Care Program for Elders at June 30, 2009 levels, for a savings of $4.8 million in FY 2010 and $14.5 million in FY 2011. As clients move off the program, new clients can begin to receive services under the state-funded program. The program will re-open without restrictions beginning in July 2011.

7 001790

Sections 55 - 58 - Money Follows the Person

For the chronic care waiver population, DSS planned to transition one individual in FY2009, 14 individuals in FY 2010 and 24 individuals in FY 2011 at an average annual cost of $148,260 per year. DSS is projected to spend $2,7 million in year one transition costs for 24 clients in FY 2011. Although this represents just under 12% of the approximately 200 transitions anticipated in FY2011, it accounts for over 26% of the costs. To address the extremely costly nature of these clients, the operational protocol will be revised to limit the number of transitions under the chronic care waiver to no more than 2% of the 700 clients expected to be transitioned under the demonstration period. By the end of the next biennium, after the bulk of the transitions have occurred under the demonstration period, DSS will reassess this policy to determine where the state's limited resources should best be targeted.

Section 59 - Small House Nursing Home Pilot Cap

PA 08-91 requires DSS to establish, within available appropriations, a pilot program to support the development of up to ten "small house nursing home" projects with the goal of improving the quality of life for nursing home residents by providing care in a more home-like setting. While each unit can house no more than ten individuals, each project can have multiple units. One project that is in the early stages of development will convert approximately 280 certified beds to this model. To control future costs, any further development of "small house nursing home" projects over the biennium is restricted by capping the number of beds at 280 through the biennium. This proposal saves $1.5 million in FY 2011.

Section 60 - Medically Necessary Definition

Savings of $4.5 million in FY 2010 and $9 million in FY 2011 are estimated under a proposal to replace the current medical necessity definition under Medicaid with the definition for SAGA medical. This medical necessity definition was recommended by the University of Connecticut Health Center Physician Advisory Team under the leadership of Dr. Peter Deckers. The definition would combine the concepts of medical necessity and appropriateness under a single definition as is done in Medicare and under most public sector and commercial health care programs, and it would update the department's definition to provide for evidenced-based medical necessity decisions.

Section 61 - State Supplement Trust

When recipients of the State Supplement Program (AABD) receive Social Security (SSA) benefits in combination with another source of income, such as a pension, their income may, over time, reach levels which makes them ineligible for further AABD assistance. When this occurs, they are likely to move into a higher cost nursing home setting. The Governor proposes allowing special needs trusts to be used to reduce the countable income of those boarding home residents whose increased income would have

8 001791

made them ineligible for AABD. This change will enable them to remain in a boarding home and avoid nursing home placement. It is anticipated that this change will affect approximately 25 residents each year, and result in a savings to the state of $918,153 in FY 10 and $1.2 million in FY11.

Section 62 - Medication Administration Revisions

The Governor recommends requiring that residential care homes and boarding homes have individual employees certified so that they can provide medication administration to their residents. Nurses will still be required to administer all injections. This proposal provides additional funds for training, liability insurance, supervision and other implementation costs and results in a net savings under the Medicaid program. This proposal has a net savings of $1.5 million in FY10 and $2.9 million in FY11.

Section 63 - Increase Capias Mittimus Officers

The governor proposes legislation to increase the number of capias mittimus sworn police officers allowed under statute from four to six. This proposal is expected to result in a revenue gain of $85,000 due to increased child support collections that offset state public assistance costs. From January 1, 2003 through December 31, 2008, a backlog of almost 5,000 unserved capias mittimus orders in family child support matters has accumulated.

In conclusion, the fiscal crisis presents clear challenges, but Governor Rell's proposed budget responds to those challenges by ensuring that critical health and human services are preserved while also respecting the fiscal limitations confronting the state. The reductions proposed in the budget are tempered by significant investments in serving additional Connecticut residents through the most critical health care and social service programs, and by new initiatives designed to help those affected by the economic downturn.

The level of resources provided in the budget for all of the health and human services agencies demonstrates an extraordinary commitment to maintaining services for those in need, despite the challenges facing Connecticut's economy.

H. B. NO. 6379 AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECOMMENDATIONS CONCERNING MAXIMIZATION OF PHARMACY REBATES.

Introduced at the request of Governor Rell, this legislation will require pharmaceutical manufacturers participating in DSS pharmacy assistance programs to provide rebates for covered prescription drugs.

The bill fast tracks the implementation of additional rebates by relieving DSS of administratively burdensome drug rebate contracting requirements by eliminating the need to enter into individual contracts for each program with each pharmaceutical labeler. It may be of interest to the committee to know that there are thousands of

9 00 I 792

labelers and without this legislation DSS would have to contract individually with each manufacturer for each program, to achieve the scope of rebates that were anticipated when DSS moved forward with the pharmacy carve-out and that have been assumed in the Governor's budget. Indeed, upon adoption, DSS will have clear authority to move forward with invoicing and collecting rebates on all drugs covered under all of our programs.

For the committee's information, please note the following circumstances under which DSS currently collects rebates. We collect rebates on all drugs we cover under the Medicaid program (which includes HUSKY A) where a federal rebate agreement is in place. DSS also receives supplemental rebates for these programs as well, based on the Department's Preferred Drug List. We also collect regular rebate from manufacturers who participate and have a signed rebate agreement under our ConnPACE program. CADAP has a limited formulary and for those drugs, we do collect rebate.

For SAGA we are currently collecting nrinimal rebate for drugs covered under that program. Prior to the SAGA program going into managed care, we required the manufacturers to have a separate rebate agreement with us in order to cover their drugs (similar to ConnPACE). Once SAGA was included under managed care, some of those manufacturers terminated those contracts and some did riot (we, the state, did not terminate any agreements). Now that SAGA is back in-house, we are working with the manufacturers to either re-initiate their old contracts or ask that they sign a new contract. This is taking some time. We currently do not collect supplemental rebate for the SAGA program at this time, but we intend to do so. For Charter Oak and HUSKY B, we are collecting neither regular rebate nor supplemental rebate as pharmaceutical manufacturers are requesting individual contracts to do so. For Medicare Part D non- formulary drugs that we pay for, we are only collecting rebate for those drugs under the ConnPACE program, not under Medicaid for the dual eligibles.

This legislation would clearly outline for the pharmaceutical manufacturers exactly what their responsibility would be in order for their drugs to be covered and paid for by DSS and we urge your support.

Legislation Introduced at Request of the Department

H. B. No. 6543 (Raised) An Act Concerning Paternity And Support Establishment And Enforcement Of Orders In Title Iv-D Child Support Cases

This bill would improve ESTABLISHMENT & MODIFICATION of support orders in the following ways.

FIRST, the bill would exempt the child support agency fromprovin g "neglect or refusal to support" as a pre-condition for a support order in a Title IV-D case. The existing language occasionally has made order establishment problematic in cases in which a child support order is required due to the custodial party's participation in the child support program, but the noncustodial parent cannot be shown specifically to have

10 001793

"refused or neglected" to support. An order in accordance with the child support guidelines offers a measure of security for the family while ensuring the obligor's ability to pay is fully considered.

SECOND, the bill would establish a procedure for notifying the parties associated with a disapproved Agreement to Support, or "ATS" and docketing that agreement for a hearing on support. Under present law, there is no procedure for when a Family Support Magistrate disapproves an ATS. Therefore a support petition is usually necessary, which causes unnecessary delay in the support establishment process. The bill provides that the reason for disapproving an ATS will be stated in the record, and the clerk will schedule a hearing to determine appropriate support amounts and notify, all parties of the hearing date.

The bill also amends the FAMILY SUPPORT MAGISTRATE'S ACT.

The bill builds on the existing authority of family support magistrates to order obligors to pursue work activities when they owe past-due support by permitting child support orders individually tailored to improve a parent's ability to meet the legal obligation to support. This provision would allow family support magistrates to enter a variety of orders related to things like work programs, and educational and skill-building programs designed to increase an obligor's capacity to satisfy current or past-due support obligations.

Next, the bill would improve ENFORCEMENT in child support cases in two ways.

FIRST, it would grant specific authority for judicial marshals, to execute child support capias mittimus orders in court facilities when the subject of the order is in the custody of the judicial marshal or within a courthouse where the judicial marshal provides security. This provision will increase the timely and expeditious service of such orders for the purpose of resolving child support matters and supporting judicial authority.

SECOND, the bill would increase the cap on the number of special police officers employed by the Department of Social Services, Bureau of Child Support Enforcement from four to eight. The increase in the cap will permit the hiring of additional officers as funds may become available.

Finally, the bill would improve INCOME WITHHOLDING for child support.

The bill would authorize electronic service of income withholding orders, and clarify the term "issue" when"applied to such orders. The provision allows service of income withholding by electronic means when the employer subject to the withholding order has agreed to accept withholdings electronically. It also clarifies the term "issue" in the context of electronic income withholding to mean transmission of the essential data by electronic means. Electronic service of income withholding will save state costs for mailing and printing the orders.

Thank you for this opportunity to testify in support of Bill # 6543, and I now invite any questions you may have.

11 00I79U

Additional Legislation Affecting the Department

H. B. No. 6524 (Raised) An Act Concerning Managed Care For Certain Medicaid Beneficiaries.

The Department opposes this bill, which calls for the enrollment of the Aged, Blind and Disabled (ABD) population of the Medicaid program into a managed care environment. While there are benefits to managed care, this would be a major program change requiring substantial policy review (for example, the implications for two-thirds of enrollees who are dually eligible for Medicaid and Medicare); contractual resources (complex because most care for dually-eligible enrollees is paid by Medicare); and administrative resources, which are stretched thin by current programs and initiatives.

More generally, the impression that the ABD population receives only minimal care utilization management is inaccurate. The Medical and Clinical Review Team does provide care utilization management. Much of the team's efforts centers on care coordination of many of our most complex and needy clients. Each member of the team follows a list of special needs clients for whom they coordinate care, facilitate referrals, arrange services, coordinate services with other state agencies, and other services as requested. These efforts are targeted to access necessary services. Additionally, depending on the progress and success of the Primary Care Case Management initiative for HUSKY members, it's possible that such model could have value for our ABD health coverage members.

The Department does not support the change called for by H.B. No. 6524 at this time.

H. B. No. 6610 (Raised) An Act Concerning Medicaid Income Limits For Aged, Blind And Disabled Persons.

This bill would increase the Medicaid program's income limit for aged, blind and disabled persons by increasing the limit for these individuals to the level used in the HUSKY program for families that include parents and caretaker relatives. The effect of this change would be to more than double the income limit for the existing program from an effective limit of approximately $788, for most elderly, blind and disabled participants, to $1670 per month, which is 185% of the federal poverty level for one person. Such an increase in the income limit would permit thousands of additional individuals to qualify at an increased cost of many millions of dollars to the state. Given the current circumstance of the state's budget, this would not be a prudent action and the department must therefore oppose this bill.

H. B. No. 6544 (Raised^ An Act Simplifying Procedures For Early Care And Early Education Facilities.

The department does not believe that legislation is necessary to address the intent of the bill. We are currently working with the proponents of this bill to address the reporting requirements for child care facilities. In light of that, we are opposed to this legislation.

12 001

H. B. No. 6526 (Raised) An Act Concerning Activities Of The Council That Monitors The Temporary Family Assistance Program And Employment Services Program.

This bill would require the Departments of Social Services and Labor to submit an ongoing quarterly report to the TANF Council and the Human Services Committee concerning a large range of detailed information about recipients of Temporary Family Assistance and Jobs First Employment Services.

The Department of Social Services has always been willing to provide the types of information required by this bill when it has been requested by the General Assembly and in particular the TANF Council. We have complied with all such requests in as timely a manner as possible. However to impose such an extensive a reporting requirement on a quarterly basis when agency resources are already burdened with other responsibilities is unreasonable. Compiling this voluminous data would require additional resources to accomplish. We therefore must strongly oppose this bill.

S. B. No. 989 (Raised) An Act Concerning The Alzheimer's Respite Care Program.

This bill seeks to increase the benefit levels of this program, add the service of Personal Care Assistant and increase the income and asset levels for participants. The department is not able to support the increased income and asset limits. The department would be in favor of greater flexibility to allow the few clients who demonstrate a need for increased services to receive them based on a regulated criteria. Not all clients would be eligible for the maximum benefit of $7,500.

Since the initial legislation creating the program in 1998, clients who participate in the Connecticut Statewide Respite Care Program have been eligible to receive up to $3,500 in respite services per year to help them to continue to reside at home. In SFY'08, 813 clients (an increase in 157 from SFY'07) received services such as adult day care, companion/homemaker and home health aide. Given that there are over 100,000 individuals in Connecticut with diagnoses of dementia who may be eligible at some time for this program, many more can be expected to seek the program's assistance in coming years. While this has represented a very meaningful respite benefit for caregivers, the cap in services per client has not kept pace with the increasing cost of community-based services and may be quickly exhausted by families in need. Care Managers for mis program utilize a multifaceted screening tool to ascertain the client's level of need for services, and money is allocated in varying increments in order to serve the greatest number of clients.

In order to increase the number of service options available to care recipients under the Connecticut Statewide Respite Care Program, the Department supports the inclusion of "personal care assistants" as a service under this program. This will allow recipients to use individual providers of their choice and possibly reduce the cost of their care or allow for a greater number of hours of service since the client or their family will be able to negotiate a rate under a provided maximum level.

13 001796

The department opposes the increase in income and asset limits for this program for the following reasons:

Currently, the income and asset limits for eligibility under this program are $30,000 and $80,000 respectively for the individual with Alzheimer's disease. The current income guideline for the Medicaid portion of the Connecticut Home Care Program for Elders, the program offering the most similar type of services, is $22,428, and higher for the state- funded portion based upon applied income and a sliding scale. Currently, the average client receiving services under the Connecticut Statewide Respite Care Program has an annual income of around $20,000. If access to the state funded portion of the Connecticut Home Care Program for Elders is frozen as of SFY' 10, it will likely result in an increase in applications for the Connecticut Statewide Respite Care Program. In order to be able to most equitably serve the neediest clients, the Department proposes maintaining the current income and asset levels for SFY' 10 and SFY' 11 and does not support this bill's proposal to increase them and build in a permanent Social Security

S. B. No. 1060 (Raised) An Act Establishing An Account For The Benefit Of Supported Living In Groups Homes.

This bill establishes a special account for support to individuals in group homes. Currently, individuals in licensed group homes and supported living setting receive financial assistance and assistance with medical and daily living/personal services through programs administered by DSS, DDS and DMHAS. These programs are administered in accordance on policies and procedures developed based applicable statutes and/or regulations. We oppose establishing a separate account to provide additional or new services that will require additional administration when existing programs are available and may be modified through state legislative and budgeting process.

At this time, I would appreciate the opportunity to respond to any questions you may have. Thank you.

14 001797 & CAHS The Connecticut Association for Human Services Michael Rhode, President 110 Bartholomew Avenue Suite 4030 James P. Horan Executive Director Hartford, Connecticut 06106 860.9512212 x 235 www.cahs.org 860.951.6511 fax

Testimony before the Human Services Committee Re: S.B. 843 - An Act Implementing the Governor's Budget Recommendations Concerning Social Services H.B. 6542- An Act Concerning Medicaid Income Limits for Aged, Blind, and Disabled Persons r\C?L H.B. 6526 - An Act Concerning Activities of the Council that Monitors the Temporary Family Assistance Program and Employment Services Program .H.B. 6609 - An Act Establishing a Community Provider Rescue Fund Account and Community-Based Services Commission Submitted by Maggie Adair, Policy Director Connecticut Association for Human Services March 3,2009

Good morning, Senator Doyle, Representative Walker, and members of the Human Services Committee. I am Maggie Adair, Policy Director of the Connecticut Association for Human Services (CAHS). CAHS is a statewide nonprofit organization that works to end poverty and to engage, equip, and empower all families in Connecticut to build a secure future.

Faced with a precipitous drop in state revenue and a budget deficit in the billions, policymakers must now make difficult decisions. CAHS believes that Connecticut's policy leaders should take the long view on budget prionties, preserving the integrity of programs and policies that support children, families, and the well-being of the state.

I am testifying on several bills before you today.

CAHS is testifying in opposition to many provisions in S.B. 843 - An Act Implementing the Governor's Budget Recommendations Concerning Social Services.

Governor's budget concerning social services makes a series of cuts to health care services to the poor, including Medicaid, SAGA, and ConnPACE. I will not go into specifics since many other people will testify today about the illogical cuts to our health care system for low-income children, parents, disabled, and senior citizens. I will make a few points:

-» The cuts to health care services and additional costs imposed on low-income families, taken all together, will have a heavy toll on our most vulnerable citizens. Rather than save health care costs, Connecticut will pay more in the end.

—» Due to increased co-pays and premiums, cost-sharing proposals, drastically limiting dental care to adults, gutting wrap-around Medicare Part D services, cutting transportation services for SAGA, and other important provisions, people will not seek the health care and drugs they need to remain healthy. They will end up getting sicker and cost the state more long-term.

-> Since Connecticut is receiving $1.3 billion in Medicaid funding under the federal stimulus plan, if the state is going to take this new Medicaid money, at a minimum, it should not take away benefits under Medicaid and the other state health insurance programs for low-income residents. The whole point of the FMAP provision is to avoid having states cut Medicaid coverage. 001798

-> Using federal funds to liberally supplant existing funds is not an economic stimulus strategy. The federal funds are temporary. It will set Connecticut back once we pull out of this economic recession.

-» When we have so much federal Medicaid money coming to Connecticut, and when we know that our health care system is broken, why would we want to start to dismantle health care for the poor, disabled, and elderly? This is exactly the time to seize the opportunity and build a blueprint to ensure that all Connecticut people - the uninsured and under-insured - have access to comprehensive health care. We should turn our attention to the SustiNet proposal rather than cutting the foundations of public health programs.

CAHS also opposes deferring the cost-of-living increases for people on Temporary Family Assistance (TFA), State Adrninistered General Assistance (SAGA), and the Aged, Blind, and Disabled. When Governor Rell said she needed to create a budget that focuses on the core services and our most vulnerable citizens, we would have expected these populations would be protected.

CAHS is also concerned about the "cost-savings" incurred through the creation of newly configured block grants. About $2.5 million in each fiscal year would be reduced through creation of a Community and Social Services Block Grant and about $425,000 in each fiscal year would be reduced through the creation of an Employment Services Block Grant. The funds transferred to these new block grants from existing line items would be re• allocated according to a plan developed by the regional planning agencies. We are concerned about the ramifications of this proposal for the well-being of low-income children and families. We know, from past history, what a block grant means: reduced investment in people.

CAHS is also concerned about the reduced funding in FY 11 for Care 4 Kids, the child care subsidy program. The Governor cuts Care 4 Kids funding from $103 million in FY10 to about $96 million in FY11. In the Governor's 3"1 deficit mitigation plan, she also proposed lapsing $9 million in Care 4 Kids funding for the current fiscal year. We have received conflicting reports from DSS, OPM, and OFA what the lapse really means. The bottom line: in the economic downturn, now is the worst time to reduce funding for Care 4 Kids. The goal should be to keep as many low-wage earners working as possible. Without a Care 4 Kids subsidy, low-wage workers cannot afford to work. We need people working and spending their earnings back into the community. We also need to keep children in high-quality educational settings so they do not fall behind in the critical early years of learning development.

The $13.7 million in new federal Child Care and Development Block Grant (CCDBG) coming to Connecticut should not be used to supplant existing services. OF the $13.7 million, about $11.9 million is allotted for child care services, with another $1,131 million for quality expansion and $655,215 for infants and toddlers. Prudent uses for the new infusion of federal CCDBG dollars could: expand access, promote affordability for existing families, improve quality of services, improve eligibility levels, raise provider rates, and beef up workforce training.

There are some positive provisions in the Governor's budget regarding social services. We applaud the Governor for increasing funding for food and nutrition programs. Under the Governor's proposal, eligibility for the Supplemental Nutrition Assistance Program (SNAP - formerly known as Food Stamps) would increase from 130 percent to 185 percent of the federal poverty level. The cost is borne nearly entirely by the federal government so the cost to the state is minimal. An estimated additional 19,000 families will be served by SNAP. Connecticut has had the option to make this change, and should have done so long ago.

The Governor also increases funding for other nutrition programs, including food pantries, the state Supplemental Food Stamp program for legal immigrants, and the purchase of protein foods.

I would point out that the federal government's economic recovery bill has infused significant new money to the SNAP program. SNAP benefits, under the federal bills, increase by 13 percent to offset rising food costs.

2 001799

Connecticut will receive $152 million more in SNAP funding and assist 240,000 participants. Connecticut will also receive $2.5 million in administrative funding to handle the influx of new SNAP recipients. Regardless of the Governor's proposal. Connecticut will be seeing plenty of new money to boost its food and nutrition programs for struggling families.

CAHS supports H.B. 6610 - An Act Concerning Medicaid Income Limits for Aged, Blind, and Disabled Persons. This bill would create equity in the Medicaid program for people with severe physical and mental disabilities and elderly citizens. The bill would align the mcome'ehgibility-threshold of elderly, blind, disabled people with those of parents and caregivers of HUSKY children at 185% of uie federal poverty level. There is no justification to allow for different income standards for different groups of people. We all get sick. We all need access to health care.

In Connecticut, low-income elders and people with physical and mental disabilities must be far poorer than other eligible groups to qualify for Medicaid. In 2007, the Legislature raised the income level to 185% of the federal poverty for adults to qualify for HUSKY A - in alignment with children. We applaud this policy change. But nothing changed for our most vulnerable citizens whose income eligibility threshold stands at a miserly 60- 70% of the federal poverty level, a level that dates back to 1990.

Given the economic crisis facing the state, we acknowledge the fiscal implications of this bill, but it is something we need to do. This policy change is long overdue.

CAHS also supports the intent of H.B. 6526 - An Act Concerning Activities of the Council that Monitors the Temporary Family Assistance Program and Employment Services Program. This bill would require the Commissioner of Social Services and the Labor Commissioner to submit reports about the Temporary Family Assistance program and Employment Services Program. The bill also requires the TANF Council to conduct a study of the status of the two programs. Connecticut needs to gather more data about the status of people enrolled in these programs and whether the programs are effective in rrairiing them and enrolling them in sustainable, good- paying jobs. If the programs are not effective in moving people into good jobs and economic security, then we are wasting money. Regarding the requirement for a study, we hope the Council will look back to the 2006 Program Review & Investigations Committee report on welfare reform and build off of that very thorough report.

CAHS supports the goal of H.B. 6609 - An Act Establishing a Community Provider Rescue Fund and Community-Based Services Commission. The nonprofit human services community forms the backbone of the human services delivery system in Connecticut. They work as partners with the State of Connecticut to provide services to our most vulnerable citizens. As partners, Connecticut needs to ensure that the nonprofits are adequately supported so they can continue to play their unique and important role in the cornmunity.

Unfortunately, nonprofit community-based providers have been historically under-funded. Last year, they did not receive a cost-of-living (COLA) adjustment, despite the rising costs of energy, electricity, and day-to-day expenses. Eventually, the system will break. The Legislature needs to address the wage disparity so that nonprofit employees earn a sufficient wage and the cost-of-living adjustments so that nonprofits can continue to serve people in the community. Again, we understand the fiscal implications of this bill. However, if we do not,address the chronic under-funding of the nonprofit providers who perform critical services, we will see a downward spriral in the community provider's capacity to meet the needs out our most vulnerable people.

BETTER CHOICES FOR CONNECTICUT

Today, CAHS is testifying in support of increasing investments in people and communities. We acknowledge the fiscal implications, particularly when the state is facing daunting budget deficits for FY10 and FY11.

However, m these unprecedented financial times, we have choices. We can make a short-sighted poor choice and attempt to cut our way out of this multi-billion budget gap. This would require slashing vital programs and services

3 001800

that are the lifeline for our most vulnerable people - our children, struggling working families, the disabled, and the elderly. It would require abandoning our investment in our schools, municipalities, transit, mfrastructure, and public safety.

During a recession, demand for public services dramatically escalates. Deep budget cuts would deny services when they are needed most. Economists agree that crippling government will harm the economy when it is most at risk.

We can make a better and smarter choice. Better Choices for Connecticut has released a White Paper, detailing ways to address the budget crisis through prudent revenue changes. As author David Osborne said when Governor Rell brought him to Connecticut last month, it is "pure fantasy" to dunk that Connecticut can address the budget deficit by spending cuts alone. Better Choices for Connecticut offers a revenue plan that will ensure Connecticut invests in its families, workforce, and infrastructure so that we come out stronger on the long run. Revenue enhancements can be carefully focused on the people and businesses with the greatest ability to pay, while mamtaining or lowering tax rates for people who are struggling the most economically, and for small businesses that are key to job creation.

We urge you to consider revenue options, keeping in mind the need to avoid hurting the state's most vulnerable people and the health of the state's economy through unwise spending cuts.

Thank you for giving me the opportunity to testify today.

4 001801 r

Leadership | Educacion | Advoc.icy | Information | Collaborai

Altai

TESTIMONY BEFORE THE HUMAN SERVICES COMMITTEE REGARDING S3. 843 - AN ACT IMPLEMENTING THE GOVERNOR'S BUDGET RECOMMENDATIONS CONCERNING SOCIAL SERVICES

March 3, 2009

Senator Doyle, Representative Walker, and members of the Human Services Committee, my name is Brian Ellsworth and I am President & CEO of the Connecticut Association for Home Care & Hospice (CAHCH), whose members serve over 100,000 elderly, disabled, and terminally ill Connecticut citizens. The Association appreciates this opportunity to speak to you about how the Governor's budget recommendations affect home care & hospice.

MEDICAID HOME CARE RATES ARE GROSSLY INADEQUATE

The Governor's proposed budget omits an increase in the Medicaid rates for home care providers. Unfortunately, the rates for home health services are approximately 30 percent below costs for the typical agency (see attached chart). This longstanding problem is now being compounded by Medicare's decision to freeze home health rates for a four-year period. Home care agencies continue to face increased wage costs due to workforce shortages, as well as double-digit annual growth in health insurance and staff mileage reimbursement costs.

This unsustainable situation is rapidly reaching a crisis point, with significant implications for patients, their families and taxpayers.

In 2007, the CT Home Care Program for Elders saved the State $91 million dollars through prevention or delay of admission to nursing homes.1 More savings are possible, but not without adequate rates. The Association has very specific proposals for rate increases (outlined below) that we believe will be offset by significant long-run savings, a viewpoint shared by a recent article published in the respected journal, Health Affairs.2

1 Annual Report by DSS on the CT Home Care Program for Elders'-'CT^s Medicaid waiver program. 2 "'Do NoninstituUonal Long-Term Care Services Reduce Medicaid Spending?" Health Affairs, January 2009.

110 Barnes Ro.id | Wallingforrl, CT. P O Box 90 | 06-192-0090 | Phone 203 265 9931 | Fax 203 949 0031 | wwwcahch org (301802

Specific Proposals Regarding Medicaid Rates

> Equalize Medicaid Rates to Medicare: Increase Medicaid base rates for skilled nursing visits, home health aide services, and therapies to the per visit rates used by the Medicare program by the end of the biennium, with half implemented in 2009 and the other half in 2010.

> Provide Funds to Financially Distressed Agencies: Design a means for home care providers to access the "distressed" facility funds, and a mechanism for "interim rate adjustments" as accorded to hospitals and nursing homes, and implement in 2009.

> Increase Medicaid Rates for Behavioral Home Care; Increase Medicaid rates for Medication Achninistration by the Consumer Price Index - Urban.

> Increase Medicaid Rates for Homemaker-Companion Services: Increase Medicaid rates for Homemaker-Companion services by the Consumer Price Index - Urban.

> Increase Medicaid Rates for Extended Nursing/Shift Care: Significantly increase the Medicaid rates for shift/extended hourly nursing so that they are equivalent to per visit skilled nursing.

> Permit Medicaid Billing for Vaccinations: Home health agencies should be able to bill Medicaid for flu shots through an approach similar to the Medicare program, including a fee for both the administration and the vaccine based on the rates utilized by Medicare.

> Authorize Medicaid Coverage for Telemonitoring: Include telemonitoring in the list of waiver services for the CT Home Care Program for Elders and amend the State Medicaid Plan to include telemonitors for Medicaid-only patients at risk of hospitalization due to chronic illness.

NECESSITY TO MAINTAIN COMMITMENT TO SYSTEM REFORM

The Association opposes Sections 55 through 58 of S.B. 843, which propose a two-year delay in the implementation of the Long Term Care Reinvestment Account and delay plans for expanding efforts to divert persons from institutions. Instead of delay, CAHCH advocates that funding for the Long Term Care Reinvestment Account be increased to include additional federal funds from converting state-funded persons to Medicaid and increasing the rate of diversion of people from nursing homes ~ see substitute language for Section 57 in Attachment B.

Laudable programs, such as "Money Follows the Person" will have diminished chances for success unless inadequate Medicaid rates are expeditiously addressed. If that program fails, CT will forego $24 million in increased federal funds for the first 700 transitions from institutions to home over the next several years. 001803

MEDICAID COVERAGE OF TELEMQNITORS

Governor RelPs budget proposes to allow Medicaid coverage of telemonitoring services provided by home health agencies, including coverage for the cost of equipment rental and 24-hour monitoring for patients with congestive heart failure or chronic obstructive pulmonary disease who meet certain medical criteria. CAHCH strongly supports this proposal, but is concerned that there is no statutory language in S.B. 843. CAHCH strongly advocates for statutory change so that details of the intended program are clear to all parties - see suggested language in Attachment C.

PROPOSAL TO MANDATE RCHs TO HAVE UNLICENSED PERSONNEL ADMINISTER MEDICATIONS

Section 62 of S.B. 843 once again proposes that Residential Care Homes (RCHs) be required to employ certified unlicensed personnel to administer medications. As we have over the last several years, the Association opposes this mandate because it will reduce quality of care in these homes and it is penny-wise and pound-foolish.

The current hybrid model, which allows for the use of either certified unlicensed personnel in RCHs and/or home health nurses to make medication administration visits, provides for much needed flexibility for RCHs that serve differing patient populations. Most RCHs do not have nursing staff available to supervise these unlicensed persons, or to make a clinical determination as to whether or not a medication should be administered or if any further follow up should occur, including reassessment or contacting a physician. This can result in significant care or safety issues, especially for residents with multiple chronic conditions.

The Governor's proposal is not likely to yield significant savings. In the long run, RCHs will either have to increase their staff, or there will be an increase in unnecessary hospitalizations.

The Association urges the General Assembly, as it has done so for the last several years, to reject this short-sighted and ill-advised proposal and instead to work with RCHs and home care agencies on ways to further collaborate to improve the quality of care to this vulnerable population. There is no need for an additional mandate on already under-funded rest homes.

Thank you for consideration of our comments. I would be pleased to answer any questions you may have. 001801*

ATTACHMENT A

Medicaid Cost Per Visit Analysis

Source 42 Home Health Aeencv Medicare Cost ReDorts with June 30. 2007 FYE :o<) • f •" - 001805

ATTACHMENT B

Proposed Substitute Language for Section 57 of S.B. 843

Section 57. Subsection (a) of section 17b-371 of the general statutes, as amended by section 1 of public act 09-1, is repealed and the foUowing is substituted in lieu thereof (Effective July 1, 2009):

(a) On July 1, 2009, to the extent permitted by federal law, there shall be established wirJiin the General Fund, a separate, nonlapsing account which shall be known as the "Long-Term Care Reinvestment account". The account shall contain any moneys required by law and this section to be deposited in the account. Any funds resulting from: (1) the enhanced federal medical assistance percentage received by the state under the Money Follows the Person demonstration project pursuant to Section 6071 of the Deficit Reduction Act of 2005, (2) federal reimbursement for persons who become eligible for medical assistance as a result of implementation of the demonstration project described in public act 08-180 and who previously would have met the financial eligibility criteria for the state-funded portion of the Connecticut home-care program for the elderly pursuant to section 17b-342 of the general statutes and (3) the estimated savings from diverting persons from nursing facility care under such demonstration project. Such savings shall be calculated by subtracting the costs of home and community based care under the demonstration from costs of nursing facility care, reduced by thirty-five percent, for all persons newly receiving home and community-based care under the demonstration. 001806

ATTACHMENT C

Proposed Language for Medicaid Coverage of Telemonitors

(NEW) (Effective July 1, 2009) On or before January 1,2010, the Department of Social Services shall a establish fee schedule and billing codes for payments to home health agencies that provide telemonitors to Medicaid eligible and state- funded persons in the community with chronic conditions, including but not limited to: (1) congestive heart failure, (2) diabetes or (3) chronic obstructive pulmonary disease. The Commissioner shall ensure that patients selected to receive telemonitoring services by a home health agency shall be evaluated for (1) the nature of the patient's medical condition and whether such medical condition requires skilled nursing visits that could be reduced through telemonitoring or if the patient has had a history of frequent hospitalizations or emergency room use over the prior twelve months, (2) the patient's cognitive ability and support system, and (3) whether the patient resides in a medically underserved area. The Commissioner of Social Services shall adopt regulations, in accordance with chapter 54 of the general statutes, to carry out the provisions of this subsection and may, while in the process of adopting such regulations, implement policies and procedures necessary to administer the provisions of this subsection, provided that the Commissioner prints notice of the intent to adopt the regulations in the Connecticut Law Journal not later than twenty days after the date of implementation. Such policies and procedures shall be valid until the time final regulations are adopted.

Subsection (c) of Section 17b-342 of the general statutes is amended as follows (Effective July 1, 2009):

(c) The community-based services covered under the program shall include, but not be limited to, the following services to the extent that they are not available under the state Medicaid plan, occupational therapy, homemaker services, telemonitoring, companion services, meals on wheels, adult day care, transportation, mental health counseling, care management, elderly foster care, minor home modifications and assisted living services provided in state-funded congregate housing and in other assisted living pilot or demonstration projects established under state law. Recipients of state-funded services and persons who are determined to be functionally eligible for community-based services who have an application for medical assistance pending shall have the cost of home health and community-based services covered by the program, provided they comply with all medical assistance application requirements. Access agencies shall not use department funds to purchase community-based services or home health services from themselves or any related parties. 001807

Advocates for people with intellectual disabilities and related developmental disabilities

43 Woodland Street, Suite 260, Hartford, CT 06105 Telephone: 860-246-6400 Facsimile: 860-246-6406 Connecticut Website: www.arcofct.org

President Executive Director Ken Cholewlnskl Lynn C. Warner SARAH Seneca Guilford March 3, 2009 First Vice President Diane Aubin Testimony before Committee on Human Services of New London Cour ^Norwich fte: H.B. #6609. "(Raised) An Act Establishing a Community Provider Rescue Fund Account and Community-Based Services Commission" Second Vice President and Barry Sheftel Arc of Merlden-wdllingford H. B. #1060, "(Raised) An Act Establishing an Account for the Benefit of Meriden Supported Living in Group Homes"

Secretary and Imelda Reno H.B. #6610, (Raised) An Act Concerning Medicaid Income Limits for Aged. Arc of Farmlngton Valley Blind, arid Disabled Persons" Canton

Treasurer by Anthony Recck Lynn Warner, Executive Director/The Arc of Connecticut Futures. Inc. Mlddletown Good morning Senator Doyle, Representative Walker, and Members of the Immediate Past President Human Services Committee. I am Lynn Warner the Executive Director of The Dawn LazarotT Trl-County Arc Arc of Connecticut, a 57-year-old statewide advocacy organization for individuals Columbia with intellectual disabilities and their families. We have 23 local chapters that

Contributions are provide supports, services, and advocacy for individuals with intellectual tax-deductible disabilities throughout Connecticut.

I am here today to testify in support of House Bill #6609. "(Raised) An Act Establishing a Community Provider Rescue Fund Account and Community- Based Services Commission, as it directly impacts the appropriate funding to stabilize the network of Private Providers in Connecticut - thereby keeping all of the individuals and families that they serve safe, healthy, and served with the highest quality of care.

For years the private providers have served these individuals with dignity and quality and yet for years private providers have been consistently under funded. In addition, they have been continuously subjected to unfunded mandates, lack of adequate cost of living increases and extensive rate changes. Make no mistake, the Private Providers can do the very same work that their State paid counterparts do, BUT they can not do it for nothing! Establishing a stable and appropriate

The Arc/Connecticut, Inc. Member Chapters: Futures, Inc., Mlddletown / Greater Enfield Arc / Family Options. Warertown / Arc of Farmingron Valley / Friends of New Milford, Inc. / Urchfield County Arc / LOV-Arc. Westbrook / MARC. Inc., Manchester / MARC Community Resources, Portland / Arc of Merlden-Wallingford / Arc of Greater New Haven / Arc/New London County / Options, Unlimited / Arc of Plainvllle / Arc of Qulnebaug Valley / SARAH Inc., Guilford / SARAH Seneca Residential Services / SARAH Tuxls Residential Services / STAR, Norwalk-/ Arc of Sourhington / Tn County Arc. Columbia / WaterburyArc / WeCAHR, Danbury Affiliated with The Arc of the United States 001808

funding stream which includes consistent increases will keep the private providers system as the primary option for care. The establishment of a commission to study long-term funding solutions for the network of private providers through a variety of sophisticated activities will be essential for their survivability and growth.

Today, Private Providers are barely being funded enough to provide for basic health and safety needs of the individuals in their care, and we fear that the quality of life for these individuals will decline due to staff turnover, reduced service hours, and just the lack of involvement in their communities due to the consistent and chronic under funding.

The Arc of Connecticut also supports H. B. #1060, "(Raised) An Act Establishing an Account for the Benefit of Supported Living in Group Homes" as a large number of the people with intellectual disabilities currently reside or will eventually reside in groups homes and they deserve to have the highest quality of care on every level that is funded appropriately and accurately - for all the same reasons previously stated. We encourage this Bill to be voted on favorably.

Additionally, we would like to go on record supporting the favorable passage of H.B. #6610, (Raised) An Act Concerning Medicaid Income Limits for Aged, Blind, and Disabled Persons" We believe it would be extremely beneficial to use a less restrictive methodology in determining the income limit when making Medicaid eligibility determinations for people who have intellectual disabilities. Clearly - this would be a wonderful way to enhance their quality of life and their ability to be more active in their individual communities. It would be wonderful step for Connecticut to not insist that people be destitute in order to receive the services they need.

Thank you for the opportunity to speak with you today. 001809

NEW HAVEN LEGAL ASSISTANCE ASSOCIATION, INC.

426 STATE STREET NEW HAVEN, CONNECTICUT 06510-2018 TELEPHONE: (203)946-4811 FAX (203)498-9271

March 3,2009

Testimony of Sheldon Toubman before the Human Services Committee in Opposition to Governor's Proposed Cuts in SB 843. and in Opposition to HB 6524, Which Would Move Elderly and Disabled Medicaid Recipients into HMOs

I am a staff attorney with New Haven Legal Assistance Association, specializing in access to health care under publicly-funded programs. Thank you for the opportunity to testify before you in opposition to the Governor's draconian cuts to health care contained in Bill 843 and also in opposition to Bill 6524, which would set in motion a plan to move elderly and disabled fee-for-service Medicaid recipients into capitated HMOs which make money by restricting access to care.

Opposition to Bill 843

Because the Governor does not propose to completely eliminate the Medicaid, SAGA or ConnPACE programs or to tighten the financial eligibility tests for Medicaid and HUSKY, some may view her cuts in Bill 843 as moderate. In fact, either alone or taken together, they are severe and would decimate access to care under our essential Medicaid, HUSKY, ConnPACE and SAGA programs, causing dramatic increases in expensive and inappropriate (and sometimes too late) treatment in hospital emergency departments. Here are just some of those cuts:

• Elimination of all adult coverage for dental care under Medicaid (including HUSKY), except for "emergencies," while subjecting most dental care for children to prior authorization (Sections 44 and 45) • Elimination of all Medicaid-like health coverage for non-citizens legally present in the country for fewer than five years, except for "emergencies" (Section 8) • Gutting of the definition of medical necessity under Medicaid (including HUSKY), so it will be much harder to argue that the state or, more likely, a HUSKY HMO, has to pay for specific medical services prescribed by a patient's doctor (e.g., treatment which is merely maintaining someone's health but not bringing improvement), and so the state or the HMO will be able to substitute much cheaper services or items that do not work nearly as well (Section 60) • Elimination of medical interpretation services for patients who don't speak English (Section 40) • Imposition of unaffordable premiums on HUSKY A adults with incomes over 100% of the federal poverty level, which will be as high as 20% of the cost of 001810

the service (potentially equaling $40 per month for these low income HUSKY enrollees) • Imposition of unaffordable copays on adults (including HUSKY parents) with incomes over 100% of the federal poverty level, which will be as high as 5% of the family's income, in addition to the high required contributions to premiums (Section 19) • Extensive cuts to pharmacy benefits under all programs

All of these cuts are severe but I will focus on the pharmacy cuts which the Governor has proposed across the board. The pharmacy cuts fall into three general categories: new program eligibility restrictions, high cost-sharing, and drug access restrictions (drugs not available at all or subject to burdensome prior authorization). These cuts will completely predictably result in our most vulnerable populations going without specific drugs or without any drug coverage whatsoever.

New Eligibility Hurdles for ConnPACE:

Bill 843 (Section 17) would implement an asset test and eliminate the COLA for income eligibility for ConnPACE, so far fewer people would qualify for this program—and this is despite the fact that the last time the legislature implemented an asset test for this program, it was repealed almost immediately upon going into effect because of the large number of elderly and disabled who dropped off as a direct result.

Even if one qualifies for ConnPACE, the bill would impose a sharply limited open enrollment period of only six weeks at the end of each year. While there would be exceptions for individuals who newly turn 65 or newly become eligible for Social Security Disability Insurance or SSI, there would be no exception, for example, for the individual over 65 who was healthy and needed no medications and so was not enrolled in ConnPACE, but who develops a serious neurological condition suddenly and becomes in need of several medications for chronic conditions. They may have to wait as many as ten months for any coverage under ConnPACE.

New and Higher Premiums for HUSKY A and ConnPACE:

Besides the new high premiums for adults on HUSKY A, Bill 843 (also Section 17) would also increase the annual premiums under ConnPACE from $30 to $45. Both of these increases will predictably result in many individuals ceasing to participate in the program at all because of the competition with other needed expenditures, like rent, utilities and food. Individuals at the low end of the income scale just don't have disposable income that they can use to cover such fees.

New Copays for Drugs and Other Services Under Medicaid:

The Connecticut legislature has twice implemented copays for drugs for Medicaid and SAGA recipients and twice repealed them (the first time, in six weeks; the second time, in a few months) because of the direct interference with access to needed medications

2 00181 It

which resulted. This result applied even to the $.50 copays applied one of these times, since most individuals are on more than one medication. Nevertheless, in Section 19 of Bill 843, the Governor would again impose copays not only for drugs but for other services.

The Governor suggests these copayments will not be burdensome because the copays for drugs will be capped at $20 per month and all copays will be capped at 5% of income. But for an individual with an income of $910 per month (exceeding 100% of the federal poverty level) and the need for both several medications and doctor visits each month, that translates to copays of $45 per month—an unaffordable expense. And if the person has slightly more income and also is paying a $40 premium for their coverage under HUSKY A,,the expected total contribution could be $100 or more each month, which is not going to be possible for anyone on Medicaid to maintain.

The result, once again, is that individuals will go without medications rather than part with money they need for other necessities.

Gutting the Part D Wraparound for Dual Eligibles:

As is well known by seniors across the country, the Medicare Part D plans have severely restrictive formularies and exceptions for non-formulary drugs are very hard to obtain from them, especially for confused seniors and disabled individuals with debilitating illnesses. Since all Medicaid coverage for drugs for dual eligible (Medicare/Medicaid) recipients was eliminated in January 2006, Connecticut took the responsible action of covering these non-formulary drugs at least initially and then contacting the Part D plan on the individual's behalf to petition it to pay for these drugs, if possible; in the meantime, access to drugs equal to what was available to them under Medicaid before the onset of Part D was assured. This essential "wraparound" protection for non- formulary drugs also was adopted for individuals on both Medicare Part D and ConnPACE.

The other responsible action Connecticut took at the time was to cover the new copays for dual eligible Medicare/Medicaid enrollees under their Part D plans. Though relatively modest (initially $1 to $5, now up to $6), copays of this size are, for the reasons set forth above, unaffordable for individuals also on Medicaid, and thus the legislature has twice repealed them. It didn't want to make the same mistake again and so, in 2006, it adopted a "wraparound" for the Part D copays immediately upon implementation of Part D.

In both cases, the goal of the wraparound accomplished by the legislature was to "hold harmless" this exceedingly vulnerable population in terms of their access to needed medications.

Nevertheless, Sections 15 and 66 of Bill 843 would eliminate these essential components of the wraparound for Part D. This would be devastating to dual eligible recipients who will simply go without many of the drugs their doctors having been prescribing. The explanation in the Governor's budget summary— that, "under federal rules,... in those

3 00 1812

cases where a particular non-formulary drug is medically necessary, plans are required to provide coverage" through an exception process, and therefore "it is anticipated that clients will continue to receive needed medications through Medicare Part D"— is preposterous. The inability of this exception process to meet the need for non-formulary drugs under Part D has become a major national concern and, indeed, the legislature's completely accurate prediction that this would be the case was the basis for its adoption of the wraparound in the first place.

Including Psychiatric Drugs Under DSS's Restrictive Preferred Drug List and Subjecting Other Drugs to Burdensome Prior Authorization:

Under DSS's restrictive Preferred Drug List (PDL), now applied to all enrollees in ConnPACE, SAGA, Medicaid and even HUSKY (since pharmacy was carved out from the HUSKY HMOs in February of 2008), drugs not on the list are available only through a prior authorization (PA) process, which is designed to discourage the use of these drugs and in fact does so in part because of the burdensomeness of the PA process. However, more problematic is the fact that doctors routinely write prescriptions for prior authorization-only drugs without first requesting such authorization, owing to the complexities of different and frequently changing long drug lists, with the result that their patients show up at the drug store with a prescription for. a drug lacking PA which is then rejected for payment on the pharmacist's computer. Absent an automatic temporary supply being electronically authorized at the pharmacy counter, the patient, lacking credit cards or other independent resources, will simply walk out of the pharmacy with none of the drug their doctor ordered.

As troubling as this is generally, this is a major concern particularly for individuals in need of psychiatric medications, some of whom may be disinclined to take these medications anyway due to unpleasant side effects, and who therefore are unlikely to follow up with their psychiatrists to advise of the lack of access. Absent followup, their conditions will simply go untreated.

For these reasons, Connecticut, like many states, has exempted all psychiatric medications from prior authorization under the preferred drug list. Section 46 of Bill 843 would remove this exemption entirely. Including mental health-related drugs on the preferred drug list such that some of them will be subject to PA means that these drugs will become difficult to obtain, and some patients, denied access to these drugs, will decompensate and need to be hospitalized at great expense to the state, which now administers both pharmacy and behavioral health benefits directly (not through capitated HMOs), even for HUSKY enrollees.

The same is true for the Governor's proposal in Section 18 of Bill 843 to impose PA on certain high cost drugs regardless of whether the drugs are on the PDL. Imposing PA on these drugs will make them harder to obtain, and threaten patients who need these drugs. In addition, several years ago, DSS on its own successfully asked to have a similar requirement which had been passed by the legislature (prior authorization for all drugs costing more than $500) repealed- because it turned out to be more expensive to

4 001813

administer this process than the money it purportedly saved. Imposing PA on drugs simply because they are expensive is not rationally related to the level of need for these drugs and has already been tried and rejected by the legislature as cost-ineffective. There is no need to re-try this failed policy.

The additional proposed requirement of Section 18, requiring prior authorization for certain off-label uses of drugs for children, including the off-label use of anti-psychotic drugs, regardless of whether the drug is on the PDL beginning July 1, 2010, will severely restrict access to additional psychiatric drugs, this time specifically for children. The pharmacists' computers are not programmed to allow input of specific diagnoses or medical conditions. As a result, there is no way that the state's system will be able to tell for what purpose the drug was prescribed, including whether it was prescribed for an off- label use. This means that the only way that DSS can as a practical matter impose PA on psychiatric drugs for children on the PDL which might be prescribed for an "off-label" use is to deny access to all psychiatric drugs prescribed for children which might be prescribed for such a purpose, unless PA was already obtained. Of course, it is unlikely that a prescriber would know in advance that such PA was necessary, let alone actually request it in advance. The harmful rejections at the pharmacy will as a result go far beyond those drugs not on the PDL.

Eliminating Automatic 30-Day Fill for Prescriptions Requiring Prior Authorization for Which Prior Authorization Was Not Obtained

Particularly coupled with the increased imposition of PA on prescription drugs generally, the elimination of the critical protection of an automatic 30-day temporary supply of PA- only drugs for which PA has not been obtained, as provided in Section 18 of Bill 843, will have a devastating impact on access to prescription drugs for the 345,000 low income HUSKY enrollees, most of whom are children.

DSS discovered, through the experience with its Medicaid Managed Care Organization (MCO) contractors, which managed pharmacy benefits under HUSKY until February 1, 2008, that busy doctors routinely write prescriptions for drugs which require PA without first requesting PA, and thus their patients end up being denied access to these drugs at the pharmacy counter. In the case one of these HMOs, Health Net, data developed in a lawsuit against that company showed that approximately 3,000 times every month a HUSKY enrollee, just in this one plan (not the largest), walked out of the pharmacy with neither the drug they were prescribed nor a temporary supply of it. Since most HUSKY enrollees are under age 18, this meant that it usually was a child who went without the medication their doctor had prescribed, as a direct result of the MCOs' PA requirements.

Thus, on its own, another MCO, CHNCT, instituted a system of essentially automatic electronic authorization of one-time temporary fillso f such PA-only drugs at the pharmacy counter, coupled with follow up to the prescribers of these drugs. When it took over the pharmacy benefits for all HUSKY enrollees in February 2008, DSS announced it would be following the system adopted by CHNCT to protect all of the HUSKY enrollees in the new pharmacy carve-out. It adopted some, but not all, of these essential

5 00 I 81 U

CHNCT protections, but, critically, it ensured that, for the first fill of a new drug subject to PA, patients lacking the resources to pay out of pocket would not walk out of the drug store without a PA-only drug their doctor prescribed, by electronically notifying the pharmacist immediately that a temporary 30-day supply was available, even in the absence of a pending request for PA.

This was done because DSS recognized that its limited 5-day supply for "emergencies" was, and continues to be for the elderly/disabled population, very difficult to obtain, and is unavailable in the situation where a drug subject to PA has not yet had a request for PA submitted. Rather, the 5-day temporary supply for "emergencies" is available only after the prescriber has already requested PA and is simply waiting for a decision; absent a PA request being pending at the time of the presentation of the prescription at the pharmacy, or the pharmacist taking time away from patients in line to call a doctor and get him or her to request PA immediately, even the 5-day supply is unavailable.

Eliminating the essential protection of an automatic temporary supply, which CHNCT adopted, and which DSS itself also adopted because of the obvious harm without it, would ensure that vulnerable HUSKY enrollees, mostly kids, would routinely go with many of their needed prescriptions unfilled, just as they did under the deeply troubled MCO pharmacy system. Indeed, bad practices such as denials at the pharmacy, which the DSS takeover of the HUSKY pharmacy benefits from the MCOs was designed to end, will become codified under the Governor's bill.

I note that the automatic temporary supply requirement adopted for the HUSKY population in February 2008 was not adopted for the elderly/disabled population (they only have the very hard to access "emergency" 5-day supply). Advocates have tried without success to get DSS to adopt what was made available to the HUSKY population for the elderly/disabled population. But now, rather than address this problem, the Governor's proposal is to go backward: drop the HUSKY population, including kids, down to this same lowest common denominator of severely restricted access to any drugs subject to PA.

Elimination of coverage for most over the counter drugs under Medicaid

While most of the cuts above involve ehgibility restrictions, higher cost sharing and access restrictions through prior authorization, in some cases, drug coverage will be eliminated entirely. This is the case with most over-the-counter drugs for adults under Medicaid. Under Section 18 of Bill 843, only insulin and insulin syringes will remain as an over-the-counter covered service. While many Medicaid enrollees will thus be denied access to medications, others will speak with their doctors, who will then write prescriptions for prescription versions of the same drugs, which will then be paid for, but at a much higher cost, under Medicaid.

In sum, I urge you to reject all of these cuts to essential health care programs contained in Bill 843 as needlessly harmful to our most vulnerable populations. Particularly since Connecticut will be receiving $1.32 billion from the federal government in stimulus

6 001815

payments specifically through enhanced Medicaid reimbursement, if the state is going to take this extra Medicaid money and use it for other purposes to fill the budget gap, at a minimum, it should at least not take away benefits from the recipients under Medicaid and the other state health insurance programs. Indeed, last week, speaking to the nations' governors, President Obama said "our administration will begin distributing more than $15 billion in federal assistance under the Recovery Act to help you cover the costs of your Medicaid programs," to "help ensure that you don V need to make cuts to essential services Americans rely on now more than ever." (See February 23,2009 White House Press Release, http://www.whitehouse.qov/the press office/President-Obama- Announces-15-Billion-in-Medicaid-Relief-from-ARRA-Headed-To-States/)

Opposition to Bill 6524

Based on the ongoing experience with the HUSKY HMOs for the generally healthy family and child population already enrolled in them, capitated HMOs covering the Medicaid population tend to have severely inadequate provider networks. But this reality will go unmentioned by the HMO marketers urging vulnerable elderly and disabled Medicaid recipients to sign up with their plans. And, because of the obvious financial incentives, even if the HMO the enrollee chooses includes his or her current doctor, the HMO will often deny access to care when that participating provider requests it. Given the access problems these HMOs already create for low-income HUSKY families, this clearly can't be a good thing for the even more vulnerable elderly/disabled Medicaid recipients, with multiple medical conditions and very low incomes.

There is a myth that proponents of HMOs commonly invoke in support of moving the elderly and disabled population to HMOs: that this population needs to have its care coordinated and the HMOs coordinate care which would not otherwise occur. But this rarely occurs now—even under the HUSKY contracts which already require it. Similarly, in the case of Oregon, which has experimented with HMOs for its elderly and disabled population, the reality has been quite the opposite. As one Oregon advocate, Attorney Timothy Baxter of the Lane County Legal Aid and Advocacy Center, recently explained:

In our collective experience serving many hundreds of elderly and disabled [Medicaid] participants over the years, true case management... ha[s] been, not just ineffective, but generally nonexistent.

* * *

The officers of commercial health plans have, quite literally, a legal duty to their corporate shareholders or other owners to maximize profits to the fullest permissible extent The conflict of interest in assuming the role of public servant invades the innermost core of the health plan's mission. To have any hope of keeping the health plan from unchecked fulfillment of its own corporate nature, the most rigorously faithful oversight must be maintained without letup.

7 001816

My own county served as a truly catastrophic illustration of how badly things can go wrong. In 2000 and later years, the state's oversight of Lane County's MCO failed — totally. As a result, the Lane County MCO ran wild over the rights of its disabled and elderly [Medicaid] members. Improper, unexplained denials of requests for medical equipment and supplies became the norm. Delay, stonewalling, and other hardball private insurance tactics, became standard operating procedure.

In sum, the movement of elderly and disabled Medicaid enrollees to the HMOs will severely restrict their access to needed health care. Nevertheless, it is possible that the proponents of this bill believe it will at least save money. But this is a myth too. It is not at all clear that having moved the HUSKY population into HMOs will save money relative to the weU-functioning non-risk system most of them were in before February 1, 2009. Moreover, based on the years of experience with the Bush Acorimistration encouraging Medicare Advantage HMOs to enroll essentially the same population, placing the elderly and disabled Medicaid population in capitated HMOs will be more expensive than continuing to adniinister health care directly to this population under the DSS-run Medicaid fee-for-service program.

Although the Bush Administration had managed to bring HMOs into the Medicare program and keep them there, this has only been possible at a fiightfulpric e to the taxpayers: HMOs have been willing to stay in that program because of the profits made possible through heavy subsidization of these plans by the federal government, such that they on average cost the taxpayers 14% more than it would cost to provide the same care under the traditional government-run Medicare program. President Obama has specifically identified this excessive cost as an example of waste in the health care system which must be eluriinated.

For all these reasons, I also urge you to vote "no" on Bill 6524.

Thank you for meopportunity to speak with you today.

8 001817

j^tafe of (EoratBciimi GENERAL ASSEMBLY

HUMAN SERVICES COMMITTEE LEGISLATIVE OFFICE BLDG. ROOM 2000 STATE CAPITOL HARTFORD, CONNECTICUT 06106 240-0490

Human Services Committee

PUBLIC HEARING AGENDA Tuesday, March 17, 2009

10:00 AM in Room 2A of the LOB

I. COMMITTEE BILLS FOR REVIEW

S.B. No. 1085 (RAISED) AN ACT CONCERNING HOMEMAKER AND COMPANION AGENCIES AND AUDITS FOR VENDOR FRAUD. S.B. No. 1086 (RAISED) AN ACT CONCERNING THE CREDITING OF SOCIAL SECURITY DEPENDENT BENEFITS. S.B. No. 1087 (RAISED) AN ACT CONCERNING CONNPACE PRESCRIPTION DRUG REVIEWS. S.B. No. 1112 (RAISED) AN ACT MAXIMIZING THE FEDERAL STIMULUS FUNDING. S.B. No. 1113 (RAISED) AN ACT CONCERNING MEDICAID. S.B. No. 1122 (RAISED) AN ACT CONCERNING CHANGES TO THE HUMAN SERVICES STATUTES. H.B. No. 6639 (RAISED) AN ACT CONCERNING COMMUNITY ACTION AGENCIES. H.B. No. 6668 (RAISED) AN ACT PROVIDING QUALITY CARE, FINANCIAL OVERSIGHT AND NURSING HOME FUNDING REFORM.

II. ANNOUNCEMENT OF TIME AND DATE OF NEXT MEETING

III. ADJOURNMENT

*«* Punted on itcydto paper 001818

HUMAN SERVICES COMMITTEE

ATTENDANCE

_ Committee Meeting _X_ Public Hearing - Subject Matter: Miscellaneous Bills

Date: _3-17-09_ Time:_10:05_ Room: _2A_LOB/Capitol

Presiding Chairmen: Sen. Paul Doyle X Rep. Toni Walker X

Vice Chairmen: Sen. Eric Coleman X Rep. Catherine Abercrombie X

Ranking Members: Sen. Robert Kane X Rep. Lile Gibbons X

Committee Members Present: Rep. Larry Butler X Rep. Clark Chapin X Rep. Michelle Cook X Rep. Christopher Coutu X Rep. Mae Flexer X Rep. Karen Jarmoc X Rep. Shawn Johnston X Rep. Christopher Lyddy X Rep. Bruce Morris X Rep. Linda Orange X Rep. John Rigby X Rep. John Thompson X Rep. Gary Winfield X

Staff: Brie Johnston 00181?

Wait of (Eorrmcitart GENERAL ASSEMBLY

HUMAN SERVICES COMMITTEE LEGISLATIVE OFFICE BLDG. ROOM 2000 STATE CAPITOL HARTFORD, CONNECTICUT 06106 240-0490

Human Services Committee Membership 2009

Co- Chairs: Senator Paul Doyle Representative Torn Walker

Vice Chairs: Senator Eric Coleman Representative Catherine Abercrombie

Ranking Members: Senator Rob Kane Representative Lile Gibbons

Members: Representative Larry Butler Representative Clark Chapin Representative Michelle Cook Representative Chris Coutu Representative Mae Flexer Representative Karen Jarmoc Representative Shawn Johnston Representative Christopher Lyddy Representative Bruce Morris Representative Linda Orange Representative John Rigby Representative John Thompson Representative Gary Winfield

Cs PnntBd on rocycled paper Public Hearing Public SJ§s*Bp> opRci^i.^ Tuesday, March 17, 2009

# Name Represents Bill #'s Pro/Con Written Testimony

/ 66 Y ^ % "i

*A €8

70

o o 00 o Public Hearing Public Sign-up

# Name Represents Bill #'s Pro/Con Written Testimony

1 cr\Hc It

2

*-3 -Uf^^a^v—•— - u • • - 4 self con vi —i 5 3d/f .(•(»{* 9 i - 6 John (k^x\r\n 1 - - 7 1 I f 8

9 pro I r 10 /hiche/ft C>c/Onfe'/r / /a 3.

11 •fcy-nn-Wa-wft f=- cT pro —rr ; —1 —r 12 G) do 6 &v p)0 ( 13 Ma/Vn Ace n do V 1 i 14 pro I 15 o -16 •—tl-M pro o h-1 00 M Public Hearing Public Sign-up

# Name Represents Bill #'s Pro/Con Written Testimony

17

18 r 19 • CACI^ pib \ f 20 Ctn • J ij r' 21 9/0 \ 1 22

23

24

25 re / P I / 26 O • ^- ii 0 ! 27- /-/-?^

28

29

30 CAFCA pro V-e/ / 1 r 31

• o 32 o 00 Public Hearing Public Sign-up

# Name Represents Bill #'s Pro/Con Written Testimony

• 33

34

35 I d i 36

37 •

• 38

39

40 tKmn Luc Can o I 41 Mate (if 1 6>ia(?n

42 V

44

45 pi D r 46 I 47 CrVMClf MIX yeir o 48 (C/^ayc^ Af(a.f4 CP o r-1 00 rsj

r '9 1 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

CHAIRMEN: Senator Doyle Representative Walker

VICE CHAIRMEN: Senator Coleman Representative Abercrombie

RANKING MEMBERS Senator Kane Representative Gibbons

MEMBERS PRESENT: REPRESENTATIVES: Butler, Chapin, Cook, Coutu, Flexer, Jarmoc, Johnston, Lyddy, Morris, Orange, Rigby, Thompson, Winfield

SENATOR DOYLE: Good morning, everyone. Happy St. Patrick's Day. I'd like to welcome everyone to the public hearing for the Human Services Committee, and before we get into specifics, as you knowj the first hour is usually, reserved for public officials from, you know, 1 the state government, and then after that we go to the second hour, we usually go to members of the public, citizens. And today we have a short list of public officials so I'm optimistic we can get to the public early as possible, which is good for everyone. And we generally we -- we stick to the members of the public and everyone we try to keep to a three-minute rule so you hear a bell; and if you hear it if you could please summarize. And then also we'll be able to ask questions by committee members, and at times there may not be a lot of committee members in the room and it's -- people are -- a lot of things going on so it may not be that -- people could be at another meeting or they could be listening in their office also, so don't feel upset if they're aren't that many people in 2 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

the room, but it's a -- it's a busy time we're winding down a lot of the committees.

With that being said my cochair, Chairman Walker, have any comments?

REP. WALKER: No sir. Just -- just to remind everybody our wonderful JF deadline is Friday, I mean Thursday -- I wish it were Friday -- Thursday at five o'clock so everything we do we have to get completed by this week, so thank you.

SENATOR DOYLE: Thank you, Madam Chair.

So at this point we have one person signed up for public officials Jame McGaughey of Protection and Advocacy.

Good morning, Jim.

JAMES MCGAUGHEY: Senator Doyle, Representative Walker, members of the committee.

For the record my name is Jim McGaughey, and I'm the director of the Office of Protection and Advocacy for Persons with Disabilities.

I'm here to comment on Raised Bill 6668, An Act Providing Quality Care, Financial Oversight and Nursing Home Funding Reform. I've submitted written testimony so I will just summarize it. Basically we have a problem with some of the language in section one of this bill that would require the Long-Term Care Planning Committee to develop a plan, a multifaceted plan, to address a number of concerns about the staffing, administration, accountability, and oversight of nursing homes but the -- the language we have a particular problem with requires one element of that plan to establish a March 17, 2009 med HUMAN SERVICES COMMITTEE 10:00 A.M.

preadmissions screening process that would ensure that individuals with certain psychiatric disabilities or a history of physical or sexual abuse are not inappropriately admitted.

The reason we think -- think this language is problematic is because it sort of creates the impression that -- perpetuates stigma basically that, you know, people with " psychiatric disabilities are associated with sort of a dangerous population. That is not to say that nursing homes are great places for people with psychiatric disabilities. As my written testimony explains, there's -- there's much, many too many people with psych disabilities winding up in nursing homes, largely because we don't have alternatives and so we -- I certainly don't oppose some kind of a screening process that would prevent people with psychiatric disabilities who don't need to go to nursing homes from going there. Particularly if you also could find some way of increasing the supply of supportive housing, which is really the alternative program that most folks would -- would benefit from.

The other -- the other section of the bill that I wanted to comment on, section two, would establish a 13 member Personal Care Attendant Quality Home Care Workforce Council that would be comprised of various state officials and persons with disabilities, surrogate decision-makers and advocates. And the council would be charged with a -- a variety of functions related to recruiting, training, recommending certification process, creating a backup, a respite service, and establishing an accurate list of the individuals currently employed by people with disabilities as personal care assistants. 4 March 17, 2009 001827 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

It sounds pretty innocuous, but I think the committee should be aware that the language in section two was part of a much more expansive proposal that was fairly recently circulated amongst people with disabilities who employ personal care assistants and it was clear from that larger proposal that the purpose of this council was essentially to become management for an effort to organize personal care assistants into a union so that there would somebody to bargain with. And I think that the proposal has stirred a lot of controversy amongst folks with disabilities who -- who rely on personal care assistants, and you're going to hear from some of them today so just to be aware of that.

And also I think it's important to understand that the role of personal care assistant really grew out of a liberation movement a -- sort of, a -- an independent,living movement where certain individuals with very significant physical disabilities, sort of, refused to continue to live in institutions, and they insisted on taking charge of.their own lives, and PCAs, personal care assistants, had an awful lot to do with their ability to do that.

Part of -- part of the way they conceptualized this was .that they were employers and they were responsible for the hiring and the firing, the training, recruiting arid directing personal care assistants, and that's really been a core philosophy if you will, of the independent living movement, but it's also more than that. It's more than just ideology because the reality is that no two people have the same needs, and the PCA relationship that they have varies from person to person and it sort of has ,to. So I think there's a certain 5 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

-- there's a threatening component to having some kind of a centralized group of people put together for good intentions, but with the history of good intentions this and Human Services are often, you know -- slippery slope starts to develop pretty quickly, and you wind up very far away from where you thought you were going to be. So that's really all I had to say. If there are any questions I'll -- I'll try and answer them.

SENATOR DOYLE: Thank you.

Any questions?

Representative Gibbons.

REP. GIBBONS: Thank you, Mr. Chairman.

Good morning, Jim. Thank you for coming this morning. A couple of questions. As I understand it now the PCAs -- the consumer can contract directly with the PCA, or does the consumer have to go through an agency?

JAMES MCGAUGHEY: There's -- there's different ways it can be done. Right now you can hire your own person. You can place ads and hire your own person. Generally there's a -- I'm not familiar with all the terminology, but there's a -- there's a -- there's a financial intermediary that can handle the -- the payment part of it, but you have to -- you have to run the payroll yourself if you're hiring.

REP. GIBBONS: I guess that's what I'm asking. Who -- if you're on Medicaid, how do you bill Medicaid if you don't go through an agency or how do you do it?

JAMES MCGAUGHEY: There's a -- there's a -- there's 6 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

an intermediary, but they don't -- they're not hiring -- the intermediary is a fiscal intermediary --

REP. GIBBONS: Okay.

JAMES MCGAUGHEY: -- they do not hire the individual.

REP. GIBBONS: Okay.

JAMES MCGAUGHEY: They just handle the -- make sure that, you know, the deductions are done appropriately, and so forth, for payroll purposes.

REP. GIBBONS: And secondly, do you have any idea how many PCAs we have in the state?

JAMES MCGAUGHEY: I don't. There are people who --

REP. GIBBONS: I mean are there hundreds or thousands-or don't we know?

JAMES MCGAUGHEY: Oh, there are hundreds.

REP. GIBBONS: Hundreds

JAMES MCGAUGHEY: Yes. There -- there may be a thousand or two, I guess, but not -- it's not -- it's not tens of thousands at any rate. And I would also say that there are a number of different state agency programs that support people's hiring PCAs, including some people who are clients of the Department of Developmental Services, and certainly there are a number of programs operated within the department of Social Services as well. So there's -- and there's different ways people do it. Some people do in fact prefer to go through an agency but, sort of, the -- 7 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. GIBBONS: You don't have to?

JAMES MCGAUGHEY: You don't have to, no.

REP. GIBBONS: And what are the licensure requirements to become a PCA?

JAMES MCGAUGHEY: There are none.

REP. GIBBONS: There're none?

JAMES MCGAUGHEY: No.

REP. GIBBONS: So it's a willing heart and a strong back.

JAMES MCGAUGHEY: And in fact, and compatibility and a number of things that, you know, it's -- it's interesting. A number of people I've known who've relied on PCA services to really to be able to live independently, very independently, and one of the women I rely on a lot for advice is basically -- she lives in Canada and she -- she describes the relationship as a, sort of, a peculiar form of intimacy with someone because they're, sort of, they're your employee, but they're doing stuff with you that most people do alone. And so this -- there has be a comfort level that's -- that -- that seems to be as much the credential they're looking -- people look for as any kind of training for instance, that's

REP. GIBBONS: Do you have any idea what these PCAs get paid an hour is that -- does that vary?

JAMES MCGAUGHEY: It -- it varies somewhat. There is a certain reimbursement rate. I don't know. You'll have to ask the folks who are coming and there's -- I mean there've been various attempts to -- to, you know, get PCAs 8 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

together and so forth. That's -- that's the other piece of this puzzle is that it's hard to do that. There -- they, too, are independent minded and so they find this role fits their particular needs as well as it fits the needs of the people with disabilities.

REP. GIBBONS: Well, I think we're going to hear from some of them today and go from there.

JAMES MCGAUGHEY: You will indeed.

REP. GIBBONS: We'll go from there. Thank you.

Thank you, Mr. Chairman.

SENATOR DOYLE: Representative Walker.

REP. WALKER: Thank you, Mr. Chairman.

Good morning, Jim. How you doing? Happy -- Happy Thanks -- Happy St. -- Happy Thanksgiving -- Happy -- gee that shows you how where I am. I'm interested. Has this type of proposal been enacted in any other states, setting up these types of programs?

JAMES MCGAUGHEY: It's my understanding that that's -- that it has. There are, I know Washington state, I believe in Michigan, as well, and possibly New York. Those are states that come to mind where -- where organizing has occurred. And I, you know, the impulse to organize is not -- it's -- it's not evil or anything. It's, sort of, a recognition that, in essence, the rates being paid are determined by a variety of government programs and there's, you know, who's going to bargain with the government if you don't, if you have to do it individually so I mean there's -- there's, sort of, a -- there's something to that, I think. But the I -- I don't know how 9 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

well -- I think it would be interesting to see how well it was working elsewhere.

REP. WALKER: It --

JAMES MCGAUGHEY: Massachusetts is another state I've --

REP. WALKER: -- I had to do this, sort of, thing with my father because I took care of my father for about, about ten years, and he was visually handicapped also, and one of the things that -- setting up the parameters and -- and, sort of, having some guidelines to work with, it was very hard for me at first because I tried to do it individually as my own contractor. And it got to the point where I had to work with some sort of body that had sort of guidelines and rules on how things needed to be prepared, you know, little things like driving him and who was going to be responsible, also the care of him and having someone, sort of, not necessarily there every day but just helping to say these are things that can be done, should be done and also in addressing pay and addressing, you know, what was required in, like, snowstorms and things like that.

There are a lot of things that -- that come into play that are questions that I just never had before because I had never done it, and it helped me once I -- I just affiliated myself with somebody just to have somebody that was there to just sort of give me guidelines on what things I needed to do and what things, because I was -- I was contracting and I didn't know really what my -- what my responsibility was, because it's a responsibility both for me and for the worker.

And so it -- it, you know, it was such a hit 10 March 17, 2009 001833 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

and miss for the very beginning that it was painful. I spent more time trying to figure out what I was supposed to than doing my --my real job so it -- I wish I, kind of, and I understand the hesitation, but the relationship with my dad and his care workers was fabulous once we had guidelines and we had understanding because it was -- it got to the point where when we when, when they had questions we had a way of venting those questions, and when there was always an issue about adding on some sort of responsibility, how did we make those determinations because being a contractor and not knowing what my boundaries were and what my responsibility was made it very difficult, like knowing when to pay and also the -- the types of skills that they needed to have. And - -- and things that happened like going to the doctor, I wanted to know what the doctor said, and they -- the person helped me understand, well, why don't you have a book and why don't you set up the things that the doctor can sign and say this is what was happening so that I didn't have to go every time.

So I -- I see both sides of it, but the -- the thing that I hear from a lot of people is when I hire somebody, and I had a friend whose mother just passed who went to this. She said, I mean -- what are they supposed to do? What can I ask, when do I pay them, what types of ways do they address my mom and -- and what is appropriate when my father -- when my mom is sleeping, is it okay for them to watch TV? I mean little things like that and it, and it got to the point where at the end I felt like I needed to write a book because I needed to help other people understand.

So, I mean, and especially as I -- as I found out about Money Follows the Person and the 11 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

fact that -- that we're now venturing into this -- this -- this world of -- of private contracting I'm -- I guess we sometimes boundaries are -- make people more secure, and boundaries are not always bad things. Boundaries just help us to understand what direction we need to go. And it doesn't say this it black and white, but it says these are the things that are, sort of, guidelines so I -- I mean I understand the need to have the independence because that helps you to feel like you're in control, but then having independence without having some, sort of, sort of a -- not a boilerplate, but a -- you know, a guideline really makes things a lot easier, so.

JAMES MCGAUGHEY: My only comments are first of all, there is somebody you will be hearing from who has written the book on hiring -- hiring PCAs so that -- there's -- and literally it is a book on how to go about doing it. But I think it's also just the -- the options are still available for people to go through home healthcare agencies, and so forth, if they want to. And that's, you know, it's, I guess, part of the liberation movement I spoke of was a sense of defining personal care as not being a medicalized type of service. It's -- it's, sort of, ordinary life. I just need help with certain things in ordinary life, and some people really don't want to deal with any kind of a power structure that they'd rather not have to deal with authorities. They'd rather just deal with people.

REP. WALKER: But is it -- is it really a power structure or is it just somebody that's there to get -- because I mean I didn't go through an agency. I went through somebody who -- who had done this, and we helped each other out. 12 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

But my -- my main thing was that I wanted to pay directly -- I wanted the money to go to the PCA. I didn't want to pay an agency to - to, you know, three quarters of per hour and have the worker just get a small pittance. I really felt that they they deserve to get the direct pay and also cost-effectively, I mean it -- it cost me an astronomical -- an arm and a leg, but still I knew that I was paying for my fathers care directly to the person that was responsible.

But the -- the, you know, I don't -- I never saw it as a power play, and I never saw it as someone coming in and telling them what to do All they were doing was giving me guidelines so any -- I mean," I think it's the way it's delivered to us. And it's also people tend t identify any.type of council as government, and government's not bad as long as you can say when it's going to be there and when it's not. So I happen to think it's an aid.

JAMES MCGAUGHEY: I'm not going to argue about government, but I think that the --

REP. WALKER: You work for government.

JAMES MCGAUGHEY: -- the perception indeed. I'm from the government, and I'm here to help. But the -- the perception of this amongst thi particular council and this particular proposal, I think is much because of the iarger package that had been circulating was that there -- there's an agenda to this that is somebody else's not -- not that of the people themselves. So that was just -- that' some of what's going on here so.

SENATOR DOYLE: Thank you.

Senator Kane. 13 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

SENATOR KANE: Thank you, Mr. Chairman.

Good morning, Mr. McGaughey. Hope I'm pronouncing that right.

JAMES MCGAUGHEY: Anything close.

SENATOR KANE: Close did you say?

JAMES MCGAUGHEY: Anything close, anything's fine with me.

SENATOR KANE: In your testimony you mentioned how part of this proposal is a bit controversial in the fact that there may be a proposal from the -- to unionize these personal care assistants. Does that mean that the people who are being served, the people with the disabilities -- are they opposed to such a proposal?

JAMES MCGAUGHEY: Well, I think there are different minds, and I think you'll hear different opinions expressed. Some people are opposed, and some people are not, and I suspect so just because they have disabilities doesn't mean they all think alike so.

SENATOR KANE: I was just wondering if there -- there was an overwhelming majority on one side or the other.

JAMES MCGAUGHEY: I -- I could not say. I -- I am aware that people that, who have contacted me over the past week are mostly opposed,to this.

SENATOR KANE: They're opposed.

JAMES MCGAUGHEY: They're opposed. But, you know, that's not a scientific sampling that's just 001837 14 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

SENATOR KANE: But it's based on your conversations, your experience, your, you know -- how about yourself, do you have an opinion on it?

JAMES MCGAUGHEY: Well, I think you have to be very careful to create, I -- I think that what's -- what's at stake here could potentially redefine what we mean by personal care assistant services. I think that it is not easy for people to negotiate the things Representative Walker was talking about. I know people who spend a lot their day making sure that sometime next week they're going to have a ride to go from this place to that place and that they'll have somebody who can, in fact, come in tonight and make sure that they can get out their wheelchair and into bed, that there's -- there's to make sure of that.

So it's not easy to manage your life this way, but on the other hand, I'm not sure that we've succeeded in creating structures that really help people that much. And so folks have learned to rely on themselves, and what they're really saying is give us the tools and let us manage our own lives. So before you create a council that could homogenize things, that would wind up taking the, you know, developing policy that would apply across the board --

SENATOR KANE: There's no one-size fits all.

JAMES MCGAUGHEY: -- that's what they do, yeah, you might lose some of that ability to individualize. And I'm not sure if it could be done in a way that's sensitive to the individual, Senator. I think that would be -- that would certainly be the challenge. 15 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

SENATOR KANE: And how about the cost associated with it. Do you think that the cost would then go up because of unionization?

JAMES MCGAUGHEY: I'm sure that that's a factor. There would be -- there, would be costs and once again I'm not saying that people -- people don't have a right to earn a decent living. I think they do. But it's -- and get benefits, I think that's another piece that's very hard to -- hard to arrange with this sort of individual work. But it's -- it's definitely a factor, because if the cost goes up, does that mean that there would be fewer hours available --

SENATOR KANE: That was going to be my next question.

JAMES MCGAUGHEY: --to support people? You know, it comes from somewhere.

SENATOR KANE: Thank you, very much for your answers.

JAMES MCGAUGHEY: Right.

SENATOR KANE: Thank you, Mr. Chairman.

SENATOR DOYLE: Thank you.

Any other questions from the committee members?

Seeing none, Thank you very much, Jim.

The next speaker -- okay that's it for public officials. So we're now on to the public, which is pretty good, not too bad, better than other meetings so. We're into the public, and again we want to try to keep it to three 16 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

minutes, and then the committee has the opportunity to ask questions. And I'll just point out after our public hearing we're going to have a committee meeting. The agenda is out, so it's undetermined what time it'll start. At the end of the public hearing we may have a brief time for caucus for the different parties, but the committee meeting will be soon thereafter and none -- none of the bills that are being heard today are on that agenda though. That would be Thursday.

Okay. So members•of the public, the first person is William Sullivan then Martha Dale then Deborah Legault.

So, Mr. Sullivan, good morning. .

WILLIAM SULLIVAN: Good morning, Happy St. Patrick's Day. Senator Doyle, Representative Walker, and members of the Human Services Committee, my name is Bill Sullivan, and I serve as the Chairman of the Board for the Connecticut Association for Home Care & Hospice and am the President and CEO of Visiting Nurse Services of Connecticut. As a home care provider, with our corporate office located in Bridgeport, we deliver over 250,000 visits per year to 49 communities. We admit over 10,000 patients annually, 2,000 of which are Medicare eligible beneficiaries.

As the voice for home care providers, and as one of the largest home care and hospice nonprofit providers in Connecticut, we strongly endorse and support sections one through five of Senate Bill 1122, and I respectfully request that each of you and your fellow Legislators, enact 1122 as crafted.

Specifically speaking about my agency, we provide care to more than 2,000 Medicare 001840 17 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

beneficiaries this past year, which resulted in a loss in excess of $2.6 million on Medicaid business. This translates into receiving 72 cents of reimbursement for every $1 of reasonable customary cost expended to deliver the care to the Medicaid patient.

This significant deficit occurs at a time when Medicare is reducing reimbursement, donations are dwindling, support for organizations such as United Way has completely evaporated, and the ability to seek cash flow advances through our equity line of credit has ended. We no longer have the financial resources to support the significant Medicaid shortfalls. We have taken prudent measures in an attempt to balance our books and exercise responsible financial management. Unfortunately, we are still unable to achieve the necessary results needed to sustain ourselves after employing a number of corrective actions. We have reduced our workforce by 16. We have reduced the employer contribution for pension and health insurance funding. Wage increases have been dramatically reduced with executive level compensation frozen for the third year. We have consolidated two of our offices into one.

As an organization we are being forced to reexamine our mission and potentially exercise some business options we have resisted, while others have adopted. Many providers today have resisted or refused Medicaid referrals thus creating a disproportionate share of services being delivered by fewer participating agencies. The implementation of the new Money Follows the Person program will be retarded as agencies will not be able to financially support this material reimbursement shortfalls. And the Connecticut Home Care Program for the Elders which saved the state of $91 million last year will be 18 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

jeopardized.

The adoption of Senate Bill 1122 is critical to save the system that is in crisis and edging towards potential collapse. There is a sense of immediate urgency to instantaneously fix.and address our precarious financial situation. Years of receiving negligible or no rate increases has now placed organizations such as ours in untenable position. Home care can be part of the solution for the state budget crisis, but it needs adequate funding. Home care costs $132 a day, nursing home care 544, and hospitalization $5,765.

By investing dollars in home care and ensuring patient accessibility and agency viability, the state will achieve significant returns on this investment. By ignoring the financial needs this bill addresses, we will be adding to the growing patient access issues and ultimately a higher cost borne by the state for extended, needless increased hospital lengths of stays and amplified nursing home placements.

I thank you for the opportunity to briefly share my concerns and thoughts and urge you to take the bold and courageous measures to pass this bill out of your committee. Thank you.

SENATOR DOYLE: Thank you.

Any questions?

Representative Cook.

REP. COOK: Good morning.

WILLIAM SULLIVAN: Good morning, Representative.

REP. COOK: You had briefly mentioned that the 19 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

state would benefit greatly --

WILLIAM SULLIVAN: Yes

REP. COOK: --by taking these measures. Could you give any examples financially, especially in this fiscal crisis, what the state would benefit if we could reimburse you those higher rates?

WILLIAM SULLIVAN: Certainly. I think for every 1,000, say, additional Medicaid patients that are diverted to nursing homes the state would save $16 million, and that's the shared -- the state shared portion on an annualized basis. You know, that's one example. I think if the dollars I gave with cost for home care versus institutional care, for every day in the hospital that the length of stay is added, you know, it's -- it's about $5,500 of additional cost to the state. So if you multiply that out by whichever, you know, number you wish, you can see there will be significant dollars that the state will have to absorb if home care is not available to take on these clients.

REP. COOK: And I have one other question and not to compare cost with care because I don't think that there's necessarily a comparison, but with the group of people that you outreach to and care for do you only go to certain areas, or do you outreach to a variety of different areas? Could you explain that.

WILLIAM SULLIVAN: Yes. Our particular home care agency we provide care to every individual regardless of where they live or what their ability to pay for the service is or they're payment source. There are a number of home care providers today that either restrict it or refuse care in certain areas or based on 001843 20 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

the payment source. I can give you an example. In Bridgeport we have about 22 to 23 agencies providing care into the city of Bridgeport, and I would say that there's two -- we are the one that has the most capacity and take on the majority of the Medicaid population -- and only two that will accept the Medicaid population. The others either restrict it or will not accept any Medicaid patient.

REP. COOK: And what about the type of environment that you'll go into? Is it certain areas or do you go into all areas?

WILLIAM SULLIVAN: We will go into every area. There are some areas, because of potential safety risks, we will have to have an escort accompanying a staff member. These are individuals that come from the area. They are not armed, but they do accompany the staff, and this can provide some street smarts to our staff.

REP. COOK: Thank you.

WILLIAM SULLIVAN: Thank you.

SENATOR DOYLE: Thank you.

Any questions?

Representative Walker.

REP. WALKER: Good morning.

WILLIAM SULLIVAN: Good morning.

REP. WALKER: Under this bill -- under your agency what types of Medicaid reimbursements are able to achieve -- to acquire? 21 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

WILLIAM SULLIVAN: Our current rate of reimbursement?

REP. WALKER: Uh-huh.

WILLIAM SULLIVAN: Our current rate of reimbursement is about 70 percent on what it's actually costing us to deliver the care. Okay? Medicaid right now the -- they're paying $94 for nursing visits, $24 for a home health aide's hour, $80 for physically therapy visit, $82 for occupational therapy, and $82 for speech therapy.

REP. WALKER: All of those are 50 percent matched?

WILLIAM SULLIVAN: Yes.

REP. WALKER: By the federal government?

WILLIAM SULLIVAN: Yes. And conversely if you just look at, you know, nursing as an example, the Medicaid -- Medicare program will reimburse at $131 compared to the 94, and if you look at your therapies, the -- especially physically therapy there was such a shortage -- Medicare reimburses $144 for a physical therapy visit, and the state is reimbursing at $80. So you see that there's a major disparity even between the federal government and the state.

REP. WALKER: Do you do case management with your clients also?

WILLIAM SULLIVAN: Yes.

REP. WALKER: Are you able to get reimbursement on that?

WILLIAM SULLIVAN: No. We -- we manage every one of our patients. The caregiver who's responsible for that care is case managing the 22 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

care and it's done in cooperation with the attending physician.

REP. WALKER: If the state added in more -- more pilot programs under PCCM, Primary Care Case Management, would you be able to -- to access that? Would you be able to utilize that -- that service and be able to get reimbursement though your agency?

WILLIAM SULLIVAN: Yeah, I think again the problem is just the level of reimbursement. It is just so inadequate that it's becoming much more difficult to sustain the organization as a whole, just because of that, you know, inequity in the reimbursement system.

REP. WALKER: Some of the -- some of the -- the rates that I've heard for case management can go up as high as 75 percent reimbursement. Are you familiar with that?

WILLIAM SULLIVAN: No, I am not.

REP. WALKER: Okay. All right. Thank you.

WILLIAM SULLIVAN: Thank you.

SENATOR DOYLE: Any other questions?

Representative Cook.

REP. COOK: I have a quick follow-up.

A VOICE: I'm sorry.

REP. COOK: On your -- your suggested plan of reimbursement to the state, what could benefit us in the long-run financially, have you discussed that with anybody giving them your proposal as to how it would benefit us? 23 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

WILLIAM SULLIVAN: Yes. I have had discussions with the Department of Social Services and actually have submitted the document to them, and we've unfortunately had intermittent conversations on the document that I submitted.

REP. COOK: Is there a possibility that the committee could get a copy of that document that shows where the cost-effective measures would be taken?

WILLIAM SULLIVAN: Yes.

SENATOR DOYLE: Thank you.

Any other questions?

Seeing none, thank you very much.

All right the next speaker will be Martha Dale and then after that we're going to go back, Deborah Polun came from Commission of Aging, but right now it's Martha Dale then Deborah Polun then Deborah Legault.

THOMAS SALEMME: Good morning, Martha Dale sends her regrets she could not be here this morning.

SENATOR DOYLE: You're not Martha Dale.

THOMAS SALEMME: Actually she's working on a closing of a building that we're opening to move people from our facility at Leeway into housing which is also relevant to the -- our --my testimony this morning.

So again, good morning, my name is Tom Salemme. I'm director of Social Services at Leeway. Leeway is Connecticut's multiservice provider to persons with HIV/AIDS and 001847 24 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Connecticut's first and only subacute facility dedicated solely to the care of people with HIV/AIDS and developer and provider of support of housing for this population. I will present below an appeal to continue work on the submission of the proposed HIV/AIDS waiver.

Since Leeway's establishment in 1995, we have provided comprehensive subacute inpatient nursing, medical and behavioral healthcare to more than 750 people living with HIV/AIDS as well as established low income supportive housing to enable frail and marginalized persons living with AIDS to move back to the community. Leeway itself is a result of work by passionate health policy change agents who sought help from government officials like you 16 years ago, having identified a crying need for care for the state's most marginalized citizens.

Three years ago Leeway asked your assistance to obtain a waiver from federal law that would pilot the provision of enhanced home and community-based services for up to 100 Medicaid-eligible persons from across Connecticut who have HIV/AIDS to avoid unnecessary or extended stays in a nursing home. This impetus for this bill was the result of five years of research and analysis to document the need for community intensive clinical case management services to the state's most frail HIV/AIDS population who are seeking an alternative to community clinical case management service. Intensive community clinical case management services have been proven to reduce the overall healthcare costs for persons with HIV/AIDS by helping them better manage this complex, chronic disease while living at home. Additionally, these supports' would help clients return to 25 March 17, 2009 001848 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

productive community living more quickly and free up scarce healthcare resources for those waiting to be discharged from hospitals to skilled nursing facilities.

And in 2006, you responded to this pressing need by passing Bill 511, An Act Concerning A Medicaid Home and Community-Based Service Waiver For Persons With HIV or AIDS. Work began in earnest last year at the Department of Social Services to complete the application for this waiver for submission to CMS in Washington. It is ready for submission right now. However, the proposed budget before the state Legislature would delay the submission of the waiver application until 2011. It is shortsighted to believe that by delaying submission of the waiver we'll save the state money. In fact, the ongoing costs of keeping persons in skilled nursing facilities or hospitals are far grater than the cost of services in the community. To delay implementation of Bill 511 also would have an untoward effect on the Money Follows the Person project underway to move Connecticut residents in skilled nursing homes back to the community. The AIDS waiver would have provided 100 additional slots for clients accepted into the project to continue receiving community services after their first year of participation in Money Follows the Person.

The savings in lives, dignity and quality of life, in addition to the dollars originally projected in 2006, 1.4 million in two years and 4 million in five years by passage of Bill 511 are only greater after the passage of the intervening years. The AIDS epidemic is still infecting and affecting the lives of Connecticut's citizens at an unabated rate. I am seeking your help to remain committed to 26 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

solving a care delivery problem that continues to cost our state, its taxpayers and those with HIV/AIDS countless dollars, lost productive lives and removing any sense of hope that we, as caregivers, can give. AIDS is no longer a death sentence. It is now regarded as a complex, chronic disease with some of the same management issues confronted by those of us with heart disease, diabetes and similar chronic illnesses. But many of our state's most vulnerable AIDS victims are languishing in skilled nursing facilities like Leeway or in hospitals for far too long because sufficient support systems in the community are not reimbursed by the Medicaid program.

It is such a shame that people like Steve or Carol or Charlie, adults who like you and me want every, opportunity to live in the community but are thwarted for lack of funded support services. Our staff at Leeway lament when they have worked for months to bring a client back from the brink of death, only to have the client return to the community without supports and, in a matter of months, end back -- end up back in the ER, ICU and once again admitted to Leeway exhausted, emaciated and discouraged. Please do not delay submission of the AIDS waiver to CMS. Allow DSS to continue its effort on the waiver, knowing its value in human lives saved and state Medicaid funds saved. Thank you very much.

SENATOR DOYLE: Thank you, Tom.

Any questions?

Representative Walker.

REP. WALKER: Good morning, Tom. 27 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

THOMAS SALEMME: Good morning.

REP. WALKER: Thank you for your -- for your testimony, and thank you for what you guys do down at Leeway. You do a fantastic job. I went down there one -- one a.couple of times just to visit, and the dignity that people feel when they're there and working with the staff is fantastic. We have --we have demonized this illness so badly in so many places, when people can actually get respect and get the help and support to try and live through something that most of the time they had no idea how they contracted, is really fantastic. I -- I thank you for that. Do you have any -- you've I'm sure you've talked to DSS on numerous occasions about this waiver. What was the reasoning why we did not submit the waiver?

THOMAS SALEMME: I believe that it had to do with some cost associated with the submission, and so I think it was a budgetary --

REP. WALKER: Was it budgetary?

THOMAS SALEMME: I believe so, yeah.

REP. WALKER: But with the waiver we are able to get reimbursement on this, so I'm -- I'm curious what -- what the cost measures are. Would we have to raise the level of services, is that what it is?

THOMAS SALEMME: Beyond the budgetary issue I'm afraid I can't elaborate any more. I'm a, sort of, a last minute stand in for Martha.

REP. WALKER: Oh I'm sorry.

THOMAS SALEMME: But I will get you that answer. 28 March 17, 2009 001851 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. WALKER: I mean we -- we -- we have every intentions of going forward and putting it into the bill and making sure that we try and go after it. I mean the thing that's really sad is that when we are putting money out to support programs and we don't get federal matching for it, that's really a very, very -- that just cannot be continued, especially in this economic times. But also I've heard some people say the reason why we had stopped was because the cost of -- of maintaining people with AIDS has gone up because we've increased their life expectancy, and the thing that's, sort of, sad is that's a good thing. So if we are helping people, then we shouldn't be going out and getting the reimbursement for the -- the good help that we're doing. So thank you for your testimony, and thank you for your commitment.

THOMAS SALEMME: Thank you.

SENATOR DOYLE: Thank you.

Any other questions from the committee?

Seeing none, thank you very much.

Next speaker is Deb Polun from Commission on Aging. After Deb is Deborah Legault, Catherine Ludlum, and John Quinn.

Yes.

DEBRA POLUN: Good morning. Good morning, members of the Human Services Committee.

For the record my name is Deb Polun I'm a 3(b [hffi^* legislative director of the Connecticut Qrt j. A ft Commission on Aging, the independent state - ' I it 0 ' . agency solely devoted to enhancing the lives 3ft 11 ^^»- 29 March 17, 2009 001852 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

of older adults of today and tomorrow.

I've submitted some written testimony, but I'd like to limit my oral remarks to just a couple of bills. The first is Senate Bill 1085, An Act Concerning Homemaker and Companion Agencies And Audits For Vendor Fraud. I'd like to just comment on section two of this bill, which is the section that adds personal care attendants to the Connecticut Home Care Program. Personal care attendants are a way to allow individuals to hire and manage their own attendants. It's an affordable to provide care and we support efforts to include this in the Home Care Program for Elders.

I think one of the most critical pieces of this is when you think about individuals who've been receiving long-term care in the community but have not yet been on the Home Care Program for Elders, those individuals probably already have a personal care attendant. So you may be injured but under 65. You may have traumatic brain injury or some, sort of, chronic condition that requires you to receive long-term care services, and you may already have PCA. And when you hit 65 and you're eligible for the Home Care Program, right now you have to get rid of that PCA and get somebody -- get services through the Home Care Program.

As it is individuals who have PCAs have very good working relationships with them. They're comfortable with them, and the quality of care provided is certainly something that ought to be continued. There is right now a PCA pilot program. It was created in the year 2000. That program has been evaluated. It's been shown that people with long-term care needs are generally able to successfully manage their own care, and so we would ask for your 001853 30 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

support, again this proposal is directly in line with the recommendations from the Long-Term Care Needs Assessment to foster flexibility and home care delivery and increase choice and independence in receiving care. Also, just because we're talking about the Home Care Program, I don't want to miss the opportunity to remind you that the Governor has proposed capping the state funded portion of this program, and I would ask you to reject that proposal.

Senate Bill 1087, An Act Concerning the ConnPACE Prescription Drug Reviews. The Commission-on Aging could support this proposal but we have a number of questions and concerns about the way the Legislation is current drafted. What this proposal would do is it would establish a pilot program whereby certain ConnPACE recipients would have their prescription drug regime looked at by a pharmacist to determine whether it's -- whether the drugs that they're on are cost-effective and so forth. It's unclear to us, one, how many participants there would be on the pilot program and how they'd be chosen. The second is why the meeting with a pharmacist would need to be face-to-face. We feel this places and undo burden on ConnPACE recipients to have to go in and meet with a pharmacist face-to-face.

Going along with that it doesn't indicate who the pharmacist would be. If it's already the person's pharmacist, then that might be okay, but if the pharmacist they need to meet with is somewhere maybe in some DSS agency branch, then that, could be a problem. Finally we're curious what the results of the review would be. Is it an academic exercise, or is the intent of the pilot' program to actually change the prescription drugs that individuals are 001854 31 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

on? We could support this if the goal is to enhance quality in ConnPACE, then we would definitely be on board. If we're only looking at saving money, then we would obviously have some concerns with that. So we'd like to offer our resources to you to work with the committee moving forward on this piece of legislation.

Finally Senate Bill 1122, An Act Concerning Changes To The Human Services Statutes, I'd just like to comment on the first two sections of this bill which increase rates to home care providers, and we recognize the fiscal climate in the^ state, and we just hope that the committee can support prioritizing rates for home care providers. We know that we are in the midst of a movement to rebalance our long-term care system and to provide more choice and independence.j We're hoping to provide more choice and independence. .We're hoping to provide more care in the home and community, and we cannot do this unless we show a commitment to ensuring that we actually have a robust home and community-based network of services and unfortunately at this time with the rates the way they are the home and community-based network is not as robust as we'd like and we do need see a bigger commitment. And this-goes right along with the Money Follows the Person Program and all of the other efforts to rebalance the program.

Finally, section five of that bill expands the sources of funding for the long-term care reinvestment account, and the reinvestment account was created last year in legislation. It was Public Act 08180. Many of you supported that legislation, had over 100 sponsors. Unfortunately in January the deficit mitigation bill did delay the establishment of that account until July so 001855 32 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

any enhanced money we get through the federal government under Money Follows the Person between now and July will go into the General Fund. Just wanted to remind you that the Governor has also proposed delaying the establishment of the account an additional two years. So again, for an additional two years any enhanced money we get from the federal government for transitioning clients out of nursing homes and back into the community, if Governor Rell's proposal is accepted, would go into the General Fund.

So we would support expanding the sources of funding for the account as proposed in this legislation, but only if we could secure a commitment that the account will exist and moving forward would be used for the purposes that it's intended to be used for. Thank you.

SENATOR DOYLE: Any questions from the Committee?

Representative Walker.

REP. WALKER: Thank you for your testimony. Just quickly to go to your comment about the pharmacist. I think the -- the person who wrote this was looking at what we did when we did Medicaid D where they -- they used the local pharmacist as a counseling tool to try and help people in looking at their drugs and their drug needs -- drug needs -- their pharmaceutical,needs so that there would be a balance In how they're getting and making sure if they have the opportunity to do generic, do generic, and if they did -- if they had to have the actual name brand, making sure that the prior authorization didn't interfere with that, and they were talking about using their pharmacist, the one that they had been using at the time, whether it be at the FQHC's or wherever, but it would be someone who they had 33 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

been interacting with in the past and it would not be at DSS.

That was -- that was one of the questions I had of the person that supported -- that proposed the bill. Are we talking about doing it. The only thing -- I think the other reason they wanted to do it face-to-face was they felt that the face-to-face contact helped to secure a little bit more and make sure that the information was totally comprehended by the person who was getting the counseling. It wasn't to put an unnecessary burden on them. It was just to follow through and make sure that they understood everything that they were being told and it wasn't, sort of, being dismissed or, you know if there was questions that they pursued those questions.

DEB POLUN: I appreciate that clarification. I just want to point out that there are many individuals who have -- who go to more than one pharmacy, and that could be an obstacle to this. As an alternative, ConnPACE has the pharmacy records for individuals, and so if, as an academic exercise, somebody were to be hired to look trough those records and for each individual determine whether there are any drug interactions that could be harmful or whether they're on the most cost-effective and -- and effective drug, that might be an alternative if it it's an academic exercise. If it's not an academic exercise then the physicians obviously need to be involved in any decision making moving forward.

REP. WALKER: I think this also part of the stimulus package allowed for some case -- case management with pharmacists, and that was one of the reasons why they also ID'd to be the pharmacist, but you're right about the fact that they have multiples. I think it will 34 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

probably be the individual's decision if this bill continues forward the way it is.

DEB POLUN: I will be glad to work with you on that. Thank you.

SENATOR DOYLE: Thank you.

Any other questions from the committee?

Seeing none, thank you.

DEB POLUN: Thank you, very much.

SENATOR DOYLE: Next speaker is Deborah Legault. Then we have Liz Brown from Commission on Children and Catherine Ludlum.

Ms. Legault?

Good Morning.

DEBORAH LEGAULT: Good morning, Senator Doyle, Representative Walker and members of the Human Services Committee.

I am a personal care attendant and also the .founder of the Connecticut Association of Personal Assistants. I am testifying in opposition to section two of House Bill 6668, which would create the Quality Workforce Council. I'm also here in a very unique position because I'm a personal assistant but also I'm married to a wonderful man with a severe disability who uses a wheelchair, and we hire personal assistants to help with his support. So I'm, kind of, here from both ends.

Personal assistants have a -- a wonderful job, and we value very highly our relationship with the people we work for. We are not private 001858 35 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

contractors. We are hired directly by the person with the disability. They hire, they manage and fire sometimes, okay. And so we -- we have a unique relationship because of the kind of job we do. It's sometimes very intimate and the -- we can get a very close relationship. As Jim McGaughey said, sometimes, you know, you can almost look at it as a very different relationship.

I was a computer programmer for over 2 0 years making 6 0,000 a year, and I turned my back on that job to become a personal assistant making a lot less money and I would never, never regret that. I have a very wonderful fulfilling job where I'm appreciated, and I'm very, very happy. I know I'm an important part of my employer's life. I'm opposed to this council because I feel this structure would interfere with the relationship that I have with my employer, with the person with a disability. It's talking about a backup list and we -- and I personally would not want to be on a massive backup list because I want to know the person that I'm working for. I want to make sure that, that relationship is compatible, and I need to know their unique ways of doing the job, and I would not know that if I just was given a name to go and see and -- and, you know, out of the blue.

I also have been approached by SEIU 1199. A couple of times I've met with them, and I was told that this was their management structure to set up unionizing personal assistants. Again it -- I feel it would interfere with our relationship and is really not necessary. We have a wonderful, wonderful job, and we don't want it ruined, and we don't want to hurt our employers. And if we get higher pay where people do not understand the structure of the waiver then the people with disabilities would 36 ' March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

be hurt because their hours for support would be decreased because the waiver is capped with a certain number of money that they are allotted for their support, and our wages come out of that cap. And also personal assistants would suffer because if the -- our employers hours are cut, so are ours. There are fewer hours for -- for working for that person. So I urge you please, to oppose -- to remove section two of the bill. Thank you.

SENATOR DOYLE: Thank you, Ms. Legault.

Any questions?

Representative Walker.

REP. WALKER: Thank you, ma'am, for your testimony and -- and I also I am -- I admire you for making that choice of doing -- being a PCA.

DEBORAH LEGAULT: Thank you.

REP. WALKER: That -- that takes -- that says that you are very committed to your fellow man and -- and I thank you for that.

I think one of the things that might be missing. You were saying that you are not personal contractor. If we were utilize this council and set it up so that people were able to get reimbursement from the state for these services, you're going to have to be a personal contractor, in order for -- for the person to get that type of reimbursement, because that -- that's going to have to be structure. We have to have a way of -- of reimbursing. And someone has to responsible for the taxes, and somebody has to be responsible for the- structure. But the other part of it is you still can be a personal care assistant for that person. It's just the 37 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

state will have just a set number of hours that they will probably allow for reimbursement, and it will be up to the person to continue your hours with them.

It will not limit or stop you from being able to work additional hours. It just says.that the state will be able to provide you with reimbursement for x number of hours. Similar to what we have when we do -- with Medicaid sometimes a patient coming out of a hospital can get maybe four hours, and it's up to the family to make the determination if they want to extend those hours, but the reimbursement from the Medicaid agency is only x amount of hours. So it wouldn't -- it would not stop you or hinder•you in any way in -- in that regard, and I think the -- as far as the reimbursement rates, it again would not affect whatever you are getting with the person privately. It would just affect the amount of money that the state would be willing to pay for that, so it might be an adjustment, but I think that it's only considered a support. It's not an interference or a way of stopping you from doing it if you do 24-hour duty or if you just eight hour duty.

I think the main thing is to try and get a structure so that we can start to allow people to get the services at home but allow the state to be able to assist you in getting that money, so in that regard I think that was the only intent of the concept, because we don't right now have a real way of addressing Money Follows a Person so that we can pay the people directly. We have to do some sort of mechanism to set them up as contract.

DEBORAH LEGAULT: I'm -T I'm sorry. I think you may have misunderstood me. I -- when I say I'm not an independent contractor that -- that 38 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

means that I am on the payroll of a person with a disability. Now, they are -- they are getting reimbursement through the PCA waiver, through the state, and partially through federal. And the taxes and, you know, their unemployment, part of it, social security, federal, you know, taxes are taken out of my paycheck because I am their employee, and that is accomplished through a fiscal intermediary, Allied Community Resources. Now they are -- are contracted with the state to do the payroll and to bill Medicaid. So actually right now I, you know, it is state funded.

REP. WALKER: Okay. Then I think then -- then this would not be a state funded. This is just a structure that Allied Resource would -- would be interfered with, because it would take them out of wash. It would be a direct contract with you and the employer. It would not have another -- a third party managing the process.

DEBORAH LEGAULT: So -- so we're changing the way the personal assistant services are -- are performed right now. Is that what you're saying? I'm sorry.

REP. WALKER: This is a suggestion to address other methods of providing services in the home, if I'm not mistaken in this. I know we do have one contract -- I didn't know Allied Resources was getting paid by the state. That -- that's very interesting, and I will look that up in the budget, but one of the things that we're trying to do is address some of the contracting possibilities for people so that we can get more people for Money Follows the Person and some of the other programs that we are suggesting in this program so that we provide more home care, but I will check into that. Thank you. 39 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

SENATOR DOYLE: Thank you.

Any other questions from committee members?

Thank you very much, Debbie. Have a nice day.

DEBORAH LEGAULT: Thank you. .

SENATOR DOYLE: Okay the next speaker is Liz Brown then it's Catherine Ludlum and John Quinn.

Is Liz Brown here? Yes she is.

ELIZABETH BROWN: Good morning, Senator Doyle, Representative Walker, and members of the committee, and Happy St. Patrick's Day to everybody.

In the interest of time, I know, I just wanted to make a comment on -- my name is Elizabeth Brown I'm the legislative director for the Commission on Children, and I'm here in support of Raised Bill 1112, An Act Maximizing The Federal Stimulus Package -- Stimulus Funding. The commission has been really watching this very closely and feel that there's many opportunities to leverage for the state of Connecticut. This bill would require the Department of Social Services to account for expenditures of federal stimulus funds and to recommend how the state can maximize federal stimulus funds for the benefit of federally qualified health centers that help individuals lacking health insurance to receive quality healthcare.

As an early and strong supporter of results-based accountability, the commission believes it is essential for state agencies to chart their strategic work in improving the health of Connecticut residents. Over the next two years a total of $2 billion in 40 ' March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

federal stimulus funding will be invested in community health centers to support renovations and repairs, investments in health information technology and health care services. Because these funds will be made available through competitive grants, the role of DSS and maximizing receipt of such funds is critical.

However, the commission believes that Raised Bill 1112 should be amended to require reporting by DSS as well as DSS recommendations for stimulus maximization to begin much sooner than January 1, 2010. Also we recommend that DSS collaborates with the Department of Public Health, who has oversight over these federally qualified health centers, in order to fully maximize the dollars. The Federal Stimulus Act requires immediate action by states and localities to access federal stimulus funds in all areas including health. Federal stimulus funds for this purpose are already being released. On March 2nd the federal government announced the release 155 million in stimulus grants to support 126 community health centers across the country. We recommend that the reporting by DSS begin in the current quarter. The legislation before you is an important strategy to improve the health of Connecticut children and adults, promote accountability, and ensure federal funds maximization. Thank you very much.

SENATOR DOYLE: Thank you, Liz.

Representative Walker.

REP. WALKER: Thank you.

Thank you, Liz. I'm glad to know that the Commission on Children is more than just a pretty face. I want to thank you for the 001864 41 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

information that you provided us about the stimulus. We ended up finding out a great deal about some of the other avenues that we have in actually going after federal matching, and I think you'll be very pleased to see that we are taking a lot of your -- your lead and instruction. We talked about it in Appropriations, and we will be putting forward some more legislation on some of the things that you -- you and your team have suggested to us, so thank you and thank you for your dedication. We would be very lost without and Commission on Children. Thank you.

ELIZABETH BROWN: Well, thank you very much.

SENATOR DOYLE: Thank you.

Any other questions?

Seeing none, thank you, Liz.

Next speaker is Catherine Ludlum, John Quinn and Deborah Chernoff.

Catherine Ludlum.

A VOICE: Can you turn the mic on?

CATHERINE LUDLUM: Ladies and gentlemen of the Human Services Committee -- can you hear me wlflo okay?

Can you move the microphone down a little?

Is that better? Can you hear me now? Great.

Thank you.

Ladies and gentlemen of the Human Services Committee, thank you for the opportunity to speak today. My name is Cathy Ludlum, and I 42 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

am here to express my strong opposition for section two of Raised Bill 6668. This section would create a Personal Care Attendant Quality Home Care Workforce Council. I have over 20 years of experience as an employer of personal care attendants, the last few years funding .them through the Personal Care Assistance Waiver. And at the end of my testimony, if you want to ask me some of those questions about the number of PCAs in the state or the going rate, I will do my best to answer them for you.

My caring and dedicated personal assistants support me in doing such basic things like getting up in the morning, getting dressed, and into my wheelchair. They help me do everything I do throughout the day. Personal care attendants make it possible for me to live in my own home, go to work, travel, and participate in my community and in society. No one is more aware than I of the challenges involved in hiring and managing PCAs. It is not an easy task, but here are some things I also know. We shouldn't be trying to fix something that isn't broken.

Connecticut's waiver programs allow many people with disabilities to live with autonomy while saving the public money over institutional care. Tampering with the structure of the waivers and driving costs up will not only endanger the independence of many, including myself, but will also result in the loss of jobs for personal assistants.

Second, the recruitment, hitting, and management of personal care attendants needs to be done individually. No centralized council in Hartford, made up of politically appointed volunteers, will be able to address the complex issues facing employers and PCAs 43 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

in their own homes and communities.

Third, at a time when Connecticut is in the most severe fiscal crisis it has ever seen, should we be talking about creating a new council?

Four, certainly there are issues with the current PCA system. I'm not saying that there aren't, but creating a council to take over a management function will not solve things. One of the chief obstacles to expanding the workforce is people's perception that only licensed medical professionals can work with people with disabilities. Creating a council and later a union will only exacerbate that problem. As you've seen too, many people with disabilities oppose the development of the council, and so do our personal assistants.

You will find attached to my testimony the names of five other personal assistants who wanted to go on record in opposition to the bill, and three others have handed in testimony today.

Finally, the only group strongly supporting the creation of the council is SEIU 1199. We all need to ask ourselves cui bono, who benefits? If people with disabilities lose, and I think we will, and if personal assistants lose, and I think they will, then the only one who wins is the union by increasing its dues and its membership. I urge you to see Raised Bill 6668 for what it is and to vote against it. Thank' you for your time.

SENATOR DOYLE: Thank you, very much.

Any questions? 44 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Representative Walker.

REP. WALKER: Thank you, for your testimony. I -- I -- I understand that many people have opposition to this idea of a council, but I wanted to just point out to you that in one of the lines it says a consumer or surrogate may hire a personal assistant, a care -- attendant who has not been referred by the council. So it does not restrict you from having your own personal -- having your contract through them. It doesn't -- it gives us an option for helping people, and that was one of the things that I was talking about when I first spoke to the gentleman from disabilities -- I forgot -- from Jim. I was talking to Jim.

CATHERINE LUDLUM: Jim McGaughey?

REP. WALKER: Yeah, was the fact that had I had a council, someone to go to, to talk to and help me in making some determinations and some guidelines that helped me out -- would have helped me out a great deal. So providing people with other options, it does not restrict you to just go through that -- through the council. It gives you the option. If you are somebody who's not aware of what -- how to do this, and you don't know exactly what the type of opportunities and the -- the jobs and what you can do, it gives you another place to -- to go to. So I don't think that -- I think I think the misunderstanding is that everybody has to use that, and that's that's the misunderstanding.

CATHERINE LUDLUM: May I ask you a question?

REP. WALKER: Sure

CATHERINE LUDLUM: Two of them. The first one is, yes we may be allowed to still hire and 45 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

contract with whom we choose, but if we are receiving reimbursement with federal and state Medicaid waiver programs, then would not hired assistants be required to register with the council? It's going to keep a list of all assistants in the state. And many of my assistants have said they do not want to be on such a standardized list. If there's a need for their name Allied Community Resources already has that so why would you need to reinvent the wheel?

REP. WALKER: Well, Allied Community Resources is the one that does the contracting for you currently, but if we have other programs that are out there, we may have to have other alternative ways of providing access. Everybody may not -- it's still a work in progress, and we're still trying to figure out how it can work in Connecticut, but it gives us another way of looking at it, and it may give us another way of accessing other PCAs. We have not concluded that everybody has to be on that list because it's still being worked on and designed right now, and your input will help us to think about how doing that -- how to do that.

CATHERINE LUDLUM: So would the council -- one of the roles of the council be to be one of the fiscal intermediary agencies then?

REP. WALKER: That has not been determined yet.

CATHERINE LUDLUM: But it could be.

REP. WALKER: It could be, yes.

CATHERINE LUDLUM: And can I respond one other thing. I appreciate your dilemma when you were caring for your father. Anyone who starts out doing this, you know, it's very 46 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

overwhelming at the beginning, you had mentioned. What I wanted to also mention is around this state there are five centers for independent living, run by people for -- with disabilities for people with disabilities, and they and other entities are skilled at teaching and advising new employers, such as yourself or myself, where to go or others and how to do that. So I'm not saying that more of that won't be needed, and I'm saying don't assume that those supports and resources are not out there. There are a lot of us doing this, and there's a big network of people who know how to do it and know how to do it well. Okay, so don't overwork it.

REP. WALKER: Thank you. I wish I had known you were around ten years ago. Thank you.

CATHERINE LUDLUM: I'd have been happy to help you.

REP. WALKER: Thank you.

SENATOR DOYLE: Thank you.

Representative Gibbons.

REP. GIBBONS: Thank you, Mr. Chairman.

Thank you, for coming up here today and testifying. You seem to indicate that you know how many PCAs might be here in the state of Connecticut.

CATHERINE LUDLUM: Approximately, I mean I don't know to the exact number, but I can tell you of the program I'm on, which is the Person Care Assistance Waiver, there are 698 of us on the program. In a given week I use eight to ten personal assistants. Most people don't use that many as I do. Most people use, I think, between about two and six, but if we do 47 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

the math your original question to Mr. McGaughey was are we talking hundreds, are we talking thousands? I would say based on that and the other waivers that I'm familiar with, you're probably talking, I don't know I'd assume maybe 4,000 total personal assistants, at least. I don't think it's anything like 10,000, or as Jim was saying he didn't think so. These are what -- it can be hundreds because there are already hundreds of us on the program. Did I help you?

REP. GIBBONS: Yes. May I continue?

We need to hire you to go and run this whole program. One -- one thing that I think that has come up about the waivers is -- is it the employer, such as yourself, who is part of the waiver, or is the PCA who's part of the waiver? And you said there are several different waivers that one could hire a PCA under so could you -- do you know a few of them please?

CATHERINE LUDLUM: I can try to explain it. The way the waivers work, and I know mine the best, so I know others one out there. The individual needing the services, such as myself, applies to DSS or DDS or whoever the funding (inaudible) agency would be, and we say we need a partner from Allied Health something like that, an assessment put together on a care code, good to go. And once you have approval, which means funding, we can go out and put ads in the paper or speak to our neighbors or go any other manner -- or however -- however we want to look through, and then interview and hire the people that we want. And then the employer can run criminal history checks on everyone to check what (inaudible) things like that. When we've made our determination, then we fill out paperwork, 48 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

and in our case online community resources to get our new employee on board, listed with them. So I am the service recipient. They are the vendor I have chosen to work under me. Does that make sense to you?

REP. GIBBONS: Yes, it does. Thank you, very much.

CATHERINE LUDLUM: You're welcome.

REP. GIBBONS: Thank you.

Thank you, Mr. Chairman.

SENATOR DOYLE: Thank you.

Any other questions?

Representative Thompson.

REP. THOMPSON: Not a question. I first met Cathy I think it's what over 3 0 years ago?

CATHERINE LUDLUM: A long time.

REP. THOMPSON: And we were private citizens. I was (inaudible) in politics, and we came together to form a group to pursue cooperative housing in Manchester. And I met Cathy that evening and before I left she informed me that she wanted to do two things in life. That time she was living at home with her family, and she said I'm going to live independently. I'm also going to write a book. Well, she's not only living independently, but she's written I think three books?

CATHERINE LUDLUM': Yeah, three books.

REP. THOMPSON: Three books and she still gives me advice on a regular basis including in regard to this issue, and she is just a very bright 49 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

capable person. And she lives in my district so don't get any ideas about tapping her for -- you'll have to go through me, okay? No, only kidding. She's a wonderful person, has great ideals and has really made a difference in how our community reacts to people who have disabilities but are out there working away every day. She's certainly a great example of somebody who has -- is living independently successfully. Thank you.

SENATOR DOYLE: Thank you.

Thank you, Catherine for testifying.

And, Representative Thompson, let's just hope she doesn't get involved in politics and interested in running for your -- the 13t District assembly seat. She's certainly impressive.

REP. THOMPSON: I've never checked out her -- but I have a couple people who keep an eye on her politically.

SENATOR DOYLE: Any other questions from committee members?

Seeing none, thank you for coming up, Catherine. You certainly are impressive. Thank you.

Next speaker is John Quinn, Deborah Chernoff, and Tom Salemme.

John Quinn.

JOHN QUINN: Well, I guess it's appropriate to say top of the morning to everybody. Good morning, Chairman Doyle, Chairwoman Walker and members of the Human Service Committee. My name is John Quinn, and I am president and CEO March 17, 2009 /med HUMAN SERVICES COMMITTEE 10:00 A.M.

of VNA Health Systems which operates the Visiting Nurse Association of South Central Connecticut, located in New Haven, and CareSource, a private duty service based in Orange. We primarily serve patients and provide home care support in the Greater New Haven, the lower Naugatuck Valley, and the Milford area. I appear before you today to support section one through five of Raised Senate Bill 1122, An Act Concerning Changes To The Human Service Statutes. Our VNA Health Systems provide care to approximately 3,500 unduplicated count patients annually.

I know full well the burden placed upon you as a member of the General Assembly. I had the honor of serving four terms in the House from 1975 to 1983 from the 132nd District of Fairfield. My tenure including serving on the Human Services Committee, and also as Assistant Majority Leader as part of the leadership bill screening committee so I can appreciate what you're going through. Our deficit then was not as grand a figure that you face today, but the basics of good legislation that is practical, effective, and cost-efficient still hold the test of time.

Unlike many of the major corporations on a national level that received taxpayer bailout money, we are asking you only to ensure that Medicaid rates for home health care be brought closer to par with Medicare rates to ensure the viability of VNAs to continue to reach out and help all social segments of our society. The new administration is ready to cut Medicare rates due to questionable profits of some, mostly proprietary, home health agencies who will take Medicare but leave Medicaid out of the mix. We don't do that at the VNA. Any Medicare surplus is put back into our operations to subsidize Title 19. If Medicaid 51 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

rates are not brought up to par and Medicare rates are decreased, then the VNAs and nonprofits just may not be there tomorrow to help keep health care costs lower by keeping our patients in their homes and out of long-term nursing home care.

Because we are nonprofit does not mean that we can run our business any differently than a for-profit on the fiscal side. Our mission and focus on quality care has given the VNA the stellar reputation that we enjoy today. But without fair and reasonable reimbursement rates under Medicaid, the business side will determine for us that the mission cannot be met. I ask to work together to assure our indigent, our frail elderly, our mothers, our fathers that we'll continue to have access to quality, mission driven home health care so they can lead a dignified, independent life for as long as is feasible. I thank the committee for listening and I encourage the joint favorable on Raised Senate Bill 1122 from this committee. Thank you.

SENATOR DOYLE: Thank you, Mr. Quinn.

Any questions?

Seeing none, thank you, and you have a nice tie.

JOHN QUINN: Thank you. Thank you.

SENATOR DOYLE: Next speaker is Deborah Chernoff and Tom Salemme -- Salamone -- I may have mispronounced that and Bill Heading.

Deborah Chernoff.

DEBORAH CHERNOFF: Good morning. My name is Deborah Chernoff, and I'm here today 001875 52 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

representing New England health care Employees Union District 1199, testifying in favor of Bill 6668,, which addresses important issues across the long-term care spectrum, and that's why the caregivers in our union support this bill. With respect to the nursing home portion of this bill, it enacts critical reforms in Medicaid reimbursement. These reforms are absolutely necessary at this time. The precarious financial condition of Connecticut nursing homes threatens the health and care of close to 30,000 nursing home residents and the jobs of at least another 30,000 of their caregivers. With ten nursing homes in receivership, five in bankruptcy and four homes closing in the last six months, we need these reforms to avert a catastrophic failure of this sector of our long-term care system.

And I'd like to acknowledge that there are members of our union who work at Crescent Manor, which is one of the homes in receivership in Waterbury that is facing possible closure here today to testify -- they're not going to testify -- but to testify by their presence as to why this is so important. I'm also testifying in support of consumer directed personal care assistants and consumers for the PCA Quality Home Care Workforce Council which would be established by this bill. As you've heard personal care attendants provide assistance to seniors and people with disabilities so they can live at home, not in an institution. We know that this is a strong preference of Connecticut citizens who need or will need these services.

PCAs, like many of the people you'll hear from today, love the work they do providing care for people in the community; however, there are major obstacles to full-time work which 53 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

include low-wages and the lack of health benefits. This has created barriers to achieving the goals of enabling choice for consumers. To ensure that personal care assistants can continue to assist and give quality care to seniors and people with disabilities,. we need this council. The council will, among other things, improve1 the ability to connect consumers and home caregiver; provide backup services; prepare the program for future growth by reducing turnover and providing training and other benefits; grant consumers majority representation on the council; maintain consumer control and direction, particularly the ability to hire, train, and fire caregivers; and give caregivers the opportunity to speak with one voice through a union if they choose.

And in order to accomplish these critical goals, I've attached to my testimony a proposed amendment to the current language, which I believe was left out in the original drafting, which is based on the experience of other states where such councils have been successful in meeting the needs of both consumers and attendants. We know that the opportunity for PCAs to organize and bargain collectively has been a key component of that success. Those states include California, Massachusetts, Michigan, Oregon, and Wisconsin. And to sum up, it's now time that we stand together to ensure that seniors and people with disabilities can continue to remain in their homes receiving quality care from personal care assistants. Let's make that possible by amending and passing this bill. Thank you.

SENATOR DOYLE: Thank you. 54 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Any questions?

Representative Walker, first.

REP. WALKER: Good morning, still.

DEBORAH CHERNOFF: Good morning.

REP. WALKER: You heard some of the testimonies that were held by a couple of people earlier today. Can you explain to me the benefits of this in comparison to some of the other comments that were made in opposition to this?

DEBORAH CHERNOFF: Certainly. I think that many of the comments in opposition are based on misapprehension. There's nothing in this council and in -- as it is proposed here or as it operates in other state, that would interfere in the relationship between the individual PCA and the person whose -- the consumer whose hiring. This is simply a way to coordinate and facilitate services. I've participated -- I serve on a long-term care advisory council and I participate in a lot of discussions about Money Follows the Person. I've participated in a forum on the workforce which is a key impediment to implementing Money Follows the Person and other waiver programs.

And the lack of coordination of services is a key obstacle. People don't necessarily know where to go, as you testified, I personally have been the PCA for two members of my family in two different circumstances, most recently with my sister. And to -- and, it was just an impossible obstacle to find suitable care under those circumstances. What the council would do is -- one of the issues that was brought up at this workforce forum was people want training, and consumers want their PCAs 55 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

to have certain kinds of training -- behavioral health was a particular issue -- but they don't know how to get it. And the other issue, which everybody acknowledges, is that low wages cause high turnover, and this is not a workforce you want high turnover in because.of. that special relationship.

And the individuals, either individual consumers or' individual PCAs simply don't have the resources to be able to put all of those things together. That's the purpose of the council, not to interfere in the relationship between the PCA and the -- as I've said, as a family member I'm very sensitive to that has to be a good match.

REP. WALKER: Do you think that the council can work side-by-side with the already existing structure, or do you feel that this should be all one organization, one council?

DEBORAH CHERNOFF: I think having a single, sort of a single entity that coordinates these services is important, as you say the bill specifically says that you can go outside of the council if you choose to hire someone. But the council -- the kinds of -- people's needs change over time, and the PCA you have now may not have the training that you want in the future as your physical or intellectual or other needs change. And the council could provide an important support structure for making sure that you can maintain that relationship and still have the quality of care.

I mean, this is the way, I think -- choice is very important in this program, and we need to enable choice. Absent some kind of coordination of services, people have a choice that isn't meaningful because they can't 56 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

access the services they need.

REP. WALKER: I think one of the things we're seeing --we don't see, is the fact that, as the young lady spoke earlier about the fact that there are, I think, 10,000 or 15,000 out there currently. When you talk about the nursing homes and the fact that our nursing homes are financially struggling -- and we're seeing more closings -- we're going to see, as you said, that 30,000, currently that you know of, we're going to see a major flood of people going into this process of getting care at home. And I understand that the long-term care agency or organization is out there, but being able to handle close to 60,000 people is going to be a very, very daunting task.

And I think what we need to look at is how we sort of build the infrastructure to handle more people requesting PCAs at home as opposed to the nursing homes. So that is -- that in itself says we've got -- we've got a lot of miles to go before we even rest. But the other concern that I have is that in this financial time, how do we look at this as a good, viable opportunity for Connecticut to obtain savings but also ensure our vulnerable population like elderly and disabled, that they have this access?

DEBORAH CHERNOFF: Well, I think if you look at the savings in the big picture, across the spectrum of long-term care, you are not going to be able to achieve the goal of rebalancing if there's no infrastructure to care for people at home, or inadequate infrastructure to care for people at home. That will, in fact, mean that more people are going to have to stay in more institutional settings.

If you can expand the workforce so that we 001880 57 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M. address some of the obstacles that we're talking about which are not enough people, insufficient back-up system, people going in and out of this workforce because they really can't afford to stay in it because the wages are so low, then we can enable a shift from more institutional care and open up the possibility that more people, even if they have a greater level of need, could be cared for at home if there were an adequate workforce.

REP. WALKER: That was one of the problems that I had that, as my father got older and more frail, the quality of skills had to improve dramatically because, before I was driving him around and taking him to the different things, but then as his body deteriorated it became an issue of how do you lift him, how do you prepare his foods, his swallowing. I mean it got to the point where he couldn't swallow. So it was really, it was -- it was overwhelming, providing that sort of that structure for me, at least in being the only one to do that, it was really somewhat emotionally draining.

One of the other things that I think that we're missing, and I -- and I don't mean any, you know, any fault to anybody, but I think we're missing the issue of making sure that people have a living wage, and I know that's such a bad word in so many things, especially when we're talking about the economy. But some of us have a living wage and other people are surviving on minimum wage, and making sure that people actually get a living wage so that, and especially once we institute, you know, a health care plan that everybody can access, a lot of these issues won't be so traumatic. 58 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

But right now where we're trying to balance those things out and not push people into the emergency room because they don't have health care, I think this is something that we -- we sort of avoid because everybody says, well that's not my problem but it is, it's our problem because it's our society's problem. So I think making sure that living wage is adequate, because when I see people being hired to many of the agencies and they get the Medicaid rate then they -- the actual care attendant gets between nine and fourteen dollars an hour.

And I know, you know, people say that they should be happy to have a job, but then on the other hand, living -- working poor is not the best way to do it. So, I think we should be able to provide options right now, and look at how do we design the system. But I think that the options should be equitable for the people that are on the front lines, so this is going to be a tough one, I know, because people sort of back away from the idea of organizing. But then the other part is, if we didn't organize, especially people from my community, would not be able to have that ability to survive. So, thank you.

DEBORAH CHERNOFF: Thank you.

SENATOR DOYLE: Thank you.

Representative Gibbons.

REP. GIBBONS: Thank you, Mr. Chairman.

Good afternoon, I guess it's almost -- still good morning. In your testimony you talked about needing -- the need to increase the Medicaid wages for the PCAs, which I totally agree with, but do you envision this council 59 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

as being a bargaining tool to get increased wages?

DEBORAH CHERNOFF: It provides structure and an organization so that people can bargain for wages, yes.

REP. GIBBONS: What would happen to the people who decide to remain outside the council, or would they ultimately be -- be pushed into joining the council?

DEBORAH CHERNOFF: Well, we're talking about two separate things, actually. The council is the council. The council would function as an employer for the purpose of collective bargaining. If --

REP. GIBBONS: Well --

DEBORAH CHERNOFF: -- if it were the desire of people who -- the PCAs, to form a union.

REP. GIBBONS: Well, that's exactly what I'm getting at. It really is going to be a union if they're going to do collective bargaining. And from some of the testimony we've already heard and from some of the written testimony we've heard, people do not want, for other reasons, to be part of a union. And I'm just trying to see where this council is going --

DEBORAH CHERNOFF: Well, I think --

REP. GIBBONS: -- and whether we can maintain a dual system or not.

DEBORAH CHERNOFF: Well, as Representative Walker said -- I mean, as the bill specifically says, people can go outside the council to hire people if they choose -- so choose. 60 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. GIBBONS: That's right, but you and I have been in this business long enough to know that that might be what it says today, and a couple years from now it will be -- something will be quite different. And I think we all on the committee have to deicide where -- what the end result will be, whether that's the goal or not and whether that's where people want to go.

DEBORAH CHERNOFF: Well, my best response, and you will hear from other people today who have other opinions on this, but this is something that has been very effective in five other states.

REP. GIBBONS: Okay.

DEBORAH CHERNOFF: And not only for the PCAs and the consumers, but you will hear from someone from Massachusetts who can tell you more about how it works in that state. And I think that if we're going to have real choice in this state, we have to enable that choice, and right now the infrastructure doesn't exist to enable that choice. And everybody, from my personal experience and from other people who have gone through this, they are hungry for having that kind of structure that can provide not only the issue that you raised, which is the wages, but coordinate the kind of training and education that people on -- both consumers and PCAs are looking for.

REP. GIBBONS: Well, that's one of the questions I'd asked Jim earlier on, is what kind of training do you have to have to have a PCA or degree or certificate, and he said there's none at all. So -- and as Representative Walker testified, as her father became more frail, she needed a higher level of skill, so maybe there's PCA one, two and three, I don't 61 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

know, and that we might have to do some sort of certification.

My only concern is maybe we're pushing legislation further ahead than what -- when we don't have all the facts, and I think that we need to, as a committee, understand what's going on in these other states and how well it's working and whether these councils have really turned into unions or if they are separate, autonomous councils that can provide help to both the consumer and the PCA and where we're going to go from there. But thank you for your testimony.

Thank you, Mr. Chairman.

SENATOR DOYLE: Thank you.

Representative Butler.

REP. BUTLER: Thank you, Mr. Chairman.

And thank you for your testimony today. It just so happens I've had office hours in my district and one of the concerns of one of my constituents was Crescent Manor and the receivership and what's happening there. A couple had their mother there, and really is looking at her health care and it's really hanging in the balance of the institution and what's going to happen going forward. I have a real concern about this particular issue because there's something that hasn't been said today, that I haven't heard anyways, that there's going to be a lot more people entering in to these nursing homes.

The baby boomers are going to actually start getting older and older, and there's going to be a lot more people requiring care, so I think we better gear up and train as many 62 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M..

people as we can to be out there to help facilitate a quality of life for these people going forward. I mean, I've heard testimony on -- and seen people start to talk about the impact on the Social Security system, in terms of the baby boomers, but when you really start to think of what it's going to mean towards the health care system, I think it's -- it tells us we need to do something. We need to train. We need to have people in place to study this to make sure that we have choices.

But, having said that, my question directly to you is, knowing the Crescent Manor situation, I know it's multifaceted as to their particular situation, but how could something like this bill be beneficial to a Crescent Manor?

DEBORAH CHERNOFF: Well, if -- when you see the number of nursing homes that we've seen fail financially recently, I mean you have to understand that it is a systemic failure. And one of the issues is something that other people have raised around other issues here, which is that the' cost of providing care through the Medicaid system, what we pay for Medicaid reimbursements is completely unaligned with what it actually costs.

And nursing homes, particularly urban nursing homes like those in Waterbury, tend to have a very high Medicaid population, they don't have a way to cost-shift the shortfall between the actual cost of care and what Medicaid reimburses, and so the language of this bill proposes some strong reforms to the way that Medicaid care is reimbursed including the option for having a DiSH program for high-Medicaid utilization homes that would be similar to hospitals -- the way that we reimburse hospitals for disproportionate share 63 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

costs, and would also reimburse the actual cost of care at a higher level than it's currently reimbursed.

This is the fundamental problem with all these nursing homes. They all -- as you said, Crescent has a particular set of. circumstances. There are other circumstances in Griswold where a nursing home is just about close and in East Hartford, but they all share a common problem which is our Medicaid reimbursement system in this state makes no sense, has been broken for a long time, and unless we address those problems systemically rather than trying to save this home or that home by adjusting a rate here and there, we're never going to get out of this mess.

And as you've said, the demographics are such that even if we expand home care, which is part of what this bill is attempting to do, we're going to need more nursing home beds, not fewer, in the years -- as baby boomers, and I'm somewhere on that spectrum, age. And more people live past the age of 85 or 90 or 95. We need to widen the spectrum at both ends.

REP. BUTLER: Thank you for your testimony.

Thank you, Mr. Chairman.

SENATOR DOYLE: Thank you.

Any other questions in the committee?

Seeing none, thank you very much.

.DEBORAH CHERNOFF: Thank you.

SENATOR DOYLE: Next speaker is Tom Salemme -- I think he already testified, though, actually, 001887 64 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

from Leeway. Is Tom here? No, I think he already testified.

All right then, Bill Henning, Michelle Ockenfels and Lynn Warner.

So Bill Henning.

BILL HENNING: Good morning, still. My name is Bill Henning. I'm director of the Boston Center for Independent Living in Massachusetts. I was invited here by 1199 SEIU to share some of the experiences with Massachusetts' effort and ultimate establishment of a PCA Quality Home Care Workforce Council, which was voted into law unanimously by the Legislature in July 2006. From hearing lots of the testimony today I feel like I could go on for hours, which obviously wouldn't suit anybody at the moment.

I appreciate the antsyness of sitting there during legislative hearings. Just to give you a little background on my credentials, I guess, I am the director of an independent living center. We provide services to approximately 3,000 people a year including 1100 on a personal care attendant program. We assess people for eligibility for the program and then make a recommendation to Medicaid. Medicaid approves or disapproves, and then the consumer goes on and runs a program themselves. We will be in a position of providing skills, training, to assist with that employment job.

Again that's 1100 people. I've also been an advocate for many years for disability rights over 25 years. And, I'd also say I don't come here with a pro-union or an anti-union bent. I've worked very closely with'1199 SEIU and it's been a very positive relationship. I 001888 65 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

have personally organized and marched picket lines against unions that have insisted on keeping institutions open and keeping people with disabilities from living independent lives in the community.

And that, I think,.is one point to emphasize here. I think what my perspective is, is the council, at least in Massachusetts, was a vehicle to promote independence and a dignified life for people with disabilities because it became a vehicle for a number of things. One was, it's in the process of establishing a directory of attendance which will -- and it will be a voluntary directory, and it's set up by the council which, it's important to note, is composed -- seven out of nine members are representatives of the disability community, including three people affiliated with our organization. But it's to help people find attendants when there is a shortage, which has always been a common problem.

Increasing pay, increasing benefits won't totally alleviate that problem, but it can help. And I think one of the mechanisms here that you see in the legislation before Connecticut which very much looks like what we had in Massachusetts, not surprisingly, establishes the right to collective bargaining. Well, why is there collective bargaining? Probably to put pressure on the state, everyone around this area, to provide fair wages for attendants. And left to it's own good graces, government isn't probably going to come out and offer a raise.

In Massachusetts we spent many years trying to get a raise. In 1999, 170 of us camped outside of the Governor's office for an afternoon and 20 of us threatened to stay 66 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

there until we negotiated a process to negotiate. And we got a good raise, but it wasn't a long-term process that disability- advocates could stay involved in. Because we're disability rights advocates or activists or service providers; we're not labor-organizers. And-what we were finding in Massachusetts, especially if the economy was good, which of course it's not now, is that there was a shortage of attendants.

You know, the problem might alleviate in bad times because everyone's looking for work, but the biggest issue we heard is there's a shortage of attendants. And one of the reasons is there isn't enough money for the job, which produces turnover. I'd have a member, you know, told this story, she's losing her hair. She'd stay in bed all day unless she got an attendant to come, who came at three in the morning to get her out of bed. She was so worried about just being able to get out of bed during- the day she lost her hair. That story was replicated a lot.

So the challenge is how do you pay people fairly, and I think you need a collective bargaining arrangement because I would never trust a state Medicaid office. I think there's an -- with all due respect to people in it, it's never going to come forth with overwhelming generosity. The pressure points are going to have to be consistent, and that's probably going to have to come from a union presence. But what the council you're talking about says -- and I'm sorry if I'm bouncing around, there's just so many points circulating in my mind -- is it preserves and protects consumer control.

What we did in Massachusetts, that was vital, and it was our bottom line with the union, we 001890 67 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

said, this isn't in the bill, no go, we're en masse and opposing it. It codified consumer control, the right of the consumer to hire, fire, supervise, direct and otherwise train consumers. If that wasn't -- I mean attendants if that wasn't in there, no go. And again, the workforce council, seven out of nine members appointed by -- had to be representatives of disability organizations or consumers themselves.

In fact, I think the majority of the nine have to be users of the PCA program, not just advocates, not just surrogates, but consumers themselves. And that was very important. And the appointment process came via disability organizations in conjunction with state officials so there was not a disassociation from the concerns of the community. I've heard people here express their concerns. They absolutely replicate a lot of the concerns in Massachusetts, and what it took was an extremely dedicated effort on both sides of the equation, and this is kind of a prescription for success and I can't speak to the dynamics of Connecticut, but a very concerted, dedicated effort for the union which was pushing this legislation to work with advocates and consumers to address concerns.

And what happened then is a lot of advocates, a lot of consumers came on board because they knew -- they knew so well that attendants were not paid well, that attendants never got a paid day off, that attendants did not have health insurance. And who are the attendants? In Massachusetts anyway, and I'm from Boston and the greater Metropolitan Boston area, many immigrants, single mothers, college students, people of color, people not in the upper reaches, upper strata of society. And their 68 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

right -- their right to organize and collectively seek redress for, really being underpaid for extremely vital work, was something, at least, my organization came to support.

You know, we didn't feel justice was ever selective. We're out there saying people with disabilities have the right to live in the community, but we're also going to support someone's right to get a fair wage and also work to make it a mutually supportive endeavor. And that's what I think is going to be the key to any of this.

Right now in Massachusetts there are 16,000 people on the attendant program, approximately 22/23,000 attendants. There's been a union since November 2007. Things seem to be working well. There is a pay -- set of pay raises put in place that will take the wage. The first one clicked in January, well November first, retroactive pay is just coming now. Wage went from 10.84 an hour to 11.60. The next step is to 12 and then about 12.48. ,There will be paid time off.

And another point that I think sometimes gets forgotten, a lot of the attendants are people with disabilities or have a household member with a disability. Probably the strongest supporter of the legislation is -- she couldn't get down here today because of travel difficulties, Liz Casey, a good friend of mine, lost one or two attendants during this campaign. The attendant had -y you know, she'd have an attendant who had a child with a disability and just needed to go out and get a job with health insurance.

So there's a lot that speaks favorably to try and better -- to better compensate attendants. 69 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

It promotes independence. It promotes the dignity you hear about. You know, I was just listening to the problems with the nursing home industry, and I think Representative Walker was saying it a little while ago, the future of long-term care in this country, you know, where Connecticut jumps in I don't know, is definitely home-based, community-based care. And it's a human rights issue, first and foremost.

We can make the analyses forever, forever about it saving money, and typically it does. But it's really a human rights issue, the right of someone to live where they choose, how they choose, with family if that's at all possible. And to the degree that this legislation can do that, I would hope it would be something you would support, but I think it's --

SENATOR DOYLE: Okay.

BILL HENNING: -- essential to really bring in disability advocates, hear their concerns and be sure they're addressed and be sure, at all times, consumer control is protected. I believe this legislation does and makes great steps, but the council in touch with them --

SENATOR DOYLE: Thank -- thank you, Bill. And we're -- you're going to get some questions anyway but --

BILL HENNING: -- Sure, then that's fine.

SENATOR DOYLE: Okay, any questions for Bill?

Representative Walker.

REP. WALKER: Thank you for coming here and letting -- and sharing with us your story. 70 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

BILL HENNING: Well, it's easy to see everyone going through the painful struggles we went through, so it's sort of a relief I can leave and it's in the rearview mirror.

REP. WALKER: Now, the council that you -- that's set up in Massachusetts right now, it is -- do you have -- when your heard some of the discussion there -- the concern was we have some infrastructures in addressing how do you connect with PCAs and things like that. Do you have others going on simultaneously along with the council, or is the council the only way you can get through state funding?

BILL HENNING: I'm not quite sure what you're asking.

REP. WALKER: Okay, wait -- right now there is a system that's in place that one of the consumers testified about earlier. And she said she,likes her system the way it is, and one of the things that's in the bill is that this does -- you do not have to go to the council. It's not mandated. Is it -- are there other options in Massachusetts --

BILL HENNING: Yeah, there's no mandate to go through the council. What the council was set up in Massachusetts is an independent quasi-government body, and it has some functions. One is to do a report on the status of the program, things of that nature, which has actually been very helpful to do surveys and they're very well-constructed surveys that provide information on the program. Another is to set up the directory so they'll -- PCAs can optionally list themselves on it so if they're seeking work attendants can have a place to find an attendant, if there's a shortage, if there's 71 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

an emergency, whatever. And it allowed for collective bargaining as an entity to establish collective bargaining. It's kind of a legalistic mechanism because how do you unionize all these independent employees of thousands of consumers?

REP. WALKER: Does the --

BILL HENNING: But -- but --

REP. WALKER: -- does the state have multiple levels of rate for PCAs?

BILL HENNING: It does not. It has one rate for the PCA program. I think one of the differences in Connecticut is that you have a series of waiver programs whereas in Massachusetts the PCA program is part of the state option, and it's -- becomes an entitlement under Medicaid, and that's enabled it to grow. The program -- you know, at the turn of the -- this decade there were about 4,000 people on the program, so it's grown four-fold in the last eight or nine years as community-based services -- the acceptance of that, the Olmstead Decision, have you know --

REP. WALKER: So your -- your PCA program is funded through your Medicaid --

BILL HENNING: -- entirely.

REP. WALKER: -- agreement. You did not do any of this through any types of waivers whatsoever?

BILL HENNING: No. There's talk about now getting a waiver, 1115 Waiver as it's called, which is an very intensive discussion we're involved in now about establishing an agency-model PCA program, which is causing tremendous amounts of nervousness among advocates because we're 72 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

not sure what kind of consumer control will exist with such a program. But, no, the general PCA program, for which the workforce council operates in Massachusetts, is just for the state plan.

But I will say, what's really important, it has not attempted to alter the relationship between consumer and attendant. And in fact, it strengthened it, because previously the right of consumer control was just in regulation, and Medicaid can always change a regulation. Now it's in law. It's state of Massachusetts law (inaudible) using personal care attendant services funded by Medicaid has the right to hire/fire direct, those words pretty much exactly.

REP. WALKER: Connecticut is looking to Massachusetts for leadership in a lot of things. So thank you for your testimony.

BILL HENNING: Thank you.

SENATOR DOYLE: Thank you.

Any other questions. Thank you very -- wait, wait --

Representative Thompson please.

REP. THOMPSON: Good afternoon. You're certainly much better versed than I am in this whole subject, but I would like to go beyond and tap your brain, if I may. Representative Butler mentioned the crying need for more people in this field --

BILL HENNING: Right.

REP. THOMPSON: -- in setting up training programs and so on. And you mentioned as part of your 001896 73 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

testimony, I believe, that there is a training program that's going on.

BILL HENNING: Well, there's beginning to be rudiments of a training program. What we have insisted on from the advocacy community -- and this requires a constant vigilance because you have now three entities, just to be clear. You have a union, you have the consumers, and you have state government. But what we're -- what a lot of consumers want is an attendant who knows what they're doing -- right. I mean, the'basis is you train them for your unique needs. You schedule them around your unique life, and that's vital. But for an attendant who knows CPR is a good thing, and attendant who may be somewhat versed in how to transfer somebody without hurting their back, though, say from bed to a wheelchair -- though there are -- every situation is unique in its own right, and the consumer should be able to teach people, but there are training programs emerging, all optional.

But we don't want to see happen is some kind of certification which starts to narrow who can become an attendant, because there's a lot of people -- the neighbor, the lifetime friend/family member who can perform that job, might not have the means to become certified or might not be good at taking tests or whatever. But, you know -- you know and we're talking about, even in Massachusetts we've been having this discussion for a year of setting up programs where you get a certificate. But being sure that there's no requirement to be an attendant with the certificate, but to make the person more marketable and to actually make this program more attractive to people with disabilities.

Many people who have disabilities can serve as 001897 74 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M. attendants, even people with physical disabilities. It's happened in many instances with people who have psychiatric disabilities or whatnot, so the word "optional" is very important because that's what keeps the control there.

REP. THOMPSON: I'm going to make a leap, if you don't mind.

BILL HENNING: I'm happy to try to answer anything.

REP. THOMPSON: But what has always intrigued me about the French child care and health care systems is that they're so popular in France, and France has the number one health care system in the world. And the last time I looked was a year or so ago, and the United States was ranked 37th. They beat us on longevity, infant mortality rates and so on. And I came to the conclusion that they must have quality people, therefore, there must be quality training. And in addition to that, it seems to me that whenever the French talk about changing that system, they get a new leadership, the whole population turns out and protests, and I think part of the reason for that is so many people are employed in the health care system that they form a real economic bloc. Do you know anything about the French system?

BILL HENNING: No, it's the first time I've heard it praised as such. I mean, the analogy we always get pummeled with is Canada, Canada, Canada. And no, I don't, do not.

REP. THOMPSON: They're way ahead of Canada right . now.

BILL HENNING: Yeah. I don't know. 75 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. THOMPSON: Well, if you come across anything, please let us know

BILL HENNING: Sure.

REP. THOMPSON: -- because it's been an interest.

BILL HENNING: And there's plenty of people in Massachusetts, if you might want to investigate this, who might be able to give a more, for lack of a better word, scientific view on what's happened. But the council seems to be working. It has not -- and the union has not interfered with the consumer's right to control attendants, and basically we have a situation now where the attendants are pretty happy because they're being paid better, and there's a prospective time -- paid vacation, which has never existed, and paid holidays which is -- I don't know if that's in there but -- so it's work. It's hot something that could've just been thrown out there and left to the good devices of one side or another side to do it, there needs to be a collaborative effort.

SENATOR DOYLE: Thank you.

Representative Morris.

REP. MORRIS: Thank you, Mr. Chairman.

Can you give us some information on the Massachusetts model or any other state that you may know of in terms of the type of control the consumer has as it relates to the attendant that I now have who is unionized, for whatever reason I just don't like the level -- quality of service that they're giving me, and right now they can just terminate them. Is that the -- problematic? Does it end up being the, you know, 76 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

traditional model where -you now have to defend it with some type of a steward or something like that?

BILL HENNING: Right now, you can dismiss at will.

REP. MORRIS: Dismiss at will?

BILL, HENNING: Yep. There are no stewards. I think the union itself, to be honest -- I can't speak for 1199 in Connecticut, that division of 1199. I don't think 1199 Massachusetts wants to get in at that level because there would be 16,000 employers and -- you know, it's almost an impossible system to manage in that way.

REP. MORRIS: So then, am I to understand in Massachusetts it's primarily bargaining --

BILL HENNING: Only.

REP. MORRIS: -- wage and benefits only?

BILL HENNING: Yeah, whatever you can get in a contract, and the contract only dealt with wage and benefits. I should've brought the contract. It's about three pages. It's probably the smallest union contract in America.

REP. MORRIS: It would be helpful. If you can forward that to us, I think it would probably be helpful because the contracts typically do have more than just wage and benefits. There are other terms that may be part of the service delivery that would be interesting.

BILL HENNING: I'll give you an interesting example of just where we are with it, and again, the word I always say is just -- words are constant interaction. There's been an issue 001900 77 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

because some attendants have been complaining to the union that they haven't been getting paid. Well, with 16,000 people there's a lot of dynamics going on, right? Maybe someone doesn't know how to submit time sheets. Maybe some one doesn't want to submit the right time sheets, or they fudge it and pocket the money. I mean, you've got a lot of poor people, too, who can see this as a way to make money. You know, 16,000 people there's -- not everyone's an angel just because they have a disability or they're elderly.

So the union was -- convened a bunch of players -- I wasn't at the meeting but one of my staff was -- and said, well what do we do? And we said, the PCA then can report to the U.S. Department of Labor, a labor grievance. We don't need to set up anything special because if we're trying to promote independence, dignity and control, and they get treated the same way, then the union comes back, well I'm worried if the DOL gets flooded with 20, you know, 150 complaints if that's what it is, they're going to come in and investigate the program, you've got auditors, and there's all kinds of problems.

So we may sit down to try to see if there's some intermediary stuff, but our -- the basic line of advocates is treat the people the way you would anyone else who isn't being paid. And if the attendant, for instance, is doing something wrong we as advocates would suggest, you know, if it's abuse you file an abuse complaint or call the police or whatever.

The system hasn't changed, there's another member in the discussion, that's a union, but per se they don't -- there's no workforce, there's nothing on how the work is run. 78 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. MORRIS: I think you answered the question or concern that I've been kind of hearing from people today. You know, the consumers, I guess they're concerned that, you know -- I think you addressed it. If there is that will

BILL HENNING: That's how we -- that's how we did it.

REP. MORRIS: Okay, there's a concern I'm seeing some of the other testimony that I know we're going to hear today, that that is a major concern because -- they were concerned that, how does a person that is already disabled defend themselves in that kind of environment if they've, you know, and they may lose service delivery in the meantime --

BILL HENNING: --Oh yeah.

REP. MORRIS: But you've -- you've addressed it.

BILL HENNING: -- if you injected stewards trying to argue, you can't do this, you know, we can only lift the patient three times a day and then you ask for four, the whole program breaks down. It doesn't exist, and then all the PCAs would be out of work as well. So it's not functional to this unique system at all.

REP. MORRIS: And then, and I guess then we can almost say that the bill implies, by, you know, the inference is certainly there that because the council will be made up of more members of consumers than of providers, that, therefore, the consumers' interests are inherently taken care of -- or paramount.

BILL HENNING: Yeah, I think that that becomes a very critical mechanism for this to work, 79 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

because they become a counterweight. And I think what we did was, you know, the structure is there, but what we've done in the state over the last eight or nine years, grow the program. And it used to be a boutique program, and everything was kind of hunky-dory for people, a few isolated programs. It was a smaller enrollment relative to the state. It's grown, so that's why I think you need a bit more structure.

REP. MORRIS: Now, I may have missed it, are there any other states that have a model similar to yours that may not operate the same way?

BILL HENNING: Sure. California, which operates different than anywhere, has a series of, I forget what they're called, council's of some sort. Their programs run by county, some of the counties have successful workforce councils. State of Washington, Michigan have succeeded. There are discussions going on intensively in Pennsylvania right now.

REP. MORRIS: But regarding, you know, terms, you know, benefits and wage. If your model -- that's all that's really negotiated --

BILL HENNING: That's all --

REP. MORRIS: -- California, regardless of the fact that its more regional, is it still just terms and wages --

BILL HENNING: That's my understanding. That's my understanding.

REP. MORRIS: Thank you very much.

BILL HENNING: Yeah, I mean the contract would tell that. There's nothing else in there that I can recall. 80 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

SENATOR DOYLE: Representative Walker.

REP. WALKER: I -- I'm glad you -- I was going to ask that exact same scenario that Representative Morris brought up was, if you .have,an issue and there is a -- because as some of the consumers said they wanted -- they have a personal relationship, and if the personal relationship does not work, they, I think their concern was that they would have to go through an arbitrator, you know, or a negotiator.

BILL HENNING: Very valid concern. That does not exist.

REP. WALKER: Okay, all right.

BILL HENNING: I don't know if you can put that in legislation. Another thing that's -- I think it's in the Connecticut Bill, though I read it two nights ago, is a no-strike clause.

REP. WALKER: No-strike claus.e to -- yeah.

BILL HENNING: We insisted on a no-strike statement.

REP. WALKER: So then the other part that's a positive is the fact that if there's a person that is doing a good job then they get recognized on the list, and the people that are doing -- not doing a good job would also be recognized on the list?

BILL HENNING: Well, I don't know. The directory hasn't been final. The directory in Massachusetts is just an -- or registry as it is in the legislation here, and that's what it was in Massachusetts, but we've -- semantics have changed it, and it's important because 81 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

it's a directory you can -- like the yellow pages or something, you can find a number there. You can find a person who can perform attendant work, but there is no requirement t be on that. It's independent of anything. It's a name. There'll be a little bit of screening by the people operating it, but basically it's not going to be an endorsement pro or con,as I understand it. And the consumers on the council are working closely in how this set up and working with the contract agency, rewarding work, which may have some role in Connecticut.

REP. WALKER: Thank you.

Thank you for your answers.

SENATOR DOYLE: Thank you very much.

Representative Morris.

REP. MORRIS: Mr. Chairman, for the second time with a quick question, it's a follow-up to what Representative Walker just said. Have you ever, have any of your -- either Massachusetts or any other states, while they're going through the process of determining what they're going to do, suggested that they would have some kind of rating system or something for the providers? Since you've got this pool, just curious, whether that ever came up as an issue and if so how was it handled?

BILL HENNING: I don't know what the other states do. The discussion arises in Massachusetts, and at some point you would -- it would be a great thing because you can have an -- you1 re talking about rating the attendant. I'm not talking about rating them on performance to - you know, each consumer rates them, and if 001905 82 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

they're good they keep them; if they're fair, they may keep them; if they're lousy, they get rid of•them soon as they can get a replacement probably.

But what- is totally unfair to the attendant, and ultimately unfair to the consumer is, the pay rate's the same for everybody. There's no merit pay there's no better pay for tasks. So if you bring somebody in to prepare a lunch which might be slopping peanut butter on a sandwich and opening a can of Campbell's soup, they get the same rate as the person who is putting you to bed, using a Hoyer lift, aiding with your personal bathing and toileting which can be much more complicated and much more sensitive.

And that's an unfair situation for attendants that ultimately doesn't benefit the consumer, I would think. If you get somebody good you want to keep them. And it becomes harder -- there's no merit pay there. How they would -- you know, that's a long-range thing to look at, I think.

•SENATOR DOYLE: Thank you.

Any other questions?

Seeing none, thank you very much.

Next speaker is Michelle Ockenfels. I'm sorry if I'm mispronouncing your name. Then Lynn Warner, Kyle Haven and Martin Acevado. Michelle? There she is. Thank you.

MICHELLE OCKENFELS: Hi, Senator Doyle, Representative Walker, and members of the Human Services Committee. My name is Michelle im. Ockenfels, and I'm the director of MidState 9S VNA & Hospice. We're a home health agency 001906 83 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

that serves, primarily Meriden, Wallingford, Cheshire, Southington and Middletown. I'm here to testify that I strongly support sections one through five of the Senate Bill 1122. Home care is much more cost-effective than providing care in hospitals, institutions and facilities. We have also experienced profound satisfaction from our patients as they prefer to get treated for their illness and injuries at home.

I feel that it is imperative that we are given the proper tools, specifically an increase in our Medicaid reimbursement rates so that we can serve our patients. The inadequacy of the Medicaid reimbursement rate is currently threatening the financial viability of MidState VNA & Hospice. Medicaid rates created a shortfall of over a half a million dollars last year in my agency.

To make up that deficit we have to generate a surplus from other payers, for example Medicare. And with the Medicare program having our rates frozen through 2011 and the President's and congressional advisor's recommendations to cut us 5 percent, that would be an additional $127,000 in reduction of revenue from my agency, which would further place out of reach my ability to subsidize our Medicaid losses.

We have done'several things to try to take off some of this burden. We've reduced our workforce by 20 percent. We've restructured operations. We've redesigned efficiencies, we've maximized productivity all while maintaining a commitment to quality home care. And that's demonstrated by our favorable outcome data that we have with state. Further cuts to my agency would jeopardize my ability to provide quality patient care and would 84 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

promote unsafe caseloads for my clinicians.

In the home health industry we're the eyes and ears of the community. We see things that most don't in the sterile environment of the hospitals where there's regimented everything. This is when you're going to eat, this is the medications that you're going to take -- oh good, your congestive heart failure is under control, it's time to go home now. And they go back to the doctor's office and the doctor says, Oh, how you doing? Did you decrease your salt? Sure I did, Doctor. And then we go into the home and we look around and we see say, oh geez Patient A, what's that big pile of canned soup in your recycle bin? And they'll say, oh, well Nurse Michelle that's my favorite soup on earth! And then I say, Okay well let's talk about that because that's contributing to your congestive heart failure.

If you take away that piece, then we can't do our job in preventative services, and that's what-we do best. We prevent people's diseases and illness and injuries from exacerbating and showing back up in the emergency rooms across the state. So in summary, I ask that in order for us to serve the entire population, which is our mission, home -- community-based home care, I ask that you please consider to increase the Medicaid reimbursement rates and pass this bill out of the Committee. Thank you.

REP. WALKER: Thank you, and thank you for your testimony.

Any other questions?

Thank you.

MICHELLE OCKENFELS: Thank you. 001908 85 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. WALKER: Next is Lynn Warner, and after Lynn is Kyle Haven, and after Kyle is Martin Acevedo.

No Lynn Warner?

Okay.

After that, Kyle Haven?

Good afternoon.

KYLE HAVEN: Good afternoon. My name is Kyle Haven, and I've been a personal care assistant for years. I'm on the PCA registry, but I haven't received any calls in a few years. I really enjoyed working with my last consumer. What I like about this work is that it's so personal, although I don't like the term "consumer". I'm helping .someone that I care about, I consider them my friend, as well as my consumer, and I"could add to that, too, my almost, like, family.

My duties varied depending on her needs and her current condition. My consumer was attending college. She could manage most things by herself, initially, but needed help carrying her books and supplies. So I would drive her places, assist her with what she needed, and in general help her get around smoothly. Later her condition deteriorated, and the assistance she needed changed. She was hospitalized off and on and required more PCAs to, manage her care. Unfortunately I had to move on at that time.

I think this council is very important. I was a PCA for years, and while it was very rewarding, there were several underlying issue that neither I nor my consumer had control 001909 86 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

over. I was making $11 an hour, and there were no benefits. I was on Medicaid but could only work 12 hours a week or I would be deemed ineligible. It put me in an odd catch-22, to do the work that I love without benefits or the ability to do it full-time or to find something else to do that I didn't feel as passionately about.

I would take more work as a PCA, and I would be willing to do backup work for a consumer or to work more regular hours if I could do full-time hours or have the possibility of getting benefits.

Why pass this council? I think it comes down to improving the quality of care for consumers. They need the ability to come together, speak about the issues they face in living independently, and PCAs need the ability to join our voices and have a say in these overriding conditions that affect our ability to improve the lives of our consumers.

PCAs and consumers having a voice translates to a higher quality of care. I urge you all to pass the quality home care council. Together we can make a difference. Thank you.

REP. WALKER: Thank you, and thank you for your testimony. Any questions?

Representative Gibbons.

REP. GIBBONS: Thank you, Madam Chairman.

Sir, I'm sorry, thank you. You just testified that you could only work a certain number of hours a week. Who -- under what regulation is that, please? Could you elaborate a little bit. 87 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

KYLE HAVEN: (inaudible) Medicaid. They told me that I had a certain number of hours, not so much per week but per month. So other than that, though, 12 hours a week, and after that the amount that I made from my wages would be over Medicaid and (inaudible).

REP. WALKER: Okay. I'll -- so, you were working as a PCA for somebody else, but because you are receiving a Medicaid health care -- you're receiving your own health care under Medicaid, you had to keep your wages -- below a certain amount, is that correct? Okay, but, the wages, if you weren't under Medicaid for your own health care, you could have had whatever wages you wanted, so those are two separate issues.

KYLE HAVEN: Well, what determined it for me, basically, was that I was making an hour, between -- I mean I didn't feel the rate was horrible at that time. It wasn't too far off what I had been doing prior to that. But the fact that, in order to keep my health care, I had to only work x number of hours a week was what turned it around for me --

REP. GIBBONS: Okay.

KYLE HAVEN: -- and the fact that the dollar amount I was making was (inaudible).

REP. GIBBONS: So either your wages had to increase as a PCA to cover the difference, or you had to stay within the Medicaid guidelines or requirements for your own health care, is that correct?

Thank you.

Thank you, Madam. 88 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. WALKER: Thank you.

Any other questions?

Thank you, and thank you for your testimony.

Next is Martin Acevedo and after Martin, Lucy Potter.

Good morning.

MARTIN ACEVEDO: Good morning.

REP. WALKER: Good morning -- good afternoon.

MARTIN ACEVEDO: Right. My name is J. Martin Acevedo, and I am the General Counsel of Companions and Homemakers Incorporated, a homemaker-companion agency serving the home care needs of older adults since 1990. The company employs approximately 1600 caregivers and cares for over 3,000 older adults. We serve private pay clients as well as clients of the Connecticut Home Care Program for Elders. We are here to testify in favor of Sections one, two and three of Senate Bill 1085.

Section one of the Bill seeks to revise the DSS current vendor audit statue, also known a the "extrapolation statute". Extrapolation i the process by which the percentage of errors found in a sample of audited claims is extrapolated to the entire universe of claims paid to the provider. Under this model a small billing discrepancy or overpayment can and will translate into thousands of dollars in extrapolated charges. Extrapolation is permissible even if no evidence of fraud exists.

The proposed bill does not eliminate 001912 89 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

extrapolation. Rather it merely revises the statute to ensure that future audits will comport with notions of fundamental fairness, adequate notice to providers and more importantly, due process rights.

First, the bill seeks to eliminate the portion of the current statue which appears to exempt agencies that do less than $150,000 in business with the state. This bill seeks to revise the statute so that it will apply to all providers regardless of how much business they do with DSS.

Second, the bill seeks to amend the statute to comport with the standard for extrapolation embodied in the Medicare Act of 2003. Under that standard the government can extrapolate provided there is either a high level of payment error involving the provider or there is evidence that, despite documented educational intervention, the provider has failed to correct the level of payment error.

Third, the bill .will grant a much needed right of judicial review of the results of the audit. Presently, no such recourse exists. DSS is the ultimate arbiter of claims arising from an audit.

Our agency recognizes the importance of audits to ensure program integrity. This bill does not eliminate the audit process or the practice of extrapolation. It simply brings these practices into check with well-settled fairness standards and minimum due process considerations.

The purpose of section two of this bill is to enable clients of the state home care program to receive personal care services, i.e., Assistance with activities of daily living, 90 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

through homemaker-companion agencies.

Under Connecticut law, a nonmedical agency like C&H can assist individuals with activities of daily living provided that the individual is deemed chronic and stable by his or her physician. See attached .opinion letter from DPH to C&H dated February 9, 1994.

Although our agency has been providing hands-on personal care services to its chronic and stable private clients without incident since the early nineties our agencies are not permitted to provide those services to clients of the state home care program.

Currently, the state reimburses a home health aid agency 24.40 per hour of CNA service plus the added cost of a monthly supervising visit by an RN, presently 23.56 per 15 minute units, or 94.26 per hour. In contrast, a homemaker-companion agency's average hourly rate for personal care services is approximately $19 without the added cost of a nurse visit. This can save the state hundreds of thousands of dollars in fees. Furthermore, because our caregivers can perform personal care in addition to homemaker and companion services, state clients can enjoy continuity of care and service by the same caregiver on a consistent basis, chief amongst many other benefits.

Section three of this bill addresses the compensation for transportation issue, perhaps one of the most significant challenges affecting providers who contract with DSS to provide companion services to clients of the state home care program. For many years, agencies have provided and continue to provide social transportation services without reimbursement for such service, even though 91 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

the regulations of the home care program explicitly state that such services must be compensated. Using their own vehicles and fuel, our caregivers transport clients to doctor appointments, shopping, and social activities. In addition to driving the client, our caregivers escort the client to the appointment, record any information given by the doctor, pick up prescriptions, and return clients home safely.

For years, case managers from the various agencies on aging have relied upon our agencies for the safe, convenient and reliable transportation of CHCPE program clients to and back from these appointments. Caregivers, on the other hand, receive no reimbursement for the transportation component of their assignment. This bill addresses the problem by establishing a flat fee of $8 per trip on top of the regular hourly rate for the companion .service, an absolute bargain when compared to --

SENATOR DOYLE: Could you please summarize? Because you're over. Thank you.

MARTIN ACEVEDO: -- the rates paid to commercial pick up/drop off livery services hired by the state.

We urge this Committee to approve this critical legislation in its entirely. We will be happy to answer any questions.

SENATOR DOYLE: Thank you.

Any questions from the Committee?

Representative Gibbons.

REP. GIBBONS: Thank you, Mr. Chairman. 92 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

I was part of the committee that worked on a bill to deal with audit fraud, potential fraud, with the DSS commissioner a couple years ago. And we discussed long and hard the method of extrapolation, and I think the issue before DSS is they have dealing with so many different vendors, from the very small vendors to very large vendors, and some of them are there to commit Medicaid fraud one way or another. I'm not saying that all are, but certainly some were. And we felt that the extrapolation --we were taking away any rights of extrapolation by DSS for vendors of a $150,000 or less, and that was at least a compromise of what they wanted and what we felt was fair.

Whether -- I see one part of the bill says that any clerical error should not be used for extrapolation. And I can see it from the vendor's point of view because you're dealing with so many different Medicaid forms, but I think from DSS, too, some of those errors might be conscious errors and some might not be.

So once again, I think that this is something that we need to go and look at once again and discuss with DSS and maybe there's some room for improvement in the original bill, but I would hate to take out all the things that we discussed two years ago and did pass with a genuine concern, both for the vendors and for the need of DSS to try and audit the fraud.

MARTIN ACEVEDO: I appreciate your concern, and again I just want to make clear this bill does not take away the right of (inaudible).

REP. GIBBONS: Okay. 93 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

MARTIN ACEVEDO: (Inaudible) -- oh, I'm sorry. To give you an example, a -- findings of $163 can translate into $100,000 worth of charges. And those are the kinds of things that we need some notice. We need some understanding of what is the criteria that DSS is implementing when, choosing to extrapolate.

REP. GIBBONS: I think that's why it's always good to review some of the legislation that we pass, because that was certainly one of the issues that we were trying not to invoke with the extrapolation, was that for small sums, or small vendors, they would not be liable to the extrapolation. But on the large sums, and DSS deals with many vendors that are hundreds of thousands of dollars, and some of the errors could be resolved within the vendor's own office, and that's up to the vendor to deal with that rather than for DSS to take the time and the money to do it. But I think if we have specific issues, we would like to hear as a committee what we can do about it, and maybe we need to make some changes in the regulations or see just what DSS has to say from their side, too.

MARTIN ACEVEDO: Absolutely.

REP. GIBBONS: But we thank you for bringing your testimony forward.

MARTIN ACEVEDO: I appreciate your concern.

SENATOR DOYLE: Thank you.

Any other questions from the committee?

Seeing none, thank you very much.

MARTIN ACEVEDO: Thank you very much. 94 March 17,' 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

SENATOR DOYLE: Next speaker is Lucy Potter. After Lucy is Susan Fuhrman and then Tashmarie Lewis.

Lucy?

LUCY POTTER:. Good afternoon Senator Doyle, Representative Walker, members of the committee. I'm Lucy Potter. I work for legal aid in Hartford, and I'm here hoping you'll support Senate Bill 1086. an Act Concerning Crediting of Social Security Dependents' Benefits. This bill addresses the situation I've spent countless hours dealing with over the last few years-, along with many of my legal service's colleagues. It addresses a very specific situation. When people qualify for Social Security Disability benefits and they owe child support, the automated system that Connecticut runs for child support enforcement will communicate with Social Security and get wind that this person is getting Social Security and will automatically attach those benefits. I have clients who are maybe getting $1,000 a month and they're left with 500.

Meanwhile, though, the law also requires, and in just about every case where somebody gets Social Security disability, the child gets a direct benefit from Social Security. So in these situations, assuming that the family knows that that is out there, the child is already getting a dependence benefit. And under Connecticut law that's a credit against the child support obligation. But what happens is the person gets caught up in this situation. Their Social Security check is being attached. They may not know that what they have to do to make this stop is bring a modification of this order. 001918 95 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M. It's not that easy to do, and unfortunately, in some of these cases, the custodial parents, maybe they don't even know where she is. So I've had cases that have lasted a year where my poor client, who's disabled, is never going to get more than the $1,000 a month that Social Security allows them to get. They're actually living on 500. Got one client right now who's stuck in a rehab facility and unable to take the next step forward, which he should, because he can't get his check because he's stuck in this process. So what this bill does is it sets up a process so that when Support Enforcement learns that this person's getting Social Security they're also supposed to find out, and are the children getting dependents' benefits?

We've been in communication with Support Enforcement a little bit about how this process works, and we've learned that in the next six months or so there's going to be even better communication between Support Enforcement and the 4D child support agency. So that they will have access to information about the dependent's benefit and how much it is.

What we're asking is that that dependent's benefit be credited. You're going to need to do a modification, in any case, because the support order is probably based on earnings that this person is no longer making. And you've got to reconcile this because you have to count the dependent's benefit that the child receives along with Social Security, both of those amounts count as the income that you base the ultimate child support award on.

But you need to reconcile that in a modification. But we're asking that also, in the meantime, the credit be acknowledged. 96 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

That these two systems be required to talk to each other. That the poor person who qualifies is caught up by an automated, automatic wage-attachment. We're asking that there also be automatic acknowledgment of the dependent's benefit and, you know, sparing a person from this situation which recurs.

Not, you know -- I don't think there are thousands of these cases, but there are probably hundreds of these cases every year.

SENATOR DOYLE: Representative Walker.

REP. WALKER: Thank you, Lucy. We also receive testimony from the judicial branch, and they were opposed to this. And one of the things that they talked about was the fact that this would decrease the revenue that Connecticut receives, because the federal funding is based on the percentage of child support collected during the month that it's due. Can you --

LUCY POTTER: Well, they're talking about a very specific thing, which is that the payments that go through the children -- directly to the children don't go through the Support Enforcement system, so they can't track them exactly. There are other states, though, that have gotten around this. North Dakota is one, I know, that has managed to do this without running afoul of federal law. So, we talked to them a little bit about that. I know they were going to contact them and see what their position was. I have also seen that the Bureau of Child Support arid Enforcement, the DSS counterpart, doesn't exactly embrace it either. They see that -- they think there's an administrative burden to having to contact the family, and again, they're concerned about tracking this third-party payment. 97 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

But what we've learned is that there is increasing communication between 4D and Support Enforcement so I -- it seems to me that our clients shouldn't be the one who have to sit there waiting because it's administratively inconvenient, you know. It's really, it's quite an impediment to people. I had a client who was homeless for three months last year, waiting for this to get sorted out and he, you know, has HIV (inaudible) positive and it was a terrible situation for him.

REP. WALKER: I think we have silos that like to be silos sometimes, and maybe we, sometimes, we just have to nudge them to communicate. We have that with the bigger agencies also, so thank you. Thank you, Lucy.

LUCY POTTER: Thank you, thank you.

SENATOR DOYLE: Lucy, I have just a question for you. If you can take a step back, when you began.your remarks you mentioned the issue between, if I'm a child receiving Social Security or SSI, how does that impact with this other side? I wasn't sure, the initial comment. You said that -- it seems to me you should be able to get SSI and get child support so how does that impact? When you started your remarks, I didn't understand that parallel.

LUCY POTTER: I was talking about, the father qualifies for Social Security disability, not SSI. If the father qualified for SSI that's a welfare program, it's considered -- and there are no dependent's benefits paid to the child in that case.

SENATOR DOYLE: Okay.

LUCY POTTER: But when the father qualifies for 98 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Social Security disability -- or retirement, if there's a minor child, the child gets a direct payment from Social Security. Doesn't come out of the (inaudible) could be a mother's check. It's a direct Social Security benefit to the child. It's usually about half the amount of the award that the parent receives. Does that answer your question?

SENATOR DOYLE: Now, how does that impact with the issue of the bill here? I thought that that had a negative impact on the House --

LUCY POTTER: What we're asking is that that payment be acknowledged and credited so -- as payment of the support obligation, so that the father's Social Security check then doesn't get attached in addition. That's what's happening'. So the father qualifies for social disability. He owes 500 a month in child support. As soon as he qualifies for Social Security disability, that check from Social Security gets attached. $500 gets sent, each month, to the child Support Enforcement agency. At' the same time Social Security's sending --

SENATOR DOYLE: Pay 250 or whatever.

LUCY POTTER: Yeah, it might even be 500, to the child directly. We are asking that the amount that goes to the child directly be considered a credit so that they don't attach his check.

SENATOR DOYLE: Isn't that, in theory, harming the child for the benefit of the father, or no?

LUCY POTTER: It's not harming the child, the child's getting the amount of the child support order --

SENATOR DOYLE: Which is 500 in your hypothetical 99 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

LUCY POTTER: Yeah. Right. I mean to the extent -- in many cases, in most cases that I've seen, the amount that Social Security sends to the child is sufficient to satisfy the child support obligation. If it's not, then you could attach the balance until you get into court and rectify it all in court. If you get into court. If you can straighten all this out. The court will acknowledge this is the credit and so on, but the trouble is that this can take some time. And for a disabled person who's, you know, living on very limited means, it's really hard to --

SENATOR DOYLE: To further complicate -- what if the father's in arrears? Is that --

LUCY POTTER: You can -- then an amount from the Social Security check can be taken to satisfy that. Under the guidelines, under the child support guidelines, it would be about 20 percent of what the current support obligation is. But that would continue. I'd add though that in many of these cases there's also a sufficient -- substantial arrearage that goes to the family because the, you know, it takes a while to qualify for Social Security, and so often when the person qualifies they get a retroactive amount that might go back a year or two --

SENATOR DOYLE: But it's 20 percent though, yeah.

LUCY POTTER: Likewise for the child. Yeah.

SENATOR DOYLE: Okay.

Any other questions from the committee.

Seeing none, thank you. 100 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

LUCY POTTER: Thank you.

SENATOR DOYLE: Next speaker is Susan Fuhrman and Tashmarie Lewis and -- no -- and then Therese Nadeau.

Susan? Thank you.

SUSAN FUHRMAN: Good afternoon. I'm Susan Fuhrman and I'm a PCA for two professional women. Today I will be reading testimony from Phyllis Zlotnick, a disabled woman who could not be here today, and I agree with what Phyllis has to say.

Honorable Chairpersons and members of the committee, do not be led to believe that all persons with disabilities want this bill. HB ,6668 is a bad bill disguised in a pretty wrapper that can be harmful for people with disabilities. A lot of people are being misled about the consequences if it passes. After the fact it will be too late to go back. The various personal care assistant programs will become more costly resulting in less hours allotted to the very recipients most in need.

Certainly there are problems with existing programs, but this bill will not correct them. HB 6668 will only add to the problems, and the true purpose has been hidden so as to avoid scrutiny. The PCA programs have always been based on cost-effectiveness of home care versus institutional care. They allow people dignity and independence and self-direction while saving public money, and that is remarkable. We will lose our empowerment to direct and manage our own care and services. I am opposed to giving a council authority to hire, train, register, certify, et cetera, my 101 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

PCAs. Many of us want to train our own people because our needs are unique to us. Certification means nothing. I have had some CNAs that are useless and noncertified aides who are wonderful simply because they care as human beings.

At a time when there is less money and programs are being cut, why destroy an existing program that saves money? As someone who has lived with a disability all my life, I can assure you that it is not what you pay someone that ensures quality care. Rather quality comes first from mutual respect and concern of the people involved, and then everything else is secondary.

If you approve this bill, you are opening the door to 1199. From the original proposed bill, quote: The PCA Quality Home Care Workforce Council shall be considered the employer of personal care attendants as defined by and solely for the purpose of said Chapter 68. The council shall have the authority and obligation to bargain and enter into agreements with the representative of personal care attendants that has been designated by the State Board of Labor Relations as the exclusive bargaining agent of such attendants and through such agreement shall have the authority to establish minimum standards governing such a (inaudible) compensation including wages and benefit, the form and manner of compensation payments, and other terms and conditions of workforce employment affecting the attendant workforce, unquote.

That language may not now appear in.HB 6668f but it will be back, here or somewhere else, later this session. That is why the bill was introduced and why 1199 still is pushing it 001925 102 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00. A.M.

today. If it is not a unionizing bill, why is the union still lobbying the proposal? SEIU and 1199 don't normally care about our programs unless there's something in it for them.

I believe in unions where workers can be saved from being abused for the sake of the bottom line; however, those of us who need personal care via PCAs are not a Wal-Mart or a Japanese car manufacturer. We are individuals with disabilities, each with both similar and yet unique needs and desire to live independently. PCAs help us do everyday activities that we cannot do for ourselves. With the state having financial problems as is, and people being laid off everywhere, does this bill seems appropriate right now? Please remove section two of HB 6668. Thank you, Phyllis Zlotnick.

SENATOR DOYLE: Thank you. Any questions? Seeing none, thank you very much for your patience.

The next speaker is Tashmarie Lewis.

A VOICE: (Inaudible.)

SENATOR DOYLE: Okay, thank you.

Then it's Therese Nadeau. Is Therese here? Yep. And then we have Gary Waterhouse, Paige Flanagan and Bertram Mcintosh.

We actually have a -- no you can get it right.

THERESE NADEAU: Good afternoon. My name is Therese Nadeau and I am a person with a significant physical disability who is an employer of personal assistants. I am also a client receiving services through the Personal Care Assistance Waiver Program. I am 001926 103 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

providing this testimony in opposition of Raised Bill Number 6668.

Before I state my opposition, I want to share with you my own personal story. As an employer of personal assistants I experience firsthand the tremendous support personal assistants play in the lives of people with disabilities. My personal assistants are my arms and my legs and are my -- and are critical to my life. Without their support, I would most likely be institutionalized/ unable to do all I do today. Today, I am a person with a masters degree in social work, a disability and emergency preparedness consultant working full-time at a well paid career and a tax-paying citizen. I wake up each morning with the goal of making a difference in people's lives.

For me, I don't wake up in the morning with an alarm clock but a good morning from my personal assistant who comes to work early each morning so I am ready to go to work on time. Then my next assistant, who's with me here today, and you'll hear from her shortly, comes to pick me up to go to a day at work, meetings, trainings, et cetera. She is there to provide me with support and helps me to motivate me, provide me with extra support on days when my physical disability can make everyday tasks even more of a challenge. Sometimes, my evenings are busy, too. But what it comes down to is thanks to my personal assistants, I live a full, productive and independent life.

So why am I opposed to bill -- Raised Bill 6668? The answer is there are a lot of unanswered questions, with a lot of opportunity to create a Workforce Council that can take away my rights as an employer to make 001927 104 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

decisions, affect the level of support I receive, which I would be happy to comment on further, and force me to change my life to meet my needs, and could ultimately cause me to be unemployed.

In addition,, the way waivers aire currently funded, there is a cap structure for services. So the only way to increase wages will be to lower the number of hours for employers. And this is something that's different in Connecticut than it is in other states like Massachusetts. This will push employers, like myself with higher-end needs over the cap and into institutions. Sorry. I'm trying to turn the page here. It will also force employers to reduce the number of hours they can offer their personal assistants. This would be a huge issue for me.

One of the largest concerns as well, is there is no representation from personal assistants on the Workforce Council. Personal assistants who have been asked -- all of my assistants -- are strongly opposed to such a council. They are saying that they like their jobs as is and any shift towards a decision-making, record-keeping council, with or without a union, would be problematic.

As someone who was very involved in helping to advocate for and create the Personal Care Assistance Waiver Program, as well as teaching new employers, how to hire and manage personal assistants, I clearly understand the program and what is possible to meet the needs of a variety of people. This bill would possibly create conflict to the structure as it is today.

I want to end my testimony stating I also want what is best for my personal assistants: 001928 105 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M. adequate wages, a respected career, the possibility for benefits. But Raised Bill 6668 is not the answer to helping this to occur. Thank you for the opportunity to share my concerns, and I'm happy to answer any questions.

SENATOR DOYLE: Thank1you. Thank you for coming, presenting your story and being patient.

Any questions from the Committee members? Seeing no, thank you very much.

Next speaker is Gary Waterhouse. After Gary is Paige Flanagan, Bertram Mcintosh, and Nancy Smith.

Mr. Waterhouse.

GARY WATERHOUSE: Good afternoon, Chairman Doyle, distinguished members of the Human Services Committee. My name is Gary Waterhouse, and I , am the executive director of the Connecticut Association of Centers for Independent Living. I'd like to say first and foremost that CACIL's allegiance is first to the people with disabilities, consumers in the state of Connecticut.

CACIL supports Raised House Bill 6668 section two because the shortage of personal care assistants in Connecticut is a significant barrier to people with disabilities, consumers, transitioning from institutions to the community with necessary supports and services. The shortage also impacts consumers and elders seeking to remain in the community and avoid nursing facilities. The baby boomer generation is poised to swamp nursing facilities and will demand community services.

The Bureau of Labor Statistics, U.S. 001929 106 , March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Department of Labor, in the latest national occupational projections for the 2 006 through 2012 period, determined that demand for direct-care workers over the next decade, particularly in-home and community-based settings, will continue to outpace supply dramatically unless policy-makers and employers .work together to make these jobs competitively attractive compared to other occupations. Nationally, personal and home care aides are among the to ten fastest growing occupations with a 50.6 percent growth from 2006 to 2016.

The mean wages for PCAs in Connecticut in 2006 was $10.26. per hour. However, "PCAs are prevented from working more than 25.75 hours per week, making maximum pay 600 -- $264.19, functionally keeping them far below a minimum wage worker's earning $8 per hour for a 4 0-hour week equaling 32 0 per week.

Administrative Regulation 17b 262-593, section ten, the regulation that created the personal care assistant program, expressly limits employment of any given employee to no more than 25.75 hours per week. The program was set up so as to use state money to pay for PCAs but to ensure that the consumer remained the de jure employer of record. The intent of the state Department of Social Services was to avoid making either themselves or -the recipient of services responsible to provide workers' compensation coverage.

A Personal Care Attendant Home Care Workforce Council is needed to meet the workforce development demands of the future. We must begin now to validate the value of the work of PCAs and provide a livable weekly wage and workers' compensation benefits as a minimum. 107 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Thank you very much for your attention. It was a pleasure being here today.

SENATOR DOYLE: Thank you. Any questions?

Seeing none, thank you, Mr. Waterhouse.

Next speaker is Paige Flanagan, is Paige here Yep, Paige. Then Bertram Mcintosh, Nancy Smith, Maura McQueeney.

Paige.

PAIGE FLANAGAN: Good afternoon, my name is Paige Flanagan, and I am a personal care assistant,. I am submitting testimony in opposition of Raised Bill 6668, both as a person who works for people with disabilities as well as someone who advocates for people with disabilities.

Before saying anything further, I would just like to say for the record, I make well-above minimum wage, and I am able to work above the 25 hours because my employer chooses to give me something of a mechanism where I can work full time.

I have been employed as a personal care assistant since 2004. Every day I go to work knowing I make a huge different in my employer's life and that without me she would be unable to work, be independent and live a full productive life. I am dedicated to my employer in anything she may need, both personally and professionally. My employer i thriving and successful in her career as well as her personal life and does not need centralization of a system that already works well.

Personal assistants are why people with 108 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

disabilities are able to live at home, keep employment and participate in society as a whole. I am employed by the person who knows best what she needs in order to perform these functions. Persons with severe disabilities who live and pursue active lifestyles would be unable to find the support they need by an outside entity controlling a system that already is extremely functional. Unionizing personal care assistants is not in our best interest or the interest of our employers. Wages will increase to cover costs, and consumers will have less hours to work with. This is not helpful.

The creation of this bill will make it impossible for my employer to control her own personal assistants. I find this absolutely unacceptable. Our current system works. Please do not try and fix it. I ask that you vote in opposition of Raised Bill 6668 so we may continue using a system that works well for both employers and employees. I want what is best for my employer and me, and this bill is not the answer.

Thank you for the opportunity to share with you my concerns.

SENATOR DOYLE: Thank you.

Any questions from Committee members? Seeing none thank you very much.

Whoops, sorry. Representative Coutu.

REP. COUTU: I don't speak too often, so I'm sure ^ you didn't expect to see my arm up. I'm just curious. It seems that you're against this bill. Do you have any idea who would be backing it and what direction this came from or why -- 109 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

PAIGE FLANAGAN: Who would be backing the bill?

REP. COUTU: Yeah, where it came from and where the potential belief is that it would benefit you.

PAIGE FLANAGAN: I don't believe it would benefit me in any way, because I don't want to be on, like they say, the back-up list. I want to work just for my employer and my employer only, and I don't think that there should be anything that limits who she can choose as her personal care assistant.

REP. COUTU: Okay.

PAIGE FLANAGAN: That's her choice. She knows best what she needs.

REP. COUTU: Okay. And how many years has the company been in business, do you know?

PAIGE FLANAGAN: I've been her employee for five years.

REP. COUTU: Okay, five years. And how many fellow employees work with you? Is there ten of you that work for that company or --

PAIGE FLANAGAN: As far as my employer? How many does she have?

REP. COUTU: Yeah.

PAIGE FLANAGAN: About five.

REP. COUTU: Okay. So basically in your view, you're happy with the current structure CPA system --

PAIGE FLANAGAN: Absolutely. 110 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. COUTU: -- and your employer and you don't see a need to --

PAIGE FLANAGAN: No.

REP. COUTU: Okay, thank you.

SENATOR DOYLE: Representative Walker. One sec, Representative Walker.

REP. WALKER: Thank -- thank you. I just wanted to sort of piggy-back on what he -- what you were saying when you talked about being happy with your provider -- with your consumer. Why -- the bill that is before us would not interfere with you. working for your consumer, so that's why I'm confused why you're testifying against the bill. If it -- it doesn't hinder what you're doing now, it doesn't change the fact, it doesn't force you to work for anybody else, then I'm concerned -- I'm curious why you're against the bill.

PAIGE FLANAGAN: Well, it puts me on a list, number one.

REP. WALKER: No, you don't have to be on the list.

PAIGE FLANAGAN: Okay. I don't think the language in this bill is very clear as far as vacation time. I know if you have paid vacation -- who fills in, when that person's on vacation?

REP. WALKER: That would be -- that would be up to the consumer, so that's why I'm -- if you do not want to be on the list, you don't have to be on the list. If your consumer does not want to utilize anybody else but you, then that's -- everything is the same. If you have a -- vacation days with your consumer, then it stays that way. Your pay is the only thing that might change, because the pay is Ill March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

something that we are talking about making sure that everybody gets adequate pay to do the j ob.

But it would not hinder anything that you're doing now. It would not change anything. It would not jeopardize your job, it would not alter whether you had paid sick days with your consumer or anything. It would have no effect on you if you do not want to participate. So I'm curious why you're against the bill.

PAIGE FLANAGAN: If the wages go up, hours go down. For my employer.

REP. WALKER: If your wages go up, then --

PAIGE FLANAGAN: -- if wages go up, then the hours' going to go down and we're going to cover costs, and that's not going to be helpful to me or to her.

REP. WALKER: That also has not been concluded either. That's -- the idea that -- the whole issue about the wages is something that we're looking at to make sure that there's a balance. But the amount of hours and everything would not go down, okay?

PAIGE FLANAGAN: Okay.

REP. WALKER: Thank you.

SENATOR DOYLE: Thank you. Any other questions from the committee? Seeing none, thank you very much.

Next speaker is Bertram Mcintosh, and then Nancy Smith, Maura McQueeney and Pat Tremblay.

Is Bertram here? Yes. 001935 112 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

BERTRAM MCINTOSH: Good afternoon, Chairman Doyle and members of the Human Service Committee. My name is Bertram Mcintosh, and I am a PCA. I just want to just state that I am also a CNA, certified nursing assistant. I currently work for a nursing home in the East Windsor area, so I'm on the other side of the coin as well to see how the residents are treated and how they're cared for in a facility-type setting.

I'm accustomed to working with the consumer who are elderly, who have Alzheimer's, Parkinson's, dementia, all sorts of physical restrictions. I currently/ as I said before, work in a nursing home, but I've also worked in home health -- for home health care agencies, doing hospice is also, and private duty.

I signed up to be on the PCA registry, I have yet to date to receive a phone call for actual assignment. This type of work isn't for everyone, but I, personally, love it. Having helped care for people in nursing homes and in their own private home's I've been able to see the broad spectrum of types of consumers and their needs. To me the home provides the ability for an individual to have privacy, their own independence, and a high level of dignity. It's easier in the home to make adjustments' for the individual, to put them in the chair or the equipment that best suits their needs for the purpose of safety measures.

I think the PCA Quality Home Care Council is long overdue. Many of us that signed up to do work under the PCA waiver or other waivers have so many specialized skills. I know we're only required to have a CPR certificate, but the current registry doesn't effectively 113 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

connect the consumers with the best (inaudible) or PCAs. I've seen some people that have been institutionalized when they could have remained in homes if they had the right match of a home caregiver. I believe strongly in keeping people in their familiar surroundings.

Home care is growing. As a direct care •provider, I can't sit back and watch this happen anymore. I want to stand up with the other direct care providers and consumers to ensure that they receive the highest quality of care that they deserve. There are so many people in the home that need qualified PCAs; there are so many qualified PCAs that want to do the work. They won't find each other until we put a system in place that allows consumers, families, advocates, and PCAs to work together to bridge the gap. Please help ensure that the consumers receive this quality care by passing the Quality Home Care Council Bill, House Bill 6668, section two. Thank you.

SENATOR DOYLE: Thank you, any questions? Just a minute.

Any questions? Seeing none, thank you very much.

BERTRAM MCINTOSH: Thank you.

SENATOR DOYLE: Next speaker is Nancy Smith. Is Nancy Smith here? Yes. Okay, Nancy. Then we have Maura McQueeney, Pat Tremblay and then Edith Karsky.

NANCY TRAWICK-SMITH: Senator Doyle, Representative Walker, members of the committee, my name is Nancy Trawick-Smith, and I am the director of Community Companion and Homemaking Services. 114 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

We're a not-for-profit companion homemaker services in Willimantic. I am also a member of the Board of Directors of the Connecticut Homemakers and Companions Association, and I am testifying in support of Senate Bill 1085, An Act Concerning Homemaker and Companion Agencies and Audits for Vendor Fraud. And I'm going to be speaking to two elements of the bill: The audits and the proposed fee for companion homemakers transporting clients of the Connecticut home care Program for Elders.

Many of you are familiar with the DSS audits. Currently homemaker and companion agencies are currently audited by the Department of Social Services' Department of Quality Assurance to ensure the providers are not being paid for service that has not been provided or service that is not authorized. They're also looking for fraud. Auditors basically review documentation which, in our case, are the companion-homemaker time sheets of the employees providing the services. They check to make sure that the service performed does not exceed the service order by the program case managers, that the time sheets are properly signed by a client or caregiver, and the activities performed are the activities ordered.

Because they can't review all of our documents they take a sampling of a hundred and they find an error and then they -- what we have issue with is their method of extrapolation. Just to, kind of, give you an example, a six -- a one hour error which amounts to about $16.32 something like that, with extrapolation could easily be $3,200 for a moderate-sized agency like mine. For a large agency that could easily be 5 or 6,000 dollars. My last audit had a 15 minute error which is $3.50, became $800. That's what extrapolation does, 001938 115 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

essentially.

And you have to understand the nature of the errors. Perhaps it's an overservicing a client for a couple of hours because the dryer broke down and the homemaker forgot to call to get it authorized. It could be that a daughter, like you, Representative Walker, would, you know, walk in and sign the time sheets instead of the clients themselves, and nobody noticed that it was you, and then they would disallow that. So you have to understand, the nature of the errors are not fraud. These things are performed. These activities are performed, and we do pay the homemaker. for it even though they may miss a check mark or they make a mistake like that.

What this bill proposes is to have a margin of error of 10 percent. Right now, if you have a near-perfect audit like I did, you know, you could have --be paying back, you know, several thousand dollars. And if it's a large agency, there'd be very, very large extrapolations. So it's basically just to have a margin, of error. Also, they talk

about, in thist bill, the appeals process. Currently any appeal of the audit process goes to just another entity within the Department of Social^ Services'. This would allow the agency to' appeal the decision of the Department of Social Services to the Superior Court. This seems only reasonable considering sometimes we're talking about the Department of Social Services recouping tens of thousands of dollars from an agency.

Lastly this bill would establish -- that I'm speaking to, would establish a fee for the transportation services that'homemakers and companions provide, and I spoke to this at another hearing. For over a decade access 116 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

agencies for the Connecticut Home Care Program for Elders have requested that homemakers and companions transport clients to medical appointments, to hair appointments, and to the store. This would -- this bill proposes having an add-on fee to the current, to our current hourly rate for the transportation services. And I believe that it could be done in a budget-neutral way by reallocating some of the funds that are currently going to transportation services that are not transporting those clients and going to the homemakers and companions that are transporting those clients. And I want to thank you for listening to me, and if you have any questions --

SENATOR DOYLE: Thank you, any questions?

Representative Gibbons.

REP. GIBBONS: Thank you, Mr. Chairman. I'll be quick.

How would this margin of error of 10 percent work? So that if you were off in your documentation by fifteen minutes, how --

NANCY TRAWICK-SMITH: Yeah if it, if it's under 10 percent, then you're paying back the dollar per dollar amount, and you know --

REP. GIBBONS: I mean, what is under 10 percent? The error or the --

NANCY TRAWICK-SMITH: If your -- okay, if your error rate. If you get, say in high school terms, a 90 percent, then you are paying -- if they find that you overserviced by an hour, then you're paying back that hour. If it's over 10 percent then they would extrapolate. 117 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. GIBBONS: Thank you. I think that might be a good suggestion, one we can work on with DSS. Thank you. Thank you.

SENATOR DOYLE: Thank you. Any other questions? Seeing none, thank you very much.

And I'll just -- remind the committee we're going to have a committee meeting after this public hearing so, I'm not -- we're coming along, there's still quite a few more, but we will have -- because our deadline's on Thursday we're having a public hearing at -- committee meeting after this public hearing. There's nine bills so there's nine votes, so I hope you will stick around.

And I just would like to change -- it is my prerogative to change the order. Mr. Armand Legault is going to come up and speak just -- it's my decision, and I hope the other -- Maura will be patient.

He may need -- could you help him with -- Representative Winfield maybe there's that other mic right there. Maybe you can get that and put it right on his wheelchair there. That will make it easier so we can^make sure we can hear him. Perfect.

ARMAND LEGAULT: Can you hear me?

SENATOR DOYLE: Thank you, Representative Winfield.

ARMAND LEGAULT: Yeah, okay. My name is Armand Legault and, you know, Mr. Chairman and members of the committee, I am an employer of personal assistants, and I oppose HB 6668. section two, okay, the Personal Care Attendant Quality Care Workforce Council. I'm opposed to this council because they -- it's just one more council, okay, that's going -- that we're 001941 118 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

trying to create. And I feel that the personal care programs that are out there now may become, you know, costly. Okay, the programs have always been -- this particular, these particular programs have always been cost-effective home care versus institutionalized care. It's always been cost-effective. I feel that if this bill goes through it could change that and make it, you know, and make it much more expensive to do business in this state.

One of the reasons I feel is that the language has been erased but everybody's talked about it today, is that the union, you know, is trying to, you know, you don't want to unionize the PCAs, and even though, everybody's saying, that the language proposed is that -- and it got even erased, but if it were put back in, it would be for the fact that I'd still have-the ability to hire and fire on my own and have the ability to manage my own program. I feel that once the unions get involved in this council, which is just another council, okay, we have enough of these.

And Representative Walker you mentioned that you had a lot of problems with trying to figure out what to do with your father's aides and that kind of stuff. We have five independent living centers throughout Connecticut that they are there for the purpose of, you know, doing, you know, giving out information and showing people how to do things. So this would just be creating another, you know, another council, okay, that we already have, independent living centers.

To sum it up I just feel that it would be -- I feel that it would be extremely costly to change our lives, and if we have to revert 119 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

back to this management company that's going to, you know, help with these, you know PCAs and unionize them and all that, then what could -- what eventually would happen is that, I have enough trouble right now trying to figure out every day, you know, how -- who is going .to put my pants on in the morning and who's going to take them off at night? And add! on to this another council? It's just another layer, you know, that we have to deal with. And so that's why I am opposed to it. Thank you.

SENATOR DOYLE: Thank you, Armand.

Any questions?

Representative Walker.

REP. WALKER: Thank you for coming up and testifying. I know that it must be difficult to make the journey up here. Can I ask a question, how many PCAs do you have working for you now?

ARMAND LEGAULT: Five.

REP. WALKER: Five? Has -- are these the -- have they been working with you for quite some time?

ARMAND LEGAULT: No, it varies. The longest I've ever had a PCA was four and a half years.

REP. WALKER: Four and a half years?

ARMAND LEGAULT: Yeah.

REP. WALKER: And you found out about this program through the state, through the independent living center? How did you find out about -- 120 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

ARMAND LEGAULT: Well, no. I've been disabled all my life so I know all these programs from coming up, you know, and seeing them happen.

REP. WALKER: Do you work with the independent living center, or do you talk to some of the people there that go there for services? Do you provide counseling or some, you know, advice on how to work within -- with a PCA?

ARMAND LEGAULT: Well, I'll give you a little bit of a history. I've been in a wheelchair all my life. I worked for the State of Connecticut for 33 years. I retired as a tax auditor for the state of Connecticut --

REP. WALKER: Ah.

ARMAND LEGAULT: Yeah, now that I'm retired for over five years, I prepare taxes and usually, or emphasizing the different loopholes that people with disabilities don't know exist. So, you know, I deal with that, and I do some counseling. And I've also gone out and actually counseled people on how to hire and fire, how to write contracts for their PCAs. I've done all that little -- missions.

REP. WALKER: Well, thank you. Excuse me. So the -- your objection to this really is that you're comfortable with the system that you have now.

ARMAND LEGAULT: Yes.

REP. WALKER: Okay.

ARMAND LEGAULT: Yeah. I mean, the only thing I can see throughout this whole deal this morning would be that the union could, possibly, you know, force the government or the state agency to actually increase wages, 121 ; March 17, 2009 as/mjed HUMAN SERVICES COMMITTEE 10:00 A.M.

okay? And possibly benefits. But in the long run, I feel that, you know, we as individuals, if we'd all get together we could do the same thing without having a union.

REP. WALKER: Unfortunately, it hasn't happened yet.

ARMAND LEGAULT: Well, yeah.

REP. WALKER: Sometimes we just --we have to come up with different methods of trying to get people to see the light.

ARMAND LEGAULT: Yeah.

REP. WALKER: So, maybe all of us collectively we can help them see the light. Thank you for your testimony.

ARMAND LEGAULT: Okay. Thank you.

SENATOR DOYLE: Any other questions? Nope, and Armand I just want to clarify, you talked about preparing taxes and, you said loopholes, you said legal loopholes, yes?

ARMAND LEGAULT: Ah, yes, legal. Yes, please.

SENATOR DOYLE: Thank you very much.

ARMAND LEGAULT: Okay.

SENATOR DOYLE: Thank you, Representative Winfield for your help.

The next person up is Maura McQueeney, then Pat Tremblay, then Edith Karsky and Joe Stengo. And I appreciate Maura and other for letting Mr. Legault go ahead of you.

MAURA MCQUEENEY: Is it on? Okay. Good afternoon. 122 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

My name is Maura McQueeney, and I'm president of Masonicare Home Health & Hospice located in Wallingford, Connecticut, but we provide home care and hospice services throughout the community, throughout Connecticut and last year served 4,500 persons in the state of Connecticut. Today I'd like to speak to you particularly about section four of House Bill .1122, which addresses telemonitoring in the home and looks for Medicaid reimbursement for telemonitoring in the home and reimbursement under the home care for Elders Program.

I've brought along a telemonitoring unit this afternoon just to put something concrete in front of you and to make this idea less abstract. Last -- when we began this' program our program of installing telemonitors in the home, we started with about 30 telemonitors with a form of experiment to see if this would be an efficient technology to reduce home care costs, to reduce home health nursing visits to persons in their home. Since that time, since starting with 30 units ,we, in 2005 -- in 2008 we installed more than 500 monitors in persons homes throughout the state of Connecticut because we have found that we can detect problems occurring earlier for patients, report- them to the physicians sooner and thereby eliminate the need for emergency room visits and rehospitalization.

We're here to request your consideration of putting telemonitoring in a situation where it can be reimbursed by Medicaid. In our own agency we, rather than set up a dual standard of care where if persons presented with heart failure had Medicare as a reimbursement they would receive the telemonitor, however persons with Medicaid as a reimbursement would not receive the telemonitor, rather than putting up that dual standard of care, we have 001946 123 March 17, 2009 as/med HUMAN SERVICES COMMITTEE . 10:00 A.M.

subsidized Medicaid patients' telemonitors with charitable dollars in some part, sponsored by employees contributions to what we call a Quality of Life Fund.

Again, these funds are dwindling, charitable dollars are dwindling, interest on charitable dollars are dwindling. So we're looking for a subsidization of this proven technology for Medicaid patients rather than set up a dual standard of care.

So for today we'd just like to show you, basically, how simple the equipment is. These -- this equipment is generally drop-shipped to the patient's home, in some cases to the agency. It can be delivered by a home health aide or a nonlicensed person. It consists basically of a scale, primarily because we realize that weight gain in patients with heart failure -- and which, by the way, is the number one diagnosis for patients in home care throughout the country -- weight gain, increases in blood pressure -- the patient slips on a blood-pressure cuff, increases in heart rate as detected by a finger pulse oximeter or a finger pulse monitor, are very early signs -- very small changes in these is detected by a nurse on a daily basis, can be trended and reported to a physician much earlier than when the patient actually becomes symptomatic.

So, in many cases, patients don't even realize -- although they actually do realize that their weight has gained, they get a telephone call from a nurse who informs them of this. But then the nurse having seen -- noted a trend will notify the physician. He can recommend an intervention much sooner than when the patient would have any symptoms: Shortness of breath or rapid heart-rate or 124 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

chest pain.

SENATOR DOYLE: Thank you.

Representative?

REP. ABERCROMBIE: Thank you, Mr. Chair.

Good afternoon. Thank you for being here. I think this is a great idea. I think that as we move towards keeping our elderly home longer, I think this is going to be something that can be put in more homes. My question for you is, you have this program currently at Masonic, right? How many people are in the units that you use right now, and the monitoring, is it 24 hours a day?

MAURA MCQUEENEY: The monitoring is generally one time per day. The patient transmits at the same time every day so there's a standardization that occurs even in the application of the technology that is an improvement over a visiting nurse. If you send a visiting nurse out one --on Tuesday the visiting nurse may be there at nine, on Wednesday the visiting nurse may be there at 2 p.m., techniques can vary. In this way the vital signs are transmitted at the same time every day over the telephone wires, via satellite they are downloaded to a central station where a skilled nurse assesses the variances to parameters that the physician has prescribed.

And so once those parameters are exceeded the nurse will most likely follow -- she follows a protocol, and this is evidence-based protocol drawn from diseased management standards. She'll call the patient and ask the patient to retake their vital signs just to verify the finding that's out of order. Sometimes, 125 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

depending on the history of the patient and the knowledge that we have of the patient we may know -- or the conversation we have with the patient, we may know that they have intentionally withheld a medication and for that reason we're seeing a variance. We work with the patient to have medication compliance and over time if there's a trend of days that's when we will notify the physician and get some kind of recommendation either to change the parameters or to change the medication.

But interestingly, in order to keep patients out of the hospital and out of the ED, if a patient is experiencing symptoms in the middle of the night they can call us because we are 24/7-. The nurse answering the call can recommend that the patient retake their vital signs, and then the nurse has more information to -- as to advising the patient to whether they can maybe make a phone call to the physician or whether there needs to be a visit to the emergency room. So it can be taken multiple times during the day. It's generally taken one time a day.

REP. ABERCROMBIE: And how many units do you have right now that are using this program? How many are you monitoring?

MAURA MCQUEENEY: Right now we have 100 out in the community. We could go an awful lot higher, because right now we are really triaging some of the Medicaid patients. In best practice, my belief is that this should not be a question as to who has telemonitoring, who's on skilled home care, but who should not have telemonitoring. And generally those are patients who are only going to be on home care for a very short period of time or who have dementia and they can't really manage the 126 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

equipment. The best practice would be to have everybody on telemonitoring, have their vital signs taken, not have the visiting nurse go out, save that money, and have the trends reported to the physician. So we are triaging, we are rationing, if you will, based upon pay resources. We'd like not to do that, and we have subsidized with our charitable dollars, but that is the reality.

REP. ABERCROMBIE: So you're looking for this to be a covered expense under Medicaid at this point?

MAURA MCQUEENEY: That's right.

REP. ABERCROMBIE: And is there any -- is any of the stimulus money, do you think, available for this to start like a pilot?

MAURA MCQUEENEY: There may be some demonstration projects, but frankly, the demonstration has already occurred. There is already evidence mounting that this is best practice, and the stimulus package there is -- there are dollars for electronic medical records. I will say that we have a mechanism now to interface this data on a daily basis with our permanent electronic medical record. And the physician can then look into the medical record and see this information on a daily basis, so it's very efficient.

And in the long run it saves money. This costs about $100 per month. A nursing visit costs about $150 per visit.

REP. ABERCROMBIE: And how much -- you said it's $100 per month, that's for the monitoring right?

MAURA MCQUEENEY: That's for the monitoring and the 127 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

cost of the skilled nurse who's overseeing the vital signs and taking -- monitoring -- observing the protocol and notifying the physician on a timely basis.

REP. ABERCROMBIE: Does that also include the upfront cost of having this -.-

MAURA MCQUEENEY: Yes.

REP. ABERCROMBIE: -- unit put into the person's home?

MAURA MCQUEENEY: Yes. It covers the cost of the unit in the home.

REP. ABERCROMBIE: It does? So there's no up-cost -"- up-front cost for the elderly to have this put in their home. It's all included with that $100 -- Really?

MAURA MCQUEENEY: Right. The agencies do have to assume some kind of up-front cost, depending on the kind of vendor that they use, and the sophistication of the equipment. But once the agency is set up the ongoing cost is about $100 per patient per month.

REP. ABERCROMBIE: And are there agencies that you've already been in contact with throughout the state that are interested in taking this on?

MAURA MCQUEENEY: Several agencies are taking it on and have taken it on, on and at their own expense. They've either pursued grants or they've gone through their auxiliaries or they've gone'through some special funding to put this in, simply because they had -- in good faith, probably in about 2005, realized that the evidence was mounting that this was the best practice. 128 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. ABERCROMBIE: Well, I can say that someone from Speaker Donovan's office recently came down to get a -- to look at a demonstration on this. I think she came down last Friday and was very impressed by this whole program so, I'm hopeful that it's.something, that we can really take a look at and hopefully, implement as we go down.

So thank you, Mr. Chair.

MAURA MCQUEENEY: Thank you. Thank you.

SENATOR DOYLE:- Thank you.

Representative Walker.

REP. WALKER: I just wanted -- do you also do sugar analysis, too?

MAURA MCQUEENEY: Yeah, this is the blood glucose.

REP. WALKER: So you do have blood glucose on there, too.

MAURA MCQUEENEY: And then probably the -- you know, the number one diagnosis for home care in the United States is heart failure, and it also is the number one problematic discharge from hospitals. So it's a win-win for the whole health care system in that we can reduce rehospitalizations, the cost of rehospitalization, the nuisance of emergency room visits and then also reduce the cost of the care even in home care.

REP. WALKER: And you've been doing this for how long?

MAURA MCQUEENEY: At Masonicare we've been doing this since 2005/2006. 129 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

REP. WALKER: Have you started to see anything that has shown improvement? Maintenance, cost, anything like that?

MAURA MCQUEENEY: Our rehospitalization rates for Medicare patients who have heart failure has gone from 46 percent to 16 percent.

REP. WALKER: Wow.

MAURA MCQUEENEY: So, and this --

REP. WALKER: Is that in your testimony?

MAURA MCQUEENEY: I don't think it is.

REP. WALKER: Could you send us that?

MAURA MCQUEENEY: Sure.

REP. WALKER: Thank you. And you do a very good Vanna White. But it was cute, he was holding it up, and you're -- yeah, are you going to get on the scale, Brian?

A VOICE: This is actually the unit itself, the telemonitor.

REP. WALKER: I've seen some of these. I mean actually on the infomercials late at night, they've had some units like -- they've even had one that, you know, somebody says, There's somebody in my house, and they have -- they project it over and say, Get out of the house. I think that -- yeah, thank you very much.

MAURA MCQUEENEY: Thank you.

REP. WALKER: You're right. Get off the scale.

A VOICE: In my case, yeah. 130 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

SENATOR DOYLE: Thank you. Next speaker is Pat Tremblay.

A VOICE: I don't think she (inaudible).

SENATOR DOYLE: Okay.. All right. Edith Karsky, Edith is here. Then Joe Stengo, Dawn Luciano and Marghie Giuliano.

EDITH KARSKY: Good afternoon, Senator Doyle, Representative Walker, ladies and gentlemen of the Human Services Committee. My name is Edith Pollock Karsky, and I'm executive director of the Connecticut Association for Community Action, or CAFCA, which is a state association for Connecticut's community action agencies. Our 12 agencies are the federally designated antipoverty agencies, and we serve all 169 towns and cities in the state.

I am here today in support of Raised Bill Number 6639, an Act Concerning Community Action Agencies, and to offer some suggestions as to how the community action network can assist the state and its citizens at this very difficult time.

During previous budget crises our network has responded to the challenges presented and offered new ideas in providing much needed services in a cost-effective, dependable, and efficient manner. A couple of the examples are, under the Weicker administration the CAAs expanded its application intake and certification role from only serving the Department of Human Resources clients to serving all energy assistance clients, including those from the Department of Income Maintenance.

Under the Rowland administration when DSS 001954 131 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

offices were closed in some districts, the CAAs became the local site and acted as an intermediary agent and partner for DSS by taking applications for services and then faxing or delivering them to the appropriate state office, even providing transportation for customers to. offices.

With Commissioner Wilson-Coker, in 2003 and 2004, we further expanded our partnership in becoming the foundational partner in the Human Services Infrastructure or HSI, a customer-focused, integrated service delivery approach to ensure that clients who need services have the access and information to comprehensive services at a single stop. Our agencies also prepare customers for their initial and important meeting with a state eligibility intake worker for state services. As most of you on this committee know, in addition to the budget crisis, for the past several years there has been a crisis in timely state service delivery, with eligibility workers having caseloads approaching 13 00 customers per worker. I believe we all agree that this is unworkable and untenable customer/worker caseload ratio.

In today's climate we think that we can be of assistance once again. Here are some of the areas where community action agencies can provide services to reduce costs to the State: Preapplication assistance for major DSS cash programs and redetermination application assistance; utilization of energy assistance eligibility as basis for categorical eligibility for DSS programs, similar to Head Start eligibility being presumptive eligibility for HUSKY; preemployment services to provide individuals with skills and paperwork necessary to complete job applications; fiduciary for small CBOs 132 March 17, 2009 001955 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

utilizing a master contracting concept to lessen unnecessary and duplicative paperwork, increase timely payments, and act as a vehicle for pilot programs.

Our workers on the front line -- are on the front line in providing direct services, and thankfully, we have the information and expertise needed to provide comprehensive support to meet many of these needs. We are already providing many services in our single-stop centers such as heating and weatherization assistance services, credit repair and money management, free tax preparation and asset development, utility matching payment plan, food assistance, child care, and Head Start.

Our elderly nutrition, Meals On Wheels, and Homemaker Services for the Elderly helps keep them at home and out of much more expensive nursing homes. Our results-based reporting indicates -- indicates in the CAFCA annual report that was recently sent to you, that you cannot get a better return on investment than with the dollars spent in our network.

In a time of scarce resources it is very important for you to know what is being accomplished with state funds, and that makes results reporting crucial. I believe we're the only network in the social service delivery system in the state that can provide you with detailed reporting.

I would like to thank you for your understanding of the importance of our network. We are the Connecticut -- we are the federally designated antipoverty agencies, and your support for the work we do for our most vulnerable residents, your on-going support has been crucial to our successes in serving 133 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

our customers. Thank you.

SENATOR DOYLE: Thank you, any questions?

Thank you, Edith. No questions.

Next speaker is Joe Stengo, is Joe here? Okay.

Next, Dawn Luciano, Marghie Giuliano, John Beaman, Rafie Podolsky.

So, Dawn? Thank you.

DAWN LUCIANO: Good afternoon. I'm -- my name is Dawn Luciano. I'm a PCA and CNA, speaking on behalf of John Estes, Sr., a consumer and advocate who could not be here today because he is at his job helping with kids with disabilities integrate into the school system.

My name is John Estes, I am a person with a disability where I require the use of a wheelchair for mobility. I am 43 years-old. I am the director of the Disability Resource Network Inc. I have been on a PCA waiver program for over six years. In that time I have had over ten different PCAs, that I have had to hire them, train them, only to lose them to a higher-paying job that also provide benefits. This is a problem that puts a person such as myself in a difficult position.

I've had to miss work, that I've had family members come to my aid at a great cost to my family and friendships. My son had to leave college and move back home to be my primary PCA, from helping me shower in the morning to getting dresses and various other duties that in any other situation I would have not had my son doing for me. 134 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

My mother's my second PCA and is 67 years-old, but is the only reliable person I can count on to be there at all times. I believe that if the PCAs I had in the past who were reliable and trustworthy in my home, would have been offered benefits and equal pay, then they would have not left my -- left me for jobs that provided benefits.

As I said earlier, I am the director of a Disability Resource Network. I employ ten people who count on me to be at work every day. I also assist other persons with disabilities to get on the PCA waiver program. Many of them suffer the same hardships when they lose their PCAs to better jobs. Some become stuck in bed for days at a time. They have no one to prepare meals for them or even check on them to see if they are okay and taking their proper medications. They are at great risk to end up in the hospital or nursing facility, which would cost the state much more money than paying for benefits or higher wages to PCAs.

If our PCAs were able to have a voice through the workforce council, I believe there would be a better database for PCAs that would be able to make this a career and provide backup when needed. I, along with other consumers that are on the PCA waiver program support our aides receiving higher wages and benefits through the quality workforce council.

Sincerely, John Estes, Sr.

Thank you.

SENATOR DOYLE: Thank you. Any questions from the committee?

Seeing none, thank you very much.

4 135 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

DAWN LUCIANO: Thank you.

SENATOR DOYLE: Next speaker is Marghie Giuliano. Is Marghie here? Oh, yes, she is. Okay. Then we have John Beaman, Rafie Podolsky and Eileen Adams.

Marghie?

MARGHIE GIULIANO: Good afternoon, Senator Doyle, Representative Walker, members of the committee. My name's Marghie Giuliano and I'm executive vice-president of the Connecticut Pharmacist's Association. We represent approximately 1,000 pharmacists in the state of Connecticut. Accompanying me today is Dr. Marie Smith, who is a pharmacist and the head of the Department of Pharmacy Practice, and a clinical professor at the University Connecticut School of Pharmacy.

And we're here today to strongly support Senate Bill 1087. An Act Concerning ConnPACE Prescription Drug Review. I want to thank Senator Doyle and Representative Walker for raising this bill. As the state faces unprecedented fiscal crisis, it is imperative that we think outside the box and find new and innovative ways to save precious state dollars while at the same time delivering quality health care to our state's most vulnerable population, the elderly. This bill will do exactly that by establishing a prescription drug review pilot program for certain ConnPACE patients. To optimize their drug regimen and improve therapeutic outcomes.

Pharmacists are uniquely qualified to identify and resolve medication-related problems, such as adverse drug events, duplication of therapy, drug interactions, polypharmacy and 001959 136 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

adherence issues. Pharmacists can then make recommendations to the patient's primary care physician or other health care provider and develop an action plan with the patient that can improve the effective use of their medication.

This drug review may remove unused and unneeded drugs from a patient's regimen as well as identifying conflicting medication therapies. The state will save dollars, and the patient's health will be better served by taking appropriate medications. Participants in the pilot project will meet in person with a licensed pharmacist who will conduct this drug review. The drug review is really just nothing more than a medication check-up, however it will encompass not only prescription medications, but also over-the-counter medications, herbal products, and other dietary supplements.

We have found that sometimes there's a lot of interactions with what patients are taking that are not recorded in their drug profile. Profile. Just as important as it is to have an annual physical, we feel it is critical that ConnPACE beneficiaries should receive an annual medication review. Many of our ConnPACE beneficiaries take around more -- around four or more medications and have two or more medical conditions. These reviews will help the beneficiaries better understand the use of their medications and enable the pharmacist to look for medication-related problems that may have a negative impact on their lifestyle.

Additional medication reviews should be performed when a patient transitions from a different care setting, such as from out of the hospital to a home. When they leave the 001960 137 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

hospitals a lot of their medications may have changed. Meds might be discontinued or added, and a patient is not really aware of that, so we feel that it would be beneficial for a patient to receive another medication review.

The pilot will demonstrate the long-term saving the state of Connecticut can obtain by insuring ConnPACE beneficiaries are on the most effective medication therapies possible. The benefits of cutting back unnecessary medications, improving the effectiveness of current medications and reviewing each medication for cost-effectiveness can result in very significant state savings. In some case we might recommend that additional -- we may need to increase medications, but savings will still be realized because the patient might have been hospitalized due to an undiagnosed or untreated condition.

I'll wrap up. I just want to mention that, you know, we've met with the Appropriations Committee to share cost-savings ideas, currently the state is spending $34 million a year for the ConnPACE wrap-around and Medicare Part D. If the beneficiaries enrolled in a plan that doesn't cover all their medicine, the state wraps around and covers those.

And we feel that, you know, in year one when Medicare Part D was first implemented DSS worked with the Connecticut Pharmacists' Association and the University of Connecticut to have the ConnPACE beneficiaries, their medication profiles -- a simple review done to get them into an appropriate plan. Well, the state hasn't done that in three years, and a lot of those patients have remained in those same plans, but the formularies changed for each of the plans. So what was good three years ago for a beneficiary, may not be valid 001961 138 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

for them now, may not cover all their medications.

So we feel that, you know, we can really help effect that and even make suggestions for maybe some cost-effective drugs so that it keeps the patient out of the doughnut-hole. We know that when patients reach the doughnut-hole they stop taking their medications. And the Appropriation's Human Services Subcommittee discussed this very issue with DSS representatives at their meeting last week, and we believe passage of this bill can have -- help alleviate the wraparound problems and save some dollars.

I just want to finish by saying that it's really time that we think outside the box and look at spending dollars on preventive therapies that can help improve the quality of care to the elderly populations. Thank you.

SENATOR DOYLE: Any questions from the committee?

Representative Walker, please.

REP. WALKER: I just wanted to thank you for all the testimony you've been giving us for the last couple of weeks and, a lot of the stuff that you suggested we have looked at. very carefully and are going to try and address some of them. Because you did provide us with some good savings.

Earlier some of -- I forgot, someone testified about this, the idea of having the pharmacists do the counseling. And the concerns they had was one, which pharmacy? Was it going to be at DSS, I forgot there was something else, but we tried to share with them the idea that we are trying to come up with a way of providing more preventive services for the clients,

\ 139 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M. i especially to try and help keep them independent, out in the communities. Do you have anything to say about that?

MARGHIE GIULIANO: Yes, actually, last time when we helped -- we, worked with DSS, we put together a network of pharmacists so, this service does not have to necessarily happen inside the pharmacy. So- this is not -- we're not using pharmacies as the basis for our network. We're using pharmacists. So the pharmacist could meet with the person anywhere, it could be at their home if they were unable to get to a pharmacy, it could be really anywhere. That is our plan.on doing this, on rolling it that way. And any pharmacist who meets certain criteria can be part of this network and provide a service.

REP. WALKER: I'think my concern was that we provide face-to-face and that, if we try and utilize people that they're familiar with, so that if they are participating in one of the local pharmacies, that to me, I think, would be a little bit more comfortable for many of the clients, because those are the people that they see at least once a month, and the familiarity will help them in connecting and asking questions and not shying off that. So that's the goal that I see, is providing them comfort and a way of getting more information about managing their meds.

MARGHIE GIULIANO: Absolutely, and we just want to make sure that it's, you know, conducive to the environment as well.

REP. WALKER: Thank you.

MARGHIE GIULIANO: You're welcome.

SENATOR DOYLE: Thank you. 140 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Any other questions from committee members?

Seeing none, thank you.

MARGHIE GIULIANO: Thank you.

SENATOR DOYLE: Our next -- next speaker is John Beaman.

JOHN BEAMAN: Good afternoon,. I'm in support of HB 668 -- 6668. I'm sorry. My name is John Beaman. I am a personal care assistant. I also work for people with developmental disabilities at the state level. I have firsthand experience as my son is Asperger's- Autistic. I have worked with consumers -- with a consumer for three years. He's an adult male with autism. He's verbal. He can read and write, and when I am with him I try to get him active and out in the community.

We do a drumming circle group with a not-for-profit organization called Drums No Guns Commission. I've also helped connect him with a program called STAR Riders which does horseback riding in the community. We go to movies or we go duckpin bowling. We do lots of hiking and walking.

As his PCA my role is -- and, well was and is, to be able to challenge him. While we would be doing activities together, I would talk with him to help discuss his problems. From time to time his mom would call me, and I'd come over to work out tough issues, like if he was having a crisis. In order to pay my bills and provide for my son's health needs and his counseling, and to be able to have an income I can live on, I applied and was lucky enough to get a job at the state level. After I had more stability at the state level I -- it was 141 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

harder to be flexible with my consumer's needs. My state job is very demanding, and I felt as though my consumer wasn't getting the proper care.

The main issue is that I felt as though I didn't have a resource to go to in order to have my consumer supported if I was ill, injured, or needed time off. I'm qualified. I felt as though my qualifications were good enough to work with this particular consumer. I'm certified in CPR. My main concern was that I wanted to make it as simple as possible for my consumer's mother to live her life and take care of as many things as possible for my consumer. But again, when I was ill or injured -- I do have personal health issues, she would have to find support from other areas. My main concern was just to be able to give him the best quality care I could. And as my -- as my job with the state demanded more of my time, I had to really push hours with this individual.

Basically, I just try to do the best job I could, and I was very compassionate, and like I say, my son is autistic. I feel people should have the right to know who's working with them and who's in their house and who's with their family members who have special needs. I provided as much information to my consumer as possible, my auto insurance information, various phone numbers for me to be contacted, but, again, at times I had personal issues that I needed to handle myself. I just wanted to be sure that my consumer had his needs met, and that wasn't always the case.

SENATOR DOYLE: Thank you.

Any questions from the committee? 001965 142 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Representative Walker.

REP. WALKER: I -- I'm sorry. How long had you worked with your consumer?

JOHN BEAMAN: Three years.

REP. WALKER: For three years?

JOHN BEAMAN: Yup.

REP. WALKER: And how did you get connected to your consumer?

JOHN BEAMAN: I was recommended through a caseworker that was working -- that was -- that had his program.

REP. WALKER: And are you paid through the consumer, or are you paid through the -- an agency?

JOHN BEAMAN: I was paid through a fiscal intermediary.

REP. WALKER: A fiscal intermediary? Okay. That's not an agency? No, okay. Thank you for your testimony.

SENATOR DOYLE: Thank you.

Next, I'll go out of order. Rafie -- just one second Ray. We have to call back Joe Stengo. We called him earlier. He wasn't here. Mr. Stengo and then Rafie, Eileen Adams, Brian Ellsworth and Gregory Allard.

Joe Stengo.

JOE STANGO: Good morning. Good afternoon as I should say. Excuse me. I'm here to testify, 143 March 17, 2009 001966 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

pardon me, on Bill 1122. In some private discussions that I've had with a number of you, your question to me was simply, do you have any ideas as to why we are so slow in moving people out under MFP? MFP one, that is. And the answer, quite simply as we had discussed is that part of the problem is the infrastructure which is why we have to set up the reinvestment account to try and support the infrastructure with higher reimbursements and, of course, expanding the labor pool.

What I brought to you today was a backup. 1122, which is not a bill that I asked to be proposed, certainly supports what we're trying to do, and if we want to quicken the pace of allowing people to get out of nursing homes we're going to have to support them in the community, and that's what 1122 will seek to do.

If you take a look at this piece that I printed out for you, this is -- DSS has a way of -- has a method of calculation. And what I did was I took that method of calculation and superimposed it, if you will, on the situation. And if you take a quick look at it, you'll notice that the cost of nursing homes, that DSS tells you, is approximately 68,400 per year. The state portion is $34,000. Now there's a net differential between home- and community-based services and nursing home care is $17,000 per year. What DSS is always concerned about is if we take somebody out of the nursing home then someone else is going to replace them in that bed, therefore increasing our cost.

Well, if you look at the worst-case scenario, we fill that bed. We still have a net savings of $11,115 per person. That doesn't sound like a lot, but if you actually go back to 001967 144 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

what we did last year with MFP and which everyone here supported, and that was to increase the number of people that we would ask to come home, to 5,000 people, take that number, multiply it by 5,000, we've got a gross total of $55 million.

Under section one of the bill, it refers to a higher reimbursement rate. Now, we do have, under Mr. Obama's administration, some monies coming back to the state, and I realize that what we want to try to do is cover the deficit. But I also would put forward to you, using it as a stimulus package, how do we do that? We take a piece of that -- of those dollars that are coming in, we put it into a higher reimbursement rate so that we can indeed handle these people coming out of the nursing home. A lot of the small businesses are reluctant to take them because, quite frankly, they're losing money because we haven't been able to increase their reimbursement rate.

As well, going back to the last portion of the, Bill 1122. it goes back to the original language that we asked for last year, and that was that we take the savings on each individual person that is transitioned from a nursing home, plus the federal match, and we take that money alone and put it towards the infrastructure; therefore, we don't have to place an extra burden on the General Fund, just simply, that using the monies that are now freed up. That's only going to be for a portion of time, obviously, so eventually that savings will go back to the General Fund, but by doing so we also increase the support system by expanding the labor pool.

To bring 5,000 people home and the very -- at the most conservative estimate, we could add 001968 145 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

10,000 new jobs to the health care system at a higher paying rate than what it's currently doing. As well, we're going to increase the -- one of the transportation system, of course create technology, which is all in the bill, by the way, the original bill. All that would take place adding more jobs into the system as well.

The savings is there, but what we need is that initial investment into the system to create stimulus that will, you know, have the effect on it. Thank you.

SENATOR DOYLE: Thank you.

Any questions?

Representative Walker?

REP. WALKER: Thank you, and thanks for your testimony. The difference between the regular Medicaid match and the stimulus match are -- is not being included in any of our funding --

JOE STANGO: I understand that.

REP. WALKER: -- this year. Or next year. It's being put into the General Fund altogether. So what we have to do is figure out how to work with what we have in front, and that's part of the problem that we're having with any shifts that we'' re making or trying to attempt to make because we can only use the -- what -- we can only use a portion of the funding to try to make any adjustments for changes.

I think your reasoning is extremely rational. I think that's what we want it -- to direct everything towards, but the problem is we're working at a negative -- with a negative line, and that's the real problem. And making that 001969 146 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

shift means that we have to lay out a portion of money before we can actually make the shift and receive the benefits that you point out. So that's going to be an extremely hard thing for us to get across to a lot of people.

JOE STANGO: My only concern with that, Representative Walker, is that under the Mitigation Act, we've increased the number of people that we want to bring home this year, actually by June, to 14 0 people. We've so far brought home four, to the best of my knowledge. We've got a long way to go before we get to 140, and there are a lot of folks within the system who are actually questioning that number simply because of the way the support system stands.

So there is a, you know -- you're all great because the fact is you guys have to make a, you know, a list of priorities. And my hope is that you're going to put this right at the top of the list because the reality is we're not just talking about health care. What we're talking about is putting people away for the rest of their lives in an institutionalized atmosphere where they don't really want to be.

And there's a whole lot of difference between, you know, forgive the analogy because I'm not quite sure what to use, but there's a whole lot of difference between putting dollars into the budget to fund ABC, and now if we don't have enough dollars there, how badly is going -- is someone going to suffer versus keeping somebody warehoused in an institution. There is a liberty issue here, and I would ask you to keep that at the top of your priority list.

More importantly, when you speak to your leaders, make sure they know and say this 147 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

amount of money needs to be done, whether it be 5 million or 10 million or whatever you folks come back with, but it needs to be done in order to get this program up and moving for us to get those savings. And to get the freedom that these people deserve.

REP. WALKER: I think it makes a world of sense. You're preaching to the choir --

JOE STANGO: I know it.

REP. WALKER: -- because we -- I mean, to solidify health care not only because it saves money but it also gives people dignity --

JOE STANGO: Absolutely.

REP. WALKER: -- is something, to many of us, we are there, but when we talk about -- I mean, and this is literally expanding a program, and anytime we use the word "expanding" in most of our -- if you just watch CTN whenever we use the word "expand" --

JOE STANGO: Bad word.

REP. WALKER: Very bad word. And even when we say solidify that's almost a bad word, so I think you're exactly where we need to be. And we need to do this not only for our elderly, we also need to do it for our children. But unfortunately -- thank you for your testimony.

JOE STANGO: I may just add one thing before I leave you. All I'm asking for is, get it out of this committee, let it go to Appropriations and allow us as advocates to do our work at the Appropriations Committee. That's all I want.

SENATOR DOYLE: Thank you, Senator Kane? 148 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

JOE STANGO: Oh, sorry.

SENATOR KANE: Thank you, Mr. Chairman. Joe, I don't have a question, I just wanted to make a comment. I appreciate you being here today and all that you do. Obviously, you were one of the driving forces of the Money Follows the Person Bill, and I just wanted to say thank you.

JOE STANGO: Thank you, Senator.

SENATOR DOYLE: Thank you, any other question --

JOE STANGO: Oh, sorry, Senator it's important to note that, you know, you've been a great help especially back home in our district on this issue, but I want to make you fully aware, because you are my Senator, that we did create lofty goals last year and you were a huge supporter of that, but the reality is we've only brought home four people. There are a waiting list of people who want to get out.

And I said this privately to our chairs, I learned something that I did not know, and that was that the Department of Corrections, when they have a case that needs long-term care, there's no wing in the penitentiary for them. There's no area that they put them in within those buildings. They send them to nursing homes. It's very disconcerting to me, anyway, to know that my mother spent the last five of her -- five years of her life in the same fashion as perhaps a common criminal. We need to change the culture. This is a hard time. But what I need here is your leadership to go back to your caucus and say, we have a priority, and even in bad times we need to make sure liberty is at the top of the list. Thank you, Senator. 149 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

SENATOR DOYLE: Thank you.

Any other questions? Seeing none, thank you.

Next up is Rafie Podolsky. Thank you for your patience Rafie. Eileen Adams, Brian Ellsworth, Gregory Allard and Brian Anderson. Rafie?

RAPHAEL PODOLSKY: Senator Doyle, members of the Human Services Committee, I'm Raphael Podolsky. I'm a lawyer with the Legal Assistance Resource Center. I'm here to speak in favor of Senate Bill 1080 -- I'm sorry, „1086 which deals with Social Security dependents' benefits. I think my role at this point is I would like in some ways to reexplain the bill. I was here earlier when you took testimony from another witness who supported it. This is a bill about noncustodial parents who are permanently and totally disabled and who are receiving Social Security and their children. What I want to stress to you is this is a procedural bill, it's not a substantive bill. Right now under the Child Support Guidelines when a noncustodial parent is -- has a child support order and Social Security is paying benefits directly to the child, those payments count towards meeting the child support order.

The bill codifies that, but that's not a change. That's the status quo that's what the law is now. The -- what the bill does is, what the underlying purpose of the bill is to do two things. Number one, to increase the likelihood that the child will get dependents' benefits, and number two, to accelerate the crediting of those benefits to the noncustodial parent. That's really what this bill is about. It is not about changing what 001973 150 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

the law is on who gets credit for what.

The underlying problem is that child support orders are typically entered against the noncustodial parent when they're working, they have a job. They -- in the cases we're talking about here, that person becomes totally and permanently disabled, which is what you have to be in order to get Social Security disability payments, that parent is going to end up with an arrearage that grows and grows because the support order is still the same, and until such time as somebody gets into court and changes the support order, that's the order and that's the liability even though that may now be 60, 70, 80, 90, 100 percent of their total income.

What this bill does is, is it says, essentially two things should happen. One has to -- the first is that when Support Enforcement finds out about the fact that a person has become -- is eligible for his Social Security disability benefits, it's going to do two types of things. Number one, it's going to determine whether or not those -- the child's dependents' benefits are, in fact, being issued by Social Security and going to the child. And number two it's going to initiate a review as to whether there is a -- because this person is no longer employed, whether the order should be modified.

If it -- if it determines that the child is getting benefits, then the bill says within 30 days start crediting those benefits to the noncustodial parent. If the state cannot figure out, does not know, then it says notify the custodial parent that the child has become eligible and apply for those benefits and let us know what the end result is. That's essentially what the bill does, and I think in 151 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

looking at the bill as I was sitting there I think that the bill could benefit from some redrafting that might make some of this clearer.

And the suggestions I would make, and I can put this in writing to you afterwards, are number one, change the sequence of the sections, because I think we -- they can be put in an order that, certainly in retrospect I think could.be more logical. Sort of following what I just said, number two, you don't need Subsection H at the end, because it -- you're really not ordering the custodial parent to do anything. You're really asking the custodial'parent to do certain things. There's no enforcement mechanism if they don't, and I think the bill would benefit from the change of actually making clearer that it's in the nature of a request, not in•the nature of an order. And I'd be happy to get you some language on that. But, to me the most important thing' was to make sure the Committee understands that those payments now are already entitled to be credited under the existing law. All we're doing is we're codifying that so that you can then say, what happens next?

SENATOR DOYLE: Thank you, Rafie. First of all, Rafie, do you -- what do you think of the comments of the Judicial Department? Are you aware of those or no?

RAPHAEL PODOLSKY: I haven't seen the (inaudible)

SENATOR DOYLE":- Yeah one of the issues is what --

RAPHAEL PODOLSKY: (Inaudible).

SENATOR DOYLE: Yeah, they alleged they may lose some federal funds because of this. 152 March 17, 2009 as/med HUMAN SERVICES -COMMITTEE 10:00 A.M.

RAPHAEL PODOLSKY: (Inaudible)

SENATOR DOYLE: So did you --on this bill you met with him?

RAPHAEL PODOLSKY: (Inaudible).

SENATOR DOYLE: Okay. Okay.

RAPHAEL PODOLSKY: (Inaudible).

SENATOR DOYLE: Okay.

RAPHAEL PODOLSKY: (Inaudible).

SENATOR DOYLE: Thank you. We have our deadline on Thursday so if you would -- if you can get us your comments I mean I --

RAPHAEL PODOLSKY: (Inaudible).

SENATOR DOYLE: -- yeah, I'm not sure I -- we can even get it by the deadline, we may have to deal with it later on, on the floor if we get there. But I can get you a copy of the Judicial Branch comments if you'd like to see them also to get their take on it.

Any other questions from the committee members? Seeing none, thank you, thank you for your patience.

Thank you for your patience, Rafie.

Next speaker is Eileen Adams, then Brian Ellsworth, Gregory Allard and Brian Anderson. Hello, Eileen.

EILEEN ADAMS: Good afternoon, Senator. This testimony is in support of Raised Bill Number 1085, which contains proposed changes to an 001976 153 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

act concerning homemaker and companion agencies. This legislation will benefit the state's elderly population in the Connecticut home care program for Elders by paying a fee for transportation services, defining procedures for vendor audits conducted by the Department of Social Services, and establishing personal care assistants services in the Home Care Program.

As providers contracted with the state's access agencies to service clients in the CHCPE, we have been driving our clients for many years without the ability to charge for those transportation expenses. This is a vital service to an aging population who can live independently but can no longer safely drive themselves. This program enables them to get out of their homes for shopping, socialization and religious services, plus ensuring their health by giving them access to sick and wellness appointments, medical testing and treatment.

Through their own research at our request, the DSS learned that the CHCPE utilization of their contracted transportation vendors is significantly below other DSS programs. Case managers have known for years that having the clients' companions drive them to appointments is more convenient, more reliable and less disruptive. Providing transportation is a priority for case mangers when selecting an agency for referrals.

So while there are many benefits to these services, the employees use their own vehicles and pay for their own fuel and maintenance expenses. Providers may bill only for the time they are with the client, but there is no provision until now with this legislation, for the homemakers and companions to be 154 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

compensated for their driving costs.

Earlier this legislative session this committee approved Bill 853, which limits the liability for homemakers and companions who drive their clients. By doing so, you have acknowledged that they are driving clients, and it would be unfair of you to ask them to continue to provide this service out of their own pocket. You should approve this amendment that establishes a fee for transportation services of no les than $8 per trip from the client's home to be paid in addition to the hourly rate of the companion.

This bill also addresses fairness and defines the procedures for the DSS compliance audits. The amendments request a two-year time limit on the audit period and that the extrapolation projections will not be used in cases where clerical errors, not fraud, result in overpayments or underpayments under a 10 percent error rate. In addition, a provider has the right to request a review of the findings and also the right to appeal a final decision to the Superior Court. While audits are necessary for the integrity of the program, these provisions ensure that the state's vendors have the right to due process, and you should approve these amendments.

Another new section in this bill adds the category of personal care assistants to the CHCPE. This is another service level being performed by homemaker and companion agencies for their private pay clients, and this section would expand services for the benefit for the home and community-based waiver programs recipients.

SENATOR DOYLE: Thank you. 155 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Any questions in the committee? Seeing none, thank you for coming and thank you for your patience, Eileen.

EILEEN ADAMS: (inaudible)

SENATOR DOYLE: Yes.

Next up is Brian Ellsworth, then Gregory Allard and Brian Anderson.

Brian Ellsworth.

BRIAN ELLSWORTH: --the CEO of the Connecticut Association for Home Care & Hospice. I'm here to speak about two bills, SB 1122 and SB 1085. Regarding SB 1122, I would just, kind of, echo the comments of the other providers that have spoken before me and stress that the Medicare issue, the threat from -- to home care coming from the Medicare program will turn out to be, potentially, a very serious threat to Medicaid because home -- because Medicare is really subsidizing the inadequate Medicaid rates, and that is an issue that I think needs urgent attention.

I also want to point out that the bill contains a proposal for Medicaid coverage of flu shots and as well as telemonitors and these are both, kind of, common sense preventative care proposals that are working in the Medicare program, and we have all the infrastructure, as you saw, on the telemonitors, same thing applies to flu shots. We have the infrastructure in place, and it would be very efficient for us to increase our penetration of both flu shots and telemonitors.

Right now I would estimate that about,• between a fifth and a third of the home care agencies 001979 156 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

provide telemonitors, primarily to their Medicare patients, and we think it makes sense to do that for Medicaid as well, and the Governor did propose it in her budget and assigned a savings to it. So there's one that you can pass out with savings attached.

Let me shift over to SB 1085, our -- our experience regarding DSS audits has dramatically improved since 2 005 when the General Assembly passed legislation addressing several components of the -- all audits including the underlying legislation of that bill. And we want to really commend the Department of Social Services and recommend to our colleagues that they work with them, identify the issues, get them to provide education and go on the record with what the issues are. That being said, I would also say that we're concerned that there's a budget deficit and that the audits may be turned back on as kind of a way -- an easy source of financing. And the use of extrapolation can create a lot of concerns because it's a way that they can recoup monies from agencies very quickly and without a lot of due process. So, I would recommend continued vigilance on the audit issues and to look at the $150,000 threshold in the bill and to provide more due process for audits.

Finally, I just want to briefly address section two of the bill, regarding adding personal care assistants under the Connecticut home care Program for the Elders, my understanding of the intent of that proposal is that it is to create an agency model of a PCA, and this would open up the home care program for the elders to provide hands-on care by a nonlicensed entity. Connecticut has historically rejected that approach. I think maybe it's time to take a look at it. 001980 157 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

We need to strike a balance between cost and quality because, if we created a less-regulated approach and then heap on all the requirements, you just end up with the same cost structure. At the same time we need to protect our citizens. We would like to participate in that process in a deliberative way and would be happy to do so.

SENATOR DOYLE: Thank you.

Any questions from the committee? Seeing none.

Thank you very much, Brian.

BRIAN ELLSWORTH: Thank you.

SENATOR DOYLE: Next speaker is Gregory Allard and Brian Anderson.

You're not Gregory.

PATTY SHEA: Mr. Chairman --

SENATOR- DOYLE: You're not Gregory.

PATTY SHEA: If it's okay with you, I've been asked to stand in --

SENATOR DOYLE: Sure.

PATTY SHEA: -- for Greg Allard.

SENATOR DOYLE: Yes.

PATTY SHEA: Happy St. Patrick's Day. I'm here on behalf of the Association of Ambulance Providers. My name is Patty Shea, I am a lobbyist. I know there was some confusion, but you do have written testimony from 158 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

President David Lowell. I'm testifying today on Senate Bill 1113 on sections three and four of the bill. Section three adds some transparency. Right now the process is such that those brokers who are brokering transportation for the Medicaid population are also doing some contracting with private insurance companies, and some of the payments that we receive, we're not clear who the payer is. And we're concerned about that. So we'd just ask for transparency up front.

The second issue, in section four we see that there can be some increase efficiencies in the system. There are certain transport that -- there are a lot of hoops that we have to go through to get payment. So the bill before you has a list of those types of transports where we ultimately get paid, but where we have -- where we think we can create some efficiencies and not have to have that prior authorization. A lot of times a hospital will get authorization to transport a patient interfacility, and we'll do the transport without us also having the authorization, and we get it later on and it ultimately is paid. So it's -- this is to create some efficiency in the system. And I'll entertain any questions.

SENATOR DOYLE: Thank you. Any questions?

Seeing none, thank you.

PATTY SHEA: Thank you very much.

SENATOR DOYLE: And the last speaker signed up is Brian Anderson. I don't see Brian Anderson, though. Are there any -- anybody else in the room willing to speak?

You want to speak, gentleman? Come on up. 159 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

Representative Winfield, could you help this person again, maybe, with the microphone? You have a new task, Representative Winfield.

A VOICE: Put it right here.

CLAUDE HOLCOMB: My name is Claude Holcomb. I live next to Pine Place, Hartford. I am here about the Bill 6668. I have been hiring personal assistants to support me at home since 1983, when I moved out of the nursing home. I've also been involved in the civil rights movement for people with disabilities for 26 years. I've supported unions in their efforts to create a level playing field between employers and employees.

Yes, attendants need better pay and health insurance. That is not up for argument. However, I believe un-unionizing home care workers will be a bad choice for the state, the disability community and the elderly. Home care services are based on one-to-one relationships. Un-unionizing attendants would make it more difficult for a person with a disability to fire someone for abuse or neglect. Abuse or neglect perpetuated by an attendant against a person with a disability in their own home would most likely happen without the presence of witnesses. It would be one person's word against another's, and the union would advocate for the attendant.

Other states have un-unionizing attendants and this is happening. If I want to terminate someone now, I need a good reason. But if attendants are un-unionized, I would have to defend my decision and make it before the employee and the union steward, and my care would cease while the case was being resolved. Also, if my care is stopped for a strike or to 160 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

resolve a grievance there, is no one to come help me like there is for people supported by an administrative structure such as nursing home or group home.

Our independence works because we are on an equal footing with the people we hire to provide our support. Allowing attendants to unionize puts us back into a medical model of support. I am fearful that the unionization of attendants will also result in an (inaudible) of available hourly supports. Unionization almost always results in individual workers receiving more hourly pay, however, the people who require those services might find themselves having no increased allotment of funding to pay for these pay increases.

I appreciate the opportunity to bring these issues before you. I believe people in the disability community in Connecticut and Legislators who support this bill really need to think about unionization for attendants because there have been reports of real problems from disability communities in other states, like Kansas and New York. I would be happy to provide more information on these problems to you. Thank you very much.

SENATOR DOYLE: Thank you Claude, for testifying and being so patient.

Do we have any questions from our committee?

Seeing none, thank you very much. Thank you for your patience and good luck.

The only other person I have signed up is Brian Anderson. I don't see Brian. Anybody else in the room wish to testify? 161 March 17, 2009 as/med HUMAN SERVICES COMMITTEE 10:00 A.M.

All right. (Inaudible) A motion to adjourn or terminate -- terminate the public hearing. So moved. Is there second? All in favor signal by saying aye --

SENATOR DOYLE: Aye. Thank you.

And now we're going to, do you want to -- okay we'll recess. We're not going to recess. We're going to convene the committee meeting at three o'clock. Okay, gives the opportunity to take a break and screen the bills. But three o'clock sharp we'll convene our committee meeting. Thank you.