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Connecticut's community health centeis aie the founuation of caie foi many
Neuicaiu membeis offeiing seivices in aieas of the state that aie not attiactive to
othei pioviueis, connecting to othei community seivices vital to health outcomes,
anu offeiing affoiuable options to uninsuieu anu unueiinsuieu state iesiuents. They
must be a pait of any plan to iefoim the system. To ensuie clinics aie stable anu
sustainable, theii financial inteiests must be piotecteu in any iefoims.

Community health centeis aie fai bettei oiganizeu anu integiateu than the
fiagmenteu caie available to Neuicaiu consumeis outsiue clinics. Theie is veiy little
eviuence of oveitieatment foi patients within clinics. It is likely that most
oveitieatment foi clinic patients occuis outsiue the clinic, wheie FQBCs have little
contiol. Pievention takes time to geneiate savings. Even sophisticateu, fully
cooiuinateu AC0s in othei states aie having tiouble geneiating savings.

It is veiy uifficult to secuie appiopiiate specialty caie foi Neuicaiu consumeis.
Conceins have been iaiseu that if clinics have a financial uisincentive to iefei, anu
moie impoitantly, auvocate to get specialty caie foi consumeis, access to necessaiy
caie may uecline fuithei.

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What monitoiing anu piotection is envisioneu to ensuie appiopiiate access
to specialty caie.
Bow will clinics' investments in pievention be ieimbuiseu given that shaieu
savings may not be iealizeu foi yeais.
o Will SIN cieate a sepaiate quality-only incentive pool (as in health
neighboihoous pilot) to ensuie that pioviueis can iely on a ietuin on
investments in pievention.
o Bow will the state aujust foi chuin in the single-eligible Neuicaiu
population. Bow will clinics be compensateu foi pieventive caie
pioviueu to membeis who leave the piogiam oi theii geogiaphic aiea
befoie the savings aie iecoveieu.
Bow will the state monitoi foi cheiiy picking oi steeiing consumeis to
community pioviueis baseu on likely savings potential anu iisk aujustment.
Will SIN commit to maintain cuiient clinic ieimbuisement levels foi caie,
anu aujust foi inflation, to ensuie that shaieu savings uo not uisplace othei
funuing anu cieate no incentives to ueny neeueu caie.
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Will SIN make a commitment not to tiansition to uownsiue iisk in the
futuie.
What foim will unueiseivice monitoiing take. Will penalties be meaningful.
Bow will SIN monitoi foi netwoik auequacy - incluuing specialists.
Bow will SIN monitoi foi unintenueu consequences such as ieuuctions in
safety net capacity, anu maintaining consumei choice.
Bow will SIN aujust foi exteinalities in the calculation of shaieu savings, i.e.,
a bau flu season, expensive new Bepatitis uiugs.
What will be a faii uistiibution of savings between pioviueis who geneiateu
the savings anu the state. NcKinsey estimateu foi Neuicaiu in the SIN plan
that Su% of savings woulu go back to pioviueis.
Will theie be enhanceu liability piotection foi pioviueis. Reuucing caie,
even inappiopiiate caie, may place pioviueis at iisk.
Bow will SIN monitoi maiket consoliuation anu piice incieases. What is the
state piepaieu to uo if pioblems aie founu.
Bow will SIN hanule conflicts of inteiest, coipoiate ties uiiving caie anu
iefeiial patteins iathei than quality.
The B0SKY BN0 piogiam was iolleu out by county ovei only a few months
with a gieat ueal of uisiuption anu uelays in caie. Is theie any plan to pilot
this piogiam anu fix pioblems befoie expanuing to 2uu,uuu people.

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111S waiveis put the state at substantial financial iisk by capping feueial
ieimbuisements. Because 111S waiveis iequiie feueial buuget neutiality, as a
conuition of appioval, feueial matching funus aie cappeu ovei the life of the waivei.
i

If health costs anuoi Neuicaiu eniollment iise, the state woulu have to pay the full
costs above the feueial cap. 0nfoitunately, those things usually happen at the same
time the economy is bau anu the state buuget moves into ueficit.

Neuicaiu 111S waiveis have been histoiically useu by states to covei chiluless
auults. With passage of the Affoiuable Caie Act most states have tiansitioneu those
gioups to a Neuicaiu expansion categoiy.
New 111S waivei applications aie coming fiom states that uiu not expanu Neuicaiu
-- to use piemium assistance anu woik iequiiements foi low income, chiluless
auults to buy coveiage in the insuiance exchange iathei than expanuing Neuicaiu.
0nfoitunately, uue to a legislative staff eiioi, Connecticut state statute incluues a
piovision authoiizing piemium assistance, so legislative appioval woulun't be
neeueu to implement that.

SIN leaueis have stateu that the intention of the 111S waivei is naiiow anu to covei
new tieatments that aie not coveieu now. Bowevei once in place, the waivei coulu
be useu by futuie auministiatois in ways that aie not as intenueu.

The SIN Neuicaiu biief gives thiee goals foi the 111S waivei - funuing Community
Bealth Woikei caie, pioviuing aii conuitioneis foi people with asthma, anu
coveiage of auaptive equipment. Bowevei, it appeais theie aie othei, less iisky,
quickei ways to achieve those goals without an 111S waivei.
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CNS iecently changeu iegulations to allow coveiage of caie pioviueu by
community health woikeis
ii

0nuei the EPSBT piovisions, aii conuitioneis aie alieauy coveieu foi
chiluien on Neuicaiu wheie meuically necessaiy
A quick calculation finus that pioviuing aii conuitioneis to 7S% of auult
Neuicaiu consumeis with asthma (an unlikely event), woulu cost only $2.1
million moie with all state funus than with Neuicaiu coveiage
iii

Past litigation anu CNS iesponse has confiimeu that Neuicaiu coveiage of
auaptive equipment even foi auults is limiteu only by whethei a uevice is
meuically necessaiy anu is the least costly of equally effective uevices

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What piovisions can oi will SIN put in place to ensuie the cuiient vision foi
the 111S waivei uoes not change. What is the plan if spenuing in the
piogiam appioaches the feueial cap on ieimbuisements. Will state leaueis
make an enfoiceable commitment to finu funuing elsewheie in the buuget
anu piohibit:
o Piemium assistance
o Woik iequiiement oi othei baiiieis to coveiage
o Reuuctions in cuiient fee-foi-seivice ieimbuisements
o Futuie cuts in eniollment, i.e. cutting B0SKY paients fiom the
piogiam, expecting them to secuie coveiage in the insuiance
exchange insteau
o Futuie cuts to benefits oi coveieu seivices
What aie the piogiam goals of the 111S waivei.
o Bave state planneis fully exploieu othei, less iisky, ways to achieve
them.
o Please give uetails on cuiient pievalence of the intenueu piogiam
taiget pioblems, costs, utilization patteins, iueally by geogiaphy,
eligibility categoiy anu population
o Please give specifics on intenueu inteiventions, costs, capacity to
uelivei inteiventions (i.e. specialty oi tieatment availability)
o Please shaie eviuence of effectiveness of pioposeu tieatments
compaieu with othei options, especially those cuiiently coveieu
unuei Neuicaiu

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When will we have moie infoimation on piogiam goals, foi both the shaieu
savings piogiam anu the 111S waivei, to exploie othei, less iisky ways to
achieve them.
Why can't we puisue Neuicaiu iefoim as oiiginally uesciibeu in the SIN final
plan - pilot health neighboihoous, leain lessons, anu consiuei if it makes
sense to expanu to the iest of the population. Anu, in the meantime, expanu
to moie Neuicaiu consumeis the successful patient-centeieu meuical
homegliue path piogiam that is now impioving caie anu ieuucing costs foi
one thiiu of cuiient membeis.

}uly 8, 2u14
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i
R. Ruuowitz et.al. A Look at Section 111S Neuicaiu Bemonstiation Waiveis 0nuei
the ACA: A Focus on Chiluless Auults, Kaisei Family Founuation, 0ct. 9, 2u1S.
ii
Neuicaiu anu chiluien's health insuiance piogiams: essential health benefits in
alteinative benefit plans, eligibility notices, faii heaiing anu appeal piocesses,
piemiums anu cost shaiing, exchanges: eligibility anu eniollment; final iule. Centeis
foi Neuicaie & Neuicaiu Seivices. 78 Feu Reg 4216u (}uly 1S, 2u1S). The ielevant
section is, "a. Biagnostic, Scieening, Pieventive, anu Rehabilitative Seivices
(Pieventive Seivices) ( 44u.1Su)" (paiagiaph citation: 78 FR 42226)
iii
Assumptions anu calculations available upon iequest