Regs., Conn. State Agencies Title 17b — Social Services

Department of Social Services Department of Social Services

17b-3 Child Care Subsidy Programs

Regs., Conn. State Agencies § 17b-3-1—17b-3-6 (Repealed)

Repealed July 10, 2001.

17b-4(a) Community-Based Services

Regs., Conn. State Agencies § 17b-4(a)-1 Definitions

As used in Sections 17b-4 (a)-1 through 17b-4 (a)-6, inclusive, as follows:

(a) "Adult" means a person with a disability between the ages of 18–64 years.

(b) "Administrative Overpayment" is an overpayment caused by the Department's incorrect action or failure to act within the appropriate time limits.

(c) "Applicant" means any person who has submitted to the Department a completed and signed application form for Community-Based Services for families and adults.

(d) "Assets" means all personal property and resources including, but not limited to, cash, bank accounts, stocks, bonds, credit union shares, mortgage notes, real estate, automobiles, cash value of life insurance, assignments of interest in estates or causes of action.

(e) "Commissioner" means the Commissioner of the Department of Social Services or a designee.

(f) "Community-Based Services" means the following services:

(1) Adult Day Care Services – day care in a center for adults provided for a scheduled number of hours per week. Elements of this service are directed toward meeting supervision, health maintenance and restoration needs of participants.

(2) Adult Companion Service – home-based supervision and monitoring activities which assist and/or instruct an adult in maintaining a safe environment, including escorting adults to medical or other appointments or recreational activities, supervising and/or assisting with activities of adult daily living, and reminding individuals to take self-administered medications.

(3) Home-Delivered Meals – the preparation and delivery of meals for adults who are unable to prepare or obtain nourishing meals on their own.

(4) Case Management – the implementation, coordination and monitoring by a department social worker of a community-based plan of care developed as a result of a comprehensive client needs assessment completed by the Department.

(5) Chore Service – the performance of heavy indoor work, outdoor work or household tasks that are necessary to maintain and promote a healthy and safe environment for recipients in their own homes.

(6) Case Work – duties performed by a social worker dealing with problems of a particular case.

(7) Homemaker Services – general household management activities provided in the home on a part-time, intermittent, or full-time basis as determined by a department social worker to assist and/or instruct the recipient in managing a household.

(8) Temporary Foster Care – the placement of minor child(ren), for a period of up to 90 days, in an approved foster home or with relatives when parents or a legal guardian are out of the home due to illness or other factors beyond their control.

(9) Social Work Services – assessment and evaluation of need by a Department social worker including service planning, contracting, counseling, case work, advocacy for the recipient, and crisis intervention when appropriate.

(10) Teaching Homemaker – a trained provider who assists and/or instructs a parent in child development, household management, shopping, meal planning, meal preparation and family household finances.

(11) Personal Emergency Response System – a 24 hour electronic alarm system placed in an adult's home that enables him or her to obtain immediate help in case of an emergency.

(g) "Department" means the Department of Social Services.

(h) "Excess Income" means the amount by which the gross income exceeds the Title XIX medical assistance level for Region A as established annually by the Department of Social Services (DSS).

(i) "Emergency Need" is a situation in which a physical and/or mental impairment prevents an individual from meeting needs of adult daily living, where there is no legally liable relative able to perform these duties or a non-legally liable relative or friend willing and able to perform these duties without compensation and lack of service would result in serious physical and/or mental deterioration.

(j) "Family" means related individuals living together as one economic unit which may include one or more child(ren) under the age of 18.

(k) "Good Cause" means that a person was prevented from informing the Department of changes in their circumstances which would affect their eligibility for Community-Based Services due to personal illness, death in the immediate family, severe weather, or other catastrophic events beyond the control of the recipient or other responsible members of the recipient's household.

(l) "Grant Reduction Recoupment" is a method of recoupment in which the Department reduces the recipient's monthly grant.

(m) "Income"

(1) "Earned income" means any compensation payable by an employer to an employee and includes wages, salaries, commissions, bonuses, and tips, as well as earnings from self-employment or contractual agreements.

(2) "Other income" may include, but is not limited to, pensions, annuities, dividends, interest, rental income, estate or trust income, royalties, social security minus any Medicare deduction or supplemental security income, unemployment compensation, workers' compensation, alimony, child support, recurring voluntary cash contributions, and cash assistance from federal, state, or municipal programs.

(n) "Installment Recoupment" is a method of recoupment in which the recipient makes monthly installment payments to the Department.

(o) "Legally liable relative" means either a spouse or a parent of a child under the age of 18.

(p) "Lump-sum Recoupment" is a method of recoupment in which the recipient makes payment to the Department of the entire amount of the overpayment in one payment.

(q) "Overpayment" is the amount of financial assistance paid to or on behalf of the recipient in excess of the amount to which the unit is properly entitled.

(r) "Person with a disability" means an adult between the ages of 18 and 64 who, due to a physical and/or mental condition lacks the ability to meet his or her own needs, and may, as determined by a Department social worker, require institutional placement if not provided with significant supportive services.

(s) "Recipient" means a person who has been determined eligible by the Department for Community-Based Services for families and adults and who has been notified of the effective date of such service and/or service payment.

(t) "Recoupment" is a process by which the Department recovers an overpayment from the recipient or service provider.

(u) "Relative" means blood relatives and their spouses, relatives of half-blood and their spouses, and relatives whose relationship with the recipient is based on legal adoption.

(v) "Risk of Institutionalization" means the probability that a person will have to be institutionalized within 60 days if services to prevent severe mental and/or physical deterioration are either withheld or withdrawn.

(w) "Service Provider" means one who provides Community-Based Services but does not include:

(1) legally liable relatives or

(2) other relatives who are members of the recipient's household unless they have suffered a demonstrable loss of income as a result of providing such services.

(x) "Service provider agency" is an organization that employs persons to provide Community-Based Services and for whom a rate of reimbursement has been approved by the Commissioner.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-4(a)-2 Conditions and standards of eligibility

(a) Eligible families:

(1) In order to be eligible for any services, families must reside in Connecticut and meet the income guidelines in subsection (d) of this section.

(2) Eligible families may receive social work and case management services in appropriate circumstances including, but not limited to, homelessness, child rearing problems, pending eviction and family violence.

(3) Eligible families may receive paid community based services when the supervising relative is temporarily incapacitated or unable to manage the household and children are in need of temporary foster care, homemaker services or the supervising relative is in need of a teaching homemaker. Additionally, paid services may also be provided if the supervising relative is a person with a disability.

(b) Eligible adults

(1) In order to be eligible for any services, the adult must reside in Connecticut, be between the ages of 18 and 64, be a person with a disability as defined in Section 17b-4 (a)-1 and meet the income guidelines as defined in subsection (d) of this section.

(2) Eligible adults may receive social work and case management services in appropriate circumstances including, but not limited to, homelessness, pending eviction, and inappropriate institutionalization.

(3) Eligible adults with disabilities may receive paid community based services if such services, as part of the overall case plan, are provided in order to maintain the individual in the community.

(c) Medical need for Community-Based Services will be determined by the Department as follows:

(1) The adult applicant for paid services shall document the medical basis of his or her need, and the Department will review all documentation submitted to determine its sufficiency. Medical data may include a statement from a medical doctor, therapist or other appropriate health care professional stating that services are necessary to allow the applicant to remain in the community. The incapacitated supervising relative of a family shall also document medical need when applying for paid services.

(2) The Department social worker shall assess the case to determine the impact of the disability on the individual and/or the family, and how this directly affects their ability to meet needs.

(3) A Department social worker shall determine whether services provided or paid for by the Department can adequately meet the need.

(4) The Department may authorize Community-Based Services for families and adults when the social worker's assessment indicates that a need for services exists due to an individual's disability, appropriate medical data confirms this assessment, and fiscal information verifies that there is financial eligibility.

No service plan shall be established unless the client has a need which can specifically be met by a Community-Based Service as defined in Section 17b-4 (a)-1.

If an applicant is eligible for or receiving comparable services from another agency, such applicant shall be considered ineligible for the same Community-Based Services through the Department.

(d) Income

(1) In determining an applicant's eligibility, or a recipient's continuing eligibility, the following income of the applicant/recipient and any legally liable relative shall be counted:

(A) All gross monthly earned income, based on the most recent 13 weeks, minus:

(i) Non-personal work expenses such as: union dues (if mandatory), tools, materials, uniforms or other special protective clothing necessary for the job if they are not furnished or paid for by the employer.

(ii) Personal work expenses such as: withholding tax based upon the maximum number of dependents to which the applicant is entitled, FICA, group life insurance, health insurance, and a mandatory retirement plan.

(B) The gross monthly amount of all other income, including any cash assistance from federal, state, or municipal assistance programs not otherwise excluded as income by federal or state law, and including the gross amount of social security benefits, minus any Medicare deductions.

(2) A person shall be eligible for services when earned and other income of his or family as determined in accordance with this subsection and based on family size, does not exceed Title XIX Medical Assistance levels for Region A as established annually by the Department of Social Services (DSS).

(e) Spend Down:

(1) Applicants and recipients who have excess income shall be eligible if the excess income is less than the authorized payment for Community Based Services, and the excess income is applied to the cost of Community Based Services.

(2) Excess income which is already being applied to medical expenses for the purpose of qualifying the applicant/recipient for Title XIX medical assistance shall not be considered available for community based services.

(f) Assets

(1) Total assets of applicants and recipients and any legally liable relatives shall be considered in determining eligibility with the exception of real property used as the primary residence, any medical or remedial appliance or device, prepaid funerals or a vehicle essential for transportation.

(2) Assets shall not have been disposed of or transferred for less than reasonable consideration or fair value, or for the purposes of qualifying for services, within a period of 30 months prior to the date of application.

(3) Total assets of applicants and recipients and any legally liable relatives minus the exclusions set forth in subdivision (1) of this subsection shall not exceed the asset limits established by the Department of Health and Human Services through the Social Security Administration for the Supplemental Security Income Program.

(g) Grandfathered Cases:

(1) Recipients of Community-Based Services at the time that the legislation transferred new intake to the State Department on Aging in 1990 were grandfathered as are those clients who turned 60 between July 1, 1990 and June 30, 1991 and will continue to receive services provided that their need for Community-Based Services continues to exist, and all the eligibility requirements other than age are met.

(2) Community-Based Services for Families and Adult recipients who were receiving service payments in excess of $650.00 per month prior to July 1, 1984, and who continue to satisfy the eligibility standards, shall not be subject to subsection (d) of Section 17b-4 (a)-4, whicn establishes a maximum payment of $650.00 per month.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-4(a)-3 Application and determination of eligibility

(a) An applicant is responsible for providing all social, medical, and financial information necessary to establish eligibility. Staff assigned by the Commissioner may assist applicants in completing applications.

(b) A determination of eligibility by the Department shall be made no later than 60 days following the receipt by the Department of the completed application. A notice of action shall be mailed to the applicant.

(c) Staff assigned by the Commissioner, with the assistance of the applicant, shall assess the applicant's needs, determine what needs are unmet, and develop an appropriate plan for Community-Based Services within established cost limits.

(d) Applicants and recipients shall report any changes in circumstances affecting eligibility to the Department within 10 days.

(e) Program eligibility for paid and unpaid services shall be reviewed at least once per year. Eligibility will be reviewed more frequently in cases where service needs are of short term.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-4(a)-4 Payments for services

(a) Community-Based Services for Families and Adults is not an entitlement program. Payments for services shall be contingent upon the availability of funds. The Commissioner may take whatever steps are necessary to ensure that expenditures do not exceed the amount of funds available.

(b) Should the Department be unable to provide payments for services to all current recipients due to a shortage of funds, the steps that the Department may take include the following:

(1) Denial of new applications for Community-Based Services as well as the denial of additional services for current recipients.

(2) A pro rata reduction in payments to all recipients until such time as sufficient funds are available. Thirty days written notice shall be given to all recipients stating that payment levels for Community-Based Services shall be reduced, the reasons for the reduction, and the date such reductions shall take effect. Unless the recipient believes that the calculation of the payment is incorrect, there shall be no appeal for this decision.

(3) Highest priority for payment may be given to those individuals at immediate risk of institutionalization, recipients who have emergency needs, and children in need of temporary foster care.

(c) There shall be no payment for any Community-Based Services for Families and Adults not authorized by the Commissioner or a designee, nor shall there be payment for any such service incurred, or paid for, by the recipient prior to the date of payment authorization.

The date of authorization is the effective date appearing on the authorization form.

(d) The maximum payment, per recipient, for Community-Based Services shall not exceed $650.00 per month.

(e) Payment will be authorized for the applicant or recipient if the expense is not payable through third party coverage.

(f) Prior to a reduction or discontinuance of a Community-Based Service for Families and Adults payment, a recipient shall be given ten days' written notice of such proposed change except in cases of reductions in accordance with subsection (b) (2) of this Section. The notice shall advise the recipient of the change and his right to a fair hearing in accordance with Sections 17-603 and 17-604 of the Connecticut General Statutes.

(g) FICA, FUTA, UC Payments

Payments for Community-Based Services shall be for the gross amount of the service payment as authorized by the Commissioner with no deductions for Social Security (FICA), Federal Unemployment Tax (FUTA), or State Unemployment Compensation (UC) payments.

The recipient of services shall be responsible for payment of the appropriate amount of FICA, FUTA, and UC.

Responsibility for FICA, FUTA and UC accounts currently established and maintained by the Department, may be transferred to the recipient of services. No such transfer shall be made until recipients are given reasonable notice of such change.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-4(a)-5 Recovery of direct services overpayments

(a) Recipients, service providers, and service provider agencies are obligated to reimburse the Department for any overpayment received whether directly, or on behalf of a recipient.

(b) The Commissioner may waive recoupment of an overpayment up to the limit of statutory authority pursuant to Connecticut General Statutes Section 3-7 if in his judgment the imposition of recoupment measures would place the recipient at significant risk of institutionalization, would place the recipient's family in a crisis situation or is not in the best interest of the State.

(c) Prior to the Department initiating any recoupment process, the recipient, service provider, or service provider agency shall be notified of the amount of the overpayment, the reason the overpayment occurred, the time period covered by the overpayment, and the proposed method for recovering the overpayment.

(d) Method of Recoupment:

(1) The Department will attempt to recover overpayments from recipients, former recipients, service providers, or service provider agencies by the lump-sum recoupment method.

(2) If the individual who owes the overpayment is unable to make a lump sum repayment, the Department will attempt to recover the money through the installment recoupment method. Active recipients and providers may agree to the grant reduction recoupment method in lieu of installment recoupment.

(3) In cases where the individual who owes the overpayment fails or refuses to make a lump sum payment, sign an installment agreement, or comply with the provisions of an installment agreement, the Department may invoke the grant reduction recoupment method by reducing each subsequent payment made to or on behalf of a recipient by up to 25% of the total amount owed until such overpayment is recovered.

(4) Service provider agencies that fail or refuse to repay overpayments may have the amount which is owed recouped from any other payments to which they are entitled on behalf of any other client.

(5) When there is failure to agree to an appropriate repayment plan, the Commissioner shall take whatever action he deems appropriate to recover such overpayment.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-4(a)-6 Fair hearings

A person aggrieved by any action or inaction of the Department may request a fair hearing in accordance with Connecticut General Statutes Sections 17-603 and 17-604 as same may be amended. The Department of Social Services' fair hearing procedures are governed by applicable provisions of the Uniform Administrative Procedure Act and the Department's separate fair hearing regulations.

History

• Effective November 30, 1995

17b-10 Uniform Policy Manual

Regs., Conn. State Agencies § 17b-10-1 Uniform policy manual

Pursuant to section 17b-10 of the Connecticut General Statutes, the Department of Social Services has prepared, and routinely updates, a state eligibility Policy Manual containing all departmental policy regulations and substantive procedures which affect the rights or procedures available to the public. In particular, the Policy Manual outlines the policies and procedures used by the department to implement and enforce federal and state laws for all of the programs which it administers.

The Policy Manual was adopted pursuant to the applicable provisions of the Uniform Administrative Procedure Act and any amendment to, or repeal of, the regulatory provisions contained therein would also be subject to UAPA procedural requirements. However, in accordance with Conn. Gen. Stat. 4-173 (c), the full text will not be published herein. Instead, the following list of sections from the Table of Contents for the Policy Manual has been reproduced in order to assist persons interested in seeking further information with respect to the regulations:

| | Rights and Responsibilities | 1000 | | --- | --- | --- | | | The Eligibility Process | 1500 | | | Assistance Unit Composition | 2000 | | | Categorical Eligibility Requirements | 2500 | | | Technical Eligibility Requirements | 3000 | | | Procedural Eligibility Requirements | 3500 | | | Treatment of Assets | 4000 | | | Standards of Assistance | 4500 | | | Treatment of Income | 5000 | | | Income Eligibility | 5500 | | | Calculation of Benefits | 6000 | | | Benefits Issuance | 6500 | | | Benefit Error | 7000 | | | Recovery | 7500 | | | Special Programs | 8000 | | | Special Benefits | 9000 |

A copy of the Policy Manual is available at the Connecticut Department of Social Services, Office of Legal Affairs, 25 Sigourney Street, Hartford, CT 06106.

History

• Effective December 21, 1990; Amended May 27, 1992; Amended June 23, 1992; Amended July 29, 1992; Amended August 26, 1992; Amended October 6, 1992; Amended October 27, 1992; Amended February 8, 1993; Amended March 3, 1993; Amended March 25, 1993; Amended May 10, 1993; Amended July 7, 1993; Amended July 20, 1993; Amended July 27, 1993; Amended August 23, 1993; Amended October 26, 1993; Amended November 22, 1993; Amended December 29, 1993; Amended February 1, 1994; Amended February 22, 1994; Amended March 23, 1994; Amended April 26, 1994; Amended May 23, 1994; Amended June 28, 1994; Amended September 28, 1994; Amended October 25, 1994; Amended March 23, 1995; Amended April 26, 1995; Amended May 18, 1995; Amended August 21, 1995; Amended October 25, 1995; Transferred from § 17-3f-1, January 31, 1996; Amended March 29, 1996; Amended July 24, 1996; Amended April 1, 1997; Amended September 4, 1997; Amended October 7, 1997; Amended December 24, 1997; Amended February 4, 1998; Amended May 8, 1998; Amended February 9, 1999; Amended September 23, 1999; Amended October 8, 1999; Amended February 9, 2000; Amended June 6, 2000; Amended November 7, 2000; Amended February 13, 2001; Amended November 5, 2001; Amended November 7, 2001; Amended December 10, 2001; Amended January 3, 2002; Amended January 4, 2002; Amended February 7, 2002; Amended May 6, 2002; Amended September 17, 2002; Amended November 6, 2002; Amended February 11, 2003; Amended March 11, 2003; Amended March 14, 2003; Amended June 11, 2003; Amended July 29, 2003; Amended September 10, 2003; Amended December 10, 2003; Amended February 10, 2004; Amended March 4, 2004; Amended March 31, 2004; Amended May 24, 2004; Amended July 9, 2004; Amended August 19, 2004; Amended August 23, 2004; Amended August 26, 2004; Amended September 8, 2004; Amended September 9, 2004; Amended October 14, 2004; Amended November 9, 2004; Amended December 14, 2004; Amended February 8, 2005; Amended February 9, 2005; Amended March 3, 2005; Amended April 4, 2005; Amended May 2, 2005; Amended May 26, 2005; Amended June 8, 2005; Amended June 13, 2005; Amended July 15, 2005; Amended July 21, 2005; Amended August 9, 2005; Amended August 11, 2005; Amended August 31, 2005; Amended September 1, 2005; Amended September 9, 2005; Amended September 14, 2005; Amended October 12, 2005; Amended November 9, 2005; Amended December 7, 2005; Amended January 5, 2006; Amended March 9, 2006; Amended April 10, 2006; Amended May 9, 2006; Amended June 14, 2006; Amended July 11, 2006; Amended August 3, 2006; Amended August 7, 2006; Amended August 23, 2006; Amended October 5, 2006; Amended December 6, 2006; Amended December 15, 2006; Amended February 7, 2007; Amended March 7, 2007; Amended June 4, 2007; Amended August 6, 2007; Amended October 11, 2007; Amended December 28, 2007; Amended January 31, 2008; Amended April 7, 2008; Amended July 7, 2008; Amended July 29, 2008; Amended July 31, 2008; Amended September 4, 2008; Amended October 9, 2008; Amended December 5, 2008; Amended January 7, 2009; Amended February 11, 2009; Amended April 8, 2009; Amended August 12, 2009; Amended September 4, 2009; Amended November 9, 2009; Amended May 10, 2010; Amended June 1, 2010; Amended July 6, 2010; Amended October 8, 2010; Amended November 5, 2010; Amended March 3, 2011; Amended March 31, 2011; Amended June 8, 2011; Amended July 11, 2011; Amended June 5, 2012; Amended July 2, 2012; Amended December 28, 2012

17b-27 Hospital-based Acknowledgment of Paternity

Regs., Conn. State Agencies § 17b-27-1 Definitions

As used in sections 17b-27-1 through 17b-27-7, inclusive:

(1) "Acknowledgment of paternity" means the form prescribed by the Department of Public Health for the purpose of establishing the legal paternity of a child born to unmarried parents, as provided in subsection (a) of section 46b-172 of the Connecticut General Statutes. The acknowledgment of paternity includes the affirmation of paternity, the waiver, and the notice of rights and responsibilities.

(2) "Affirmation of paternity" means the signed and sworn portion of the acknowledgment of paternity in which the mother names the biological father of her child and consents to such acknowledgment of paternity.

(3) "Birthing institution" means a hospital that has an obstetric care unit or provides obstetric services, or a birthing center associated with a hospital.

(4) "Commissioner" means the commissioner of the Department of Social Services, a designee, or authorized representative.

(5) "Department" means the Department of Social Services or any bureau, division, or agency of the Department of Social Services.

(6) "Notice of rights and responsibilities" means the portion of the acknowledgment of paternity that contains the written notice to the mother and the putative father of the alternatives to, the legal consequences of, and the rights and responsibilities that arise from signing such acknowledgment, including the right to rescind the acknowledgment, as required by subdivision (a) (1) of Section 46b-172 of the Connecticut General Statutes.

(7) "Protocol" means the standards and procedures established by a birthing institution to comply with Sections 17b-27-1 to 17b-27-7, inclusive, of the Regulations of Connecticut State Agencies.

(8) "Waiver" means the portion of the acknowledgment of paternity that is signed and sworn to by the putative father wherein such father voluntarily acknowledges that he is the biological father of the child, accepts the obligation to support such child, and waives his rights to a trial, a lawyer to represent him, and a genetic test to determine paternity.

History

• Effective August 21, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-27-2 Protocol requirement

(a) In general

Each birthing institution shall develop and follow a protocol for the voluntary acknowledgment of paternity during the period immediately before or after the birth of a child to an unmarried woman in such institution.

(b) Submittal

The protocol developed under subsection (a) of this section shall be in writing and submitted to the commissioner. An amended protocol document shall be submitted no later than 60 days after the adoption of a significant change to an existing protocol.

(c) Required components

The written protocol submitted in accordance with subsection (b) of this section shall specify, at a minimum, how, when, and by whom each of the following services shall be provided:

(1) distribution of the informational materials specified in section 17b-27-3 of the Regulations of Connecticut State Agencies to the mother and the putative father;

(2) provision of the forms and notices specified in section 17b-27-4 of the Regulations of Connecticut State Agencies to the mother and the putative father;

(3) consultation regarding paternity establishment as required by section 17b-27-5 of the Regulations of Connecticut State Agencies;

(4) provision of an opportunity for the mother and the father to sign an acknowledgment of paternity, as provided in section 17b-27-6 of the Regulations of Connecticut State Agencies, in the birthing institution in the presence of a notary public; and

(5) forwarding of the completed acknowledgment of paternity to the paternity registry, as provided in section 17b-27-7 of the Regulations of Connecticut State Agencies.

History

• Effective August 21, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-27-3 Informational materials

The birthing institution shall distribute to both the mother and the putative father, if he is present in such institution, written informational materials about paternity establishment. Such materials shall include, but not be limited to, those developed by the department and provided to such birthing institutions specifically for the operation of the hospital-based acknowledgment of paternity program. The department shall provide such informational materials to any birthing institution upon request.

History

• Effective August 21, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-27-4 Forms and notices

The birthing institution shall provide to both the mother and the putative father, if he is present in such institution, the forms and notices necessary to voluntarily affirm and acknowledge paternity, respectively. The department shall provide such forms and notices to any birthing institution upon request. All of the required forms and notices are included in the acknowledgment of paternity form prescribed by the Department of Public Health pursuant to subdivision (a) (3) of Section 46b-172 of the Connecticut General Statutes.

History

• Effective August 21, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-27-5 Consultation

The birthing institution shall provide to both the mother and the putative father, if he is present in such institution, the opportunity to speak with staff, either by telephone or in person, who are trained to clarify information and answer questions about paternity establishment.

History

• Effective August 21, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-27-6 Affirmation and acknowledgment opportunity

(a) In general

The requirements of this section shall be satisfied if the birthing institution provides the required services, including notarization, prior to the mother's discharge, if practicable, or, if not practicable, within 10 calendar days thereafter.

(b) Affirmation procedure

The birthing institution shall provide to each unmarried mother the opportunity to voluntarily sign an affirmation of paternity in such institution. The birthing institution shall provide an oral and written notice of rights and responsibilities to the mother before the mother signs an affirmation of paternity. The mother's sworn signature on the affirmation of paternity shall be sufficient to ensure that she is informed, competent to understand and agree to an affirmation of paternity, and that such affirmation is voluntary and free from coercion.

(c) Acknowledgment procedure

The birthing institution shall provide to each putative father the opportunity to voluntarily sign an acknowledgment of paternity in such institution. The birthing institution shall provide an oral and written notice of rights and responsibilities to such father before the father signs an acknowledgment of paternity. The father's sworn signature on the waiver shall be sufficient to ensure that he is informed, competent to understand and agree to an acknowledgment of paternity, and that such acknowledgment is voluntary and free from coercion.

History

• Effective August 21, 1995; Amended June 8, 1998; Amended May 24, 2004

Regs., Conn. State Agencies § 17b-27-7 Filing

The birthing institution shall promptly forward the acknowledgment of paternity completed in accordance with section 17b-27-6 of the Regulations of Connecticut State Agencies to the paternity registry established and maintained by the Department of Public Health in accordance with section 19a-42a of the Connecticut General Statutes.

History

• Effective August 21, 1995; Amended June 8, 1998; Amended July 10, 2000

Regs., Conn. State Agencies § 17b-27-8 (Repealed)

Repealed June 8, 1998.

17b-34 Electronic Health Records Incentive Program

Regs., Conn. State Agencies § 17b-34-1 Scope

The department distributes Electronic Health Record Incentive Program payments to eligible providers who meet the criteria set forth in 42 CFR 495.2 to 42 CFR 495.10, inclusive, and 42 CFR 495.300 to 42 CFR 495.370, inclusive. Eligible providers include: Physicians, nurse practitioners, certified nurse-midwives, dentists, physician assistants, acute care hospitals and children’s hospitals. Eligible providers shall meet applicable federal and state requirements, including licensure and scope of practice requirements.

History

• Effective January 13, 2013

Regs., Conn. State Agencies § 17b-34-2 Definitions

Unless otherwise defined in this section, the definitions provided in 42 CFR 495.4 and 42 CFR 495.302 apply to sections 17b-34-1 to 17b-34-9, inclusive, of the Regulations of Connecticut State Agencies. As used in sections 17b-34-1 to 17b-34-9, inclusive, of the Regulations of Connecticut State Agencies:

(1) “Adopt, implement or upgrade” or “AIU” means one or more of the following:

(A) Acquire, purchase or install a certified EHR system;

(B) install or commence use of a certified EHR system and have started one of the following: A training program for the certified EHR system; data entry of patient demographic and administrative data into the EHR; or establishment of data exchange agreements and a relationship between the provider’s certified EHR system and health information exchanges or other providers including, but not limited to, laboratories and pharmacies;

(C) expand available functionality of certified EHR technology capable of meeting meaningful use requirements at a practice site, including staffing, maintenance and training; or

(D) upgrade from existing EHR technology to certified EHR technology, including, but not limited to, upgrades to the addition of clinical decision support, e-prescribing functionality and computerized physician order entry;

(2) “Certified electronic health record” or “certified EHR” means EHR technology certified in accordance with the EHR certification criteria of the Office of the National Coordinator for Health Information Technology;

(3) “CMS” means the Centers for Medicare and Medicaid Services;

(4) “Commissioner” means the Commissioner of Social Services or the commissioner’s designee;

(5) “Department” means the Department of Social Services or its agent;

(6) “Electronic health record” or “EHR” means a systematic collection of electronic health information on individual patients in a digital format that includes a range of data in comprehensive or summary form, such as: Demographics; medical history; medication; medication allergies; immunization status; laboratory test results; radiology images; vital signs; and personal statistics such as age, weight and billing information;

(7) “Electronic Health Record Incentive Program” or “EHR Incentive Program” means the incentive program established pursuant to section 17b-34 of the Connecticut General Statues and authorized by 42 USC 1396b(a)(3)(F) and 42 USC 1396b(t), that enables providers to receive funding from the department to promote AIU and meaningful use;

(8) “Eligible hospital” means a children’s hospital or an acute care hospital, as such terms are defined in 42 CFR 495.302;

(9) “Eligible professional” or “EP” means a professional as described in 42 CFR 495.304(b) to 42 CFR 495.304(d), inclusive;

(10) “Hospital-based EP” means an EP who furnishes ninety percent or more of the EP’s covered professional services in a hospital setting as measured by data in the calendar year preceding the payment year;

(11) “Hospital setting” means a site of service that is identified by the codes used in Health Insurance Portability and Accountability Act standard transactions as an inpatient hospital or emergency room setting;

(12) “Meaningful use” means use of certified EHR in a meaningful manner, including, but not limited to: E-prescribing; the use of certified EHR technology for electronic exchange of health information to improve quality of health care; or the use of certified EHR technology to submit clinical quality and other measures;

(13) “Medicaid” means the program operated by the department pursuant to section 17b-261 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(14) “Patient volume” means the minimum participation threshold that is estimated using the methodology in 42 CFR 495.306(c);

(15) “Pediatrician” means a physician whose practice is comprised of at least ninety percent of patients age 18 and under, and who:

(A) Holds board certification by the American Board of Pediatrics in pediatrics or a pediatric subspecialty;

(B) in the opinion of the department has training or experience comparable to that required for board certification by the American Board of Pediatrics in pediatrics or a pediatric subspecialty;

(C) holds board certification by the American Board of Medical Specialties in any specialty recognized by such board and serves a pediatric patient population; or

(D) in the opinion of the department provides what is generally accepted to be specialty care to a pediatric patient population;

(16) “Physician” means a person licensed pursuant to section 20-13 of the Connecticut General Statutes; and

(17) “Provider” means a provider enrolled in Medicaid.

History

• Effective January 13, 2013

Regs., Conn. State Agencies § 17b-34-3 General Requirements for Participation

To be eligible for participation in the EHR Incentive Program, a provider shall:

(1) Be an EP or an eligible hospital but not a hospital-based EP;

(2) comply with sections 17b-34-1 to 17b-34-9, inclusive, of the Regulations of Connecticut State Agencies;

(3) meet all applicable requirements of 42 CFR 495.304;

(4) be enrolled in Medicaid with a valid provider enrollment agreement on file with the department and comply with all of the department’s Medicaid requirements, including, but not limited to, sections 17b-262-522 to 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies;

(5) not have any current sanctions that temporarily or permanently bar the provider from participation in the Medicare program or any state’s Medicaid program;

(6) demonstrate, in a manner specified by the department, that the provider:

(A) For the first payment year, is adopting, implementing or upgrading an EHR system; and

(B) for the second and subsequent payment years, satisfies the meaningful use criteria applicable to the provider under 42 CFR 495.6;

(7) comply with all requirements in 42 CFR 495.310 regarding limitations on provider participation in more than one EHR incentive program; and

(8) comply with all other applicable requirements in 42 CFR 495, Subparts A and D, including 42 CFR 495.304.

History

• Effective January 13, 2013

Regs., Conn. State Agencies § 17b-34-4 Incentive Payment Requirements for Eligible Professionals

In addition to meeting the requirements of section 17b-34-3 of the Regulations of Connecticut State Agencies, an EP shall meet the following requirements in order to be eligible to participate in the EHR Incentive Program:

(1) Comply with all applicable requirements of 42 CFR 440, be licensed pursuant to Title 20 of the Connecticut General Statutes and act within the EP’s scope of practice under state law.

(2) Except for the first payment year as provided in subdivision (3) of this section, satisfy the requirements for meaningful use, as follows:

(A) Unless otherwise provided in 42 CFR 495.6(a), an EP shall meet: (i) All of the objectives and associated measures in 42 CFR 495.6(d), (ii) five objectives of the EP’s choice from the objectives in 42 CFR 495.6(e) and (iii) if applicable, the criteria in 42 CFR 495.6(h); and

(B) as provided in 42 CFR 495.8(a), an EP shall attest, in a manner specified by the department, that the EP satisfies each of the applicable objectives and associated measures required pursuant to 42 CFR 495.6(a).

(3) In the first payment year only, an EP may either satisfy the requirements for meaningful use provided in subdivision (2) of this section or the EP may demonstrate that the EP has adopted, implemented or upgraded an EHR system during the payment year by attesting that:

(A) The EP has adopted, implemented or upgraded certified EHR technology; and

(B) the EP meets the applicable patient volume requirements in 42 CFR 495.304.

(4) Except as otherwise provided in subdivision (3) of this section, for program years one through six, an EP shall attest not more than ninety days after the close of each program calendar year that the EP has met the requirements for meaningful use of certified EHR technology, as follows:

(A) In program calendar years one and two, the EP shall attest to meeting the objectives and associated measures of meaningful use criteria in subdivision (2) of this section for any continuous ninety-day period within such program calendar year; and

(B) in program calendar years three through six, the EP shall attest to meeting the objectives and associated measures of meaningful use criteria in subdivision (2) of this section for the entirety of each program calendar year.

(5) An EP shall submit the information described in 42 CFR 495.10 to the department in the manner specified by CMS.

History

• Effective January 13, 2013

Regs., Conn. State Agencies § 17b-34-5 Incentive Payment Requirements for Eligible Hospitals

In addition to meeting the requirements of section 17b-34-3 of the Regulations of Connecticut State Agencies, an eligible hospital shall meet the following requirements in order to be eligible to participate in the EHR Incentive Program:

(1) Hold a valid license issued by the Department of Public Health and comply with all applicable state statutes and regulations.

(2) Except for the first payment year as provided in subdivision (3) of this section, satisfy the requirements for meaningful use, as follows:

(A) Unless otherwise provided in 42 CFR 495.6(b), an eligible hospital shall meet: (i) All of the objectives and associated measures of the criteria in 42 CFR 495.6(f); (ii) five objectives of the eligible hospital’s choice, from the objectives in 42 CFR 495.6(g); and (iii) if applicable, the criteria in 42 CFR 495.6(i); and

(B) as provided in 42 CFR 495.8(b), an eligible hospital shall attest, in a manner specified by the department, that the eligible hospital satisfies each of the objectives and associated measures required pursuant to 42 CFR 495.6(b).

(3) In the first payment year only, an eligible hospital may either satisfy the requirements for meaningful use provided in subdivision (2) of this section or demonstrate that it has adopted, implemented or upgraded an EHR system during the payment year by attesting to the criteria in section 17b-34-4(c) of the Regulations of Connecticut State Agencies.

(4) Except as otherwise provided in subdivision (3) of this section, for program years one through six, an eligible hospital shall attest not more than 90 days after the close of each program federal fiscal year that it has met meaningful use of certified EHR technology, as follows:

(A) To be considered a meaningful EHR user in program federal fiscal years one and two, an eligible hospital shall attest to meeting the objectives and associated measures of meaningful use criteria in subdivision (2) of this section for any continuous ninety-day period within the program federal fiscal year; and

(B) to be considered a meaningful EHR user in program federal fiscal years three through six, an eligible hospital shall attest to meeting the objectives and associated measures of meaningful use criteria in subdivision (2) of this section for each program federal fiscal year in its entirety.

(5) An eligible hospital shall submit the information described in 42 CFR 495.10 to the department in the manner specified by CMS.

History

• Effective January 13, 2013

Regs., Conn. State Agencies § 17b-34-6 Methodology for Determining Patient Volume

(a) Each EP and eligible hospital shall, on an annual basis, meet the applicable patient volume requirements of 42 CFR 495.304 using the methodology in 42 CFR 495.306(c).

(b) Only an EP who is a pediatrician as defined in section 17b-34-2 of the Regulations of Connecticut State Agencies may use the reduced minimum Medicaid patient volume requirement for participation in the EHR Incentive Program pursuant to 42 CFR 495.304(c). Such pediatrician shall comply with applicable requirements of 42 CFR 495.310.

History

• Effective January 13, 2013

Regs., Conn. State Agencies § 17b-34-7 Incentive Payments

To receive incentive payments, an EP or eligible hospital shall meet the applicable requirements under 42 CFR 495.314. The department shall make incentive payments to each eligible Medicaid provider in accordance with 42 CFR 495.308, 42 CFR 495.310 and sections 17b-34-1 to 17b-34-9, inclusive, of the Regulations of Connecticut State Agencies.

History

• Effective January 13, 2013

Regs., Conn. State Agencies § 17b-34-8 Initial Review and Right to Request an Administrative Hearing

(a) A provider aggrieved by a decision concerning only the issues set forth in 42 CFR 495.370(a) or section 17b-34(c) of the Connecticut General Statutes may request an initial review of the department’s determination, and such review shall occur only if the department receives the provider’s written request for an initial review, together with any supporting documents or data, not more than thirty days after the provider received the department’s determination.

(b) An individual other than the person who made the department’s determination shall conduct the initial review. The individual who conducts the initial review shall issue a written decision to the provider not more than thirty days after the department receives the request for initial review.

(c) If the provider is aggrieved by the outcome of the initial review, the provider may request an administrative hearing in writing to the commissioner, together with a detailed written description of all items of aggrievement, not more than fourteen days after the date the written initial review decision was issued.

(d) The department shall conduct an administrative hearing requested pursuant to subsection (c) of this section in accordance with chapter 54 of the Connecticut General Statutes.

History

• Effective January 13, 2013

Regs., Conn. State Agencies § 17b-34-9 Audits and Documentation

(a) The department may access all relevant records and documentation and take any other appropriate quality assurance measures it deems necessary to verify provider attestations or conduct pre-payment or post-payment audits to assure compliance with the provisions of sections 17b-34-1 to 17b-34-9, inclusive, of the Regulations of Connecticut State Agencies and other regulatory and statutory requirements. The department may disallow or recover any amounts paid or pending to the provider for which required documentation is not maintained or not provided to the department upon request.

(b) For purposes of documenting AIU, the provider shall make available to the department all relevant documents, including, but not limited to, one or more of the following documents, as directed by the department:

(1) Contract;

(2) software license;

(3) receipt or evidence of cost;

(4) purchase order;

(5) evidence of cost or contract for training; or

(6) payroll record demonstrating hiring of staff to assist with the implementation.

(c) After conducting an audit, if the department finds that the provider was not eligible for payments made to the provider, the department may disallow and recover those funds. The provider shall promptly repay all disallowed funds to the department not more than forty-five days after receiving notice of the disallowance. In addition to taking any other lawful actions, the department may also offset such funds against current or future payments that the department otherwise would have made to the provider.

(d) A provider aggrieved by a decision in a final written audit conducted under this section may request a written review from the department. The provider shall request such review in writing and not later than thirty days after the department’s final audit report was issued, together with a detailed written description of each specific item of aggrievement. The scope of the review shall not include or consider facts or circumstances outside of the audit and the final written audit report. An individual other than a person who conducted the audit or made the department’s final audit determination shall conduct the review. At the discretion of the person presiding over the review, the person may make informal inquiries to the provider or the department; accept written statements from the provider and the department; and hold an informal conference with the department and the provider for the purpose of fact finding, accepting oral statements, or hearing witness testimony, after giving appropriate notice thereof to the provider and the department. After completing the final review, the person presiding over the review shall issue a final written decision regarding what, if any action will be taken, including, but not limited to, revising the final written audit or any other action within the scope of the department’s authority.

History

• Effective January 13, 2013

17b-78 The General Assistance Policy Manual

Regs., Conn. State Agencies § 17b-78-Acknowledgment1 Acknowledgement

The provisions of Section 17b-78-44, which implements Public Act 97-2 of the June 18th Special Session, shall include Sections 17b-78-11 through 17b-78-43 of the Regulations of Connecticut State Agencies (the General Assistance Policy Manual).

For purposes of clarity, this Section shall incorporate the provisions of Public Acts 95-194, 95-351, 96-209 and 96-268. Except as specifically noted in the text of this Section, all towns are required to administer the General Assistance program in accordance with regulations enacted herein as Section 17b-78-44.

Regs., Conn. State Agencies § 17b-78-44 The general assistance policy manual

The text of these regulations will not be published herein in accordance with the provisions of Section 4-173 of the Connecticut General Statutes. Copies of this regulation are available at the Department of Social Services. Interested members of the public may obtain a copy by writing to the General Assistance Unit, Department of Social Services, 25 Sigourney St., Hartford, CT 06106. Telephone (860) 424-5382 or toll free 1-800-842-2159.

History

• Transferred from § 17-3a-11 through 17-3a-42.1, February 10, 1998; Amended February 10, 1998

17b-102 Requirements for Providing Financial Incentive for the Reporting of Vendor Fraud

Regs., Conn. State Agencies § 17b-102-Acknowledgment1

Sections 17b-102-01 to 17b-102-04, inclusive, set forth the Department of Social Services requirements for providing a financial incentive for the reporting of vendor fraud in any program under the jurisdiction of the Department of Social Services.

Regs., Conn. State Agencies § 17b-102-01 Definitions

For the purposes of sections 17b-102-01 to 17b-102-04, inclusive, the following definitions shall apply:

(1) "Commissioner" means the chief executive officer of the department appointed pursuant to subsection (a) of section 17b-1 of the general statutes.

(2) "Department" means the Department of Social Services or its agent.

(3) "Fraud" means, with intent to defraud the department or a program under the jurisdiction of the department by:

(A) presenting for payment any false claim for goods or services performed;

(B) or accepting payment for goods or services performed, which exceeds either the amounts due for goods or services performed, or the amounts authorized by law for the cost of such goods or services;

(C) or soliciting to perform services for or sell goods to any beneficiary, knowing that such beneficiary is not in need of such goods or services;

(D) or selling goods to or performing services for any beneficiary without prior authorization by the department, when prior authorization is required by said department for the buying of such goods or the performance of any service;

(E) or accepting from any person or source other than the state an additional compensation in excess of the amount authorized by law.

(4) "Vendor" means the definition contained in section 17-83k-1 of the Regulations of Connecticut State Agencies.

History

• Adopted effective April 2, 1998

Regs., Conn. State Agencies § 17b-102-02 Eligibility

Payment of a financial incentive shall be provided to any person reporting vendor fraud in connection with any program under the jurisdiction of the department subject to the payment conditions and limitations which apply to this financial incentive pursuant to section 17b-102 of the general statutes and section 17b-102-01 to 17b-102-04, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective April 2, 1998

Regs., Conn. State Agencies § 17b-102-03 Payment

(a) The commissioner shall be the sole determiner of whether the person is entitled to the financial incentive.

(b) The payment shall not exceed 15% of the amounts recovered by the state that are directly attributed to the person's report.

(c) The commissioner shall be the sole determiner of the amount of the incentive.

History

• Adopted effective April 2, 1998

Regs., Conn. State Agencies § 17b-102-04 Payment limitations

(a) The department shall pay a financial incentive when:

(1) the person reporting has not materially participated in or benefited from any of the fraudulent activity being reported; and

(2) a direct correlation exists between the information reported and amounts recovered by the state as a result of such report; and

(3) the person reporting submits a claim for the financial incentive, in writing, on a form specified by the department and files it within six months from the date of when the vendor fraud was first reported;

(b) The department shall not pay a financial incentive when:

(1) the person reporting requests anonymity; or

(2) a claim is made regarding a case where the department or other state or federal agency has initiated an audit, investigation or similar proceedings prior to the person reporting the fraud; or

(3) the person reporting or a member of his immediate family is employed in a job which requires auditing, investigation or enforcement involving the programs under the jurisdiction of the department.

History

• Adopted effective April 2, 1998

17b-112f Safety Net Services Account

Regs., Conn. State Agencies § 17b-112f-1 Safety net services account. Regulations

(a) All moneys deposited in the Safety net services account shall be used to provide assistance to individuals receiving Safety net services pursuant to Section 17b-112e of the Connecticut General Statutes.

(b) All moneys deposited in the Safety net services account shall be used for the following purposes:

(1) Payment for food, shelter, clothing and employment assistance to individuals receiving Safety net services;

(2) Payment for eviction prevention;

(3) Payment for the purposes specified in subdivisions (3) and (4) of subsection (b) of Section 17b-112e of the Connecticut General Statutes, to the extent funds are available.

(c) There shall be no direct cash payments made to individuals enrolled in Safety net.

(d) Payments shall be made either through vendor or voucher payment.

History

• Adopted effective January 5, 2001

17b-179(a) Title IV-D Child Support Enforcement Program

Regs., Conn. State Agencies § 17b-179(a)-1 Definitions for the Title IV-D program

As used in sections 17b-179(a)-1 through 17b-179(a)-4, inclusive; 17b-179(b)-1; 17b-179(b)-2; 17b-179(f)-1; 17b-179(i)-1; 17b-179(m)-1 through 17b-179(m)-13, inclusive; 52-362d-1 through 52-362d-5, inclusive; and 52-362e-1 through 52-362e-3, inclusive:

(1) "AGO" means the Connecticut Attorney General's office, or any assistant attorney general within such office who is responsible for performing any IV-D function in accordance with the cooperative agreement between the department and such office.

(2) "Assistance case" means one in which the recipient of IV-D services is receiving benefits under the TFA or foster care programs, or the federal waiver granted under section 1115 of the Social Security Act.

(3) "BCSE" means the Bureau of Child Support Enforcement established within the department by section 17b-179 of the Connecticut General Statutes as the IV-D agency for the State of Connecticut.

(4) "Case record" means the automated and paper files of BCSE and its cooperating agencies relating to a particular child support enforcement case, which shall include all information and documents pertaining to the case, as well as all relevant facts, dates, actions taken, contacts made, and results in the case.

(5) "CCSES" means the Connecticut Child Support Enforcement System, the automated system used by BCSE and its cooperating agencies to collect and distribute child support and maintain related records.

(6) "Commissioner" means the commissioner of the Department of Social Services, a designee, or authorized representative.

(7) "Cooperating agency" means any Connecticut state agency under cooperative or purchase of service agreement with BCSE to provide IV-D services or perform IV-D functions as specified in federal or state statutes or regulations.

(8) "Custodial party" means the individual who has physical custody of a child, or, in foster care cases, the Commissioner of the Department of Children and Families.

(9) "Department" means the Department of Social Services or any bureau, division, or agency of the Department of Social Services.

(10) "FPLS" means the Federal Parent Locator Service operated by OCSE.

(11) "IV-D" means the child support enforcement program mandated by Title IV-D of the federal Social Security Act and implementing OCSE regulations, as implemented in Connecticut under section 17b-179 of the Connecticut General Statutes and related statutes and regulations.

(12) "IV-D agency" means the single and separate organizational unit within state government that has the responsibility for administering or supervising the administration of the IV-D state plan.

(13) "Location" means information concerning the physical whereabouts of the noncustodial parent, the noncustodial parent's employer(s), and other sources of income or assets, as appropriate, which is sufficient and necessary to take the next appropriate action in a case.

(14) "Non-assistance case" means one in which the recipient of IV-D services applied for such services, is a Medicaid recipient, or is receiving continuation of services following discontinuance of an assistance or Medicaid case.

(15) "Noncustodial parent" means the parent who does not have physical custody of the child receiving IV-D services.

(16) "OCSE" means the federal Office of Child Support Enforcement within the Department of Health and Human Services, Administration for Children and Families.

(17) "SED" means the Support Enforcement Division within the Connecticut Judicial Branch, an agency under cooperative agreement with BCSE to assist in administering the IV-D program for the State of Connecticut.

(18) "SPLS" means the State Parent Locator Service operated by BCSE.

(19) "Support order" means a judgment, decree, or order, whether temporary, final, or subject to modification, issued by a court or an administrative agency of competent jurisdiction, for the support and maintenance of a child, including a child who has attained the age of majority under the law of the issuing state, or of the parent with whom the child is living, which provides for monetary support, health care, arrearages, or reimbursement, and which may include related costs and fees, interest and penalties, income withholding, attorneys' fees, and other relief.

(20) "TFA" means the Temporary Family Assistance program established under section 17b-112 of the Connecticut General Statutes.

(21) "UIFSA" means the Uniform Interstate Family Support Act, model legislation approved and recommended for enactment in all the states by the National Conference of Commissioners on Uniform State Laws and adopted in Connecticut as sections 46b-212 to 46b-213v, inclusive, of the Connecticut General Statutes.

History

• Effective July 31, 1995; Amended June 8, 1998; Amended July 10, 2000

Regs., Conn. State Agencies § 17b-179(a)-2 Publication of names of delinquent obligors

(a) Definitions

The definitions in sections 17b-179(a)-1 and 52-362d-1 of the Regulations of Connecticut State Agencies shall apply to this section.

(b) Developing a pre-publication list

The department may develop a pre-publication list consisting of randomly selected obligors whose cases meet the following criteria.

(1) IV-D case

The obligor's case is subject to the Title IV-D state plan.

(2) Court order

The obligor's overdue support accrued under a court order to pay current and/or past-due support

(3) CCSES obligation

The IV-D obligation has been monitored through CCSES for at least 180 days prior to development of the pre-publication list.

(4) Duration of non-payment

The obligor made no payments on any CCSES obligations within 180 days immediately preceding the development of the pre-publication list. For the purpose of this subdivision, collections received as a result of any of the following actions shall not be considered as payments made by the obligor:

(A) release of a lien on the obligor's property in accordance with section 52-362d-2 of the Regulations of Connecticut State Agencies;

(B) withholding of an obligor's lottery winnings in accordance with section 52-362d-4 of the Regulations of Connecticut State Agencies;

(C) seizure of financial assets in accordance with section 52-362d-5 of the Regulations of Connecticut State Agencies;

(D) withholding of an obligor's federal income tax refund in accordance with section 52-362e-2 of the Regulations of Connecticut State Agencies; or

(E) withholding of an obligor's state income tax refund in accordance with section 52-362e-3 of the Regulations of Connecticut State Agencies.

(5) Overdue support amount

The obligor's total overdue support on all CCSES obligations for a single case is at least $5,000.

(6) Custodial party's address

The custodial party's address, according to CCSES records, is known and valid.

(c) Obtaining the custodial party's consent

The name of the delinquent obligor shall not be publicized without the signed written consent of the custodial party. BCSE shall use the following procedures to obtain the custodial party's consent.

(1) Identify custodial parties

BCSE shall identify the custodial parties associated with the obligors included on the pre-publication list developed in accordance with subsection (b) of this section.

(2) Mail consent request

BCSE shall prepare and mail to the custodial parties identified in subdivision (1) of this subsection a letter requesting such parties' consent to publication of the name of the delinquent obligor. The letter shall:

(A) cite the regulatory authority governing the proposed publicity;

(B) state the department's intent to publicize the obligor's name and other information, as provided in subdivision (g) (1) of this section, provided all requirements of this section are met, including the department's receipt within 30 days of a signed custodial party consent document;

(C) identify the delinquent obligor, the information the department intends to publicize, and the method or methods of publication that may be used;

(D) state the overdue support amount and the date of last payment;

(E) request the custodial party's consent to such publicity, and explain that the custodial party is not required to provide such consent as a condition of receiving IV-D services, and that the granting of consent does not ensure publication;

(F) explain the conditions under which consent may be withdrawn; and

(G) request a recent photograph of the obligor, if available, and a physical description of the obligor, if the custodial party consents to the proposed publicity.

(3) Consent documentation

The request for consent letter shall be accompanied by a consent document and a self-addressed return envelope. If a signed consent document is not received within 30 days of the request, BCSE shall delete the obligor from the pre-publication list.

(4) Withdrawal of consent

The custodial party may withdraw consent in writing at any time. If consent is withdrawn within 60 days of the signing of the consent document, BCSE shall exclude the obligor's name from the publication list. If consent is withdrawn later than 60 days after the signing of the consent document, BCSE shall exclude or delete the obligor's name from the publication list, or cease publicizing the obligor's name, only if administratively feasible.

(d) Notifying obligors

The department shall notify the obligor of the proposed publication and provide an opportunity for the obligor to challenge such publication at a fair hearing held by the department. BCSE shall use the following procedures to notify the obligor.

(1) Compile notice list

BCSE shall compile a notice list of the delinquent obligors with respect to whom the department has received the consent of the custodial party pursuant to subsection (c) of this section.

(2) Mail notice

BCSE shall prepare and mail to the delinquent obligors identified in subdivision (1) of this subsection, at their last known address as reflected in the department's records, a notice of intent to publicize the obligor's name. The notice shall:

(A) state the regulatory authority governing the proposed publicity;

(B) state the department's intent to publicize the obligor's name and other information, as provided in subdivision (g) (1) of this section;

(C) state the overdue support amount and the date of last payment;

(D) list the defenses available to the obligor to challenge the proposed action, as specified in subsection (e) of this section; and

(E) inform the obligor of the method and timeframe for requesting a fair hearing.

(e) Providing a fair hearing

The department shall provide a fair hearing, in accordance with section 17b-60 of the Connecticut General Statutes, to any obligor who challenges the publication of his name under this section, provided the request is made within 60 days of the mailing date of the notice of intent in accordance with subsection (d) of this section. The obligor's available defenses shall include, but not be limited to, the following:

(1) Mistaken identity

The obligor is not the individual identified by the department as a non-payer of child support.

(2) No court order

There is no child support order against the alleged obligor.

(3) Overdue support less than $5,000

The obligor's total overdue support on the case is less than $5,000 on the date of the notice issued under subsection (d) of this section.

(4) Inability to pay

During the 180 days of non-payment monitored by CCSES and used as the basis for development of the pre-publication list, the obligor was unable to pay any amount on the court order(s) for any of the following reasons:

(A) The obligor was receiving a federal, state, or local public assistance grant.

(B) The obligor was disabled as defined in section 2530.05 of the department's Uniform Policy Manual, or incapacitated as defined in section 8530.10 of the department's Uniform Policy Manual.

(C) The obligor was incarcerated.

(D) The obligor was institutionalized.

(E) The income of the obligor was such that application of the child support guidelines, section 46b-215a-2 of the Regulations of Connecticut State Agencies, would have resulted in a recommended support amount of zero.

(f) Compiling the publication list

BCSE may compile a publication list which shall be based on the following criteria:

(1) Fair hearing opportunity

The list shall be limited to those obligors who fail to request a fair hearing within 60 days after the mailing date of the notice of intent or who receive an adverse fair hearing decision and fail to appeal such decision to the superior court in a timely manner.

(2) Obligor not receiving assistance

The list shall be limited to obligors who are not current recipients of public assistance from the State of Connecticut or public assistance from the town of the obligor's residence in this state, if known.

(3) Custodial party's request

The department may consider, in the compilation of any initial or amended publication list, the custodial party's request to publicize the name of an obligor who is the noncustodial parent in his or her IV-D case provided:

(A) the obligor's name was included on the pre-publication list developed in accordance with subsection (b) of this section or otherwise selected by the department on the basis of non-payment of child support, and

(B) all requirements other than those included in subsection (b) of this section are met.

(g) Publicizing names

Publicizing the names of the obligors included on the publication list compiled in accordance with subsection (f) of this section may proceed as follows:

(1) Data publicized

The data to be publicized shall include, but not be limited to, the following:

(A) the obligor's name and date of birth;

(B) the obligor's town of residence, and street address, if known;

(C) the total amount of overdue support as of a date certain; and

(D) the date of last payment.

The department may, in its discretion, also publicize the obligor's photograph and physical description.

(2) Publication methods

The department may use any publication methods, subject to available appropriations. The methods may include, but shall not be limited to, the following:

(A) news releases and advertisements;

(B) radio and television public service announcements;

(C) utility and cable television bill inserts;

(D) billboards;

(E) posters;

(F) transit advertising;

(G) radio and television public affairs shows; and

(H) other state IV-D agencies.

History

• Effective August 3, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-179(a)-3 Recovery of misapplied child support payments

(a) Definitions

(1) The definitions of "BCSE", "CCSES", "cooperating agency", "custodial party", "department", "IV-D", "non-assistance case", and "SED" in section 17b-179(a)-1 of the Regulations of Connecticut State Agencies and the definitions of "fair hearing", "obligor", and "past-due support" in section 52-362d-1 of the Regulations of Connecticut State Agencies shall apply to this section.

(2) As used in this section:

(A) "Child support collection" means child and spousal support received from an obligor by BCSE, SED, or the state disbursement unit, as defined in subdivision (a)(3) of section 17b-179(m)-6 of the Regulations of Connecticut State Agencies, pursuant to operation of the IV-D program or the state disbursement unit.

(B) "Misapplied payment" means a child support collection or refund posted to the account of the wrong obligor or obligee, or the amount of which exceeds that due the obligor or obligee.

(C) "Misapplied payment recipient" means the custodial party in a non-assistance IV-D case or a case in which payments are directed to the state disbursement unit pursuant to subsection (p) of section 52-362 of the Connecticut General Statutes, to whose account a misapplied payment has been posted or an obligor who has received a misapplied payment in the form of a refund.

(D) "Repayment agreement" means a document signed by the misapplied payment recipient which shall state the amount of the misapplied payment, the repayment schedule established in accordance with subdivision (d)(2) of this section, and a statement that failure to abide by such schedule shall result in the establishment of a wrong account posting.

(E) "Wrong account posting" means a CCSES entry that results in the automatic interception of all or a part of any future child support collections made in behalf of the misapplied payment recipient for the purpose of repayment of such misapplied payment.

(b) Notice of misapplied payment

BCSE shall provide written notice to the misapplied payment recipient which notice shall contain, at a minimum, the following information:

(1) the alleged amount of the misapplied payment;

(2) a demand for repayment;

(3) a description of the available methods for repayment;

(4) a statement of the department's intent to establish a wrong account posting or make a referral to the Department of Administrative Services if such recipient fails or refuses to cooperate in the voluntary repayment of the misapplied payment;

(5) a statement of such recipient's right to request a fair hearing, and the method and timeframe for doing so; and

(6) a list of possible reasons for requesting a fair hearing.

(c) Right to a fair hearing

An individual who receives notice of a misapplied payment shall have the right to a fair hearing. Reasons for requesting a hearing, and defenses which may be raised at a hearing, include, but are not limited to, the following:

(1) the individual who received the notice is not the person identified as having received the misapplied payment;

(2) the alleged amount of the misapplied payment is incorrect; and

(3) the misapplied payment was not received.

(d) Recovery methods

BCSE, a cooperating agency, or the State Disbursement Unit shall attempt to recover a misapplied payment from the misapplied payment recipient using the methods described in this subsection.

(1) Lump sum recovery

Recovery by lump sum repayment equal to the full amount of the misapplied payment shall be attempted first.

(2) Repayment agreement

(A) In general

If the misapplied payment recipient fails or refuses to repay the full amount of such payment in one lump sum, such recipient shall be given an opportunity to sign a repayment agreement. Such repayment agreement shall specify either the establishment of a wrong account posting or regular installment payments in the amount specified in subparagraph (B) in this subdivision.

(B) Amount

The amount of the installment payments shall be not less than three percent (3%) but not more than ten percent (10%) of the sum of the amounts described in subparagraphs (B) (i) and (B) (ii) of this subdivision. The following factors shall be considered in determining the appropriate percentage: the total liquid assets available to the misapplied payment recipient, shelter costs relative to such recipient's household income, unreimbursable medical expenses, and support or alimony payments regularly made by such recipient.

(i) The first amount is "net income" as defined in subdivision (15) of section 46b-215a-1 of the Regulations of Connecticut State Agencies.

(ii) The second amount is the average periodic payment, as determined over the preceding thirteen week or three month period, of any current or past-due child support received by the misapplied payment recipient.

(C) Exception

The installment payment may exceed the amounts specified in subparagraph (B) of this subdivision at the sole option of the misapplied payment recipient.

(3) Wrong account posting

BCSE shall establish a wrong account posting pursuant to the terms of a repayment agreement or in the case of any individual who fails to respond to the notice of misapplied payment, or fails or refuses to abide by the terms of a repayment agreement. The wrong account posting shall be established no earlier than 60 days after the mailing date of the notice of misapplied payment.

(4) Referral to the Department of Administrative Services

(A) Agreement and purpose

Referral under this subdivision shall be made to the Department of Administrative Services, Collection Services Business Center, for the purpose of debt collection or Governor's cancellation, as appropriate, provided an agreement is reached in accordance with subdivision (a) (4) of section 4a-12 of the Connecticut General Statutes.

(B) Referral criteria

Cases referred under this subdivision shall be limited to those in which the misapplied payment recipient has failed or refused to repay the misapplied payment and in whose case either (i) or (ii) applies:

(i) No payments have been applied to the wrong account posting for a period of at least six months.

(ii) The establishment of a wrong account posting is inappropriate.

History

• Effective November 27, 1996; Amended June 8, 1998; Amended May 24, 2004

Regs., Conn. State Agencies § 17b-179(a)-4 Cooperation with the child support program

(a) Definitions

(1) The definitions of "BCSE", "cooperating agency", "department", and "IV-D agency" in section 17b-179(a)-1 of the Regulations of Connecticut State Agencies shall apply to this section.

(2) As used in this section:

(A) "Child" means one for whom TFA, Medicaid, SAGA or child care assistance has been applied or received;

(B) "Child care assistance" means a subsidy for child care expenses authorized under the child care assistance program in accordance with sections 17b-749-01 to 17b-749-23, inclusive, of the Regulations of Connecticut State Agencies;

(C) "Client" means an applicant or recipient of TFA, Medicaid, SAGA or child care assistance;

(D) "Medicaid" means the medical assistance program funded under Title XIX of the Social Security Act;

(E) "SAGA" means the State Administered General Assistance program established under section 17b-111 of the Connecticut General Statutes; and

(F) "TFA" means the Temporary Family Assistance program for cash assistance to families funded under the Temporary Assistance to Needy Families block grant.

(b) Cooperation requirements

(1) In general

Except as provided in subsection (c) of this section, each client shall be required to cooperate in good faith with the department in the following efforts on behalf of each child for whom assistance is applied or received:

(A) locating the child's noncustodial parent;

(B) establishing the child's legal paternity;

(C) establishing, modifying, or enforcing a monetary support order; and

(D) establishing, modifying, or enforcing a medical support order.

Cooperation for the purposes of this section shall include the activities described in subdivisions (2) through (5) of this subsection.

(2) Providing information

The activity required under this subdivision is providing the department with information with respect to the noncustodial parent of each child. The purpose of gathering this information is to enable the department to confirm the identity of the noncustodial parent and to locate such parent for service of process. The minimum information required is described in the following subparagraphs.

(A) Name

The first or given name and the last or surname of the noncustodial parent shall be required.

(B) Social security number

The information required under this subparagraph is the social security number of the noncustodial parent, if available. If unavailable, the client shall provide either the information required under subparagraph (C) or the information required under two of the subparagraphs (D) to (I), inclusive of this subdivision.

(C) Current or former employer

The information required under this subparagraph is the name and location of a current or former employer of the noncustodial parent. Such information shall be provided with sufficient specificity to enable the department to contact the employer by mail or telephone.

(D) Date and place of birth

The information required under this subparagraph is the exact date and the town and state or foreign country of the birth of the noncustodial parent. If such information is not provided, an approximate age and all of the information listed in one of the following items (i)-(iii) may be substituted.

(i) mother's and father's full names and, if still living, their address(es),

(ii) make, model, and approximate year of any motor vehicle owned, or

(iii) license plate number of any motor vehicle owned.

(E) Schools attended

The information required under this subparagraph is the name, the town, and the state of any secondary or postsecondary educational institution attended by the noncustodial parent and the year or years of attendance.

(F) Trade or profession

The information required under this subparagraph is all of the information specified in at least one of the following items (i)-(ii):

(i) the name and location or telephone number of any union or trade association of which the noncustodial parent is currently or was within the last five years a member, or

(ii) the name of any licensed profession or occupation in which the noncustodial parent is currently or was within the last five years engaged, and the jurisdiction in which the noncustodial parent is currently or was within the last five years licensed.

(G) Arrest or incarceration

The information required under this subparagraph is all of the information specified in at least one of the following items (i)-(ii):

(i) the approximate date and the town and state of any arrest of the noncustodial parent within the last five years, or

(ii) the approximate dates and the name and state of the correctional institution in which the noncustodial parent was incarcerated within the last five years.

(H) Military service

The information required under this subparagraph is the branch and the approximate dates of any military service of the noncustodial parent.

(I) Other information

The information required under this subparagraph is any other information which can be verified by the department and could reasonably be expected to lead to the determination of the parent's social security number.

(3) Assisting in court actions and other proceedings

The client shall assist in court actions and other proceedings as necessary to establish the paternity of, or to establish, modify, or enforce a medical or monetary support order for, any child receiving assistance by participating in the following activities:

(A) appearing as a witness in court, before a family support magistrate, or at a fair hearing;

(B) assisting an attorney representing the interests of the IV-D agency in the preparation or conduct of a court action;

(C) appearing at interviews as requested by a representative of the department or a cooperating agency; and

(D) providing the department or a cooperating agency with information or documentation in addition to that specifically identified in subdivision (2) of this subsection to the extent it is known to, possessed by, or reasonably obtainable by such client.

(4) Submitting to genetic tests

The client shall submit to genetic tests and shall submit the child to genetic tests pursuant to an order of a court or family support magistrate or as required by the IV-D agency pursuant to subsection (a) of section 46b-168a of the Connecticut General Statutes and section 46b-168a-1 of the regulations of Connecticut State Agencies.

(5) Turning over support payments

A recipient of TFA only, not medicaid, SAGA, or child care assistance, shall turn over to the department any support payments received directly from the noncustodial parent for a child receiving such assistance. Any such payment that is not turned over shall result in an overpayment.

(c) Exemptions from cooperation requirements

(1) Domestic violence

A client who is a past or present victim of domestic violence, as defined in section 17b-112a of the Connecticut General Statutes, or who is at risk of further domestic violence shall be exempt from all cooperation requirements of subsection (b) of this section provided the department determines that fulfilling such requirements would result in the inability or increased difficulty of such client to escape or prevent such domestic violence.

(2) Deceitful noncustodial parent

A client shall be exempt from providing information under subdivision (2) of subsection (b) of this section to the extent such client provides evidence and the department determines that the noncustodial parent was deceitful concerning such information and the required information is unavailable to the client.

(3) Mental impairment

A client shall be exempt from providing information under subdivision (2) of subsection (b) of this section if the department determines that such client suffers from a permanent or temporary mental illness or disability which impairs memory or otherwise impedes the client's ability to obtain such information.

(4) Other good faith reason

A client shall be exempt from providing information under subdivision (2) of subsection (b) of this section if the department determines that such client has any other good faith reason for not being able to provide such information.

(5) Exceptional circumstances

A client shall be excused from discrete acts such as but not limited to the keeping of scheduled appointments as required under subdivisions (3) and (4) of subsection (b) of this section, but shall not be exempt from otherwise cooperating under such subdivisions, if such client demonstrates and the department determines that a good faith effort was made to cooperate and that circumstances beyond the client's control prevented cooperation.

(6) Documentation

A client who is claiming an exemption under subdivisions (1) through (4), inclusive of this subsection shall be required to submit a sworn statement describing the circumstances justifying the claimed exemption. The department shall inform such client of the following potential penalties prior to requesting such statement:

(A) penalties for false statement under sections 53a-157b and 17b-97 of the Connecticut General Statutes,

(B) penalties for larceny under sections 53a-122 and 53a-123 of the Connecticut General Statutes, and

(C) penalties for perjury under federal law.

(d) Cooperation determination by the department

(1) General rule

BCSE shall make all cooperation determinations pursuant to this section, except as provided in subdivision (2) of this subsection.

(2) Exceptions

(A) Minimum information obtained

BCSE shall not be required to make a determination of cooperation where the minimum information required under subdivision (2) of subsection (b) of this section is provided by the client at application or redetermination.

(B) Domestic violence claimed

Exemption determinations on the basis of a claim of domestic violence pursuant to subdivision (1) of subsection (c) of this section shall be made by departmental staff who are not assigned to BCSE.

History

• Adopted effective December 24, 1997; Amended June 8, 1998; Amended July 10, 2000; Amended May 24, 2004

17b-179(b) Child Support and Arrearage Guidelines

Regs., Conn. State Agencies § 17b-179(b)-1 Use of child support and arrearage guidelines

In all IV-D cases, current child support and arrearage obligations shall be computed in accordance with the child support and arrearage guidelines promulgated by Connecticut's Commission for Child Support Guidelines, as required by Section 46b-215b of the Connecticut General Statutes. Such guidelines, and any updates, are incorporated herein by reference as though fully set forth herein.

History

• Effective July 31, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-179(b)-2 Redirection of support payments

(a) Payment to the state

Upon the establishment of a IV-D case, BCSE shall take appropriate CCSES and other actions to redirect all payments under pre-existing support orders to the State of Connecticut acting by and through the IV-D agency. When an order is redirected, BCSE shall notify the obligee and shall mail promptly to the obligor a notice informing him or her of such actions, which notice shall provide

(1) an explanation of the basis for such actions;

(2) information on the terms of the support order;

(3) instructions for making payments to the state disbursement unit, as defined in subdivision (a) (3) of Section 17b-179(m)-6 of the Regulations of Connecticut State Agencies;

(4) a summary of the remedies for noncompliance with the support order;

(5) notice of the obligor's right to a hearing prior to imposition of any sanction, the right to appointment of an attorney to represent him or her prior to incarceration for contempt in the case of indigency, the right to request a review of the support order, and the right to petition the court for a modification of such order; and

(6) the address and telephone number of the individual or agency to contact if the obligor has any questions about the notice or disputes any information about the support order.

(b) Distribution to the custodial relative

Payments redirected to the state acting by and through the IV-D agency under subsection (a) of this section shall continue to be made to the state disbursement unit for as long as IV-D services are being provided. Upon the discontinuance of cases in which support rights have been assigned to the state in accordance with section 17b-77 of the Connecticut General Statutes, current child support payments shall be distributed to the custodial party of record on the date of discontinuance, for the benefit of the children named in the support order.

History

• Effective July 31, 1995; Amended June 8, 1998

17b-179(f) Title IV-D Child Support Enforcement Program

Regs., Conn. State Agencies § 17b-179(f)-1 Referrals to the federal parent locator service

(a) Definitions

As used in this section:

(1) "Authorized person" means the Office of the State's Attorney; the Office of the U.S. Attorney; a family relations counselor of the Family Division of the Superior Court; or the Department of Public Safety, Division of State Police, Missing Persons Unit.

(2) "Custody or visitation determination" means a judgment, decree, or other order of a court of competent jurisdiction providing for custody or visitation of a child, and includes permanent and temporary orders, and initial orders and modifications.

(3) "Parental kidnapping" means the unlawful taking or restraint of a child by a parent.

(b) SPLS established

There is established within BCSE a central SPLS with sole responsibility, under subsection (f) of section 17b-179 of the Connecticut General Statutes, to make referrals to the FPLS in accordance with this section and in compliance with applicable federal regulations.

(c) SPLS functions

(1) Accept requests to use the FPLS

The SPLS shall only accept requests to use the FPLS from:

(A) BCSE or an agency under cooperative agreement with BCSE or the department which has the duty under such agreement to seek to recover any amounts owed as child and spousal support;

(B) a court or agency thereof that has authority to issue a support order or to serve as the initiating court in an action to seek an order against a noncustodial parent for the support and maintenance of a child;

(C) the resident parent, legal guardian, attorney, or agent of a child who is not receiving TFA, without regard to the existence of a court order against a noncustodial parent who has a duty to support and maintain any such child; or

(D) an authorized person, for the sole purpose of making or enforcing a child custody or visitation determination, or investigating or prosecuting a parental kidnapping case.

(2) Access FPLS

The SPLS shall:

(A) enter the required data into the FPLS automated system within five working days of receipt of a proper referral and

(B) forward information received from the FPLS to the requesting agency or individual within five working days from the date the information is received.

(3) Access other states' SPLS

When a request is made to access another state's SPLS, the SPLS shall, in addition to the efforts of subdivision (2) of this subsection:

(A) send a referral to such other state within five working days of receipt of a proper referral and

(B) forward information received from the other state within five working days of receipt of any information received.

(4) Protect information

(A) In general

Except as provided in subparagraph (B) in this subdivision, any information obtained by the SPLS shall be used and disclosed only in connection with the administration of the IV-D program.

(B) Parental kidnapping and child custody cases

BCSE and the SPLS shall:

(i) restrict access to any information obtained in a parental kidnapping or child custody case to such persons whose duties or responsibilities require access;

(ii) send information obtained from the FPLS only to the requester of such information, and make no other use of the information; and

(iii) destroy any confidential records or information related to the request after the information is sent to the requester.

(d) Processing fees

A processing fee shall be charged by BCSE in accordance with this subsection to all applicants for location services who are not receiving any other IV-D services. All such fees shall be paid in advance to the commissioner, and shall be nonrefundable even if no information is found.

(1) Location-only cases

The fee for the location of a noncustodial parent when location is the only service requested shall be $10.00 for the basic service, plus $4.00 additional if the noncustodial parent's social security number is not provided by the applicant.

(2) Parental kidnapping and child custody cases

The fee for the location of a noncustodial parent or child in a parental kidnapping or child custody case shall be $20.00 for the basic service, plus $4.00 additional if the noncustodial parent's social security number is not provided by the applicant.

History

• Effective July 31, 1995; Amended June 8, 1998

17b-179(i) Title IV-D Child Support Enforcement Program

Regs., Conn. State Agencies § 17b-179(i)-1 Application fee for non-assistance cases

Individuals who request IV-D services and are not at the time of the request receiving TFA, foster care, or medicaid assistance from the state, or continuing IV-D services pursuant to such programs, shall be charged an application fee in the amount of $1.00, which shall be paid by the state.

History

• Effective July 31, 1995; Amended June 8, 1998; Amended May 24, 2004

17b-179(m) Title IV-D Child Support Enforcement Program

Regs., Conn. State Agencies § 17b-179(m)-1 Intake and establishment of cases

(a) Assistance and Medicaid cases

(1) Required activities

In assistance and Medicaid cases, BCSE shall, except as provided in subdivision (2) in this subsection:

(A) ensure the availability of at intake or provide to the recipient within 5 working days of referral from the appropriate referral source, information describing available services, the individual's rights and responsibilities, and the state's fees, cost recovery, and distribution policies;

(B) within 5 working days of receipt of referral from the appropriate referral source, open a IV-D case by establishing a case record; and

(C) within 20 calendar days of receipt of referral from the appropriate referral source, based on an assessment of the case to determine necessary action,

(i) solicit necessary and relevant information from the custodial party and other relevant sources and initiate verification of information, if appropriate; and

(ii) if there is inadequate location information to proceed with the case, request additional information from the custodial party or refer the case to the SPLS for further location attempts.

(2) Domestic violence exemption

(A) Request

Upon receiving notice that a client, as defined in subparagraph (a)(2)(B) of section 17b-179(a)-4 of the Regulations of Connecticut State Agencies, has requested an exemption from cooperation requirements on the basis of a claim of domestic violence pursuant to section 17b-112a of the Connecticut General Statutes, BCSE shall suspend all activities to establish paternity or establish, modify, or enforce a child or medical support order until notified of a final determination pursuant to subparagraph (d)(2)(B) of section 17b-179(a)-4 of the Regulations of Connecticut State Agencies.

(B) Determination

BCSE shall not undertake to establish paternity or establish, modify, or enforce a child or medical support order for any client who is determined exempt from cooperation requirements pursuant to subdivision (c)(1) of section 17b-179(a)-4 of the Regulations of Connecticut State Agencies.

(b) Non-assistance cases

In non-assistance cases, BCSE shall:

(1) provide an application for IV-D services to any individual who requests the application or any IV-D service

(A) on the day of the request if the request is made in person or

(B) within 5 working days if the request is in writing or by telephone;

(2) provide with each application information describing available services, the individual's rights and responsibilities, and the state's fees, cost recovery, and distribution policies;

(3) accept a completed application as filed on the day it and the application fee are received; and

(4) within 20 calendar days of the filing of an application, based on an assessment of the case to determine necessary action:

(A) open a IV-D case by establishing a case record;

(B) solicit necessary and relevant information from the applicant and other relevant sources and initiate verification of information, if appropriate; and

(C) if there is inadequate location information to proceed with the case, request additional information from the applicant or refer the case to the SPLS for further location attempts.

(c) Continuation of services

Upon receiving notice from the department that a final determination to discontinue an assistance or Medicaid case has been made, BCSE shall:

(1) continue to provide all appropriate IV-D services without an application or application fee, provided the IV-D case has not been closed;

(2) redirect all future current support collections to the family;

(3) determine the amount of any IV-D collections which must be refunded to the custodial party;

(4) transfer to the custodial party's non-assistance accounts any assigned support amounts which exceed the amount of unreimbursed assistance paid to the family; and

(5) mail a notice to the custodial party informing him or her of the available child support services and his or her rights with respect thereto, any applicable fees, how any support collections will be distributed, and that all appropriate IV-D services will continue to be provided unless the custodial party requests case closure in accordance with section 17b-179(m)-12 of the Regulations of Connecticut State Agencies.

History

• Effective July 31, 1995; Amended June 8, 1998; Amended July 10, 2000

Regs., Conn. State Agencies § 17b-179(m)-2 Location of noncustodial parents

(a) Responsible agencies

(1) BCSE

BCSE shall be responsible for location pursuant to the intake process in all IV-D cases, including those in which there is a pre-existing support order which has not already been established on CCSES. Such responsibility shall remain with BCSE until the noncustodial parent is located and an enforceable order is established.

(2) SED

SED shall be responsible for location in all IV-D cases after the establishment of an enforceable order even if such order should subsequently become unenforceable or the noncustodial parent's whereabouts become unknown.

(b) General requirement

The responsible agency as specified in subsection (a) shall attempt to locate all noncustodial parents or sources of income and/or assets when location is necessary to take other necessary action in a case.

(c) Sources to be accessed

When location is necessary, the responsible agency shall use the following location sources, as appropriate:

(1) the FPLS and interstate location networks;

(2) state and local officials and employees administering public assistance, general assistance, medical assistance, food stamps, and social services;

(3) relatives and friends of the noncustodial parent;

(4) current or past employers;

(5) the local telephone company;

(6) the U.S. Postal Service;

(7) financial references;

(8) unions;

(9) fraternal organizations;

(10) police, parole, probation, and criminal records;

(11) state labor department;

(12) motor vehicle department; and

(13) any other sources described in Section 17b-137 of the Connecticut General Statutes.

(d) Processing times

(1) Local sources

Within 30 calendar days of determining that location is necessary, the responsible agency shall access all appropriate location sources other than the SPLS, the FPLS, and interstate location networks; and either locate the noncustodial parent or a source of income or assets, or refer the case to the SPLS for further location attempts.

(2) All sources

Within 75 calendar days of determining that location is necessary, the responsible agency shall access all appropriate location sources including the SPLS, the FPLS, and interstate location networks; and ensure that location information is sufficient to take the next appropriate action in a case.

(e) Repeated location attempts

(1) When required

The responsible agency shall repeat location attempts in cases in which previous attempts have failed, but adequate identifying and other information exists to meet requirements for submittal for location, on the earlier of

(A) quarterly or

(B) immediately upon receipt of new information which may aid in location.

(2) Required sources

Quarterly attempts shall be limited to currently available automated sources and shall include accessing state labor department files.

(3) Time standards

Repeated attempts because of new information which may aid in location shall meet the time standards in subsection (d).

History

• Effective July 31, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-179(m)-3 Service of process

(a) Responsible agencies

(1) AGO

The AGO shall be responsible for meeting the requirements of this section in actions for the legal determination of paternity in all IV-D cases, provided that the AGO shall refer cases in which repeated attempts to serve process are required under subdivision (b) (2) of this section to BCSE for location efforts, and shall repeat such attempts when the alleged father is located and the case is returned to the AGO by BCSE.

(2) BCSE

BCSE shall be responsible for meeting the requirements of this section in actions for the establishment of court-ordered support (exclusive of paternity actions) in all IV-D cases.

(3) SED

SED shall be responsible for meeting the requirements of this section in actions for the enforcement and modification of court-ordered support in all IV-D cases.

(b) General requirement

When service of process is necessary for the establishment, modification, or enforcement of court-ordered support, the responsible agency, as specified in subsection (a), shall ensure that diligent efforts to serve process are

(1) undertaken initially, and

(2) repeated at least quarterly in cases in which previous efforts have failed, but adequate identifying and other information exists to attempt service of process.

(c) Diligent efforts

Diligent efforts to serve process upon a noncustodial parent shall include the following:

(1) at least one attempt to serve process in hand, and

(2) if that fails, service at the verified abode of the noncustodial parent, and

(3) if that fails, by service on the employer of the noncustodial parent, if known, in accordance with subsection (f) of section 52-57 of the Connecticut General Statutes.

(d) Documentation

Diligent efforts, as required by this section, shall be documented in the case record, and the responsible agency, as specified in subsection (a), shall obtain such documentation from a sheriff or other party authorized to make the service whenever the agency arranges for such other party to make service.

History

• Effective July 31, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-179(m)-4 Establishment of paternity

(a) BCSE functions

BCSE shall:

(1) identify and use laboratories which perform, at reasonable cost, legally and medically acceptable genetic tests which tend to identify the father or exclude the alleged father. BCSE shall make available a list of such laboratories to SED, the Attorney General's Office (AGO), family support magistrates, and the public upon request.

(2) in all IV-D cases in which paternity of a child has not been established, within 30 calendar days of locating the alleged father:

(A) establish legal paternity by obtaining an acknowledgment of paternity, or, if that fails,

(B) refer the case to the AGO for establishment of paternity and a support order by court action.

(b) AGO functions

The AGO shall, within 60 calendar days of receipt of a referral for paternity and support action from BCSE,

(1) file a verified paternity petition, refer the case to an authorized party for service of process, and complete service of process to establish paternity and support, or

(2) document unsuccessful attempts to serve process, despite diligent efforts to do so, in accordance with section 17b-179(m)-3.

(c) Expedited process

Cases requiring service under this section shall be completed, from the date of service of process to the date on which paternity and a support order are established or the court action is dismissed, within the following timeframes:

(1) 75% within 6 months and

(2) 90% within 12 months.

History

• Effective September 26, 1996; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-179(m)-5 Establishment of support orders

(a) Initial activity

In all intrastate IV-D cases in which a support order does not already exist, BCSE shall, within 90 calendar days of locating the alleged father or noncustodial parent, either:

(1) establish a support order by obtaining a child support agreement and, if necessary, an acknowledgment of paternity, or

(2) obtain the AGO's approval of the documents necessary to commence proceedings to establish a support order, and either:

(A) complete service of process of such documents, or

(B) document unsuccessful attempts to serve process, despite diligent efforts to do so.

(b) Initiating income withholding

(1) AGO functions

The AGO shall, when an immediate order for withholding is issued by a court or family support magistrate against a nonappearing obligor, attempt service by certified mail of the notice required by subsection (b) of section 52-362 of the Connecticut General Statutes.

(2) BCSE functions

Except as provided in subdivision (1) of this subsection, BCSE shall take the actions required in subsection (b) of section 17b-179(m)-9 to initiate an income withholding order upon the establishment of an initial support order or the redirection of a pre-existing order to the State of Connecticut.

(c) Review in the case of dismissal

If the court or family support magistrate dismisses a petition for a support order without prejudice, BCSE shall, in consultation with the AGO, examine the reasons for dismissal at the time of dismissal and determine when it would be appropriate to seek an order in the future, and schedule a review for that time.

(d) Expedited process

Cases requiring service under this section shall be completed, from the date of service of process to the date on which a support order is established or the court action is dismissed, within the following timeframes:

(1) 75% within 6 months and

(2) 90% within 12 months.

History

• Effective September 26, 1996; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-179(m)-6 Collection of support payments

(a) Definitions

As used in this section:

(1) "Deposit" means credit to an account owned by the State of Connecticut.

(2) "Post" means credit to the correct obligor's account in CCSES.

(3) "State Disbursement Unit" means the entity under contract with the department to provide comprehensive collection and disbursement services for the Connecticut IV-D program.

(b) Time standards

The department shall take steps to ensure that the State Disbursement Unit:

(1) deposits all IV-D support collections within 24 hours of receipt and

(2) transmits to the department the necessary posting data for at least 95% of such collections within 24 hours of receipt.

History

• Effective July 31, 1995; Amended June 8, 1998

Regs., Conn. State Agencies § 17b-179(m)-7 Medical support

(a) BCSE functions

BCSE shall:

(1) attempt to establish a medical support order, either solely in appropriate Medicaid-only cases, or in conjunction with efforts to establish a monetary order in any IV-D case, if there is no existing monetary support order;

(2) coordinate the collection of information concerning the noncustodial parent's health insurance policy or plan and transmit the necessary information to the appropriate unit within the department for cases receiving medical assistance;

(3) recommend to the court to include employment related or other group health insurance in support orders;

(4) inform individuals who are not receiving financial or medical assistance that medical support enforcement services are available to them; and

(5) enter medical insurance information on CCSES within 10 calendar days from the date that an order is entered, or from the date when the obligor secures health insurance under the order.

(b) SED functions

SED shall:

(1) attempt to establish medical support through the modification process if a monetary support order already exists;

(2) assist BCSE in obtaining and maintaining basic medical support information on child support obligors;

(3) recommend to the court to include employment related or other group health insurance in support orders;

(4) take the steps necessary to enforce the health coverage required by a court or administrative order by ensuring that the obligor secure and maintain the health coverage as ordered;

(5) transfer notice of a health insurance coverage requirement, in accordance with subsection (e) of section 38a-497a of the Connecticut General Statutes, to the obligor's new employer when an obligor changes employment; and

(6) enter medical insurance information on CCSES within 10 calendar days from the date that an order is modified, or from the date when the obligor secures health insurance under the order.

History

• Effective July 31, 1995; Amended June 8, 1998; Amended July 10, 2000

Regs., Conn. State Agencies § 17b-179(m)-8 Review and modification

SED shall perform the following functions with respect to the review and modification of support orders in IV-D cases.

(a) Review

Review the orders in all IV-D cases in accordance with subdivision (s) (4) of Section 46b-231 of the Connecticut General Statutes and in compliance with applicable federal regulations. The review shall include a determination of the appropriateness of a motion for modification as well as the application of appropriate enforcement remedies.

(b) Modification

SED shall prepare, serve, and be available for testifying at court on motions for modification for all orders identified pursuant to subsection (a), herein, as appropriate for modification. All types of modifications, including, but not limited to, the following shall be the responsibility of SED:

(1) upward and downward modifications due to increased or decreased income of either party or other change in financial circumstances causing a 15% or more deviation from the child support guidelines;

(2) addition or removal of a child resulting from emancipation, changed household residence, consolidation or modification of orders after a paternity acknowledgment or adjudication, or a child born after divorce;

(3) establishment of a current support order if only an arrearage order or a medical support order exists;

(4) addition of a health insurance coverage requirement to an existing financial support order;

(5) change of unallocated order when the children now reside with different custodial parties; and

(6) custody modifications, payee changes, and motions to add party plaintiff when ordered by the court during enforcement or modification proceedings.

History

• Effective July 31, 1995; Amended June 8, 1998; Amended July 10, 2000

Regs., Conn. State Agencies § 17b-179(m)-9 Enforcement of support orders

(a) In general

(1) Use of CCSES

The CCSES automated enforcement module shall be maintained by SED and shall be used in all IV-D cases to monitor compliance with support orders. Cases of noncompliance shall be identified by CCSES on the date the obligor fails to make payments in an amount equal to the support payable for one month.

(2) Required actions

Support orders in IV-D cases shall be enforced as follows:

(A) Income withholding

Income withholding shall be initiated in accordance with subsection (b) of this section.

(B) Income tax refund withholding

(i) Federal

All IV-D cases which satisfy the criteria set forth in section 52-362e-2 of the Regulations of Connecticut State Agencies shall be submitted in accordance with such section once a year for federal income tax refund withholding.

(ii) State

All IV-D cases which satisfy the criteria set forth in section 52-362e-3 of the Regulations of Connecticut State Agencies shall be submitted in accordance with such section once a year for state income tax refund withholding.

(C) Other enforcement actions

Except as otherwise provided in this section, SED shall be responsible for taking the actions required by this subparagraph. Enforcement actions other than income withholding and income tax refund withholding shall be taken as follows:

(i) Service of process not required

If service of process is not required, the action shall be taken within 30 calendar days of the later of the date the delinquency or other support-related noncompliance is identified, or the noncustodial parent is located.

(ii) Service of process required

If service of process is required, the action shall be taken within 60 calendar days of the date the delinquency or other support-related noncompliance is identified, or the noncustodial parent is located. If service of process cannot be made, diligent efforts to serve process, as described in section 17b-179(m)-3 of the Regulations of Connecticut State Agencies, shall be made and documented within the specified time period.

(D) Review when attempts fail

In cases in which enforcement attempts have been unsuccessful, the agency responsible for taking the particular enforcement action shall examine, at the time an attempt to enforce fails, the reason the attempt failed and determine when it would be appropriate to take an enforcement action in the future, and review the case at that time.

(3) Communication and referral

BCSE shall assist SED in the enforcement of IV-D support orders by:

(A) referring to SED all persons requesting the enforcement of support orders which have already been established on CCSES;

(B) assisting SED in communicating with IV-D agencies in other jurisdictions regarding the collection and enforcement of support orders;

(C) notifying SED within five working days of any changes in the status of an assistance or Medicaid case affecting the child support obligation; and

(D) providing SED with any new information on the obligor that becomes available to BCSE, including but not limited to address, employer, unemployment compensation intercept data, and increased wages.

(4) Motions to add party plaintiff

BCSE shall take the necessary steps to prepare a motion to add party plaintiff in situations where the state and the custodial party applying for IV-D services for the child were not parties to the original court action.

(5) Fatherhood initiative

SED shall, within existing resources, provide information regarding work activity and education programs to noncustodial parents when appropriate. SED shall also make recommendations to the family support magistrate that certain noncustodial parents participate in work activities and education programs when brought before the court. SED shall monitor cases for compliance when the family support magistrate issues an order to participate in work activities and education programs.

(b) Income withholding

(1) General provisions

(A) Responsible agency

Except as otherwise provided, BCSE shall be responsible for the procedures in this subsection pursuant to the establishment of an initial support order or the initiation of withholding on the basis of a pre-existing support order not already on CCSES, provided the obligor's income source is known at the time the order is established or the withholding is initiated. SED shall be responsible for such procedures in all other IV-D cases.

(B) Termination of withholding

BCSE shall examine CCSES reports to identify all cases in which

(i) a payment is received,

(ii) there is no longer a current support order,

(iii) all arrearages have been satisfied, and

(iv) income withholding is still in effect.

BCSE shall notify SED of all cases so identified, and SED shall promptly notify the obligor's employer or other payer of income to terminate withholding.

(C) Refunds

SED shall identify all IV-D cases in which amounts have been improperly withheld, and promptly prepare and refer to BCSE a request for refund of such amounts. BCSE shall promptly process such requests.

(D) Reporting requirements

All support orders issued or modified in IV-D cases shall include a provision requiring the obligor to keep the IV-D agency informed of:

(i) the name and address of his or her current employer,

(ii) whether the obligor has access to health insurance coverage at reasonable cost and, if so,

(iii) the health insurance policy information.

(E) Unemployment compensation

SED shall review on a monthly basis computer printouts of unemployment compensation recipients to determine if an income withholding order should be served on the labor department commissioner.

(F) Action on new hire reporting information

SED shall review information received through the new hire reporting process pursuant to section 31-254 of the Connecticut General Statutes and take the necessary action to establish, transfer or enforce an income withholding order pursuant to section 52-362 of the Connecticut General Statutes.

(2) Immediate withholding

All support orders issued or modified in IV-D cases shall include an order for immediate income withholding, regardless of any arrearage, except where:

(A) a party demonstrates, and the court or family support magistrate finds, that there is good cause not to require immediate withholding, or

(B) the parties reach a written agreement which provides for an alternative arrangement.

For the purposes of this subparagraph, "written agreement" means a written alternative arrangement signed by all parties, approved by the IV-D agency, and reviewed and entered in the record by the court or family support magistrate.

(3) Initiated withholding

This subdivision applies in all IV-D cases not subject to an order for immediate income withholding, including cases subject to a finding of good cause or to a written agreement, as provided in subdivision (2) of this subsection.

(A) When obligor subject to withholding

The income, as defined in subdivision (a)(5) of section 52-362 of the Connecticut General Statutes, of the obligor shall become subject to withholding on the date on which the payments the obligor has failed to make under a support order are at least equal to the support payable for one month or, if earlier, and without regard to any arrearage, on the earlier of:

(i) the date on which the obligor requests that withholding begin, provided a voluntary wage deduction is executed and approved in accordance with section 52-362c of the Connecticut General Statutes, or

(ii) the date on which the custodial party requests that withholding begin, provided such request is in writing and the procedures in subparagraph (B) of this subdivision are followed.

(B) Issuance of withholding order

The responsible agency shall issue an income withholding order as provided in subsection (e) of section 52-362 of the Connecticut General Statutes when the obligor becomes subject to withholding in accordance with subparagraph (a) of this subdivision. The order for withholding shall include all provisions required by section 52-362 of the Connecticut General Statutes and applicable federal law and regulations.

(C) Notice to obligor

The responsible agency shall serve notice of the withholding issued under subparagraph (B) of this subdivision promptly in accordance with subsection (h) of section 52-362 of the Connecticut General Statutes. Such notice shall comply in all respects with the provisions of subsection (c) of section 52-362 of the Connecticut General Statutes, and shall be accompanied by a copy of the withholding order.

(D) Hearing

A hearing shall be held in accordance with subsection (d) of section 52-362 of the Connecticut General Statutes if the obligor contests the withholding in response to the notice served in accordance with subparagraph (C) of this subdivision. When a hearing is requested, the responsible agency shall notify the employer or other payer of income that the withholding order is stayed under said subsection until the claim or motion is decided by the court or a family support magistrate.

(4) Processing times

(A) Immediate withholding

In the case of an immediate withholding order under subdivision (2) of this subsection, the responsible agency shall use CCSES to send the withholding order to the employer within two business days of the date the support order is entered if the employer is known on that date or, if the employer is unknown on that date, within two business days of locating the employer.

(B) Initiated withholding

In the case of initiated withholding pursuant to subdivision (3) of this subsection, the responsible agency shall use CCSES to send the withholding order to the employer within two business days of the date the obligor becomes subject to withholding if the employer is known on that date or, if the employer is unknown on that date, within two business days of locating the employer.

(5) Interstate withholding

(A) Initiating cases

Within 20 calendar days of a determination that an obligor has earnings subject to income withholding in another jurisdiction and, if appropriate, receipt of any information necessary to carry out the withholding, SED shall follow the procedure set forth in section 52-362f of the Connecticut General Statutes to request interstate withholding.

(B) Responding cases

SED shall, in addition to any other requirements set forth in section 52-362f of the Connecticut General Statutes, upon filing a foreign support order as provided in subsection (d) of section 52-362f of the Connecticut General Statutes, proceed as provided in section 46b-213k of the Connecticut General Statutes.

(c) Administrative enforcement functions

(1) BCSE functions

BCSE shall meet the requirements of this subdivision in all IV-D cases.

(A) Liens

Liens shall be placed in accordance with section 52-362d-2 of the Regulations of Connecticut State Agencies.

(B) Reporting overdue support to consumer reporting agencies

Overdue support information shall be reported to consumer reporting agencies in accordance with section 52-362d-3 of the Regulations of Connecticut State Agencies.

(C) Withholding of lottery winnings

Lottery winnings shall be withheld in accordance with section 52-362d-4 of the Regulations of Connecticut State Agencies.

(D) Seizure of financial assets

Financial assets shall be seized in accordance with section 52-362d-5 of the Regulations of Connecticut State Agencies, as provided in subsection (e) of section 52-362d of the Connecticut General Statutes.

(E) State and federal income tax refund withholding

State and federal income tax refunds shall be withheld in accordance with sections 52-362e-1 through 52-362e-3 of the Regulations of Connecticut State Agencies. Information concerning modifications, deletions and state payments relative to certified cases shall be submitted in a timely manner to the appropriate agency.

(F) Federal administrative enforcement certifications

Cases appropriate for passport denial, revocation, restriction or limitation, and cases appropriate for administrative offset of federal payments shall be certified to the appropriate federal agency in accordance with applicable federal law. Information concerning modifications, deletions and state payments relative to certified cases shall be submitted in a timely manner to the appropriate agency.

(G) Fair hearings

When a fair hearing in cases not yet referred to SED, or in cases involving recoupment or seizure of financial assets, is requested by a IV-D obligor,

(i) A hearing summary shall be prepared and

(ii) Appropriate personnel shall attend and participate in the fair hearing.

Testimony regarding the procedures followed by BCSE to establish support orders or to calculate arrearages shall be provided at fair hearings for which SED is responsible when requested by the hearing officer.

(H) Capias mittimus

Capias mittimus orders shall be served in accordance with the order of the court or family support magistrate.

(I) IRS full collection

Applications for IRS full collection services shall be submitted to OCSE within 30 days of receipt from SED, provided such applications are properly completed and adequately documented, and the fee has been paid.

(J) Fraudulent transfers

BCSE shall, in any case in which it determines that a child support obligor has made a transfer of income or property that is fraudulent as to the state or the recipient of IV-D services under chapter 923a of the Connecticut General Statutes,

(i) seek to avoid such transfer under section 52-552h of the Connecticut General Statutes or

(ii) obtain a settlement in the best interests of the state or such recipient.

(2) SED functions

SED shall meet the requirements of this subdivision in all IV-D cases.

(A) Account audit

An audit of an obligor's account shall be performed upon the obligor's request.

(B) Fair hearings

When a fair hearing on matters other than recoupment or seizure of financial assets is requested by a IV-D obligor,

(i) a hearing summary shall be prepared and

(ii) appropriate personnel shall attend and participate in the fair hearing.

(C) Liens and fraudulent transfers

(i) A determination shall be made, when enforcing or modifying an order, whether the obligor owns real or personal property which can be encumbered for the purpose of securing any past-due support or may have made a transfer of any such property that is fraudulent as to the state or the recipient of IV-D services under chapter 923a of the general statutes.

(ii) Cases identified in step (i) shall be referred to BCSE within fifteen days for appropriate action.

(D) Record maintenance

CCSES and manual records related to the enforcement functions described in this section shall be maintained.

(E) IRS full collection

(i) Applications for IRS full collection services shall be prepared in IV-D cases in which other legal remedies have been exhausted.

(ii) The appropriate fee shall be collected and forwarded with the application to BCSE.

(iii) Appropriate cases in which SED cannot identify assets sufficient for requesting full collection services shall be referred to BCSE for obtaining information subject to disclosure by the IRS.

History

• Effective September 26, 1996; Amended June 8, 1998; Amended July 10, 2000; Amended May 24, 2004

Regs., Conn. State Agencies § 17b-179(m)-10 Provision of services in interstate IV-D cases

(a) Central registry

(1) Definition

"Central registry" means a single centralized office within or under cooperative agreement with the IV-D agency which is responsible for receiving, distributing, and responding to automated and manual inquiries on all incoming interstate IV-D cases, including UIFSA petitions and requests for income withholding.

(2) Functions

There shall be a central registry located within SED which shall:

(A) within 10 working days of receipt of an interstate IV-D case from an initiating state,

(i) review submitted documentation for completeness,

(ii) forward the case to either the SPLS or the appropriate local office of SED for processing,

(iii) acknowledge receipt of the case and ensure that any missing documentation has been requested from the initiating state, and

(iv) inform the IV-D agency in the initiating state where the case was sent for action;

(B) if the documentation received with a case is inadequate and cannot be remedied by the central registry without the assistance of the initiating state, forward the case to the appropriate agency for any action which can be taken pending receipt of necessary documentation from the initiating state; and

(C) respond to inquiries from other states within 5 working days of receipt of the request for a case status review.

(b) Responding state functions

When Connecticut is the responding state, SED shall:

(1) serve as the support enforcement agency under UIFSA and provide any necessary services within the applicable timeframes for the given services which shall include paternity and support obligation establishment, in conjunction with the AGO, enforcement of court orders, and collection and monitoring of support payments;

(2) perform clerical, administrative and other non-judicial functions on behalf of the family support magistrate division pursuant to UIFSA;

(3) maintain a registry of support orders of the Family Support Magistrate Division;

(4) maintain a registry of paternity judgments of other states, which registry shall include both paternity acknowledgments and adjudications;

(5) serve as the state information agency under UIFSA;

(6) provide timely notice to the parties and the IV-D agency in the initiating state of:

(A) Hearings to establish or modify a support order,

(B) Hearings to contest the registration of a support or income withholding order, and

(C) Hearings to contest the direct filing of an income withholding order from another state with a Connecticut employer;

(7) Provide a copy of any support order established or modified, or a notice of determination that there should be no change in the amount of the support order, within 14 days of issuance, to each party and the state case registry;

(8) Provide the petitioner within 5 days, excluding weekends and holidays with:

(A) copies of written notice from an initiating, responding or registering tribunal,

(B) copies of written communication from the respondent or respondent's attorney, and

(C) notice if jurisdiction over the respondent cannot be obtained;

(9) within 10 working days of receipt of new information on a case, notify the IV-D agency in the initiating state by submitting an updated form;

(10) within 75 calendar days of receipt of a standardized interstate Child Support Enforcement Transmittal and documentation from the central registry:

(A) provide location services in accordance with section 17b-179(m)-2 of the Regulations of Connecticut State Agencies if the request is for location services or the form or documentation does not include adequate location information on the noncustodial parent,

(B) if unable to proceed with the case because of inadequate documentation, notify the IV-D agency in the initiating state of the necessary additions or corrections to the form or documentation, and

(C) if the documentation received with a case is inadequate and cannot be remedied by SED without the assistance of the initiating state, process the interstate IV-D case to the extent possible pending necessary action by the initiating state;

(11) within 10 working days of locating the noncustodial parent in a different jurisdiction within the state, forward the form and documentation to the appropriate jurisdiction and notify the initiating state and central registry of its action;

(12) within 10 working days of locating the noncustodial parent in a different state:

(A) return the form and documentation, including the new location, to the initiating state, or, if directed by the initiating state, forward the form and documentation to the central registry in the state where the noncustodial parent has been located, and

(B) notify the central registry where the case has been sent;

(13) If a petition or comparable pleading is received by an inappropriate tribunal of this state, promptly forward the pleadings and the accompanying documents to an appropriate tribunal in this state or another state and notify the petitioner by first class mail where and when the pleading was sent;

(14) Accept and process international requests for child support services from any foreign jurisdiction that has enacted a law or established procedures for issuance and enforcement of support orders which are substantially similar to UIFSA, the Uniform Reciprocal Enforcement of Support Act, or the Revised Uniform Reciprocal Enforcement of Support Act;

(15) notify the central registry in the initiating state when a case is closed; and

(16) coordinate genetic testing arrangements with the initiating court.

(c) Initiating state functions

When Connecticut is the initiating state, SED shall perform the functions assigned to it under UIFSA. SED shall also accept and process requests from BCSE for child support services in foreign nations that have enacted a law or established procedures for issuance and enforcement of support orders which are substantially similar to UIFSA, the Uniform Reciprocal Enforcement of Support Act, or the Revised Uniform Reciprocal Enforcement of Support Act. SED shall also perform the following additional functions specified in this subsection.

(1) Establishment

In cases requiring the establishment of paternity where the putative father resides out of or is absent from the state, BCSE shall first attempt to establish legal paternity in accordance with section 17b-179(m)-4 of the Regulations of Connecticut State Agencies, to the extent provided in section 46b-160 of the Connecticut General Statutes, before proceeding under this section. In other cases when Connecticut is the initiating state, BCSE shall, in cases requiring the establishment of a support order through the UIFSA petition process:

(A) complete all required forms for the interstate referral package and refer to the responding state's central registry within 20 calendar days of determining that the noncustodial parent is in another state;

(B) provide the petitioner within five days, excluding weekends and holidays with:

(i) copies of written notice from an initiating, responding or registering tribunal,

(ii) copies of written communication from the respondent or the respondent's attorney, and

(iii) notice if jurisdiction over the respondent cannot be obtained;

(C) provide the IV-D agency or central registry in the responding state any requested additional information or notify the responding state when the information will be provided within 30 calendar days of receipt of the request for information by submitting an updated form and any necessary additional documentation;

(D) notify the IV-D agency in the responding state within 10 working days of receipt of new information on a case by submitting an updated form and any necessary additional documentation;

(E) coordinate genetic testing arrangements when ordered by the responding court; and

(F) provide a copy of any support order established or modified, or a notice of determination that there should be no change in the amount of the support order, within 14 days of issuance, to each party and the state case registry.

(2) Enforcement

(A) Responsible agency

BCSE shall perform the functions in this subdivision if it determines, pursuant to the intake process, that there is a pre-existing support order which has not already been established on CCSES. SED shall perform such functions if BCSE determines that there is a pre-existing support order which has already been established on CCSES.

When BCSE performs the functions in this subdivision, it shall also, where required for the remedy chosen, complete all forms for the interstate referral package and forward the completed package along with all required documentation, such as financial affidavits and certified copies of court orders, to the responding state's central registry within 20 calendar days of determining that the noncustodial parent is in another state.

(B) Initiate remedy

The responsible agency shall obtain sufficient information and documentation to determine the appropriate remedy, depending on the noncustodial parent's income source, and initiate such remedy as follows:

(i) income withholding served on resident agent if the noncustodial parent is employed by a company doing business in Connecticut,

(ii) direct income withholding if the noncustodial parent is employed by a company in another state with the UIFSA direct withholding provision;

(iii) interstate income withholding or request for enforcement of responding state's own local order if the noncustodial parent is employed by a company not doing business in Connecticut and direct income withholding is not appropriate,

(iv) involuntary military allotment if the noncustodial parent is in active military service,

(v) withholding served on designated agent if the noncustodial parent is employed by the federal government,

(vi) registration of order or request for enforcement of responding state's own local order if the noncustodial parent is self-employed or his or her income source is unknown, or

(vii) UIFSA petition to establish a support order if there are no orders entitled to recognition under UIFSA.

(C) Provide information

The responsible agency shall provide the IV-D agency or central registry in the responding state any requested additional information or notify the responding state when the information will be provided within 30 calendar days of receipt of the request for information by submitting an updated form and any necessary additional documentation.

(D) Update information

The responsible agency shall notify the IV-D agency in the responding state within 10 working days of receipt of new information on a case by submitting an updated form and any necessary additional documentation.

(E) Notify petitioner

The responsible agency shall provide the petitioner within five days, excluding weekends and holidays with:

(i) copies of written notice from an initiating, responding or registering tribunal,

(ii) copies of written communication from the respondent or the respondent's attorney, and

(iii) notice if jurisdiction over the respondent cannot be obtained.

(F) Coordinate genetic testing

The responsible agency shall coordinate genetic testing arrangements when ordered by the responding court.

(G) Provide copy of order

The responsible agency shall provide a copy of any support order established or modified, or a notice of determination that there should be no change in the amount of the support order, within 14 days of issuance, to each party and the State Case Registry.

(H) Update CCSES

The responsible agency shall update CCSES upon completion of the responding state action.

History

• Effective July 31, 1995; Amended June 8, 1998; Amended July 10, 2000

Regs., Conn. State Agencies § 17b-179(m)-11 Administration

(a) BCSE or department functions

BCSE, the department, or an entity under contract with the department shall perform the following administrative functions.

(1) Federal reports

Prepare the federal reports required by OCSE for the IV-D program.

(2) Fair hearings

Provide obligors aggrieved by an alleged action or inaction with an opportunity for a fair hearing on matters concerning the withholding of state and federal income tax refunds; placement of liens on real or personal property; reporting overdue support to consumer reporting agencies; withholding of lottery winnings; SED determinations not to pursue motions for modification; certifications for passport denial, revocation, restriction or limitation, and administrative offset of federal payments; and seizure of financial assets.

(3) Oversight

Ensure that the functions delegated to cooperating agencies pursuant to the IV-D state plan are being carried out properly, efficiently and effectively.

(4) CCSES reports

Provide existing reports, and create and provide new reports, that are appropriate and necessary for the administration of the Connecticut IV-D program based on information contained in CCSES.

(5) Labor department cooperative agreement

Maintain a cooperative agreement with the state labor department that defines procedures for serving income withholding orders on the labor commissioner against the unemployment compensation benefits of child support obligors. The cooperative agreement shall also provide for payment of the labor department's costs by the IV-D program.

(6) Access to automated databases

Ensure access by SED to the automated databases of the departments of labor, motor vehicles, correction, and others as available, through CCSES.

(7) Automated interface

Arrange for and maintain an automated interface capability between CCSES and the department's Eligibility Management System for referral and information exchange in assistance and Medicaid cases.

(8) Bad checks

Receive IV-D support checks which have been charged back and returned by financial institutions, establish a bad check recovery disposition on CCSES, and return the original charged back check to the payer with appropriate notification and instructions.

(9) Returned checks

Receive IV-D support checks returned by the post office as undeliverable and remail such checks to a more recent valid address if one appears on CCSES. If a more recent valid address does not appear on CCSES, void such checks and invalidate the custodial party's address on CCSES using a unique code.

(10) Refunds

Process all refund requests and respond to all inquiries concerning such refunds other than those related to the preparation of the request itself.

(11) Recovery of retained direct support

Recover child support payments received directly and retained by custodial parties.

(12) Recovery of misapplied child support payments

Recover misapplied child support payments in accordance with section 17b-179(a)-3 of the Regulations of Connecticut State Agencies.

(13) Resolution of inquiries and complaints

Assist in the resolution of inquiries and complaints.

(14) Administrative enforcement inquiries

Accept and respond to initial telephone inquiries regarding the administrative enforcement mechanisms for which BCSE is responsible under subsection (c) of section 17b-179(m)-9 of the Regulations of Connecticut State Agencies.

(15) IV-D management forum

Establish a forum for the cooperating agencies at the managerial level to maintain open communications between the primary agencies involved in the administration of the IV-D program for the State of Connecticut. Such forum shall hold regular meetings for the purpose of identifying and resolving any functional issues not otherwise adequately addressed, maintaining a clear and unified vision of the aims and policies of the IV-D program, and planning for the implementation of any new federal or state requirements.

(b) SED functions

SED shall perform the following administrative functions.

(1) Interstate correspondence

Cooperate with BCSE in responding to any requests for information or services received from IV-D agencies in other jurisdictions.

(2) Financial statements

Submit to BCSE for the purpose of federal financial participation a quarterly statement of costs incurred in the performance of its responsibilities under the IV-D state plan no later than twenty days from the last day of each quarter, in accordance with an agreed cost allocation plan and the annual personnel plan consisting of the number of positions by job classification and a budget for the cost of services provided. Indirect costs shall be submitted annually no later than the second quarter of the state fiscal year, and calculated utilizing the statewide cost allocation plan and the standard indirect cost rate.

(3) Statistical reports

Submit monthly statistical reports to BCSE as required for the implementation of the IV-D state plan, subject to the availability of staffing and electronic data processing resources.

(4) Oversight

Assist BCSE in its monitoring responsibilities in accordance with the self-assessment plan issued by BCSE pursuant to federal IV-D program requirements to ensure that the IV-D agency remains in compliance with federal regulations and OCSE audit guidelines.

(5) Record retention

Retain all records for cases closed for a minimum of three years from the date of closure.

(6) Bad checks

Assist BCSE in the recovery of bad checks issued to the State of Connecticut in non-assistance cases when a payer fails to provide restitution to the department. SED assistance shall be limited to notifying the court of the existence of a bad check in the automated enforcement process and remitting any recovery to BCSE for proper credit.

(7) Refund requests

Investigate and prepare requests for refunds of child support monies to obligors and custodial parties, and refer such requests to the department for processing. Respond to inquiries concerning such refunds that are related to the preparation of the request itself. Refer to the department or the State Disbursement Unit, as appropriate, cases associated with problems resulting from operator error or systemic failure for completing the refund request.

(8) Resolution of inquiries and complaints

Maintain a unit of judicial branch employees referred to as the child support information and problem resolution unit whose responsibilities shall include: responding to requests for child support program information, responding to questions and inquiries related to the child support enforcement program, and resolving case-related problems that require extensive, detailed research or time.

(9) Payment processing

(A) Transfer child support payments or other funds received by SED field offices to the State Disbursement Unit by electronic fund transfer, check or other automated process when appropriate. Such transfers shall be made in accordance with state and federal laws and regulations.

(B) Prepare and fax to the State Disbursement Unit a transmittal, which contains the appropriate detail, related to each payment received by SED and transferred to the State Disbursement Unit.

(C) Notify the State Disbursement Unit of misapplied or missing payments that are discovered by SED and document such payments in CCSES or on an appropriate form to ensure resolution.

(D) Assist the State Disbursement Unit in the resolution of non-disbursed funds due to a "not valid address" indicator in CCSES.

(E) Assist the State Disbursement Unit in the resolution of returned checks (not deliverable by the post office) by performing the following activities, as resources permit:

(i) locate activities as appropriate,

(ii) case closure,

(iii) termination of income withholding, if appropriate, and

(iv) notifying BCSE of action taken.

(F) Assist the State Disbursement Unit in contacting employers who are not in compliance with an income withholding order.

(10) Non-IV-D cases

(A) Process income withholding order forms from non-IV-D litigants or their attorneys.

(B) Enter the required information for non-IV-D cases in the state case registry.

History

• Effective July 31, 1995; Amended June 8, 1998; Amended July 10, 2000

Regs., Conn. State Agencies § 17b-179(m)-12 Case closure

BCSE, in pre-obligation cases, and SED, in obligation cases, shall close cases in accordance with this section. The agency responsible for case closure shall also be responsible for verifying the circumstances justifying closure.

(a) Criteria

In order to be eligible for closure, a IV-D case must meet at least one of the following criteria:

(1) There is no longer a current support order and arrearages are under $150 if owed to the state, under $500 if owed to the custodial party, or unenforceable under state law.

(2) The noncustodial parent or putative father is deceased and no further action, including a levy against the estate, can be taken.

(3) Paternity cannot be established because:

(A) the child is at least 18 years old and action to establish paternity is barred by section 46b-160 of the Connecticut General Statutes,

(B) a genetic test or a court or administrative process has excluded the putative father and no other putative father can be identified,

(C) the department has determined that it would not be in the best interests of the child to establish paternity in a case involving incest or forcible rape, or in any case where legal proceedings for adoption are pending, or

(D) The identity of the biological father is unknown and cannot be identified after diligent efforts, including at least one interview by the IV-D agency with the recipient of services.

(4) The noncustodial parent's location is unknown, and BCSE or a cooperating agency has made diligent efforts using multiple sources, in accordance with section 17b-179(m)-2 of the Regulations of Connecticut State Agencies, all of which have been unsuccessful, to locate the noncustodial parent:

(A) Over a three-year period when there is sufficient information to initiate an automated locate effort, or

(B) Over a one-year period when there is not sufficient information to initiate an automated locate effort.

(5) The noncustodial parent cannot pay support for the duration of the child's minority because the parent has been institutionalized in a psychiatric facility, is incarcerated with no chance for parole, or has a medically verified total and permanent disability with no evidence of support potential, and no income or assets available which could be levied or attached for support.

(6) The noncustodial parent is a citizen of, and lives in, a foreign country, does not work for the federal government or a company with headquarters or offices in the United States, and has no reachable domestic income or assets; and Connecticut has been unable to establish reciprocity with such country.

(7) In a non-assistance case,

(A) BCSE or SED is unable to contact the recipient of services within a 60 calendar day period despite an attempt by at least one letter sent by first class mail to the recipient's last known address, or

(B) BCSE or SED documents the circumstances of the recipient of services noncooperation and an action by the recipient of services is essential for the next step in providing IV-D services.

(8) BCSE or SED documents failure by the initiating state to take an action which is essential for the next step in providing services.

(9) BCSE has provided location-only services as requested pursuant to section 17b-179(f)-1 of the Regulations of Connecticut State Agencies.

(10) The non-assistance recipient of services requests closure of a case in writing and there is no assignment to the state of medical support or arrearages which accrued under a support order.

(11) The client has been determined exempt from cooperation requirements in accordance with subsection (c) of section 17b-179(a)-4 of the Regulations of Connecticut State Agencies and the department has determined that support enforcement may not proceed without risk of harm to the child or custodial party.

(b) Notice of closure

In cases meeting the criteria in subdivisions (1) through (8) of subsection (a) of this section, BCSE, in pre-obligation cases, and SED, in obligation cases, shall notify the recipient of services, or in an interstate case meeting the criteria for closure under subdivision (a)(8) of this section, the initiating state, in writing 60 calendar days prior to closure of the state's intent to close the case. The case shall be kept open if the recipient of services or the initiating state supplies information in response to the notice which could lead to the establishment of paternity or a support order or enforcement of an order or, in the instance of subparagraph (a)(7)(A) of this section, if contact is reestablished with the recipient of services. If the case is closed, the former recipient of services may request at a later date that the case be reopened if there is a change in circumstances which could lead to the establishment of paternity or a support order or enforcement of an order by completing a new application for IV-D services and paying any applicable application fee in accordance with section 17b-179(i)-1 of the Regulations of Connecticut State Agencies.

(c) Retention of case records

BCSE and cooperating agencies shall retain all records for cases closed pursuant to this section for a minimum of three years.

History

• Effective July 31, 1995; Amended June 8, 1998; Amended July 10, 2000

Regs., Conn. State Agencies § 17b-179(m)-13 Substantial compliance

(a) Definition

(1) 90% standard

Substantial compliance with the standards established in

(A) subparagraph (a)(1)(A) and subdivisions (b)(1) through (b)(3) of section 17b-179(m)-1, and

(B) section 17b-179(m)-12

shall be defined as achievement of the given standard in at least 90% of the cases requiring the action regulated by such standard.

(2) 75% standard

Except as provided in subsection (c) of section 17b-179(m)-4 and subsection (d) of section 17b-179(m)-5 of the Regulations of Connecticut State Agencies, substantial compliance with the standards established in sections 17b-179(m)-1 (exclusive of those subject to the standard established in subdivision (1) of this subsection) through 17b-179(m)-11, inclusive, shall be defined as achievement of the given standard in at least 75% of the cases requiring the action regulated by such standard.

(b) How determined

Substantial compliance shall be determined separately for each case activity described in sections 17b-179 (m)-1 through 17b-179 (m)-12, to the extent of the monitoring capabilities of CCSES.

(c) Notice of deficiency

The department may issue a notice of deficiency to any cooperating agency determined to be not in substantial compliance with any of sections 17b-179 (m)-1 through 17b-179 (m)-12. The notice shall identify the specific deficiencies and how they were determined, and shall specify the date by which a corrective action plan shall be submitted.

(d) Corrective action plan

(1) Submittal

Any agency to which a notice of deficiency has been issued shall prepare, in consultation with the director of BCSE and any other appropriate department officials, a corrective action plan detailing the steps such agency will take to achieve compliance. The plan shall be submitted to the department within 45 calendar days of the issuance date of the notice of deficiency.

(2) Review

The department shall review a cooperating agency's corrective action plan within 90 calendar days of its submittal date. The results of such review shall be reported to the cooperating agency within 30 calendar days.

(3) Implementation

The department shall review a cooperating agency's implementation of any corrective action plan a minimum of 180 calendar days from the date of approval of such plan. The results of such review shall be reported to the cooperating agency within 30 calendar days. Any deficiencies remaining at the time of the review shall be noted in the annual report of BCSE to the judiciary and human services committees of the general assembly, as required by subsection (n) of section 17b-179 of the Connecticut General Statutes.

History

• Effective September 26, 1996; Amended July 10, 2000

17b-179b Title IV-D Child Support Enforcement Program

Regs., Conn. State Agencies § 17b-179b-3 Arrearage adjustment program for Parenthood Program participants (Repealed)

Repealed April 2, 2015.

History

• Adopted effective May 24, 2004; Repealed April 2, 2015

Regs., Conn. State Agencies § 17b-179b-3a Arrearage adjustment program for Parenthood Program participants

(a) Eligibility for program

A noncustodial parent or obligor shall be eligible for the arrearage adjustment program for Parenthood Program participants if the Department of Social Services determines, based on information provided by a participating program or otherwise available to the department, that the requirements of this subsection are met.

(1) The noncustodial parent or obligor is participating and making satisfactory progress in a Parenthood Program, as demonstrated by quantifiable achievements that facilitate positive involvement with the child or the participant’s ability to provide support, such as (A) signing a paternity acknowledgment, (B) signing a voluntary support agreement, (C) signing a co-parenting or mediation agreement, (D) attending one or more child development classes or (E) registering with the Department of Labor for skills training;

(2) The noncustodial parent meets program goals for appropriate involvement and interaction with the child or children and (A) has an active child support case where an arrearage is owed to the State of Connecticut and there is a current payment due to the custodial party or (B) is an obligor who now resides with the child or children to whom support is owed;

(3) The noncustodial parent or obligor applies for an arrearage adjustment and enters into a voluntary agreement as defined in subdivision (15) of section 17b-179b-1 of the Regulations of Connecticut State Agencies; and

(4) There have been no acts of domestic violence committed by the noncustodial parent or obligor against the custodial party of the child or the child involved in the child support case. For purposes of this subdivision, allegations of domestic violence may be sufficient to establish such acts of domestic violence when the commissioner has no independent, reasonable basis to find the custodial party not credible. The commissioner shall request a custodial party who alleges domestic violence by the noncustodial parent or obligor to provide a sworn statement or to submit any evidence of such violence available to such custodial party. Evidence of domestic violence may include, but is not limited to: (A) Police, government agency or court records; (B) documentation from a shelter worker, legal, medical, clerical or other professional from whom the custodial party has sought assistance in dealing with domestic violence; or (C) a statement from an individual with knowledge of the circumstances which provide the basis for the allegation of domestic violence.

(b) Adjustment amounts

(1) Completes Parenthood Program

An eligible noncustodial parent or obligor who successfully completes a parenthood program shall receive a one-time arrearage adjustment of ten percent of the starting arrearage.

(2) Pays current child support obligation

(A) General rule

An eligible noncustodial parent or obligor who makes payments on the current child support obligation identified in the voluntary agreement shall receive arrearage adjustments in the amount of fifty percent of the dollar amount paid on such current child support obligation, subject to subparagraph (B) of this subsection. Such adjustments may be received during participation in the Parenthood Program and after successful completion of such program.

(B) Annual review of payment record

At the end of each year of eligibility the commissioner shall review the eligible obligor’s payment record. Based on such review the commissioner shall take action in accordance with clauses (i) and (ii) of this subparagraph.

(i) If the eligible obligor has paid fifty percent or more of the current child support obligation identified in the voluntary agreement, arrearage adjustments in accordance with subparagraph (A) shall continue until the next review.

(ii) If the eligible obligor has paid less than fifty percent of the current child support obligation identified in the voluntary agreement the commissioner shall suspend arrearage adjustments for a period of six months after which the commissioner shall conduct a compliance review of the obligor’s payment record in accordance with subparagraph (C) of this subsection.

(C) Compliance review

At the end of the six-month suspension required under clause (ii) of subparagraph (B) of this subdivision the commissioner shall again review the obligor’s payment record, and:

(i) During the suspension period, if the obligor has paid fifty percent or more of the current child support obligation identified in the voluntary agreement the commissioner shall reinstate arrearage adjustments for a six-month period after which the commissioner shall conduct the regularly scheduled annual review of the obligor’s payment record for compliance.

(ii) During the suspension period, if the obligor has paid less than fifty percent of the current child support obligation identified in the voluntary agreement the commissioner shall terminate arrearage adjustments in the child support case identified in the voluntary agreement.

(3) Resides with the child

(A) General rule

An eligible obligor who resides with the child and is employed a minimum of one hundred twenty hours per month shall receive arrearage adjustments at the end of each calendar quarter subject to subparagraphs (B) and (C) of this subdivision. The amount of such adjustment shall be fifty percent of the presumptive current support amount calculated under the child support and arrearage guidelines adopted pursuant to section 46b-215c of the Connecticut General Statutes, based solely on the eligible obligor’s net income at the time such obligor is found eligible for such adjustment. Such adjustment may be received during participation in the Parenthood Program and after successful completion of such program.

(B) Quarterly compliance review

The eligible obligor who resides with the child shall provide the commissioner quarterly documentation of the employment and income information needed to determine the appropriateness and amount of the arrearage adjustment prescribed in subparagraph (A) of this subdivision.

(i) If the eligible obligor who resides with the child has maintained a minimum average of one hundred twenty hours employment per month during the three month quarterly review period, arrearage adjustments in accordance with subparagraph (A) of this subdivision shall be made for the completed quarter.

(ii) If the eligible obligor who resides with the child has not maintained a minimum average of one hundred and twenty hours employment or fails to provide the commissioner the documentation needed to determine the appropriateness and amount of the arrearage adjustment prescribed in subparagraph (A) of this subdivision, arrearage adjustments for the eligible obligor shall be suspended for the completed quarter but such obligor shall be eligible for an arrearage adjustment for the following quarter subject to subparagraph (C) of this subdivision.

(C) Reinstatement and termination from the program

(i) If the eligible obligor who resides with the child becomes employed and provides the commissioner documentation in accordance with subparagraph (B) of this subdivision during the quarter following the suspension period, the eligible obligor shall receive an arrearage adjustment in accordance with subparagraph (A) of this subdivision for the completed quarter.

(ii) If the eligible obligor who resides with the child fails to meet the requirements of subparagraphs (A) and (B) of this subdivision for two consecutive quarterly review periods, the commissioner shall terminate the eligible obligor from the arrearage adjustment program.

(c) Eligibility following termination from program

An obligor who is terminated from the arrearage adjustment program for Parenthood Program participants pursuant to section 17b-179b-3a(b)(2)(C)(ii) or 17b-179b-3a(b)(3)(C)(ii) may re-apply for such program no earlier than six months following the date of termination. If all other eligibility requirements are met the obligor may again enter into a voluntary agreement and receive adjustments under subsection (b) of this section.

(d) Notice of action

The commissioner shall issue a notice of action to the noncustodial parent or obligor not later than thirty calendar days after the date of a determination of eligibility, reinstatement, suspension, termination or adjustment in accordance with this section.

(e) Desk review

(1) Right to review

The commissioner shall provide a desk review to any noncustodial parent or obligor who is denied eligibility for or reinstatement in the arrearage adjustment program for Parenthood Program participants, suspended or terminated from such program, or who allegedly received an incorrect adjustment amount.

(2) When held

A desk review under this subsection shall be provided upon written request of the noncustodial parent or obligor received not later than thirty calendar days after the date of a notice of action issued under subsection (d) of this section. A desk review based on an alleged incorrect adjustment amount shall be provided no more than once each calendar year.

(3) Notice of results

Notice of the results of a desk review shall be issued to the noncustodial parent or obligor by the commissioner not later than sixty calendar days after the date of receipt of a timely written request for such review.

History

• Effective April 2, 2015

Regs., Conn. State Agencies § 17b-179b-4 Arrearage liquidation

(a) Definitions

As used in this section:

(1) "Arrearage liquidation" means an arrearage adjustment, as defined in section 17b-179b-1 of the Regulations of Connecticut State Agencies, of one hundred percent in accordance with this section based on a lump sum payment by the noncustodial parent of a specified percentage of the existing arrearage;

(2) "Liquidation percentage" means the portion of a noncustodial parent's total arrearage that may be accepted by the Commissioner of Social Services in full satisfaction of the support arrearage owed to the State of Connecticut.

(b) Eligibility

A noncustodial parent or obligor shall be eligible for arrearage liquidation of state-owed arrearages if the requirements of this subsection are met.

(1) State-owed arrearage

There is an arrearage owed to the State in a child support case that would take the obligor at least five years to pay in full at the rate of payment calculated in accordance with the Arrearage Guidelines established in section 46b-215a-4a of the Regulations of Connecticut State Agencies.

(2) Obligations to custodial party

(A) Current support

If there is a current child support obligation payable to the custodial party:

(i) payments shall be current, or

(ii) any payments owed to the custodial party shall be paid prior to or at the time of the arrearage liquidation.

(B) Arrearage

Any arrearage payable to the custodial party shall be paid in full prior to or at the time of the arrearage liquidation.

(c) Liquidation percentage

The liquidation percentage for State-owed arrearages shall be determined with reference to the following "Arrearage Liquidation Table", to be used in conjunction with the liquidation percentage factors set forth in subsection (d) of this section:

ARREARAGE LIQUIDATION TABLEIf it would take the obligor the following number of years to pay the arrearage in full:the liquidation percentage shall be . . .at least . . .but no more than . . .570%85%668%83%766%81%864%79%962%77%1060%75%1158%73%1256%71%1354%69%1452%67%1550%65%1648%63%1746%61%1844%59%1942%57%20 or more40%55%

(d) Liquidation percentage factors

(1) Specific

The applicable liquidation percentage shall be reduced by three percent from the higher percentage listed in the table set forth in subsection (c) of this section for each of the following factors:

(A) The obligor is presently living with the child or has made regular support payments for the past three months.

(B) The obligor has paid at least twenty-five percent of the child's college or private secondary school tuition for one semester.

(C) The obligor has satisfactorily completed a Parenthood Program, as defined in section 17b-179b-1 of the Regulations of Connecticut State Agencies.

(D) The obligor was not present at a court hearing held to determine the obligor's initial arrearage, and the court used a standard other than the obligor's actual past ability to pay to determine at least six months of such arrearage.

(E) At least six months of the obligor's arrearage accrued while the obligor was incarcerated or unemployed.

(F) The obligor has received a disability determination from the federal Social Security Administration.

(2) Non-specific

If full payment of the arrearage would take twenty years or more, the applicable liquidation percentage shall be reduced by the following percentages from the higher percentage listed in the table set forth in subsection (c) of this section:

(A) Three percent if full payment of the arrearage at the guidelines rate would take twenty-five years or more.

(B) Six percent if full payment of the arrearage at the guidelines rate would take thirty years or more.

(C) Nine percent if full payment of the arrearage at the guidelines rate would take thirty-five years or more.

(D) Twelve percent if full payment of the arrearage at the guidelines rate would take forty years or more.

(3) Limitation

The combined percentage reductions applied pursuant to subdivisions (1) and (2) of this subsection shall not reduce the applicable liquidation percentage below the lower percentage listed in the table set forth in subsection (c) of this section.

History

• Adopted effective May 24, 2004

17b-192 Requirements for Payments of Services Provided under the State Administered General Assistance Program

Regs., Conn. State Agencies § 17b-192-1 Scope (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-2 Definitions (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-3 Administration of the SAGA medical program (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-4 Responsibilities of the ASO (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-5 Provider network (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-6 Services covered and limitations (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-7 Service management (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-8 Billing and payment procedures (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-9 Payment for hospitals (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-10 Payment rates for providers (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-11 Documentation (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-192-12 Grievance and administrative hearing process (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective October 12, 2005; Repealed June 11, 2014

17b-198 The State-Administered General Assistance Program

Regs., Conn. State Agencies § 17b-198-1 Scope. Effective date

As authorized by section 17b-198 of the Connecticut General Statutes, sections 17b-198-1 to 17b-198-19, inclusive, of the Regulations of Connecticut State Agencies, in conjunction with sections 8080 and 8080.10 of the Department of Social Services' Uniform Policy Manual, set forth the standards and eligibility guidelines for the state-administered general assistance program. The provisions of said sections shall be effective on and after written certification by the Commissioner of Social Services of the implementation of a computer system that integrates said standards and eligibility guidelines. The commissioner shall post the certification, and a copy of said regulations, on the department's website and the Secretary of the State's eRegulations System prior to implementing the regulations.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-2 Definitions

As used in sections 17b-198-1 to 17b-198-19, inclusive, of the Regulations of Connecticut State Agencies:

(1) "AABD" means the state supplement to the aged, blind or disabled administered pursuant to section 17b-600 of the Connecticut General Statutes;

(2) "Applicant" means the person for whom assistance is requested;

(3) "Application process" means all activity related to the exploration, investigation and disposition of an application beginning with the filing of an application for assistance and ending with disposition of the application;

(4) "Assistance unit," "assistance unit member" or "member of an assistance unit" means a SAGA applicant or recipient, as described in section 17b-198-4(a) of the Regulations of Connecticut State Agencies;

(5) "Commissioner" means the Commissioner of Social Services;

(6) "Department" means the Department of Social Services;

(7) "DMHAS" means the Department of Mental Health and Addiction Services;

(8) "Eligibility process" means all activity related to the application process, the renewal process, the period transpiring after assistance is granted but prior to termination and the fair hearing process;

(9) "Fair hearing" means an administrative hearing held pursuant to the provisions of sections 17b-60, 17b-61 and 17b-66 of the Connecticut General Statutes;

(10) "Mental health facility" has the same meaning as provided in section 19a-490 of the Connecticut General Statutes;

(11) "Mental illness" means a diagnosable mental, behavioral or emotional disorder that results in functional impairment that substantially interferes with or limits one or more major life activities;

(12) "Notice" means a written statement sent by the department to the assistance unit that informs the assistance unit that the department has taken or intends to take a specific action in the assistance unit's case;

(13) "Rated housing facility" has the same meaning as provided in section 17b-82 of the Connecticut General Statutes;

(14) "RCA" means the refugee cash assistance program administered pursuant to the Refugee Act of 1980, as amended from time to time;

(15) "Residential care home" has the same meaning as provided in section 19a-490 of the Connecticut General Statutes;

(16) "SAGA" means the state-administered general assistance program administered pursuant to section 17b-190 of the Connecticut General Statutes;

(17) "SNAP" means the supplemental nutrition assistance program administered pursuant to the Food and Nutrition Act of 2008, as amended from time to time;

(18) "SSI" means the Supplemental Security Income Program administered pursuant to the Social Security Act;

(19) "SSDI" means the Social Security Disability Insurance Program administered pursuant to the Social Security Act;

(20) "Substance abuser" means a person whose dependence on or inability to voluntarily control the use of alcohol or drugs interferes with his or her functioning and productivity;

(21) "TFA" means the temporary family assistance program administered pursuant to section 17b-112 of the Connecticut General Statutes; and

(22) "Verify" means to confirm that a fact, circumstance or condition is more likely than not true through the submission and examination of direct evidence or another form of reliable documentation, or through a contact with a knowledgeable source other than the assistance unit.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-3 Beginning the eligibility process

(a) Application required. (1) Except as provided in subsection (b) of this section, any person seeking assistance pursuant to SAGA shall complete and submit to the department an application on a form prescribed by the department. Each application shall be in writing and include, at a minimum: (A) A formal request for assistance; (B) the applicant's full name and address; and (C) the signature of the applicant or person authorized to request assistance on the applicant's behalf. The signature required pursuant to this subdivision may be an electronic signature. The department shall forward application materials to any person who requests a paper application, and shall afford any person who appears in person and requests assistance an opportunity to file an application for assistance pursuant to SAGA or any other pertinent program administered by the department on the day such person appears in person.

(2) Any telephone contact or other request for assistance that is not written, does not contain the minimum information required by subdivision (1) of this subsection or is not made on an application form prescribed by the department shall be considered an inquiry and shall not constitute an application.

(3) In addition to the minimum information required under subdivision (1) of this subsection, an applicant shall complete all pertinent sections of the application form to the satisfaction of the department prior to being granted assistance. Any applicant who fails to complete all pertinent sections of the application form by a date requested by the department, shall be denied assistance.

(b) New application not required. The department shall determine a person's eligibility for assistance pursuant to SAGA without requiring a new application meeting the requirements of subsection (a) of this section when:

(1) Cash assistance requested by or provided to such person pursuant to TFA, AABD or RCA is denied or discontinued;

(2) Such person requests that the department resume assistance not later than thirty days after such person is released from a correctional or mental health facility, provided such person was previously determined eligible for assistance pursuant to SAGA and lost eligibility due to institutionalization in such facility not earlier than twenty-four months prior to the date of such release; or

(3) Such person (A) is discharged from a residential substance abuse treatment facility, and (B) was a recipient of assistance pursuant to SAGA within sixty days of the date of such discharge.

(c) Where to file. A completed application may be filed with the department electronically, in person at, or by mail to, any department regional office or by mail to any other address approved by the department for receipt of applications.

(d) Date of application. (1) The date of application shall be the date on which a signed application requesting cash assistance is received by the department. If the department receives a signed application that does not indicate which form of assistance the applicant is requesting, the date of receipt shall remain the date of application if such applicant indicates he or she is requesting cash assistance at the application interview or when contacted by the department for the purpose of determining which form of assistance such applicant is requesting, whichever occurs first.

(2) When the date of application for cash assistance is established pursuant to the provisions of subdivision (1) of this subsection and an applicant subsequently and for the first time requests a different form of assistance, such applicant shall be required to sign and submit a new application concerning such request, and the date of application for such different form of assistance shall be the date such new application is submitted to a department office.

(e) Persons qualified to participate in the eligibility process. Any person who requests assistance solely for himself or herself may file an application and complete the eligibility process, unless such person has been declared incompetent by a court of appropriate jurisdiction. Any applicant may choose to be assisted in the eligibility process by another person or persons, and may be accompanied and represented by such chosen person or persons during contact with the department. In the case of a person declared incompetent by a court of appropriate jurisdiction, such person's conservator, guardian or court-appointed fiduciary may file an application and complete the eligibility process on behalf of such person.

(f) Authorized representatives. (1) An assistance unit member may appoint a person to act as an authorized representative on his or her behalf, unless such member has been declared incompetent by a court of appropriate jurisdiction, in which case such member's conservator, guardian or court-appointed fiduciary may appoint an authorized representative for such member. Such appointment shall be in writing and include the signature of the assistance unit member, or such member's conservator, guardian or court-appointed fiduciary. The appointment of an authorized representative shall not be effective until received by the department and shall be subject to the department's determination that the person selected as an authorized representative is a responsible individual. For purposes of this subsection, "responsible individual" means a person who: (A) is eighteen years of age or older; (B) is sufficiently familiar with the assistance unit's household circumstances to answer with reasonable accuracy questions concerning the assistance unit's need and eligibility for assistance; (C) understands the responsibilities assumed by virtue of acting as an authorized representative; (D) is able to communicate with members of the assistance unit in order to obtain information from such members and provide such members with an explanation of their rights and responsibilities; (E) has an interest in the well-being of the assistance unit; and (F) has not been disqualified from receiving assistance pursuant to SAGA.

(2) Unless an assistance unit member's signature is otherwise required by state or federal law, an authorized representative may sign any document, including an application, and otherwise act on behalf of the assistance unit on all matters. The department shall send notice of any case action to the assistance unit and its authorized representative. The department shall not take any action based on information provided by an authorized representative until such authorized representative verifies his or her identity.

(3) The department may appoint an authorized representative for an assistance unit when it determines that there has been financial mismanagement and that a protective payee is necessary, as described in subsection (e) of section 17b-198-12 of the Regulations of Connecticut State Agencies, in which case such protective payee shall act as the assistance unit's authorized representative.

(4) An assistance unit shall have no more than one authorized representative at any given time. An authorized representative may represent multiple assistance units and may terminate his or her representation of an assistance unit at any time by notifying the department of such termination in writing. No department employee involved in the eligibility process or the issuance of benefits may act as an authorized representative without the specific, written approval of the commissioner or the commissioner's designee.

(5) An assistance unit member shall not be relieved of any responsibility imposed by statute or regulation due to the appointment of an authorized representative. An assistance unit member and his or her authorized representative shall be jointly responsible for any assistance improperly obtained from the department due to the actions of the authorized representative.

(6) An assistance unit member may, at any time, revoke the appointment of any authorized representative, provided such revocation is in writing and received by the department. The department may remove an authorized representative if such representative knowingly misrepresents the assistance unit's circumstances and eligibility for assistance.

(g) Application interviews. (1) Each applicant requesting assistance pursuant to SAGA, or such applicant's authorized representative, shall be interviewed by the department as a condition of eligibility for such assistance. The department shall conduct such interview for the purpose of reviewing the application form and any other relevant information or documents for accuracy and completeness, and to ascertain pertinent information relating to the current circumstances of the assistance unit. Such interview may be conducted in person or by telephone on the day an application is filed or within a reasonable amount of time thereafter, as determined by the department.

(2) The department shall not schedule a second application interview for a person who misses a scheduled application interview and does not contact the department to reschedule such interview. The department shall schedule a second application interview for any person who misses a scheduled application interview if such person requests that the department reschedule such interview and such person's failure to complete the previously scheduled interview was due to a hardship such as, but not limited to, an accident or a family illness. Any delay in processing an application that results from rescheduling such an interview shall be attributed to the applicant.

(3) If, at any time after the application interview but prior to granting assistance, a change occurs with respect to the information provided by the applicant on the application or at the application interview, and such change could impact the applicant's eligibility for or appropriate level of SAGA assistance, such applicant shall report such change to the department not later than ten days after the date on which such change occurred.

(h) Date on which documents are considered received during the eligibility process. Unless specifically provided otherwise by a statute or regulation, during the eligibility process any application, written verification, report or request, redetermination form, waiver, petition or other document shall be considered received by the department on the day any such item is actually received by the department, except that any such item received on a weekend day, holiday or any day after normal business hours shall be considered received on the next business day.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-4 Rules for forming the assistance unit and needs group

(a) Assistance unit composition. Each person requesting or receiving assistance pursuant to SAGA shall be designated a one-member assistance unit, regardless of whether such person lives with a spouse, family member or other person who is requesting and eligible for assistance pursuant to SAGA.

(b) Needs group composition. To determine whether an assistance unit meets asset and income requirements for assistance pursuant to SAGA, as described in sections 17b-198-8 and 17b-198-9 of the Regulations of Connecticut State Agencies, and for the purpose of calculating the appropriate level of assistance for an eligible assistance unit, as described in section 17b-198-10 of said regulations, the department shall consider the assets and income of each member of the needs group to which the assistance unit member belongs. The needs group shall consist of the assistance unit member and his or her spouse, except that, whenever an assistance unit member and his or her spouse separate and no longer live together, such spouse shall be excluded from such member's needs group on the first day of the month following the month in which such spouse and member cease living together.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-5 Determining eligibility. Threshold considerations

(a) Citizenship status. Only (1) a United States citizen, (2) a qualified alien, as defined in 8 USC 1641, as amended from time to time, who is not eligible for federally funded forms of cash assistance, (3) an immigrant alien who, prior to August 22, 1996, entered the United States and was recognized as permanently residing under color of law, or (4) a lawfully residing immigrant alien shall be eligible for assistance pursuant to SAGA. For purposes of this subsection, “lawfully residing immigrant alien” has the same meaning as “alien who is lawfully present in the United States,” as defined by 8 CFR 1.3, as amended from time to time.

(b) Residency. (1) Only a person who resides in Connecticut and intends to remain in Connecticut permanently or for the foreseeable future shall be eligible for assistance pursuant to SAGA. Except as provided in subdivision (2) of this subsection, a person who resides in Connecticut and is otherwise eligible for assistance pursuant to SAGA shall not be required to have a permanent dwelling or a fixed address to establish his or her Connecticut residency. A person who is temporarily absent from Connecticut shall remain eligible for assistance pursuant to SAGA, except that a person who is temporarily absent from Connecticut and establishes a legal residence in or is granted any public benefit by another state shall not be considered a resident of Connecticut, regardless of whether such person continues to maintain a residence in Connecticut or intends to return to Connecticut.

(2) A person's temporary absence from Connecticut shall not constitute abandonment of his or her Connecticut residency, provided such person (A) maintains permanent housing or has a fixed address in Connecticut, and (B) intends to return to Connecticut not later than thirty days after leaving the state.

(c) Institutional status. No person shall be eligible for assistance pursuant to SAGA while living in any of the following institutions:

(1) A general hospital, except that any person who is receiving assistance pursuant to SAGA shall not become ineligible for assistance upon living in a general hospital if such recipient is expected to return home not later than ninety days after the date of admission to such general hospital;

(2) A long-term care facility;

(3) A residential substance abuse treatment facility;

(4) A correctional facility, unless such person voluntarily lives in such facility; or

(5) A mental health facility.

(d) Concurrent eligibility for assistance. No person shall be eligible to receive assistance pursuant to SAGA while also eligible to receive cash assistance pursuant to another state or federal cash assistance program, including, but not limited to, TFA, RCA, AABD, SSI or SSDI.

(e) Participation in a strike.

(1) For purposes of this subsection, a person participates in a strike when such person is an employee who (A) chooses not to go to work because he or she is a member of a bargaining unit on strike, (B) acts in concert with other employees to effectuate a work stoppage due to the expiration of a collective bargaining agreement or any other motive directly related to such person's job, or (C) chooses not to go to work due to sympathy with a bargaining unit on strike. A person who does not belong to a collective bargaining unit that is on strike and refuses to cross a picket line established by such collective bargaining unit due to fear of personal injury or death shall not be considered a participant in such strike. A person who previously participated in a strike shall no longer be considered a participant in such strike upon returning to work or after such person's position is permanently filled or eliminated by his or her employer.

(2) Except as provided in subdivision (3) of this subsection, no person participating in a strike or living with a spouse who is participating in a strike shall be eligible for assistance pursuant to SAGA.

(3) The provisions of this subsection shall not apply to an assistance unit already receiving assistance pursuant to SAGA at the time any person described in this subsection begins participation in a strike.

(f) Improper transfer of assets. (1) For purposes of this subsection, "legal owner" has the same meaning as provided in subsection (a) of section 17b-198-8 of the Regulations of Connecticut State Agencies, and "undue influence" means acts that cause another party, through misrepresentation, deceit, fraud or any other improper means, to do something that would otherwise not be done.

(2) (A) Except as provided in subparagraph (C) of this subdivision and subdivision (5) of this subsection, an assistance unit member residing in or admitted to a rated housing facility or a licensed residential care home shall be subject to a penalty, as described in subdivision (6) of this subsection, if such member (i) transfers an asset, other than an asset excluded from eligibility determinations under any provision of section 17b-198-8 of the Regulations of Connecticut State Agencies, for the purpose of establishing or maintaining eligibility for assistance pursuant to SAGA, and (ii) such transfer occurred during the twenty-four month period immediately preceding the date of application for assistance, while an application for such assistance was pending or while such member was receiving such assistance. The department shall investigate the circumstances under which an asset was transferred if such asset was transferred during any time period set forth in this subparagraph.

(B) An assistance unit member's placement of an asset into joint ownership with another person, including such member's spouse, shall be considered a transfer within the meaning of this subdivision if such person subsequently transfers or otherwise liquidates such asset, or if such member subsequently grants full ownership of such asset to such person. The date of transfer in such a situation shall be the date such person transferred or otherwise liquidated such asset, or was granted full ownership of such asset by the assistance unit member, whichever occurs first.

(C) Notwithstanding the provisions of subparagraph (A)(i) of this subdivision, the department shall impose a penalty when an assistance unit member residing in or admitted to a rated housing facility or a licensed residential care home transfers non-home property excluded pursuant to subdivision (8) of subsection (d) of section 17b-198-8 of the Regulations of Connecticut State Agencies for the purpose of establishing or maintaining eligibility for assistance pursuant to SAGA during any period of time described in subparagraph (A)(ii) of this subdivision.

(3) (A) The department shall consider an asset to have been transferred for the purpose of establishing or maintaining eligibility for assistance pursuant to SAGA, as described in subdivision (2) of this subsection, if: (i) Fair market value was not received for such asset; (ii) there is no convincing evidence that the transfer was for another purpose; and (iii) the transferor did not retain funds sufficient to account for the transferor's foreseeable needs.

(B) In determining whether fair market value was received as compensation for a transferred asset, the department shall consider any compensation received at the time of or after the transfer. The department shall consider compensation received prior to the transfer only if such compensation was received in accordance with a legally enforceable agreement, or in the form of services or payment for services that were: (i) Of the type provided by a homemaker or a home health aide; (ii) essential to avoid the transferor's institutionalization; and (iii) either provided by the transferee while sharing the home of the transferor or paid for by the transferee. Any non-monetary compensation received shall be assigned a monetary value for the purpose of determining whether such compensation constituted fair market value for the transferred asset. A monetary value shall be assigned for services of the type normally rendered by a homemaker or home health aide according to the current state minimum hourly wage for such services. For all other services provided as compensation at the time of transfer, after the transfer or in connection with a legally enforceable agreement, a monetary value shall be assigned according to the actual cost of the services. Any compensation received in the form of real or personal property shall be valued according to such property's fair market value. Compensation in the form of a note of indebtedness shall be valued according to the total amount owed on such note. An out-of-pocket payment by the transferee may include payment for alterations to the transferor's home that are necessary to allow the transferor to continue to use such home and avoid institutionalization.

(C) A transferor retains funds sufficient to account for his or her foreseeable needs when, at the time of the transfer, such transferor retains other income and assets sufficient to cover basic living expenses and medical costs as they could have reasonably been expected based on the transferor's health and financial situation at the time of the transfer.

(4) Notwithstanding the provisions of subdivision (3) of this subsection, the department shall not consider an asset's transfer to have been made for the purpose of establishing or maintaining eligibility for assistance pursuant to SAGA if:

(A) There is clear and convincing evidence that objectively establishes that the transferor merely entrusted such asset with the transferee with the intent of retaining all beneficial interest in such asset;

(B) The asset was jointly held by the assistance unit member and the person who received or transferred the asset, and such member demonstrates that such person, rather than such member, was the legal owner of such asset, as described in subsection (e) of section 17b-198-8 of the Regulations of Connecticut State Agencies; or

(C) The assistance unit member transferred the asset to his or her spouse if (i) such member and spouse were separated at the time of the transfer, and (ii) the transfer was made in accordance with a written agreement executed prior to the transfer that divided the asset into equal shares of distinct property. For purposes of this subparagraph, the department shall consider an assistance unit member and his or her spouse to be separated if such member or spouse has left the home and does not intend to return, or such member and spouse are residing in different rooms in the same rated housing facility or licensed residential care home.

(5) (A) The department shall not impose a penalty pursuant to this subsection if:

(i) The total uncompensated fair market value for all improperly transferred assets, including multiple transfers of one asset, does not exceed the asset limits established pursuant to section 17b-198-8 of the Regulations of Connecticut State Agencies when added to all other assets counted under the provisions of said section;

(ii) Such member has been declared incompetent by a court of appropriate jurisdiction at the time of the transfer; or

(iii) Such transfer was the result of a third party's undue influence on such member, such as, but not limited to, when the asset was jointly held with another person and such person gained sole ownership of or liquidated such asset without the knowledge or consent of such member.

(B) When undue influence is claimed, the assistance unit member, or, if such member has been declared incompetent by a court of appropriate jurisdiction at the time of the department's investigation of the transfer, such member's conservator shall provide the department with detailed information concerning the circumstances that led to the transfer. The department shall review all available information and determine whether it is more likely than not that the transfer resulted from undue influence.

(6) The penalty for transferring an asset under the circumstances described in subdivision (2) of this subsection shall be ineligibility for assistance pursuant to SAGA beginning on the first day of the month such asset was transferred and lasting for a period of time calculated by dividing the uncompensated value of the transferred asset by five hundred dollars, with (A) any resulting whole number equating to the number of months such person shall remain ineligible, and (B) any resulting fraction of a whole number used to prorate the number of days such person shall remain ineligible during the last month of ineligibility.

(7) The department shall notify each applicant for assistance pursuant to SAGA of the potential impact of transferring an asset. Whenever the department intends to deny or discontinue assistance pursuant to SAGA due to a penalty imposed pursuant to this subsection, the department shall, not later than fifteen days prior to taking such intended action, provide the assistance unit member with notice clearly explaining the reason for the decision and that such member has a right to rebut the findings of the department by a date provided in such notice. An assistance unit may, within the time allowed, rebut such findings through objective evidence. For purposes of this subdivision, evidence, whether documentary or nondocumentary, shall be considered objective if a rational person would agree that it is real and valid. If the department, in its discretion, concludes that objective evidence submitted by an assistance unit member rebuts the department's findings, it shall not impose a penalty pursuant to this subsection.

(8) An applicant's decision to withdraw an application shall not interrupt the department's processing of its evaluation of an asset transfer or the imposition of any penalty imposed as a result of such an evaluation. When an applicant withdraws his or her application and the department's evaluation leads to the imposition of a penalty, such penalty shall be applied to any subsequent application filed by such applicant, subject to the recalculation of the penalty period based on any additional information presented at the time of the subsequent application.

(g) Failure to comply with TFA program requirements. No person who would be eligible for assistance pursuant to TFA but for the failure of such person or an individual in such person's household to comply with a TFA program requirement shall be eligible for assistance pursuant to SAGA.

(h) Fleeing felons disqualified. Any person who is fleeing prosecution for a crime or attempted crime that constitutes a felony under the laws of the jurisdiction from which such person is fleeing, or who is fleeing to avoid custody or confinement following his or her conviction for such a crime or attempted crime, shall be disqualified from receiving assistance pursuant to SAGA. If any person disqualified pursuant to this subsection is pardoned by the President of the United States, such disqualification shall terminate on the first day of the month following the month in which such pardon is granted.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-6 Determining eligibility. Assistance unit obligations

(a) Disclosure of Social Security number. (1) Each assistance unit member shall disclose his or her Social Security number as a condition of eligibility for assistance pursuant to SAGA. An assistance unit member who has been issued multiple Social Security numbers shall disclose each number. Disclosure of a Social Security number pursuant to this subsection may be based upon such member's memory or a written document, including, but not limited to, a wage stub, a Social Security award or denial letter, an income tax return, a Social Security card, a bank book or statement, an insurance policy or any other document such member believes accurately reflects his or her Social Security number. An assistance unit member shall be required to apply for a Social Security number as a condition of such member's eligibility for assistance if such member has not been issued a Social Security number or has been issued such a number but (A) does not recall such number and has no record of it, (B) the department is unable to confirm such number, or (C) a discrepancy exists between the number provided to the department by such member and information from other sources available to the department. Notwithstanding the provisions of subdivision (5) of this subsection, the assistance unit member shall be responsible for ensuring that any application for a Social Security number required by this subsection is filed with the Social Security Administration. An assistance unit member shall remain ineligible for assistance pursuant to SAGA until such member discloses a Social Security number or files an application for such a number, whichever is required under this subsection.

(2) The department shall confirm the validity of each Social Security number disclosed to it pursuant to this subsection, and each such number shall be used by the department only for verifying the identity of an assistance unit member, such member's income and assets and any benefits received by such member.

(3) Any person who is not applying for or eligible to receive assistance pursuant to SAGA for any reason other than failing to disclose or apply for a Social Security number may voluntarily disclose his or her Social Security number to the department or apply for such a number, but such disclosure or application shall not be required as a condition of eligibility for any assistance unit member.

(4) Whenever the department requests that a person disclose or apply for a Social Security number, the department shall inform such person of whether cooperation with such request is mandatory or voluntary, of the statutory or other authority pursuant to which such request is made and how such number will be used by the department when disclosed, including that the Social Security number of any person whose income is considered in determining whether an applicant is financially eligible shall be used to verify such income. The department shall inform any person whose disclosure of a Social Security number is voluntary that his or her failure to disclose such number shall not result in the denial or discontinuance of assistance for any person.

(5) If a member of an assistance unit informs the department that he or she does not recall his or her Social Security number or has not been issued such a number, the department shall offer to assist such member. If such member requests the department's assistance, the department shall:

(A) Assist such member in completing an application for a Social Security number;

(B) Obtain any evidence pertaining to such member's citizenship or alien status, age and identity that is required by the Social Security Administration and necessary to complete such application; and

(C) When appropriate, send such application to the Social Security Administration or, if evidence suggests that a Social Security number was previously issued to such member, request such number from the Social Security Administration.

(6) The department shall not delay an eligibility determination while confirmation or issuance of a Social Security number is pending unless (A) there is a discrepancy between the Social Security number disclosed by an assistance unit member and other information obtained from a source used by the department, and (B) such member fails to cooperate in resolving such discrepancy. The department shall not penalize an assistance unit member for failing to disclose or apply for a Social Security number unless the department first complies with the provisions of subdivision (5) of this subsection.

(b) Cooperation during the eligibility process generally. (1) Except as provided in subdivision (3) of this subsection, an assistance unit member shall, as a condition of eligibility for assistance, cooperate during the application and eligibility processes. The cooperation required pursuant to this subsection during the application process includes fully completing the application form, providing the signature of any person who is required to sign such form, responding to any appointment for an interview scheduled by the department and providing and verifying information when requested by the department. The cooperation required pursuant to this subsection during any portion of the eligibility process following the application process includes completing and signing any form as requested by the department, responding to any appointment for an interview scheduled by the department, reporting changes in income and any other conditions that may impact eligibility for assistance pursuant to SAGA and providing and verifying information when requested by the department.

(2) Except as provided in subdivision (3) of this subsection, whenever cooperation required by this subsection is not provided during the application process, the department shall deny the application. Whenever cooperation required by this subsection is not provided during any portion of the eligibility process following the application process, the assistance unit member shall be ineligible for assistance until such member provides such cooperation. If an assistance unit member fails to cooperate with a quality control review conducted by the department and does not cooperate sooner than ninety-five days after the end of the annual quality control review period during which such cooperation was withheld, such member shall be required to file a new application for assistance pursuant to SAGA prior to the renewal of such assistance. The department shall not consider an assistance unit member's prior failure to cooperate while reviewing any such new application for assistance. For purposes of this subdivision, "quality control review period" means the period beginning October 1 each year and ending September 30 the following year.

(3) No assistance unit shall be ineligible for assistance for failing to provide the cooperation required by this subsection if there is good cause for the assistance unit's failure to cooperate. For purposes of this subdivision, good cause exists whenever the lack of cooperation resulted from (A) circumstances beyond the assistance unit's control, or (B) the failure of a representative of an incompetent or incapacitated assistance unit member to act in such member's best interest.

(c) Cooperation in pursuing support. (1) An assistance unit member shall, as a condition of eligibility for assistance, provide accurate and complete information about any spouse who may be legally obligated to provide support to such member. A spouse shall be considered legally obligated to provide support to an assistance unit member regardless of whether such spouse lives with such member. Each assistance unit member shall, as a further condition of eligibility for assistance, cooperate in securing support from any such spouse, unless the department determines that circumstances justify such member's refusal to provide such cooperation, as described in subdivision (3) of this subsection. The cooperation required pursuant to this subsection includes (A) identifying and locating such member's spouse, and (B) obtaining support payments, medical or other benefits or any other property when such payments, benefits or property are due to such member. Notwithstanding any other provision of this subsection, an assistance unit shall not be ineligible for assistance for failing to cooperate with the department's request to perform a discrete act needed to obtain spousal support if there is good cause for the assistance unit's failure to cooperate. For purposes of this subsection, good cause has the same meaning as provided in subdivision (3) of subsection (b) of this section.

(2) The cooperation required by subdivision (1) of this subsection is demonstrated by:

(A) Providing to the department known information and documentary evidence that is in the assistance unit member's possession or readily obtainable;

(B) Appearing as a witness in court or in any other proceeding related to obtaining support and providing information or attesting under oath to a lack of information; and

(C) Notifying the department of any direct support payments received while also receiving assistance pursuant to SAGA.

(3) A member of an assistance unit may refuse to provide cooperation required by this subsection if it is anticipated that, by providing such cooperation, the assistance unit member may be subjected to serious physical or emotional harm.

(4) Any assistance unit member who alleges that he or she is justified in refusing to cooperate with the department's efforts to secure support from such member's spouse under the provisions of subdivision (3) of this subsection shall verify the circumstances that allegedly constitute justification for such refusal not later than twenty days after the date on which such circumstances are first alleged. The department may grant an extension of such deadline in exceptional cases in which an assistance unit member's failure to cooperate by providing verification is beyond such member's control. The department shall issue a written decision concerning an assistance unit member's allegation of circumstances justifying his or her refusal to cooperate not later than forty-five days after the date on which such circumstances were first alleged by such member, except that, if such member was granted an extension, the department's deadline for issuing a decision shall be extended by a number of days commensurate with the length of the extension granted to such member. In no event shall the department delay, deny or discontinue assistance pending the resolution of an assistance unit's allegation of circumstances justifying his or her refusal to cooperate under subdivision (3) of this subsection.

(5) Whenever the department decides that an assistance unit member's refusal to cooperate is justified under subdivision (3) of this subsection, the department shall either cease its efforts to secure support, or continue such efforts without the assistance of such member. Whenever the department decides that circumstances justifying an assistance unit member's refusal to cooperate do not exist, such member shall:

(A) Cooperate with the department's efforts to secure support, in which case such member shall continue to be eligible for assistance pursuant to SAGA;

(B) Request that the department discontinue the eligibility process or voluntarily withdraw the application for assistance rather than continue efforts to secure support; or

(C) Be determined ineligible for assistance pursuant to SAGA.

(d) Cooperation in pursuing potential income. (1) As a condition of eligibility for assistance, an assistance unit member shall apply for and actively pursue any benefit to which such member may be eligible, and shall otherwise cooperate with any department request concerning the pursuit of any other form of income rightfully belonging to such member. Such benefits include, but are not limited to, old-age, survivors and disability insurance benefits, veterans' disability compensation or pension benefits, railroad retirement benefits, unemployment compensation benefits, worker's compensation benefits, benefits paid pursuant to a private pension or disability insurance contract and benefits from any other cash assistance program administered by the department.

(2) Any application or cooperation required pursuant to this subsection shall be completed by a date established by the department in each case. An assistance unit member shall be ineligible for assistance if such member fails to comply with the provisions of this subsection in a timely manner, unless there is good cause for such failure. For purposes of this subsection, good cause exists whenever such failure resulted from (A) circumstances beyond such member's control, or (B) the failure of a representative of an incompetent or incapacitated assistance unit member to act in such member's best interest.

(e) Cooperation in pursuing assets. (1) An assistance unit member shall pursue potential assets, including, but not limited to, property in probate, jointly owned property, property held in trust, any security deposit held by a landlord that is owed to such member and any asset that such member has verified cannot be converted to cash, and shall cooperate with any department request concerning the pursuit of such assets.

(2) The cooperation required pursuant to this subsection includes: (A) Taking reasonable measures to pursue any potential asset of the assistance unit member or such member's spouse; and (B) complying with any department request for information or action by such member, including, but not limited to, a request to (i) provide details concerning an asset, including names and addresses of persons involved with such asset, (ii) make a petition concerning an asset to the probate court or other court of appropriate jurisdiction, (iii) commence a legal action for compensation equal to the value of such member's interest in an asset, and (iv) send a letter of demand or inquiry to the holder of an asset.

(3) Whenever an assistance unit member fails to cooperate with the provisions of this subsection, the department shall (A) consider the full value of the asset in question as available to the assistance unit, if such value is known, or (B) determine that such member is ineligible for assistance, if such member is eighteen years of age or older and the value of such asset is unknown.

(f) Assignment of interests. (1) An assistance unit member shall, as a condition of eligibility for assistance, assign to the department (A) any interest such member has in a decedent's estate, (B) the net proceeds of any monetary damages or settlement received by such member in connection with a cause of action, and (C) any potential retroactive SSI award. Any assignment of a potential retroactive SSI award shall be valid only until such member is denied SSI benefits and fails to file a timely appeal or exhausts all appellate rights, or for one year from the date of such assignment, whichever occurs first. The amount of an assignment of an assistance unit member's interest in a decedent's estate shall be equal to the total amount of SAGA benefits received by such member, or fifty per cent of the assets from the estate that are payable to such member, whichever is less. The amount of an assignment of an assistance unit member's interest in a cause of action shall be equal to the total amount of SAGA benefits received by such member, or fifty per cent of the proceeds received by such member in connection with such cause of action after payment of all expenses connected with the cause of action, whichever is less.

(2) Any assistance unit member who fails to make an assignment required under this subsection shall be ineligible for assistance pursuant to SAGA.

(g) Treatment for substance abuse. (1) No person who is a substance abuser shall be eligible for assistance pursuant to SAGA unless such person participates in treatment, including counseling, for such substance abuse.

(2) Notwithstanding the provisions of subdivision (1) of this subsection, a substance abuser shall be eligible for assistance pursuant to SAGA while waiting for appropriate treatment to become available.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-7 Determining eligibility. Employability status

(a) Impairment to employability required. No person shall be eligible for assistance pursuant to SAGA unless such person is unemployable, as described in subsections (b) and (c) of this section, or transitional, as described in subsections (d) and (e) of this section.

(b) Medical unemployability. A person shall be considered unemployable due to medical impairment when such person provides the department with current medical and vocational information, including information concerning such person's employment history, verifying that such person:

(1) Has been diagnosed with one or more physical or mental illnesses or conditions and:

(A) One or more of such illnesses or conditions are expected to last not less than six months;

(B) One or more of such illnesses or conditions, individually or collectively, prevent such person from working or participating in education or training; and

(C) One or more of such illnesses or conditions are severe, as determined by the department or the department's designee after consulting a schedule of medical-disability standards maintained and made available to the public by the department;

(2) Meets the disability requirements established by the Social Security Administration; or

(3) Has received an award letter from the Social Security Administration granting SSI or SSDI benefits, but has not yet received such benefits.

(c) Non-medical unemployability. A person shall be considered unemployable due to considerations apart from medical impairment when such person provides the department with current information, including, when necessary, information concerning such person's employment history, verifying that such person:

(1) Is sixty-five years of age or older or is under sixteen years of age and emancipated by a court of appropriate jurisdiction or legally married;

(2) Is needed at home to care for an incapacitated spouse or child, or a child under two years of age, provided such person verifies that:

(A) The incapacitated person (i) receives SSI or Social Security benefits based on disability or blindness, or (ii) has a physical or mental illness or impairment, or combination thereof, that is expected to last not less than thirty days and is of such a debilitating nature that, in the case of a spouse, it precludes such spouse from engaging in employment on a predictable basis with reasonable regularity, or, in the case of a child, it requires care by an adult at unpredictable times with reasonable regularity or on a substantially continuous basis; and

(B) No other household member of the spouse or child, as the case may be, can provide such care.

(3) Has been granted but is pending receipt of Social Security income or cash assistance from any program administered by the department other than SAGA;

(4) Is a VISTA volunteer;

(5) Is a full-time student in good standing at a high school or another secondary school offering an equivalent level of vocational or technical training;

(6) Is fifty-five years of age or older and has worked less than six months, cumulatively, during the five years immediately preceding such person's application for assistance; or

(7) Is (A) unmarried, (B) between the ages of eighteen and twenty-one, (C) living with an active TFA assistance unit, and (D) no longer a member of such TFA assistance unit due to attaining the age of eighteen.

(d) Long-term transitional persons. A person shall be considered transitional due to long-term impairment when such person:

(1) Provides the department with current medical and vocational information, including information concerning such person's employment history, verifying that such person has one or more documented, severe physical or mental illnesses or conditions that, individually or collectively, are expected to preclude employment for a period of not less than six months; and

(2) Submits to and cooperates with a medical review for the purpose of determining whether such person's impairments meet any of the criteria for medical unemployability, as described in subsection (b) of this section.

(e) Short-term transitional persons. (1) A person shall be considered transitional due to short-term impairment when such person provides the department with current medical and vocational information, including information concerning such person's employment history, verifying that such person:

(A) Has one or more documented physical or mental illnesses or conditions that, individually or collectively, are expected to preclude employment for a period of not less than two months but fewer than six months; and

(B) Has a recent connection to the labor market or:

(i) Was institutionalized as a resident of (I) an acute care or chronic disease hospital, (II) a nursing home, (III) a correctional facility, or (IV) a residential treatment facility, halfway house or group home for not less than forty-five days during each of three of the five calendar quarters immediately preceding the month such person applied for assistance;

(ii) Was receiving cash assistance pursuant to SAGA, SSI, SSDI or AABD for not less than three of the five calendar quarters immediately preceding the month such person applied for assistance;

(iii) Graduated from a full-time secondary school, such as a high school or a vocational or technical school, not earlier than six months prior to the month such person applied for assistance; or

(iv) Was needed in the home to care for his or her child under two years of age for not less than three of the five calendar quarters immediately preceding the month such person applied for assistance.

(2) For purposes of this subsection, "chronic disease hospital" means a facility for the treatment or care of persons with prolonged illnesses, and "recent connection to the labor market" means that a person:

(A) Worked and earned not less than five hundred dollars in each of three of the five calendar quarters immediately preceding the month such person applied for assistance, regardless of the dates on which payment was received for such work;

(B) Collected unemployment compensation at any time during the six months immediately preceding the date such person applied for assistance; or

(C) Had sufficient wage credits to qualify for unemployment compensation at any time during the six months immediately preceding the date such person applied for assistance but was unable to collect such compensation because (i) he or she was unable to work or unavailable for suitable work, or (ii) such compensation was withheld for the purpose of recouping a previous overpayment of unemployment compensation.

(f) Petition for reconsideration. (1) Any person previously determined to be transitional pursuant to subsection (d) or (e) of this section may file a petition for reconsideration of the department's determination that such person does not qualify as unemployable. Such petition shall be filed not later than sixty days after such person's assistance is discontinued due to the expiration of the period of time such person was determined to be transitional, and may be filed while such person is still receiving assistance.

(2) Each petition for reconsideration filed pursuant to subdivision (1) of this subsection shall include the name, date of birth, Social Security number and the signature of the petitioner, the date on which such petition was signed and a written statement explaining why the petitioner believes he or she is unemployable. Such petition may include any of the following:

(A) Medical or psychiatric reports;

(B) Reports from counselors;

(C) Photographs of the petitioner;

(D) Evidence concerning the petitioner's education, vocational training or work history;

(E) A statement offered by the petitioner's friend or family member, or by another person with knowledge of the petitioner's circumstances, explaining his or her relationship to the petitioner and the specific reasons he or she believes the petitioner is unemployable; and

(F) Any other information relevant to the petitioner's ability to find and maintain employment.

(3) Any petition for reconsideration filed with a regional office shall be forwarded to the department's central office for consideration and the issuance of a decision. Assistance shall not be continued beyond the time the department previously determined the petitioner would be transitional while such a petition is pending, nor shall assistance be reinstated upon the filing of such a petition after assistance was discontinued due to the expiration of such time.

(4) Prior to rendering a decision on such petition, the department may:

(A) Request additional medical or vocational information from the petitioner, including information concerning the petitioner's work history;

(B) Require that the petitioner appear for an in-person interview to discuss his or her employment status; and

(C) Require verification of any information contained in a statement or document submitted to the department that the department has reason to question.

(5) In reaching a decision on a petition for reconsideration, the department may consider the petitioner's mental and physical health, age, educational background, work history and how each such factor relates to the petitioner's ability to work, but may not grant a petition based on the petitioner's inability to find employment due to labor market conditions, lack of transportation or any other factor that is not a criterion used in determining whether a person is unemployable.

(6) The department's central office shall issue a written decision on each petition for reconsideration not later than sixty days after such petition was filed with the department. Such decision shall be forwarded to the regional office of appropriate jurisdiction and notice of such decision shall be provided to the petitioner and any authorized representative of such petitioner. Any favorable decision on such petition shall be implemented by the regional office not later than ten days after the date on which such decision was forwarded to the regional office by (A) granting assistance, if such assistance was previously discontinued, and (B) issuing a corrective assistance payment, if necessary, retroactive to either the first day of the month in which such petition was filed, or the first day of the month during which the department determines the petitioner became unemployable and was not receiving assistance to which he or she was entitled, whichever is earlier. Any adverse decision on such petition shall be final and may not be appealed. Nothing in this subsection shall be construed to interfere with an assistance unit member's right to request a fair hearing on the department's initial determination that such member does not qualify as unemployable, or to appeal a hearing officer's decision following such a fair hearing to the Superior Court.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-8 Determining eligibility. Asset restrictions

(a) Definitions. As used in this section, the following terms shall have the following meanings, unless a provision expressly provides otherwise:

(1) "Available asset" or "asset that is available" means any item of value that is actually available to a person or that such person has the legal right, authority or power to obtain or to have applied for such person's general or medical support;

(2) "Beneficiary" means a person who is entitled to receive funds, property or other benefits from an insurance policy, will, trust, contract or settlement;

(3) "Burial plot" means the contractual right to a grave site, opening and closing of a grave site, cremation urn, casket, outer burial container and a headstone or marker;

(4) "Cash surrender value" means the amount of money the owner of a life insurance policy, annuity or similar instrument may obtain by surrendering such instrument;

(5) "Corrective payment" means assistance paid to a person by the department as a refund or an adjustment for a previous underpayment of any cash, medical or other benefit provided by the department;

(6) "Equity value" means an amount calculated by subtracting the amount of all encumbrances on an asset from the fair market value of such asset;

(7) "Essential household item" means all furniture, furnishings and equipment found in or about a home that are used in connection with the operation, maintenance and occupancy of such home, and any other item used in the daily functions and activities of home or family life or for comfort or accommodation, but does not include items purchased as an investment to be sold for a profit in the future, such as, but not limited to, antiques, art or jewelry, other than a wedding or engagement ring;

(8) "Fair market value" means an amount for which an asset would commonly be sold on the open market in the geographic area where such asset is located if the owner of such asset made a reasonable, bona fide effort to gain the highest possible price for such asset in an arm's-length transaction;

(9) "Irrevocable burial fund" means funds held by a licensed funeral director pursuant to a contractual arrangement that authorizes the release of such funds for funeral arrangements only upon the death of the beneficiary of such contract, but that permits the transfer of such funds to another licensed funeral director;

(10) "Legal owner" means the person who is legally entitled to enjoy the benefit and use of an asset and who is therefore treated as the person to whom an asset is considered available;

(11) "Motor vehicle" means any vehicle propelled or drawn by any nonmuscular power that is intended and used for the transportation of persons or goods on public roads;

(12) "Personal effect" means clothing, jewelry or any other item that is used for personal care or education;

(13) "Record owner" means the person who has apparent ownership of an asset as verified by a title, registration or other documentation; and

(14) "Settlor" means the person whose funds are used to establish a trust.

(b) Asset limits. No person who belongs to a needs group consisting solely of such person shall be eligible for assistance pursuant to SAGA if the counted assets of such person's needs group exceed two hundred fifty dollars. No person who belongs to a needs group consisting of such person and his or her spouse shall be eligible for assistance pursuant to SAGA if the counted assets of such person's needs group exceed five hundred dollars.

(c) Counted assets. Subject to the provisions of subsections (e) to (p), inclusive, of this section, the equity value of each available asset that is not excluded under subsection (d) of this section shall be included among the counted assets of such person and the needs group to which he or she belongs. An assistance unit member shall, as a condition of eligibility for assistance pursuant to SAGA, cooperate with the department in verifying all counted assets of the needs group to which he or she belongs, the equity value of such assets and any reduction in such assets.

(d) Excluded assets. In addition to any other assets excluded pursuant to this section, the following assets shall be excluded from the counted assets of a person and the needs group to which he or she belongs if the circumstances concerning such asset are not in question or are verified by such person:

(1) Any of the following forms of government assistance or payments, if such forms are maintained or can be identified separate from counted assets:

(A) Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, as amended from time to time;

(B) Any federally insured grant, loan or work-study payment intended for books, tuition, or fees that is made to an undergraduate student;

(C) Any payment received as a volunteer under Title I of the Domestic Volunteer Service Act of 1973, Public Law 93-113, as amended from time to time;

(D) Any supplemental food assistance received under the Child Nutrition Act of 1966, Public Law 89-642, as amended by Public Law 92-433, or assistance provided pursuant to the special food service program for children under the National School Lunch Act of 1946, Public Law 79-396, as amended by Public Law 93-150;

(E) Any food received from a donation of a surplus commodity by the United States Department of Agriculture;

(F) Any nutritional assistance provided pursuant to the Older Americans Act of 1965, as amended from time to time;

(G) Any disaster assistance paid under the Disaster Relief Act of 1974, Public Law 93-288, as amended from time to time, including the individual and family grant program administered by the Federal Emergency Management Agency, and comparable disaster assistance provided by states, local governments and private organizations; or

(H) Any payment received pursuant to a federal, state or local law that provides energy assistance;

(2) Any essential household item;

(3) Any personal effect;

(4) Not more than one burial plot;

(5) Irrevocable burial funds;

(6) Real property that such person uses as his or her principal residence, including a house, trailer, camper or mobile home used by such person as a residence or an entire multi-family dwelling if it contains at least one unit occupied by such person as a principal residence, and any surrounding property and buildings or structures on such surrounding property if such principal residence and surrounding property are contiguous and not separated by intervening property owned by another person;

(7) Any real property described in subdivision (6) of this subsection that is not currently used as a principal residence due to employment, training for future employment, illness or uninhabitability caused by a catastrophic event, provided such person intends to return to such real property and use it as his or her principal residence when possible;

(8) Any real property not used by such person as his or her principal residence that, if treated as a counted asset, would result in such person's ineligibility for assistance, provided such property shall be excluded only if such person (A) signs a written agreement with a realtor to dispose of such property, (B) immediately lists such property for sale, (C) makes a bona fide effort to sell such property, (D) does not reject any offer that is approximately equal to the fair market value of such property, and (E) if such property is situated outside the state, grants the department a security mortgage on such property;

(9) Any tangible business asset, other than land and buildings, including, but not limited to, equipment, supplies, inventory, cash on hand and accounts receivable, provided such business produces income sufficient to justify possession of such business asset;

(10) Any asset, other than a tangible business asset, money, stocks, bonds or other similar liquid asset, that is essential to self-support, including any asset used for the sole purpose of producing items for such person's consumption, any item such person is required to own as a condition of his or her employment, including tools, equipment and uniforms;

(11) Any life insurance policy, including, but not limited to, a term insurance policy, that provides temporary coverage and has no cash surrender value;

(12) Any corrective payment for the month in which such payment is received and the ensuing month;

(13) Any funds deposited into, held in, credited to or withdrawn from an individual development account for a purpose consistent with an approved plan, as defined in section 31-51ww of the Connecticut General Statutes;

(14) Any portion of a lump sum payment that is paid to such person for the purpose of paying outstanding expenses incurred through no fault of such person, such as, but not limited to, settlement of outstanding medical bills or compensation for resources lost due to theft or a catastrophic event, provided such portion is maintained or can be identified separate from other funds;

(15) Any amount received by a person as beneficiary of a life insurance policy if such person intends to and does use such amount to pay for the burial expenses of the deceased insured;

(16) Any rental security deposit while held by a landlord, provided that such deposit shall be treated as a counted asset in the month that it is returned to such person;

(17) Any asset included in a decedent's estate that is in probate court if:

(A) The decedent's estate is undergoing administration;

(B) Such person does not have the legal right to make use of such asset until the probate court completes its administration of the estate;

(C) Such person takes reasonable steps to ensure that the administration of the decedent's estate is not unduly prolonged; and

(D) Such person assigns his or her interest in such asset to the department; and

(18) Any asset such person verifies cannot be converted to cash.

(e) Determining ownership. (1) For purposes of applying the provisions of this section, the record owner of an asset shall be treated as its legal owner unless the record owner submits evidence to the department verifying that he or she is not the legal owner. Whenever evidence submitted by the record owner of an asset verifies that he or she is not the legal owner of such asset, and treating such asset as a counted asset would cause such person to be ineligible for assistance pursuant to SAGA, such person shall, as a condition of eligibility for assistance, transfer such asset to the legal owner and provide evidence to the department verifying such transfer.

(2) Except as provided in subdivision (3) of this subsection, whenever an asset, including, but not limited to, a bank account, is jointly owned by two legal owners, one of whom is in a needs group and one of whom is outside such needs group, the full value of such asset shall be treated as a counted asset of such needs group, unless evidence is submitted to the department verifying that such needs group member is merely a record owner of all or a portion of such asset and the transfer provisions of subdivision (1) of this subsection are satisfied, in which case the department shall only include as a counted asset any portion of such asset that is legally owned by such needs group member.

(3) When real property is jointly owned by two or more record owners, at least one of whom is in a needs group and at least one of whom is outside such needs group, and there is no dispute that such record owners are the legal owners of such real property, the department shall consider such real property to be shared equally on a pro-rata basis by such record owners, unless the deed for such real property specifies otherwise.

(4) The insured shall be treated as the owner of any life insurance policy having a cash surrender value, unless such policy provides otherwise or the insurer verifies to the department that (A) a person other than the insured is entitled to cash in such policy and (B) the insured may not cash in such policy.

(f) Bank accounts. Money received on a recurring basis that, in the month of receipt, is deposited into a bank account shall be treated as income in the month of receipt. Said money shall be treated as a counted asset, unless excluded pursuant to this section or subsection (d) of section 17b-198-9 of the Regulations of Connecticut State Agencies, each following month if retained, except that any income derived from an income tax refund, an earned income tax credit payment, the transfer or sale of personal or real property or the return of a security deposit or the liquidation of a counted asset shall be treated as a counted asset during the month it is received and deposited.

(g) Money not deposited into bank account. Money received on a recurring basis by a person who is a member of a needs group shall be treated as counted income in the month of receipt, and as a counted asset, unless otherwise excluded pursuant to this section, each following month to the extent retained.

(h) Borrowed money. Any borrowed money derived from a loan that is received in one lump sum shall be treated as a counted asset of the person receiving such lump sum and the needs group to which he or she belongs. Any borrowed money derived from a loan that is received in regular installments, including money derived from a reverse mortgage, shall be treated as income during the month in which it is received, but shall be treated as a counted asset each following month to the extent retained.

(i) Stocks and bonds. The equity value of any share of stock or bond held by a person shall be treated as a counted asset of such person and the needs group to which he or she belongs. The equity value shall be the amount that such person will receive when he or she cashes such bond or would receive if he or she were to sell such stock.

(j) Lump-sum payments. Any lump-sum payment shall be treated as a counted asset of the person receiving such payment and the needs group to which he or she belongs. For purposes of this subsection, "lump-sum payment" means a one-time payment of money that is not expected to recur and includes, but is not limited to, any of the following if received as a one-time payment: a settlement from a personal injury or property claim, money received pursuant to a claim under an insurance policy, lottery winnings, an earned income tax credit payment, a tax refund, an arrearage of child support and a retroactive benefit payment from unemployment compensation or the Social Security Administration.

(k) Mortgage notes, loan documents and installment contracts. (1) Except as described in subdivision (2) of this subsection, the equity in any mortgage note, loan document, installment contract or similar financial instrument held by a person shall be treated as a counted asset of such person and the needs group to which he or she belongs if such person is entitled to sell or otherwise obtain the entire amount of equity in such instrument.

(2) Whenever a person who holds a financial instrument described in subdivision (1) of this subsection believes that the equity in such instrument does not accurately reflect its fair market value, such person may submit evidence concerning the true fair market value of such instrument. If, in the department's judgment, the evidence submitted more accurately approximates the true value of such instrument, the department shall value such instrument accordingly.

(l) Trusts. (1) Any trust payment received by or used to benefit the beneficiary of such trust shall be treated as the income of such beneficiary and the needs group to which he or she belongs in the month in which such payment is received or used, and as a counted asset of such beneficiary and needs group in each following month to the extent retained.

(2) The corpus of a trust shall be treated as a counted asset of a person and the needs group to which he or she belongs if the terms of the trust permit such person to revoke the trust and receive the corpus of the trust upon revocation.

(3) (A) With respect to a testamentary trust or an inter vivos trust that (i) was not established or funded by the beneficiary of such a trust or such beneficiary's spouse, and (ii) has terms that expressly entitle such beneficiary to receive distributions from the corpus of the trust for his or her general or medical support, the entire corpus or the maximum amount of the corpus that the trustee has authority or discretion to distribute for such beneficiary's general or medical support, if less than the entire corpus, shall be treated as a counted asset of such beneficiary and the needs group to which he or she belongs, regardless of whether the trustee actually makes the maximum allowable distribution.

(B) If the terms of a trust described in subparagraph (A)(i) of this subdivision do not expressly entitle the beneficiary to receive distributions from the corpus of such trust for his or her general or medical support, the department shall treat the entire corpus or the maximum amount of the corpus that the trustee has authority or discretion to distribute to the beneficiary, if less than the entire corpus, as a counted asset if the department concludes that the trustee's failure to make the maximum allowable distribution constitutes an abuse of discretion. In making this determination, the department shall consider the following factors:

(i) The clarity of the settlor's intention to provide for the general or medical support of such beneficiary;

(ii) The degree of discretion afforded to the trustee under the terms of the trust;

(iii) The value of the trust created, with a large value indicating that the settlor intended to provide for general or medical support for such beneficiary; and

(iv) The history of expenditures from such trust prior to the filing of an application seeking assistance for the beneficiary.

(4) When an assistance unit member residing in or admitted to a rated housing facility or a licensed residential care home, or such member's spouse, transfers assets to an irrevocable trust, such transfer shall be examined by the department to determine whether a penalty should be imposed under the provisions of subsection (f) of section 17b-198-5 of the Regulations of Connecticut State Agencies.

(5) Notwithstanding any other provision of this subsection, whenever the department determines that a beneficiary of a trust is not receiving payments from a trust to which he or she is entitled, the portion of the trust to which he or she is entitled shall be treated as an excluded asset, provided such beneficiary cooperates with the department in attempting to obtain such portion of the trust, as described in subsection (e) of section 17b-198-6 of the Regulations of Connecticut State Agencies.

(6) The provisions of this subsection shall apply to trusts and any other legal instrument similar to a trust, such as, but not limited to, an annuity.

(m) Life insurance policies. The cash surrender value of any life insurance policy owned by a person who is a member of a needs group shall be treated as a counted asset of such person and the needs group to which he or she belongs.

(n) Motor vehicles. (1) The department shall exclude (A) not more than four thousand five hundred dollars of the equity value of one motor vehicle per needs group, or (B) if such motor vehicle has been modified to enable operation by or transportation of any person with a disability who lives in a needs group member's household, the department shall exclude the entire equity value of such motor vehicle.

(2) If the members of a needs group own multiple motor vehicles, the department shall apply the provisions of subdivision (1) of this subsection in a manner that provides the greatest exemption allowable.

(3) For purposes of calculating the equity value of a motor vehicle, the fair market value of such vehicle shall be the average trade-in value for such vehicle, as listed in the National Automobile Dealers Association used car guide or, for older motor vehicle models, such association's appraisal guide. The department shall not increase the fair market value of any motor vehicle due to such vehicle being specially equipped with apparatus for persons with disabilities, the low mileage of such vehicle or any other factor. Any needs group member who disagrees with the fair market value adopted by the department may contest such fair market value by submitting to the department documentation from a reliable source that sets forth the actual fair market value of such vehicle. If the department is satisfied that such documentation more accurately approximates the true fair market value of such vehicle, the department shall use such fair market value to compute such vehicle's equity value.

(o) Liquidation of asset. Any money received from the liquidation of an asset shall be treated as the counted asset of the person receiving such money and the needs group to which he or she belongs.

(p) Effect of life use. (1) As used in this subsection "life use" means an alienable property interest in an asset that is measured by a life in being.

(2) Except as described in subdivisions (3) and (4) of this subsection, any asset to which a person is entitled to life use shall be treated as a counted asset of such person and the needs group to which he or she belongs. Any proceeds received by such person for the sale of such an interest shall be treated as a counted asset of such person and the needs group to which he or she belongs for the month such sale takes place and each ensuing month to the extent such proceeds are retained. Any income collected from renting an asset to which a person is entitled to life use shall be treated as the counted income of such person in the month received and as a counted asset each following month to the extent retained.

(3) If an asset described in subdivision (2) of this subsection is real property that such person (A) uses as his or her principal residence, or (B) is currently unable to use as his or her principal residence due to employment, training for future employment, illness or uninhabitability caused by a catastrophic event, but intends to use as his or her principal residence when possible, then such real property shall be treated as an excluded asset to the same extent that real property is excluded pursuant to subdivisions (6) and (7) of subsection (d) of this section.

(4) If an asset described in subdivision (2) of this subsection is real property that such person previously used, but no longer uses, as his or her principal residence, such property shall be treated as an excluded asset during any month in which such person attempts to sell his or her interest in such property but is unable to sell such interest because he or she cannot find a willing and able buyer.

(5) The department shall determine the equity value of a person's right to life use of an asset by considering:

(A) Whether such person is a sole or joint owner of such interest;

(B) The equity value of the asset; and

(C) Such person's life expectancy based upon his or her age and gender.

(q) Placement of lien on certain excluded real property. Whenever real property situated in Connecticut is excluded from the counted assets of a needs group or member thereof, the department shall place a lien on such property on the first day on which an assistance payment is made to any member of such needs group.

(r) Period of ineligibility. A person whose application for assistance pursuant to SAGA is pending and who belongs to a needs group that owns assets in excess of the limits established under subsection (b) of this section shall remain ineligible for assistance until such assets are reduced below such limits. A person receiving assistance pursuant to SAGA who belongs to a needs group that acquires assets in excess of such limits shall become ineligible for assistance on the first day of the month following the month in which such assets are acquired, unless such assets are reduced below such limits prior to such time. No transfer of assets for less than their fair market value shall be considered a reduction in such assets unless the person making such transfer verifies that the transfer was made for a purpose other than establishing eligibility for assistance. The transfer of an asset by a resident of or person admitted to a rated housing facility or a licensed residential care home for less than fair market value for the purpose of establishing eligibility for assistance pursuant to SAGA may result in the imposition of a penalty under the provisions of subsection (f) of section 17b-198-5 of the Regulations of Connecticut State Agencies.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-9 Determining eligibility. Income restrictions

(a) Definitions. As used in this section, the following terms shall have the following meanings:

(1) "Applied income" means the portion of the counted income of a person or needs group that remains after subtracting applicable deductions, as described in subsection (e) of this section;

(2) "Earned income" means income that a person receives (A) from a third party in exchange for the performance of duties, or (B) through self-employment, and may be in the form of wages, salary, benefits or proceeds from self-employment, but does not include income derived from renting property;

(3) "Gross income" or "gross counted income" means a person's or needs group's counted income prior to subtracting applicable deductions, as described in subsection (e) of this section;

(4) "Income in kind" means goods, commodities or services, valued according to their fair market value, that are provided to a person or to a third party on such person's behalf in lieu of cash that is owed to such person;

(5) "Personal employment expenses" means costs incident to being employed, including, but not limited to, the cost of transportation, parking, professional licensure and certification, tools and a uniform or other work-appropriate clothing; and

(6) "Unearned income" means income that does not constitute compensation for work, services performed or business conducted and includes returns from capital investments and the rent of property when the person is not actively involved in the production of the income.

(b) Income limits. (1) No person who belongs to a needs group consisting of one person shall be eligible for assistance pursuant to SAGA if such needs group has monthly (A) gross income that exceeds three hundred per cent of the maximum SSI benefit for an individual who has no income and lives alone, or (B) applied income that is equal to or exceeds the applicable payment standard for such person, as described in subsection (b) of section 17b-198-10 of the Regulations of Connecticut State Agencies.

(2) No person who belongs to a needs group that includes his or her spouse shall be eligible for assistance pursuant to SAGA if such needs group has monthly (A) gross income that exceeds six hundred percent of the maximum SSI benefit for a married couple, or (B) applied income that is equal to or exceeds the applicable payment standard for such person, as described in subsection (b) of section 17b-198-10 of the Regulations of Connecticut State Agencies.

(c) Counted income. (1) Subject to the provisions of subsections (f) to (s), inclusive, of this section, income that is not excluded under subsection (d) of this section shall be included among the counted income of such person and the needs group to which he or she belongs for purposes of calculating the gross income and applied income of such person and needs group. An assistance unit member shall, as a condition of eligibility for assistance pursuant to SAGA, cooperate with the department in verifying all counted income of such member and the needs group to which he or she belongs. Such cooperation shall be provided at the time of application, during each renewal of eligibility and whenever such income changes.

(2) Counted income shall be treated as such only in the month received and as a counted asset each subsequent month to the extent retained.

(d) Excluded income. The following income shall be excluded from the counted income of such person and the needs group to which he or she belongs if the source of the income is verified:

(1) Any federal, state or local adoption assistance payment;

(2) Any federal, state or local assistance payment for the care of a foster child who is placed in the care of such person

(3) Any supplemental food assistance received under the Child Nutrition Act of 1966, Public Law 89-642, as amended by Public Law 92-433, or assistance provided pursuant to the special food service program for children under the National School Lunch Act of 1946, Public Law 79-396, as amended by Public Law 93-150;

(4) The value of allotments made under SNAP;

(5) Not more than thirty dollars per calendar quarter that is received as a gift to commemorate a special occasion or is otherwise distinguishable from income due to its infrequent or irregular receipt;

(6) Income in kind;

(7) Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970, as amended from time to time;

(8) Any federal, state or local payment made under a means-tested energy assistance program;

(9) Any money received as a protective payee for another person pursuant to SAGA or a program administered by the Social Security Administration, provided such money is used exclusively for such other person's support;

(10) Any payment made to such person by the department for the expense of day care or essential services unless such person is the provider of such day care or services;

(11) Any payment received as a volunteer under Title I of the Domestic Volunteer Service Act of 1973, Public Law 93-113, as amended from time to time, unless such payment is equal to or greater than the minimum wage in effect under the Fair Labor Standards Act of 1938, as amended from time to time, or the state minimum wage, whichever is greater;

(12) Any disaster assistance paid under the Disaster Relief Act of 1974, Public Law 93-288, as amended from time to time, including the individual and family grant program administered by the Federal Emergency Management Agency, and comparable disaster assistance provided by states, local governments and private organizations;

(13) Any payment made to such person by the Department of Labor to offset the cost of pursuing employment;

(14) Any security deposit returned to such person;

(15) Any portion of a grant, loan, scholarship or work-study payment that is provided to an undergraduate student by the federal government, a state government or any private source and is intended for books, tuition or fees, but not any portion intended for food, shelter, clothing or transportation, provided such student (A) verifies his or her status as a student, (B) verifies that the portion to be excluded is intended for a purpose warranting exclusion, and (C) maintains or is able to identify the portion to be excluded separate from other counted income and counted assets;

(16) Any benefit received from the Puerto Rico nutrition assistance program;

(17) Any payment received as earned or unearned income under the Workforce Investment Act of 1998, Public Law 105-220, as amended from time to time; and

(18) Notwithstanding the provisions of subsection (l) of this section, Aid and Attendance pension benefits paid to such person by the United States Department of Veterans Affairs.

(e) Income deductions. For purposes of calculating the applied income of a needs group, the department shall make the following deductions from the gross counted income of such needs group if the applicability of such a deduction is verified:

(1) Up to one hundred fifty dollars for personal employment expenses shall be deducted from the gross earned income of each person in such needs group who is employed full or part time, except that no such deduction shall be made in any month during which a person fails to report his or her income within ten days of receipt of such income;

(2) Business expenses, including overhead expenses such as rent, fuel, utilities and equipment, the cost of stock and raw materials and payments to or on behalf of employees, shall be deducted from the gross earned income derived from such business for any person in such needs group who is self-employed;

(3) The following expenses associated with renting real or personal property shall be deducted from gross unearned income derived from renting such property, provided that no such deduction shall be made for any expense associated with a portion of real property occupied by a member of such needs group:

(A) The cost of labor, including wages paid to employees or money paid to independent contractors;

(B) Interest on the principal of a loan used to purchase such property;

(C) Insurance premiums;

(D) Taxes, assessments and the cost of utilities paid for such property;

(E) Service and repair of such property;

(F) Rental of business equipment and property used in connection with such property;

(G) The cost of advertising such property;

(H) The cost of any licenses or permits necessary for such property;

(I) Any legal or other professional fees incurred in connection with the acquisition or rental of such property; and

(J) Business supplies used in connection with the rental of such property;

(4) For income derived from providing a room without board, the costs associated with operating and maintaining the residence shall be deducted from such income after prorating such costs according to the number of bedrooms rented for such purpose;

(5) For income derived from providing room and board, one of the following shall be deducted:

(A) The cost of a Thrifty Food Plan for a SNAP assistance unit of a size that is equal to the number of boarders involved; or

(B) An amount calculated by adding the actual cost of providing a room, as described in subdivision (4) of this subsection, and meals if (i) such amount is greater than the cost permitted as a deduction pursuant to subparagraph (A) of this subdivision, and (ii) such actual costs are separate and identifiable as the costs of providing room and meals to the boarders.

(f) Intermittent income. (1) For purposes of this subsection, "intermittent income" means money received on a recurring, sporadic basis in intervals exceeding one month, and includes both earned and unearned income. Such income includes, but is not limited to:

(A) Payment of money earned by a person over a past period that exceeds one calendar month;

(B) Advance payments that are made pursuant to a contract for expected future expenses, provided such payments are made in intervals exceeding one month;

(C) Payments made in intervals exceeding one month due to an agreement between a payor and payee, such as, but not limited to, money paid due to a settlement with an insurer and payment of dividends and interest or from a pension or annuity; and

(D) Compensation for sporadic, short-term employment.

(2) Each payment of intermittent income shall be divided by the number of months for which such payment is intended to compensate, reimburse or otherwise be applied and the resulting amount shall be treated as counted income for each such month. Intermittent income intended to compensate, reimburse or otherwise be applied during past months shall be treated as counted income in such months retroactively. Whenever treating intermittent income as counted income retroactively results in an assistance unit's ineligibility for assistance pursuant to SAGA for a month during which such assistance was previously paid, such previous payment of assistance shall be treated as an overpayment, as described in section 17b-198-17 of the Regulations of Connecticut State Agencies.

(g) Lump-sum payments. Any lump-sum payment shall be treated as a counted asset, rather than as counted income, of the person receiving such payment and the needs group to which he or she belongs. For purposes of this subsection, "lump-sum payment" has the same meaning as provided in subsection (j) of section 17b-198-8 of the Regulations of Connecticut State Agencies.

(h) Housing subsidies. (1) For purposes of this subsection, "housing subsidy" means housing assistance provided pursuant to Section 8 of the Housing Act of 1937, as amended from time to time, or the state rental assistance program established pursuant to section 8-345 of the Connecticut General Statutes, or in federal low-income public housing.

(2) Any housing subsidy provided to an assistance unit member shall be treated as the counted unearned income of such member and the needs group to which he or she belongs. Such subsidy shall be valued according to an amount equal to eight per cent of the appropriate payment standard for such member, as determined under the provisions of subsection (b) of section 17b-198-10 of the Regulations of Connecticut State Agencies.

(i) Alimony and child support. Any alimony payment received by a person shall be treated as the counted unearned income of such person and the needs group to which he or she belongs. Any arrearage of child support received by a person shall be treated as a lump-sum payment pursuant to subsection (g) of this section if received in a lump sum, and as the counted unearned income of such person if received in routine, periodic installments. The provisions of this subsection concerning child support arrearages shall apply regardless of whether such arrearage is paid directly to the person entitled to such arrearage or to the department's Bureau of Child Support Enforcement.

(j) Annuities, pensions, trusts, dividends, royalties and interest. (1) Any payment received by a person from an annuity plan, pension or trust, or as interest, a dividend or a royalty, shall be treated as the counted unearned income of such person and the needs group to which he or she belongs.

(2) When a payment from a trust, annuity or pension is received on a recurring basis less frequently than monthly, each payment received shall be averaged forward over the number of months that transpire between such payments in order to calculate the monthly gross counted income of such member and needs group.

(3) Whenever an interest payment or a payment from a trust, dividend or royalty could be paid to a person but instead is left to accumulate with existing principal or is reinvested, the amount of the payment that could have been made shall be treated as the counted income of such person and the needs group to which he or she belongs in the month first payable, and shall be treated as a counted asset each month thereafter.

(k) Public assistance from other states. Any public assistance paid by another state to a person during any month in which the application for assistance pursuant to SAGA is pending shall be treated as the counted unearned income of such person and the needs group to which he or she belongs.

(l) Social Security and veterans' benefits. Any Social Security survivor or retirement benefits or veterans' benefits issued by the United States Department of Veterans Affairs that are paid to a person shall be treated as the counted unearned income of such person and the needs group to which he or she belongs.

(m) Uniformed services pay. Any money paid to a person as compensation for service in the uniformed services, including, but not limited to, the United States Army, Navy, Air Force, Marine Corps, Coast Guard and Public Health Services, shall be treated as the counted earned income of such person and the needs group to which he or she belongs. The provisions of this subsection shall apply to money paid to a person as a dependent's allotment of compensation earned by another person for service in the uniformed services, but such compensation shall be counted as unearned income.

(n) Cash contributions. Any cash contribution paid to a person by a relative, friend, agency or organization shall be treated as the counted unearned income of such person and the needs group to which he or she belongs if such contribution is made regularly and predictably, exceeds thirty dollars in a calendar quarter and is not legally required. Any such cash so received that is subject to a repayment agreement shall be treated as a loan, as described in subsection (p) of this section, rather than a cash contribution.

(o) Gratuities and special allowances. (1) If a person's compensation for employment involves receipt of a gratuity and such person is able to distinguish such gratuity from other earned wages, the actual amount of such gratuity shall be treated as the counted earned income of such person and the needs group to which he or she belongs. If such person is unable to distinguish such a gratuity from other earned wages, an amount equal to fifteen per cent of such person's monthly gross wages attributable to the job for which a gratuity was earned shall be treated as the counted earned income of such person and the needs group to which he or she belongs.

(2) If a person's compensation for employment includes a special allowance for items such as, but not limited to, uniform cleaning and meals, and such allowance is provided in addition to basic wages, such special allowance shall be treated as the counted earned income of such person and the needs group to which he or she belongs.

(p) Loans. (1) For purposes of this subsection, "loan" means any money paid by a person or organization to another person or organization that is subject to repayment pursuant to a written contract or agreement.

(2) Any loan received by a person in one lump sum shall be treated as a counted asset, rather than the counted income, of such person and the needs group to which he or she belongs. Any loan received by a person in regular installments, including money derived from a reverse mortgage or home equity conversion plan, shall be treated as the counted unearned income of such person and the needs group to which he or she belongs in the month received, but shall be treated as a counted asset each following month to the extent retained.

(3) Any money received by a person as repayment of a loan provided by such person shall be treated as a counted asset of such person and the needs group to which he or she belongs to the extent such money represents a repayment of loan principal. Any money paid to a person who provided a loan that constitutes interest or a penalty on such loan, or that otherwise represents a gain or profit, shall be treated as the counted unearned income of such person and the needs group to which he or she belongs in the month received, and as a counted asset each following month to the extent retained.

(q) Connecticut Uniform Relocation Assistance Act. Any payment received by a person pursuant to the Connecticut Uniform Relocation Assistance Act, section 8-266 of the Connecticut General Statutes, et seq., shall be treated as excluded income to the extent that such payment is maintained or can be identified separate from other funds and used for the purposes for which such payment was made, and shall otherwise be treated as a lump sum payment, as described in subsection (g) of this section.

(r) Cashed-in fringe benefits, unemployment compensation, workers' compensation and severance pay. Any money received by a person as compensation for use of accrued sick or vacation time or severance pay shall be treated as the counted earned income of such person and the needs group to which he or she belongs. Any unemployment compensation, workers' compensation or reimbursement pursuant to a private insurance policy for lost wages and other expenses due to injury or sickness shall be treated as the counted unearned income of such person and the needs group to which he or she belongs.

(s) Room and board. Any money received by a person for providing room or room and board shall be treated as earned income derived from self-employment. The monthly amount of income derived from such self-employment shall be determined by dividing the total amount received on an annual basis by twelve, unless this calculation does not accurately reflect current circumstances or such income is only intended to cover the assistance unit's needs for a portion of the year.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-10 Calculation of benefits

(a) Method. (1) For an eligible assistance unit consisting of a married person whose spouse is included in his or her needs group, the monthly benefit payment shall be determined by:

(A) Selecting the appropriate payment standard pursuant to subsection (b) of this section;

(B) Subtracting from the appropriate payment standard the monthly applied income of such assistance unit's needs group;

(C) Multiplying the resulting amount by an amount calculated by dividing the amount that would be applied as a payment standard under subsection (b) of this section if such person were unmarried by the appropriate payment standard for such person; and

(D) Rounding down to the nearest whole dollar.

(2) For all other eligible assistance units, the monthly benefit payment shall be determined by:

(A) Selecting the appropriate payment standard pursuant to subsection (b) of this section;

(B) Subtracting from the appropriate payment standard the monthly applied income of such assistance unit's needs group; and

(C) Rounding down to the nearest whole dollar.

(3) Notwithstanding the provisions of subdivisions (1) and (2) of this subsection:

(A) The department shall prorate the benefit amount calculated pursuant to said subdivisions for the first month assistance is granted if such assistance is granted on a day other than the first day of the month;

(B) In any month in which an assistance unit member leaves the community and begins residing in a rated housing facility or a licensed residential care home on a day other than the first day of the month, the department shall issue a payment to such facility or home prorated according to the number of days such member resided in such facility or home; and

(C) In any month in which an assistance unit member returns to the community from a rated housing facility or a licensed residential care home on a day other than the last day of the month, the department shall issue one payment to such facility or home prorated according to the number of days such member resided in such facility or home, and one payment to such member prorated according to the number of days such member resided in the community.

(4) Any prorating required pursuant to subdivision (3) of this subsection shall be completed prior to the rounding required under subdivisions (1) and (2) of this subsection. In the event that a benefit payment is reduced for the purpose of recouping a past overpayment, as described in section 17b-198-17 of the Regulations of Connecticut State Agencies, such rounding shall not be performed until after such reduction has been calculated. In no event shall the department issue a benefit payment when, after the prorating required pursuant to subdivision (3) of this subsection, the total benefit amount is less than one dollar.

(b) Payment standard. (1) The appropriate payment standard shall be determined as follows:

(A) For an unmarried person between the ages of eighteen and twenty-one who (i) lives with a TFA family assistance unit, and (ii) is no longer a member of such assistance unit due to attaining eighteen years of age, the payment standard shall be an amount calculated by subtracting the TFA payment standard for such family assistance unit from the TFA payment standard that would be applied for such family assistance unit if such person was still a member of such family assistance unit;

(B) For a person residing in a rated housing facility or a licensed residential care home, the payment standard shall be the monthly rate for residential services established for the particular facility or home in which such person resides;

(C) For any person not referred to in subparagraphs (A) and (B) of this subdivision who is unmarried or whose spouse is not included in his or her needs group, the payment standard shall be (i) two hundred nineteen dollars if the department deems such person unemployable, (ii) two hundred nineteen dollars if the department deems such person transitional and such person is obligated to pay shelter costs, and (iii) fifty-five dollars if the department deems such person transitional and such person is not obligated to pay such shelter costs or resides in an emergency shelter;

(D) For any person not referred to in subparagraphs (A) to (C), inclusive, of this subdivision whose needs group includes a spouse who is receiving or is also requesting and eligible for assistance pursuant to SAGA, the payment standard shall be calculated by (i) determining the amount that would be applied as a payment standard for such person pursuant to subparagraph (C) of this subdivision if such person was unmarried, (ii) determining the amount that would be applied as a payment standard for such person's spouse pursuant to subparagraph (C) of this subdivision if such spouse was unmarried, and (iii) adding such amounts together; and

(E) For any married person not referred to in subparagraphs (A) to (C), inclusive, of this subdivision whose needs group includes a spouse who is not requesting or is ineligible for assistance pursuant to SAGA, the payment standard shall be calculated by doubling the amount that would be applied as a payment standard for such person pursuant to subparagraph (C) of this subdivision if such person was unmarried.

(2) The payment standards described in subparagraph (C) of subdivision (1) of this subsection shall be increased annually in accordance with the provisions of section 17b-104 of the Connecticut General Statutes.

(3) For purposes of applying the provisions of subparagraph (B) of subdivision (1) of this subsection, a person shall be considered a resident of a rated housing facility or licensed residential care home if he or she does not maintain a separate residence outside such facility or home. A person who is temporarily absent from such a facility or home where he or she resides shall continue to be considered a resident of such facility or home if such person does not enter into another permanent housing agreement during the period of absence and is expected to return to such facility or home not later than the last day of the month following the month that such person became temporarily absent from such facility or home.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-11 Special benefits

(a) Generally. In addition to providing the assistance described in section 17b-198-10 of the Regulations of Connecticut State Agencies, the department shall, as a component of SAGA, provide special benefit payments, as described in this section.

(b) Funeral and burial expenses. (1) As used in this this subsection:

(A) "Available estate" means the portion of the net value of a decedent's assets, including (i) all liquid assets, (ii) any asset or income to which the decedent was entitled at the time of death, (iii) the face value of any life insurance policy issued on the life of the decedent, (iv) the value of any burial reserve account, revocable or irrevocable funeral fund or prepaid funeral contract, and (v) all real and personal property, such as, but not limited to, the decedent's home and motor vehicle, that remains after subtracting the cost or anticipated cost of administering the decedent's estate.

(B) "Covered funeral and burial expenses" means expenses typically associated with providing funeral and burial services for a decedent, including, but not limited to, the cost of (i) transporting the decedent from the place of death to the funeral home and on to the place of burial, (ii) a wake, (iii) church services, (iv) a burial plot, as defined in subsection (a) of section 17b-198-8 of the Regulations of Connecticut State Agencies, (v) opening and closing a grave, and (vi) other cemetery or cremation charges;

(C) "Eligible decedent" means a deceased person, other than a stillborn child, who was a SAGA recipient at the time of his or her death or who:

(i) Left an available estate of less than one thousand four hundred dollars or the actual cost of his or her funeral and burial, whichever is less;

(ii) Has no legally liable relative who is able to pay for the cost of his or her funeral and burial;

(iii) Was not receiving assistance pursuant to TFA, AABD or RCA at the time of his or her death; and

(iv) Was a resident of Connecticut at the time of his or her death, as determined under the rules described in subsection (b) of section 17b-198-5 of the Regulations of Connecticut State Agencies;

(D) "Legally liable relative" means a decedent's spouse or, if the decedent was under eighteen years of age, unmarried and not emancipated by a court of appropriate jurisdiction at the time of death, parents; and

(E) "Vendor" means a funeral home, cemetery or crematory.

(2) Upon receipt of the death certificate of an eligible decedent, a bill for such eligible decedent's covered funeral and burial expenses and any application required pursuant to this subdivision, the department shall provide payment, in an amount determined pursuant to subdivision (3) of this subsection, for such funeral and burial expenses to the vendor providing funeral and burial services for the eligible decedent. An application for such payment shall be required unless, at the time of his or her death, the eligible decedent was receiving benefits pursuant to SAGA or a Medicaid coverage group limited to individuals below a particular asset level. In no event shall the department issue a payment pursuant to this subsection if a request for payment and any application required pursuant to this subdivision are received more than one year after the date of the eligible decedent's death. Such request and application may be made by the vendor providing funeral and burial services for the eligible decedent, any person who has legal custody of the eligible decedent's remains or a relative, friend or conservator of the eligible decedent.

(3) Any payment provided pursuant to this subsection shall be calculated by subtracting the following amounts from either the actual cost of the eligible decedent's funeral and burial, or one thousand four hundred dollars, whichever is less:

(A) The amount in any revocable or irrevocable funeral fund;

(B) The value of any prepaid funeral contract;

(C) The face value of any life insurance policy owned by the eligible decedent; and

(D) The amount in excess of three thousand two hundred dollars that is contributed towards the eligible decedent's funeral and burial expenses by any other source, with the cost of any item that is purchased and donated or provided in lieu of money, including, but not limited to, a burial plot, as defined in subsection (a) of section 17b-198-8 of the Regulations of Connecticut State Agencies, valued according to its fair market value.

(c) Transportation out of state. (1) The department shall pay for the cost of transportation for an assistance unit member who is moving to another state or country if:

(A) Such member has neither the income nor the assets to pay for such transportation;

(B) Such member has either (i) relatives who are able or friends who express willingness to aid in such person's support in such other state or country, or (ii) other private means of support in such other state or country; and

(C) The department determines that such move is in the best interest of such member and the state of Connecticut after considering the following factors:

(i) Whether the majority of such member's family and friends live in Connecticut or the state or country to which he or she intends to move;

(ii) Whether such member has employment history, opportunity for employment or other plans for becoming self-sufficient in Connecticut or the state or country to which he or she intends to move;

(iii) Whether such member wishes to maintain residency in Connecticut or establish permanent residency in the state or country to which he or she intends to move; and

(iv) Any other circumstance relevant to determining whether it is in the best interest of such member and Connecticut for such person to move to such other state or country.

(2) Any payment made by the department pursuant to this subsection shall be for the principal mode of transportation used to move a person out of the state and shall not include (A) the cost of any secondary mode of transportation necessary to access such principal mode of transportation, or (B) the cost of moving or storing such person's home furnishings, furniture or other personal property. Such payment shall be in an amount calculated by subtracting from the most economical rate for air or land transportation, whichever is appropriate, any income or assets such person has to pay for such transportation, including any income such person receives upon selling home furnishings or other personal property prior to the move. Any person for whom a payment is made pursuant to this subsection shall, as a condition of such payment being made on his or her behalf, sell any personal property he or she does not intend to transport to such other state or country.

(d) Property repairs. (1) The department shall pay for the cost of repairs to real property on behalf of a person receiving assistance pursuant to SAGA if:

(A) Such person has an equitable interest in such property;

(B) Such person uses such property as his or her home;

(C) Such person cannot continue to safely live in such property unless the repairs for which payment is sought are completed;

(D) Such person will have to rent alternative housing if the repairs for which payment is sought are not completed and the projected cost of renting such alternative housing over a two-year period exceeds the cost of the pertinent repairs and any other costs attributable to continued occupancy of such property over such two-year period;

(E) The department verifies the need for the repairs for which payment is sought;

(F) Such person obtains and submits to the department no fewer than three bids estimating the cost of the repairs for which payment is sought; and

(G) The department concludes that the winning bid is reasonable.

(2) Any payment made by the department pursuant to this subsection shall be in an amount equal to the lowest bid that the department concludes is reasonable, but in no event shall the department pay for any portion of such bid that is not attributable to repairs necessary for the safe habitation of such property. Any payment made pursuant to this subsection shall be made directly to the contractor providing such repairs after the department verifies such repairs have been satisfactorily completed.

(e) Emergency housing. (1) The department shall pay for an assistance unit member's emergency housing and not more than three meals per day served by the provider of such emergency housing if such member:

(A) Cannot remain in permanent housing because:

(i) A judgment was entered against such member in a summary process action instituted pursuant to chapter 832 of the Connecticut General Statutes, provided such action was not based on the criminal activity of such member;

(ii) Such member left such permanent housing to escape the threat of domestic violence;

(iii) A judgment was entered against such member in a foreclosure action pursuant to chapter 846 of the Connecticut General Statutes;

(iv) Such member was required to relocate by local health or building officials because (I) a child who is under such member's supervision was found to have a level of lead in the blood equal to or greater than twenty micrograms per deciliter or any other abnormal level of lead, and (II) the local director of health determined that the source of the lead poisoning is such member's permanent housing;

(v) A catastrophic event rendered such permanent housing uninhabitable, as determined by appropriate state or local officials or the department;

(vi) Such member was ordered to vacate such permanent housing by a local building or housing code enforcement official;

(vii) Such permanent housing was a shared living arrangement that such member left because the primary tenant (I) was in the process of being evicted, (II) received a preliminary notice from his or her landlord pursuant to Connecticut General Statutes 47a-15, (III) received a notice to quit due to termination of a rental agreement for lapse of time; or (IV) was engaged in criminal activity; or

(viii) Such member was illegally locked out of such permanent housing by his or her landlord and has filed a complaint with the police concerning such illegal lockout;

(B) Was unable to move into new permanent housing on the day that the previous permanent housing was lost;

(C) Has not received relocation assistance, pursuant to the Connecticut Uniform Relocation Assistance Act, section 8-266 of the Connecticut General Statutes, et seq., in the form of placement by a town welfare agency in temporary or permanent housing despite having made reasonable efforts to obtain such assistance;

(D) Applies for the department to pay for his or her emergency housing not later than forty-five days after the date on which such member's permanent housing was lost;

(E) Agrees to (i) make reasonable efforts to locate new permanent housing, (ii) accept any reasonable alternative permanent housing that is less costly than the previous permanent housing, if requested to do so by the department, and (iii) accept any permanent housing constructed, renovated or rehabilitated with state or federal funding; and

(F) Selects emergency housing that is not a hotel or motel, except that if such member's need for emergency housing was caused by a catastrophic event, as described in subparagraph (A)(v) of this subsection, a hotel or motel may be selected as emergency housing.

(2) Any payment made by the department pursuant to this subsection shall be in an amount equivalent to the actual amount charged for the emergency housing and meals, provided such amount shall not exceed eleven dollars per night for such emergency housing and one dollar per meal served. No assistance unit member shall be eligible for a special benefit payment under this subsection for more than one occurrence during a calendar year or for more than sixty days per occurrence, except that any assistance unit whose need for emergency housing is caused by lead poisoning, as described in subparagraph (A)(iv) of this subsection, may receive such additional assistance for more than one occurrence during a calendar year and for not more than eighty days per calendar year.

(f) Storage charges. (1) The department shall pay for the cost of storing an assistance unit member's furnishings and appliances in a commercial facility and preparing such furnishings and appliances for such storage if:

(A) The department has agreed to pay for such member's emergency housing under subsection (e) of this section;

(B) There is no other source of payment for the cost of storing such furnishings and appliances commercially; and

(C) Such member submits to the department two estimates for the cost of preparing and storing such furnishings and appliances.

(2) Any payment made by the department pursuant to this subsection shall be provided in an amount equivalent to the lower of the two estimates submitted by the assistance unit. In no event shall an assistance unit member be eligible for a special benefit payment under this subsection for a period longer than such member is eligible for an emergency housing special benefit payment under subsection (e) of this section.

(g) Meals-on-wheels program. (1) The department shall pay for the cost of an assistance unit's participation in a meals-on-wheels program if:

(A) Such member is unable to prepare meals at home due to physical or mental incapacity or a lack of cooking facilities; and

(B) The department completes a casework assessment recommending such member for participation in a meals-on-wheels program.

(2) Any payment made by the department pursuant to this subsection shall be calculated on a per diem basis at the monthly rate of seventy-three dollars and fifty cents if one meal is delivered each day and one hundred forty-seven dollars if two meals are delivered each day. Such payment shall be provided on a recurring basis, but shall be issued only for days on which such meals are delivered.

(h) Moving expenses. (1) The department shall pay for the cost of moving an assistance unit's household and personal items during a relocation if such relocation is from one location in the state to another location in the state and is necessary due to:

(A) A need for different living quarters that are more conducive to the health needs and limitations of the assistance unit member due to a chronic illness;

(B) An increase in the cost of shelter, provided the cost of shelter at the new residence does not exceed the cost of shelter at the former residence prior to such increase;

(C) A need for living quarters that are closer to the assistance unit member's place of employment or a new job site;

(D) The occurrence of any event justifying a special benefit payment for emergency housing, as described in subparagraph (A) of subdivision (1) of subsection (e) of this section; or

(E) The assistance unit member living beyond his or her means, provided the cost of the new housing selected is lower than the cost of housing at the previous location.

(2) Any payment made by the department pursuant to this subsection shall be non-recurring and in an amount equivalent to the reasonable cost incurred by the assistance unit member for moving household furnishings and personal belongings and preparing such furnishings and belongings for such move, provided such member submits evidence of such cost to the department. In no event shall such payment exceed an amount that such member's mover would ordinarily charge the general public for similar services or, if such mover does not regularly provide similar services to the general public, an amount that a moving contractor providing similar services to the general public in the assistance unit's area would ordinarily charge.

(i) Repair or replacement of essential household items. (1) For purposes of this subsection, "essential household item" means any item listed in subdivision (5) of this subsection, in the quantity considered essential under said subdivision.

(2) The department shall pay for the cost of replacing any essential household item owned by an assistance unit member if:

(A) Such item was damaged or destroyed during a catastrophic event;

(B) Such item is not otherwise available to such member in a furnished apartment or shared living arrangement;

(C) The loss of such item is not covered by an insurance policy;

(D) Such member permits the department to conduct a home visit for the purpose of examining such item;

(E) The needs group obtains an estimate of the cost of repair for any such item that (i) was not totally destroyed or damaged beyond repair, and (ii) is assigned a replacement cost in excess of one hundred dollars under subdivision (5) of this subsection; and

(F) The department determines that the cost of repairing such item would exceed the replacement cost assigned for such item under subdivision (5) of this subsection.

(3) The department shall pay for the cost of repairing any essential household item owned by an assistance unit member if:

(A) The requirements of subparagraphs (A) to (E), inclusive, of subdivision (2) of this subsection are met; and

(B) The department determines that the cost of repairing such item would not exceed the replacement cost assigned for such item under subdivision (5) of this subsection.

(4) Any payment made by the department for the replacement of an essential household item shall be non-recurring and in an amount equal to the replacement cost assigned for such item under subdivision (5) of this subsection. Any payment made by the department for the repair of an essential household item shall be in an amount equal to the estimated cost of repairing such item. Whenever an assistance unit member is required to obtain an estimate of the cost of repairing an essential household item, as described in subdivisions (2) and (3) of this subsection, the department shall reimburse such member for any cost incurred in obtaining such estimate.

(5) The department shall utilize the following table for the purposes of determining whether an item constitutes an essential household item and, if so, the replacement cost of such item: ItemQuantity considered essentialReplacement costBedOne bed space per individual, with a twin bed constituting one bed space and a full bed constituting two bed spaces Thirty-five dollars per twin or full bed for a frame;Fifty-eight dollars per twin bed and seventy-six dollars per full bed for a box spring; and Fifty-eight dollars per twin bed and seventy-six dollars per full bed for a mattressDinette setOne table and one chair per individualEighty dollars per table and ten dollars per chairChest of drawersOne chest per individualSixty dollars per chestLampOne lamp per individualTwenty dollars per lampLiving room chairOne per individual Fifty dollars per living room chairSofaOne sofaOne hundred forty-six dollars per sofaBathing towelsTwo hand towels and two bath towels per individualTwo dollars per hand towel and seven dollars per bath towelBedding suppliesOne pillow and one pillowcase set per individual; two blankets per bed replaced pursuant to this subsection; two sheet sets per bed replaced pursuant to this subsection; and one mattress pad per bed replaced pursuant to this subsection Ten dollars per pillow;Eight dollars per pillowcase set;Fifteen dollars per blanket for a twin bed and eighteen dollars per blanket for a full bed; Eleven dollars per sheet set for a twin bed and fifteen dollars per sheet set for a full bed; and Ten dollars per mattress pad per twin bed and fourteen dollars per mattress pad per full bed Cooking utensilsOne setThirty dollars per setSilverwareOne set sufficient to serve eight people Seventeen dollars per setDishesOne set sufficient to serve eight people Twenty-six dollars per setDish towelsOne set of three dish towels Four dollars and fifty cents per setGlasswareOne set sufficient to serve eight people Ten dollars per setIroning boardOne ironing boardEighteen dollars per ironing boardWindow shadesOne window shade per window in the individual's homeFive dollars per window shadeIronOne ironEighteen dollars per ironRangeOne rangeOne hundred fifty dollars per rangeRefrigeratorOne refrigeratorOne hundred eighty dollars per refrigeratorWashing machineOne washing machineOne hundred sixty dollars per washing machineGarbage canOne garbage canFive dollars per garbage can

(j) Replacement of clothing. (1) The department shall pay for the cost of replacing an assistance unit member's clothing if:

(A) Such clothing was damaged or destroyed during a catastrophic event; and

(B) The loss of such clothing is not covered by an insurance policy.

(2) Any payment made by the department under this subsection shall be non-recurring and shall not exceed the following amount:

(A) Three hundred sixty-two dollars and sixty cents if such member is male and eighteen years of age or younger;

(B) Three hundred seventy-one dollars and forty cents if such member is female and eighteen years of age or younger;

(C) Three hundred ninety-nine dollars and sixty cents if such member is male and nineteen years of age or older; and

(D) Four hundred fifteen dollars and forty cents if such member is female and nineteen years of age or older.

(k) Heating services security deposit. (1) The department shall pay for the cost of a security deposit that is necessary for an assistance unit member to obtain heating services if such services are provided by (A) a municipal utility company or a private fuel supplier, such as, but not limited to, a propane or bottle gas company, and (B) such security deposit is required for the use of such equipment. In no event shall the department make a payment under this subsection if the assistance unit member obtains heating services from a fuel supplier that is a public service company regulated by the Department of Public Utility Control.

(2) Any payment made by the department under this subsection shall be non-recurring and in an amount equal to that required by the heating services provider as a security deposit, provided that such payment shall not exceed two hundred dollars.

(l) Payment of special benefits. Any special benefit payment authorized pursuant to this section shall be issued as a supplemental payment and, unless another provision of this section provides otherwise, may, at the department's discretion, be paid to the assistance unit member or directly to the vendor, contractor or other person who provides goods or services for such member.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-12 Issuance of benefits

(a) Definitions. As used in this section, "electronic benefits transfer account" means an account in a financial institution into which the department may deposit benefit payments that may be accessed by an appropriate payee, as described in subsection (b) of this section, by means of a debit card and personal identification number issued by the department.

(b) Determining the appropriate payee. The department shall make payment of any benefit issued pursuant to SAGA to the assistance unit member in whose name assistance is requested, except that when:

(1) Such member has appointed an authorized representative and has notified the department that such authorized representative should receive such payment on his or her behalf, payment shall be made to such authorized representative;

(2) Such member is an unmarried person between the ages of eighteen and twenty-one who lives with a TFA assistance unit under the circumstances described in subparagraph (A) of subdivision (2) of subsection (b) of section 17b-198-10 of the Regulations of Connecticut State Agencies, payment shall be made to the TFA assistance unit's head of household;

(3) Such member has a legally appointed conservator, guardian or other legal representative, payment shall be made to such conservator, guardian or other legal representative;

(4) Such payment is for a special benefit authorized pursuant to section 17b-198-11 of the Regulations of Connecticut State Agencies, payment shall be made in accordance with subsection (l) of said section;

(5) Such member resides in a rated housing facility or a licensed residential care home, payment shall be made to such facility or home and the department shall notify such member that payment in his or her name has been made to such facility or home; or

(6) DMHAS, or its designee, or the department determines that there has been financial mismanagement pursuant to subsection (e) of this section, the department may appoint a protective payee to receive and manage such payments or a portion thereof on behalf of the assistance unit.

(c) Method of payment. The department shall issue payment to (1) any assistance unit eligible for assistance pursuant to SAGA by electronically depositing benefits into an appropriate payee's personal banking account held at a financial institution or into an electronic benefits transfer account that is accessible to an appropriate payee, or, (2) if the appropriate payee is a rated housing facility, licensed residential care home or a vendor, contractor or other person providing goods or services to the assistance unit, such payment may be issued to the appropriate payee in the form of a check or, if possible, by electronic means. The department shall, at the time eligibility for assistance pursuant to SAGA is established, issue a debit card associated with an electronic benefits transfer account to any appropriate payee who elects to receive payment by deposit into such an account. Such debit card shall be accompanied by instructions for selecting a personal identification number by use of an automated telephone system. Any payment deposited into an electronic benefits transfer account may be accessed by an appropriate payee at the financial institution where such payment was deposited or by using such debit card and personal identification number at any location that accepts such debit cards, including an automatic teller machine, a point of banking terminal and any point of sale device, including a point of sale device that is located at a retail or merchant establishment or used by a public housing authority for the payment of bills or monthly rent. The assistance unit shall be responsible for any fees charged by a financial institution in conjunction with the use of a debit card associated with an electronic benefits transfer account.

(d) Expiration of payments. Any check issued as payment pursuant to subsection (c) of this section shall expire three calendar months after the day following the date such check is issued and may not be negotiated after such expiration date. Any benefit payment deposited into an electronic benefits transfer account may be accessed by an appropriate payee at any time, except that any benefits deposited in such a manner shall be expunged from such account whenever no withdrawals are made from such account for a period of twelve months.

(e) Financial mismanagement. (1) Whenever DMHAS, or its designee, or the department believes and verifies that there has been financial mismanagement of benefits issued to an appropriate payee, the department may appoint a protective payee to receive and manage benefit payments on behalf of and in the best interest of the assistance unit, make such payments to a vendor or other person providing services to or for such assistance unit or issue such payments by virtue of a combination of such methods. In determining which of these methods to use in a particular case, the department shall consider the extent to which the appropriate payee is able or unable to manage such benefit payments, the availability of a person authorized to serve as a protective payee pursuant to subdivision (2) of this subsection and the method of payment that is most conducive to rehabilitating the appropriate payee. The department shall make a finding of financial mismanagement whenever (A) a person who would otherwise be an appropriate payee demonstrates an inability to manage benefit payments because such person has not or is not using such payments in the best interest of the assistance unit, and (B) allowing such person to continue to manage such benefit payments would pose a threat to the health or safety of an assistance unit member. Evidence relied upon by the department to verify a finding of financial mismanagement shall be documented and maintained with the case file. Whenever financial mismanagement is determined to exist, the department shall refer the assistance unit to a social worker for assistance with financial management.

(2) The department shall involve the assistance unit member in the selection of a protective payee to the greatest extent possible, but may select a protective payee based solely on the judgment of the department. The protective payee (A) shall be (i) a relative of the assistance unit member, (ii) a member of the clergy, (iii) a close friend of the assistance unit member, (iv) a volunteer from a community social services agency, or (v) a department employee who is duly delegated to serve as a conservator by the commissioner, and (B) shall (i) have an interest in or concern about the welfare of the assistance unit beyond that which would be expected of a friend or neighbor, (ii) be able to manage funds effectively, (iii) be available to assist the assistance unit with household planning, budgeting and home management problems, (iv) be capable of establishing and maintaining a good working relationship with the assistance unit member, and (v) be responsible and dependable, as evidenced by positive character references. The department shall verify a person's identity, relationship to the assistance unit member, qualifications and occupation or other means of subsistence prior to such person's appointment as a protective payee. In no event shall a protective payee be a department employee who has not been delegated to serve as a conservator by the commissioner, a landlord, grocer or other vendor of goods or services who has direct dealing with the assistance unit member, or a staff member of a public or private agency or organization that assists in the determination of the assistance unit's financial eligibility for department assistance, performs investigative or resource duties for the department or handles fiscal processes related to the assistance unit.

(3) Whenever the department appoints a protective payee, the department shall develop a written plan to govern the protective payee's responsibilities. Such plan shall be signed by the protective payee and notarized, and copies of such plan shall be provided to the protective payee and the assistance unit. Such plan shall include provisions concerning:

(A) The assistance unit's primary financial obligations and how money paid to the protective payee should be spent;

(B) The primary objectives of such plan;

(C) Methods to increase the ability of the assistance unit member to handle assistance payments in the future;

(D) Reporting requirements to which the protective payee and assistance unit member must adhere;

(E) The rights of the assistance unit member and the need to maintain confidentiality of personal information concerning such member;

(F) Any other provisions the department deems necessary to assure the health and safety of the assistance unit member and the proper use of assistance payments; and

(G) A description of legal penalties that may be imposed on the protective payee for misuse of assistance payments.

(4) Payments to a protective payee shall continue for a period no longer than twenty-four months and shall be discontinued prior to the expiration of such twenty-four month period (A) upon the advice of an appropriate social service agency that is assisting the assistance unit, (B) when the appropriate payee to whom payments were discontinued due to financial mismanagement demonstrates an increased ability to manage funds such that the assistance unit member's health or safety is not threatened by renewed payment to such appropriate payee, or (C) upon the appointment of a guardian or other legal representative for the assistance unit member, in which case payment shall be made to such guardian or other legal representative. The department shall seek judicial appointment of a guardian or other legal representative whenever the need for a protective payee will or is likely to continue beyond a period of twenty-four months or when the physical or mental condition of the appropriate payee is such that appointment of a legal representative is essential immediately.

(5) Notwithstanding the provisions of subdivision (2) of this subsection, when a finding of financial mismanagement is made pursuant to subdivision (1) of this subsection and the assistance unit member is entitled to a special benefit pursuant to section 17b-198-11 of the Regulations of Connecticut State Agencies, the department may issue the special benefit payment directly to the vendor, contractor or other person providing goods or services to such member.

(6) Any case involving a finding of financial mismanagement shall be reviewed as frequently as the department deems necessary due to the circumstances, but in no event shall such review occur less frequently than once every twelve months.

(7) An appropriate payee may request a fair hearing in response to the department's finding of financial mismanagement. The department may initiate or continue to make assistance payments to a protective payee while a decision stemming from such fair hearing remains pending.

(f) Payment cycle. (1) The first payment shall be issued not later than the first business day after the date on which eligibility for assistance pursuant to SAGA is determined and shall include any retroactive payment to which the assistance unit is entitled. The second payment shall be made on the first day of the month following the month in which the first payment was made and subsequent payments shall be issued on a monthly basis.

(2) Notwithstanding the provisions of subdivision (1) of this subsection:

(A) Any payment made to a rated housing facility or a licensed residential care home shall be issued in the month following the month in which the eligible assistance unit member resided in such facility or home, due to the department's need to determine the appropriate payment standard, as described in subsection (b) of section 17b-198-10 of the Regulations of Connecticut State Agencies, on a per diem basis;

(B) Any special benefit payment, as described in section 17b-198-11 of the Regulations of Connecticut State Agencies, shall be made as a supplemental payment to the appropriate payee as soon as possible when eligibility for such special benefit is verified, and shall be made on a recurring or non-recurring basis, as specified in said section; and

(C) Any corrective payment shall be made (i) not later than the next monthly assistance payment after the date on which such corrective benefit payment is approved for any assistance unit whose case remains open, and (ii) as soon as possible for any assistance unit whose case has been closed.

(3) The department shall provide notice to the appropriate payee describing the frequency with which benefit payments shall be made, the period such payments are intended to cover and the amount in which such payments shall be issued.

(g) Determining the effective date for the start of assistance. The effective date for the start of assistance shall be:

(1) The date the department received a signed application for assistance if:

(A) The assistance unit complies with all obligations for eligibility set forth in section 17b-198-6 of the Regulations of Connecticut State Agencies during the application process;

(B) All eligibility criteria set forth in sections 17b-198-5 and 17b-198-7 of the Regulations of Connecticut State Agencies are met on the date of application; and

(C) All financial eligibility criteria, as set forth in sections 17b-198-8 and 17b-198-9 of the Regulations of Connecticut State Agencies, are met during the month of application;

(2) The date all eligibility factors are satisfied if:

(A) The assistance unit complies with all obligations for eligibility set forth in 17b-198-6 of the Regulations of Connecticut State Agencies during the application process; and

(B) The assistance unit was ineligible for assistance on the date of application solely due to the assistance unit's failure to satisfy one or more of the eligibility requirements set forth in sections 17b-198-5 and 17b-198-7 of the Regulations of Connecticut State Agencies, but satisfies such requirement or requirements at a later date during the application process; or

(3) The first day of the month following the month of application if:

(A) The assistance unit complies with all obligations for eligibility set forth in 17b-198-6 of the Regulations of Connecticut State Agencies during the application process;

(B) The assistance unit's assets or income exceeded the limits for financial eligibility set forth in sections 17b-198-8 and 17b-198-9 of the Regulations of Connecticut State Agencies in the month of application; and

(C) The assistance unit's assets and income no longer exceed the limits for financial eligibility set forth in sections 17b-198-8 and 17b-198-9 of the Regulations of Connecticut State Agencies in the month following the month of application and all other eligibility criteria are met at such time.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-13 Application processing standards

(a) Standard processing deadline. (1) Except as provided in subsections (b) and (c) of this section:

(A) For any application for assistance that requires the department to make a determination concerning whether a person has a physical or mental disability that renders him or her unemployable, as described in section 17b-198-7 of the Regulations of Connecticut State Agencies, the department shall, not later than sixty days after the date such application is received, (i) grant assistance and issue the initial benefit payment if eligibility has been established, (ii) deny assistance and issue a notice of denial to the applicant if eligibility has not been established, or (iii) provide the applicant with notice that a decision has not yet been made on his or her application and that he or she may request a fair hearing; and

(B) For any other application for assistance, the department shall, not later than forty-five days after the date such application is received, (i) grant assistance and issue the initial benefit payment if eligibility has been established, (ii) deny assistance and issue a notice of denial to the applicant, if eligibility has not been established, or (iii) provide the applicant with notice that a decision has not yet been made on his or her application and that he or she may request a fair hearing.

(2) Notwithstanding the provisions of subdivision (1) of this subsection, when the department receives all information necessary to determine an applicant's eligibility for assistance, the department shall, not later than ten days after the date on which all such information was received, (A) grant assistance and issue the initial benefit payment if eligibility has been established, or (B) deny assistance and issue a notice of denial to the applicant if eligibility has not been established.

(3) The department may complete its application determination prior to the expiration of the standard processing deadline whenever the application is withdrawn or the applicant refuses to cooperate with respect to an aspect of the application process that results in ineligibility for assistance.

(4) The department may deny an application on or after the thirtieth day following the date such application was filed if the applicant fails to provide information requested by the department that is necessary to verify his or her eligibility for assistance and the provisions of subdivision (3) of subsection (b) of this section do not apply.

(5) If, after reviewing an application, information necessary to make a determination regarding the applicant's eligibility remains outstanding or unverified, the department shall notify the applicant in writing of the need to provide such information.

(b) Extensions of the standard processing deadline. The department may extend the standard processing deadline:

(1) By ten days when information necessary to verify an applicant's eligibility for assistance is not submitted with the application and is requested by the department;

(2) As necessary if the department has assumed responsibility for obtaining information that is required to verify an applicant's eligibility for assistance and is waiting for receipt of such information from a third party or is otherwise unable to obtain such information prior to the standard processing deadline, provided that, (A) upon receipt of such information, the department shall either immediately process the application or grant an additional extension pursuant to this subsection, if applicable, and (B) the applicant may request a fair hearing; and

(3) When information necessary to verify an applicant's eligibility for assistance is currently unavailable for reasons beyond the applicant's control and eligibility cannot be determined in the applicant's favor without such information, in which case a determination shall be delayed until such information becomes available or the reason for the unavailability of such information is no longer beyond the applicant's control.

(c) Expedited applications. The department shall, contingent upon the ability to verify all information necessary to establish an applicant's eligibility for assistance pursuant to SAGA, grant or deny assistance not later than four days after the date an application for assistance pursuant to SAGA is received if such applicant:

(1) Submits his or her application to a department regional office in person; and

(2) Is homeless and unable to stay with a relative or friend or at an emergency housing shelter, or has no food and is unable to obtain food from relatives, friends, soup kitchens, food pantries, community organizations or churches.

(d) Reopening. (1) The department shall reopen an application denied on the standard processing deadline due to an applicant's failure to provide requested information that is necessary to verify his or her eligibility for assistance, as described in subdivision (3) of subsection (a) of this section, if, not later than thirty days after the date of such denial, the applicant provides the information previously requested. Whenever an application is reopened and ultimately granted, the date on which the applicant provided information necessary to reopen such application shall be treated as the date of application and the earliest date on which assistance may be effective. If an applicant fails to provide the requested information prior to the expiration of the thirty-day period for reopening, or is denied assistance due to ineligibility after providing such information, such applicant shall be required to file a new application prior to being granted assistance and shall not be entitled to benefits retroactive to the date of the initial application.

(2) The department shall, not later than ten days after the date an application is reopened, grant assistance pursuant to SAGA and issue the initial benefit payment to the appropriate payee, or deny assistance and issue a notice of denial to the applicant if eligibility has not been established, except that the department may grant an extension for any reason described in subsection (b) of this section.

(e) Notice. Right to fair hearing. The department shall notify an applicant (1) of any action taken on his or her application, and (2) when it determines that timely action will not be taken on his or her application. If the department does not act on an application prior to the applicable standard processing deadline, the assistance unit has a right to a fair hearing.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-14 Continuing eligibility

(a) The renewal process. The department shall periodically determine whether an assistance unit's eligibility for assistance pursuant to SAGA should be renewed and whether such assistance unit is receiving the appropriate level of assistance. The department shall provide notice of its intention to begin the renewal process not later than during the month preceding the month in which such renewal process will occur.

(b) Renewal frequency. (1) The department shall begin the renewal process for an assistance unit as necessary based on the likelihood that such assistance unit's eligibility status has changed or will change, provided (A) the first renewal shall occur not later than during the twelfth month after the month in which the assistance unit became eligible for assistance, and (B) each subsequent renewal shall occur not later than the twelfth month after the month in which the previous renewal occurred.

(2) Notwithstanding the provisions of subdivision (1) of this subsection, an eligibility renewal shall occur not later than the third month after the month in which a person became eligible for assistance for any person (A) who was granted assistance without filing a new application after requesting such assistance not later than thirty days after being released from a correctional or mental health facility, as described in subdivision (2) of subsection (b) of section 17b-198-3 of the Regulations of Connecticut State Agencies, and (B) whose eligibility for assistance would have been subject to the renewal process prior to the expiration of the month in which renewal is required by this subsection, had such person not been institutionalized in such facility.

(c) Renewal interviews. As part of the renewal process, the department shall interview the assistance unit by telephone or, at the assistance unit's request, in person. The renewal interview shall be conducted in the same manner as, and pursuant to the same rules that apply to, the application interview, as described in subsection (g) of section 17b-198-3 of the Regulations of Connecticut State Agencies. The department shall include in the notice required pursuant to subsection (a) of this section the date and time by which such interview shall be conducted. An assistance unit shall be responsible for rescheduling any renewal interview that such assistance unit is unable or fails to attend. Any renewal interview that is rescheduled shall be rescheduled to occur by a date that ensures the renewal process is completed in a timely manner, as described in subsection (b) of this section.

(d) Renewal form required. The department shall attach to the notice required pursuant to subsection (a) of this section a renewal form. Such form shall be completed by the assistance unit member, such member's authorized representative or, in the case of an incompetent or incapacitated assistance unit member, a court-appointed fiduciary. Such form shall be completed and returned to the department by the date provided in the notice described in subsection (a) of this section. To be considered sufficiently complete for purposes of the timely filing requirements of this subsection, such form must bear a legible name and address and be signed by the assistance unit member or other person authorized to complete such form.

(e) Renewal verification. The assistance unit shall provide verification of any information requested by the department as part of the renewal process not later than the fifteenth day of the renewal month or ten days after the date the department sends the assistance unit a request for such verification, whichever is later.

(f) Renewal processing standards. (1) For any case in which all necessary verification has been timely received and additional information is not needed, the department shall complete the renewal process not later than the last day of the renewal month and provide notice of its decision to the assistance unit. If eligibility is renewed, the department shall continue to issue benefit payments according to the established payment cycle beginning on the first day of the month following the renewal month, provided that such payments shall reflect any increase in assistance deemed appropriate during the renewal process. If the department determines that an assistance unit is no longer eligible for assistance or that a reduction in assistance is necessary, the department shall, prior to discontinuing or reducing such assistance, comply with the provisions of section 17b-198-15 of the Regulations of Connecticut State Agencies.

(2) If a renewal decision has not been completed by the end of the renewal month, the department shall continue to issue benefit payments according to the established payment cycle if none of the circumstances described in subsection (c) of section 17b-198-15 of the Regulations of Connecticut State Agencies are true and: (A) The department is responsible for not completing the renewal in a timely manner; (B) the assistance unit failed to comply with the requirements of this section in a timely manner, but complied with such requirements not later than the last day of the renewal month; or (C) the assistance unit provides verification demonstrating that there was good cause for failing to timely comply with the requirements of this section. For purposes of this subsection, good cause shall exist when such failure was due to illness, severe weather, a death in the assistance unit member's immediate family or other circumstances beyond the assistance unit's control. Whenever assistance is continued pursuant to this subdivision, the assistance unit shall complete all requirements of the renewal process not later than the last day of the month following the renewal month, unless the circumstances constituting good cause continue to delay the renewal process. The department shall continue to issue benefit payments to the assistance unit according to the established payment cycle as long as none of the circumstances described in subsection (c) of section 17b-198-15 of the Regulations of Connecticut State Agencies are true and the circumstances constituting good cause continue to delay the renewal process.

(3) Whenever the assistance unit fails to file a renewal form, provide necessary verification or participate in a renewal interview prior to the end of the renewal month, assistance shall be discontinued on the last day of such month. If assistance is discontinued pursuant to this subdivision due to an assistance unit's failure to file a renewal form during the renewal month, any renewal form filed in the month following the renewal month shall be treated as a new application for assistance pursuant to SAGA unless such assistance unit verifies circumstances constituting good cause for such untimely filing. When an assistance unit files a renewal form during the renewal month but is discontinued assistance for failure to complete the renewal interview or provide all necessary verification during the renewal month, such assistance unit's completion of the renewal interview and verification of all necessary information in the month following the renewal month shall result in the renewal form being treated as a new application for assistance pursuant to SAGA unless such assistance unit verifies circumstances constituting good cause for such untimely compliance. If good cause is verified, the department shall process such case as a renewal and make a renewal decision not later than five business days after the date the assistance unit completes all required actions.

(g) Interim eligibility changes. Each assistance unit granted assistance pursuant to SAGA shall report any change that could impact eligibility for continued assistance or the appropriate level of assistance not later than ten days after the date of such change. A change is considered reported on the day any department regional office or case worker receives notification of such change. An assistance unit receiving assistance pursuant to multiple programs administered by the department shall not be required to report a change separately for each such program. After reporting a change, the assistance unit shall verify any information concerning such change not later than ten days after the date on which the department sends a request for such verification, and the department shall assist in obtaining any verification that would be difficult for the assistance unit to obtain prior to such deadline. Changes that shall be reported pursuant to this subsection include, but are not limited to:

(1) Changes in the source of income;

(2) Changes in the amount of income or assets, regardless of whether such income or assets are countable;

(3) Changes in the status of excluded income or assets that may become countable;

(4) The acquisition of a motor vehicle;

(5) Changes in the household or needs group composition;

(6) Address changes and any change in the cost of shelter;

(7) Changes in the amount of deductible expenses;

(8) Changes with respect to the status of an authorized representative;

(9) Changes concerning special benefits; and

(10) Any other change impacting eligibility criteria set forth in sections 17b-198-5 to 17b-198-7, inclusive, of the Regulations of Connecticut State Agencies.

(h) Method for reporting interim changes. An assistance unit may notify the department of any change that must be reported pursuant to subsection (g) of this section in person, in writing, by telephone or by any other method approved by the department, provided such assistance unit shall subsequently verify such change as required by the department.

(i) Failure to report or verify an interim change in a timely manner. Failure to timely report or verify a change, as required pursuant to subsection (g) of this section, may result in the discontinuance of assistance if eligibility is contingent upon verification of the circumstance that changed. The department shall not discontinue assistance pursuant to this subsection if there was good cause, as defined in subsection (f) of this section, for such assistance unit's failure to timely report or verify such a change. When circumstances constituting good cause are verified, the department may afford the assistance unit additional time to report or verify such change prior to discontinuing assistance, but may take future corrective action to prevent benefit error.

(j) Processing standards for interim changes. Any programmatic change affecting continued eligibility or the appropriate level of assistance that is necessary due to a change in state law shall be completed within the time constraints imposed by such law and notice shall be provided to each assistance unit impacted by such programmatic change. For all other interim changes, the department shall determine whether such change affects an assistance unit's eligibility for continued assistance or the appropriate level of assistance within a reasonable amount of time after being notified of such change. The department shall attempt to make such determination not later than thirty days after such notice is received, and shall act promptly to determine the accuracy of any information provided to the department and to require verification of any reported information that appears questionable. Notice shall be sent to an assistance unit whose eligibility or level of assistance is adversely impacted by such determination not later than ten days after the department receives information verifying the need for such adverse action.

(k) Effective date of benefit and eligibility changes. (1) When the department becomes aware of a change that renders an assistance unit member ineligible for assistance pursuant to SAGA or reduces such member's benefit level, the effective date of such ineligibility or reduction shall be determined as follows:

(A) For such a change that is timely reported, the effective date shall be:

(i) The first day of the month following the month in which the change was reported if no advance notice is required under the provisions of section 17b-198-15 of the Regulations of Connecticut State Agencies; or

(ii) The first day of the month following the month in which the ten-day adverse action period described in subsection (b) of section 17b-198-15 of the Regulations of Connecticut State Agencies concludes; and

(B) For such a change that was not timely reported, the effective date shall be the first day of the month the change would have been effective under the provisions of subparagraph (A) of this subdivision, had the change been timely reported.

(2) When the department becomes aware of a change that increases an assistance unit member's benefit level, the effective date of such increase shall be determined as follows:

(A) For such a change that is reported and satisfactorily verified in a timely manner, the effective date shall be the day such change occurred;

(B) For a change that is not reported and verified in a timely manner, the effective date shall be:

(i) The first day such change has been both reported and satisfactorily verified; or

(ii) The day the change occurred if there was good cause for such member's failure to timely report and verify such change. For purposes of this subparagraph, “good cause” has the same meaning as provided in subsection (f) of this section.

(3) An overpayment subject to recoupment occurs whenever (i) an assistance unit member fails to timely report a change affecting eligibility and benefits to which such member is not entitled are incorrectly issued by the department as a result, or (ii) an assistance unit timely reports a change adversely affecting eligibility or benefit level, but the department fails to act in a timely manner according to the effective-date provisions of subdivision (1) of this subsection. When a change entitling an assistance unit to an increased level of assistance occurs, the department shall issue a supplemental payment in an amount calculated by taking into consideration the effective-date provisions of subdivision (2) of this subsection.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-15 Adverse action notice

(a) Definitions. For purposes of this section, "adequate notice" means notice concerning a termination, reduction or suspension of assistance pursuant to SAGA, or concerning a change in the manner or form of payment of such assistance, that includes a statement of the department's intended action, the reasons for the intended action, the regulatory or statutory authority supporting such action, an explanation of the assistance unit's right to request a fair hearing to contest the action and the circumstances under which benefits are continued if the assistance unit requests a fair hearing.

(b) Advance notice required. Except as provided in subsection (c) of this section, the department shall provide an assistance unit with adequate notice of its intent to terminate, reduce or suspend assistance pursuant to SAGA, or to modify the manner or form of payment of such assistance, not later than ten days prior to the date it implements any such action. For purposes of this subsection, the date on which the department mails or otherwise transmits adequate notice to an assistance unit shall be considered the date such notice was provided.

(c) Advance notice not required. The department may take any action described in subsection (b) of this section that is applicable to a particular case without providing the advance notice required pursuant to said subsection, provided adequate notice is provided not later than the date such action is taken, whenever:

(1) The department receives information verifying that the assistance unit member died, moved to another state or has been granted SSI or SSDI benefits or cash assistance pursuant to any other state or public assistance program;

(2) The department receives a clear, written statement signed by the assistance unit member indicating that such member (A) no longer wishes to receive assistance pursuant to SAGA, or (B) is providing information to the department that requires the department to terminate or reduce the level of assistance being provided to such member, and that such member understands that such adverse action must result due to such information;

(3) The department receives information verifying that such member has been committed to an institution that results in his or her ineligibility for continued assistance pursuant to SAGA;

(4) At the time the department granted assistance, it provided written notice to such member informing him or her that such assistance would automatically terminate at the end of a specific period and such period has now ended;

(5) The department determines that an appropriate payee has committed financial mismanagement, as described in subsection (e) of section 17b-198-12 of the Regulations of Connecticut State Agencies; or

(6) The assistance unit member's whereabouts are unknown and the post office returns departmental mail directed to such member, indicating there is no known forwarding address for such member.

(d) Eligibility pending fair hearing. (1) When advance notice of an adverse action is required pursuant to subsection (b) of this section and the department receives an assistance unit member's request for a fair hearing prior to the conclusion of the ten-day adverse action period described in said subsection, the department shall not terminate, suspend or reduce such member's assistance prior to the issuance of a decision on such fair hearing, except that:

(A) The department may implement the challenged adverse action prior to such time if the department provides the assistance unit with notice that it is implementing such action prior to the fair hearing and: (i) The assistance unit member expressly waives his or her right to continued receipt of assistance pending such a decision; or (ii) the department makes a determination at the fair hearing that the sole issue to be resolved is one of federal or state law or departmental policy, as opposed to one concerning administrative processing, such as, but not limited to, the computation of income, assets or benefit amount; and

(B) The department may terminate, suspend or reduce an assistance unit member's assistance if a separate change, including a mass change, that affects such member's eligibility or benefit level occurs while such fair hearing is pending and the assistance unit is issued separate notice pursuant to subsection (b) of this section, but fails to request a fair hearing during the ten-day adverse action period. For purposes of this subparagraph, “mass change” means a change that affects all or a portion of assistance units who share similar circumstances.

(2) When the department erroneously terminates, suspends or reduces an assistance unit member's benefits prior to the expiration of the ten-day advance notice period prescribed under subsection (b) of this subsection, the department shall reinstate such member's benefits pending a fair hearing decision if (i) the department receives a request for a fair hearing from such member not later than ten days after the date the notice required under subsection (b) was sent, (ii) the department determines that the sole issue to be resolved is not one of federal or state law or departmental policy, and (iii) the provisions of subsection (c) of this section do not apply.

(3) When the department maintains an assistance unit member's level of assistance pending a fair hearing, and such hearing is subsequently resolved against such member, any benefits such member received pending such hearing that, based on the results of the hearing, such member was not eligible to receive, shall be treated as an overpayment subject to recoupment, as described in section 17b-198-17 of the Regulations of Connecticut State Agencies. If the department terminates, suspends or reduces an assistance unit member's benefits pending a fair hearing, and such fair hearing is subsequently resolved in such member's favor, any benefits that, based on the results of the hearing, such member was entitled to but did not receive shall be treated as an underpayment and promptly corrected, as described in said section.

(4) Notwithstanding the provisions of subsection (h) of section 17b-198-3 of the Regulations of Connecticut State Agencies, the department shall consider a written request for a fair hearing that is mailed to the department to be received on the date the envelope containing such request is postmarked.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-16 Benefit and debit card replacement

(a) Definitions. As used in this section, "electronic benefits transfer account" has the same meaning as provided in subsection (a) of section 17b-198-12 of the Regulations of Connecticut State Agencies.

(b) Generally. (1) Subject to the provisions of this section, the department shall replace any benefit payment that is stolen, lost, destroyed or mutilated after issuance in an amount equivalent to the amount initially issued or, if such payment was initially issued in an incorrect amount, in the amount that should have initially been issued, except that the department shall not replace any benefit payment that was previously issued in error. Prior to issuing a benefit replacement payment, the department shall verify all pertinent information concerning the original payment of such benefits, including, but not limited to, the method used to issue such payment, the date such payment was issued, the address to which such payment, if issued by check, was mailed and whether such payment, if attempted by electronic deposit, was successfully completed.

(2) Subject to the provisions of this section, the department shall replace any debit card associated with an electronic benefits transfer account when such card is lost, stolen, mutilated, destroyed or demagnetized such that it no longer functions properly, or when the appropriate payee changes. The department shall issue a replacement debit card within three business days of the date the department is notified of the occurrence of any event requiring the replacement of such card. An appropriate payee shall immediately notify the department or its designee whenever a debit card is lost or stolen. Upon receipt of such notification, the department or its designee shall, as soon as practicable, deactivate such debit card. The department may charge a fee for the replacement of any debit card that is replaced due to the negligence of the person for whose benefit payments are deposited into such account.

(c) Persons who may request replacement. Replacement of a previous benefit payment may be requested by the appropriate payee or, if the appropriate payee is a protective payee accused of misuse, as described in subsection (i) of this section, by the assistance unit member.

(d) Method for making request. Any request for replacement of a benefit payment initially issued by check shall be made in writing and, except as provided in subdivision (2) of subsection (j) of this section, accompanied by a notarized affidavit, submitted in triplicate, explaining the circumstances that resulted in the need for such replacement. Any request for replacement of a benefit payment initially issued by electronic deposit into an appropriate payee's personal banking account may be made by telephone. Any request for replacement of a lost benefit payment initially issued by electronic deposit into an electronic benefits transfer account may be made by telephone, unless such benefits were stolen, in which case such request shall be in writing and accompanied by the affidavit required pursuant to subdivision (2) of subsection (h) of this section. Any request for replacement of a lost or stolen debit card used to access such an account shall be made in writing and accompanied by a notarized affidavit explaining the circumstances under which such debit card was stolen.

(e) Time for making request. A request for replacement of benefits previously issued by the department:

(1) In the form of a check may be made any time prior to the date on which such check expires, except that, if the reason for the request is that such check was never received, such request shall be made no sooner than the fourth mail delivery day after the date such check was mailed;

(2) By electronic deposit in a personal banking account or an electronic benefits transfer account may be made on the day such benefits were scheduled for deposit if the reason for such request is that such deposit was not successfully completed, but in no event shall such a request be made later than three months after the date on which such benefits were scheduled for deposit; or

(3) By electronic deposit into an electronic benefits transfer account may be made not later than three months after it is reported to the department or its designee that a debit card associated with such account has been lost or stolen, provided such benefits were stolen after the date of such report but before the department or its designee deactivated such debit card.

(f) Processing standard for payment of replacement benefits. (1) Except as provided in subdivision (2) of this subsection and subdivision (2) of subsection (i) of this section, any replacement payment authorized pursuant to this section shall be issued by mail, at the appropriate regional office or by electronic deposit, if applicable, not later than the fifth day after a timely and complete request for such payment is received by the department. At the time a replacement payment is authorized, the department shall concomitantly place a stop payment order on the original benefit payment.

(2) The department may delay payment of replacement benefits for a period not to exceed fourteen days after the date on which a timely and complete request for such payment is made if the department has reason to suspect that such request involves an attempt to perpetrate fraud and anticipates that information that will resolve such suspicion will become available prior to the expiration of such fourteen-day period. The department shall not issue a replacement benefit when fraud is verified. Circumstances suggesting fraud include, but are not limited to, those in which:

(A) A fraudulent request for a replacement payment was made within the past twelve months by the person now requesting a replacement payment; or

(B) A check used to issue the original benefit payment is negotiated after the date on which a request for a replacement payment was made, but prior to the issuance of a replacement payment.

(g) Replacement of benefits prohibited in certain circumstances. Except in situations involving misuse of a benefit payment by a protective payee, as described in subsection (i) of this section, the department shall not issue a replacement payment for any benefits that were successfully deposited into an electronic benefits transfer account and withdrawn by a person other than the appropriate payee after the appropriate payee voluntarily provided his or her department-issued debit card and personal identification number to such person.

(h) Stolen benefits. (1) Benefits previously issued by the department shall be considered stolen when the appropriate payee does not have access to such benefits and:

(A) In the case of benefits issued by check, the department or appropriate payee knows or has reason to believe such benefits were misappropriated by a person other than the appropriate payee; or

(B) In the case of benefits deposited into an electronic benefits transfer account, such benefits are withdrawn by a person other than the appropriate payee or the member of the assistance unit for whom such benefits were intended during the interval between the time when the department or its designee was notified that the debit card associated with such account was lost or stolen and the time when the department or its designee deactivated such debit card. Benefits shall only be considered stolen pursuant to this subparagraph upon verification by the department that such withdrawal occurred during such interval.

(2) The department shall not grant a request for replacement of stolen benefits or a stolen debit card unless the assistance unit member or appropriate payee, if a person other than such member:

(A) Files a police report concerning the theft of such benefits or debit card and the department receives verification that such a police report has been filed; and

(B) Appears in person at a department regional office and completes an affidavit, submitted in triplicate, certifying that such benefits or debit card were stolen, except that the department may, upon request, waive the requirement of in-person appearance for any elderly or disabled person who is unable to appear in person due to severe incapacity, provided such person shall either complete such affidavit during an in-home visit conducted by the department within three days of such request, or (i) provide an address to which such affidavit may be mailed, (ii) complete and notarize such affidavit upon receipt, and (iii) return such affidavit, in triplicate, to the department. The department shall not be responsible for any delay in issuing replacement benefits when such affidavit is completed by means other than during an in person appearance at a regional office.

(3) The department shall, on a monthly basis, notify the postal authority of any benefit payments issued in the form of a check that were reported stolen after the department mailed such check to, but before it was received by, an appropriate payee. The department shall assist the postal authority in any investigation of the disappearance of such check and make available to the postal authority any documentation concerning the issuance of the initial benefit payment and any replacement benefit payment made by the department, including, but not limited to, the appropriate payee's request for a replacement payment.

(i) Lost benefits. (1) Benefits previously issued by the department shall be considered lost when the appropriate payee does not have access to such benefits and:

(A) In the case of benefits issued by check, such check is not received by the appropriate payee and there is no evidence such check was stolen, or such check is misplaced by the appropriate payee after receipt but prior to negotiating the check;

(B) In the case of benefits issued by electronic deposit into the appropriate payee's personal banking account, such benefits were not accepted for deposit into such account;

(C) In the case of benefits issued by electronic deposit into an electronic benefits transfer account, such benefits were not accepted into such account due to department error or a malfunction of the system used by the department to make such electronic transfers of benefits; or

(D) In the case of benefits issued by any means to a protective payee, the department determines that such benefits were misused by the protective payee, as described in subdivisions (2) and (3) of this subsection.

(2) Whenever a member of an assistance unit believes that benefits to which he or she is entitled that have been issued to a protective payee were misused by such protective payee, such member may submit a signed affidavit to the department attesting: (A) To the alleged misuse of such benefits; (B) that such benefits are unavailable to such member; (C) that the protective payee's acts constituting misuse were taken without the approval of such member; and (D) to such member's willingness to cooperate in any legal action taken by the department against such protective payee. An assistance unit member alleging misuse shall provide to the department all documentation that corroborates such misuse that is in his or her possession. The department shall investigate the alleged misuse of any benefit payment made to a protective payee upon receipt of such an affidavit and shall provide the protective payee with an opportunity to refute the allegations contained in such affidavit. Such investigation shall be completed and any replacement payment deemed appropriate shall be issued not later than thirty days after the date on which such affidavit was received by the department.

(3) Upon the conclusion of any investigation conducted pursuant to subdivision (2) of this subsection, the department shall make a finding of misuse only if the evidence gathered during the investigation, when considered with any refutation provided by the protective payee, verifies that: (A) Benefits issued to the protective payee were withheld from the assistance unit for a purpose other than to meet the financial obligations of such assistance unit; (B) such benefits are unavailable to the assistance unit; and (C) the protective payee acted without the knowledge and approval of the assistance unit. Upon a finding of misuse, the department shall either issue a replacement payment to the assistance unit member or appoint a new protective payee and issue such payment to such new protective payee, whichever option is appropriate under the circumstances. Notwithstanding the provisions of subsection (b) of this section, any such replacement payment shall be limited to an amount equal to the portion of the previously issued benefit payment or payments that were misused.

(j) Destroyed and mutilated benefits. (1) Benefits previously issued by the department in the form of a check shall be considered destroyed when the check is damaged by a natural or man-made disaster, such as, but not limited to, a fire or flood, and cannot be negotiated by the appropriate payee due to such damage. The department shall not issue replacement benefits pursuant to this subdivision until the department receives verification from a public safety, health or community organization of the occurrence of the alleged disaster.

(2) Benefits previously issued by the department in the form of a check shall be considered mutilated if the check (A) has been improperly manufactured or damaged by an event other than a natural or man-made disaster, (B) cannot be negotiated due to such improper manufacturer or damage, and (C) is still identifiable as a department-issued benefit payment. The department shall not issue a replacement payment of benefits for a mutilated check unless such check is returned to the department for inspection. An assistance unit shall not be required to provide a notarized affidavit pursuant to subsection (d) of this section if a mutilated check identifiable as a benefit payment issued by the department to the person requesting such replacement payment is returned to the department.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-17 Benefit payment error and correction. Administrative disqualification hearings

(a) Definitions. As used in this section, the following terms shall have the following meanings:

(1) "Overpayment" means an amount of benefits issued to an assistance unit by the department in excess of the amount of benefits to which such assistance unit was properly entitled; and

(2) "Underpayment" means an amount of benefits to which an assistance unit was properly entitled that the department did not issue to such assistance unit.

(b) Correcting an underpayment. (1) The department shall investigate and correct any past underpayment when such underpayment is discovered, regardless of when the underpayment occurred or whether the underpaid assistance unit's case has been closed. The investigation required pursuant to this subsection shall occur prior to the issuance of a corrective payment and shall be for the purpose of determining whether such assistance unit also experienced a past overpayment that has not been recouped. If the investigation reveals such an overpayment, the department shall offset the overpayment against the underpayment and, if the underpayment was larger than the overpayment, issue a corrective payment that is equal to the difference between the underpayment and overpayment. Any corrective payment issued pursuant to this subsection shall be issued to an appropriate payee: (A) Not later than the next benefit issuance date that is part of the normal payment cycle if the assistance unit's case is still open, and (B) as soon as possible if the assistance unit's case is closed. The provisions of this subsection shall apply to underpayments resulting from benefits incorrectly issued during one month or during multiple months.

(2) Any corrective payment issued by the department pursuant to this subsection shall be treated as excluded income in the month received, as an excluded asset to the extent retained in the month after it is received and as a counted asset to the extent retained in any subsequent month.

(c) Recouping an overpayment. (1) The department shall investigate and take action in accordance with this subdivision with respect to any past overpayment when such overpayment is discovered, regardless of when the overpayment occurred or whether the overpaid assistance unit's case has been closed. The investigation required pursuant to this subsection shall occur prior to the department taking action with respect to the discovered overpayment and shall be for the purpose of determining whether such assistance unit also experienced a past underpayment that has not been corrected, and whether overpaid benefits were subsequently expunged from the assistance unit's electronic benefits transfer account pursuant to subsection (d) of section 17b-198-12 of the Regulations of Connecticut State Agencies. If the investigation reveals a past underpayment or expungement of benefits, the department shall offset the underpayment or expungement against the overpayment. If there was no underpayment or expungement, or if the overpayment was larger than the underpayment or expungement, the department shall, following consultation with the assistance unit, take one of the following actions not later than the last day of the calendar quarter after the quarter in which the overpayment was discovered:

(A) Execute an agreement for the recoupment of the outstanding balance of the overpayment from the assistance unit in a lump sum, if such assistance unit elects to repay all or a portion of the overpayment by this method and has income and assets that are sufficient to allow such assistance unit to repay such overpayment by this method;

(B) Execute a monthly recoupment agreement with the assistance unit for the gradual recoupment of such overpayment by monthly installment payments if such assistance unit elects to repay the overpayment by this method;

(C) Begin to recoup such overpayment by reducing the monthly benefits issued to such assistance unit if the assistance unit's case remains open and the assistance unit (i) specifically expresses an unwillingness or inability to repay the overpayment by the methods described in subparagraphs (A) and (B) of this subdivision, (ii) fails to honor an agreement entered into pursuant to subparagraphs (A) and (B) of this subdivision, or (iii) refuses to discuss the overpayment with the department or respond to notice of the overpayment provided by the department;

(D) Initiate an action with the Department of Administrative Services to locate and recoup the overpayment, if the assistance unit's case is closed and the assistance unit refuses to cooperate with alternative methods of recoupment;

(E) Execute an agreement for the recoupment of all or a portion of the outstanding balance of the overpayment from SAGA benefits in the assistance unit's electronic benefits transfer account, or

(F) Pursue recoupment through any combination of methods set forth in this subdivision.

(2) In addition to recouping an overpayment from the assistance unit that received the overpayment, the department shall recoup such overpayment from the spouse of the member of such assistance unit by any method outlined in subdivision (1) of this subsection, provided such spouse lives in the same household as such member and is a member of a separate assistance unit that receives assistance pursuant to SAGA.

(3) If the department recovers money paid as SAGA benefits to or on behalf of an assistance unit for a particular month, as described in section 17b-198-18 of the Regulations of Connecticut State Agencies, and an overpayment is discovered to have occurred in such month, the department shall subtract from the overpayment the amount of money so recovered.

(4) Unless a recoupment rate has been established to the contrary by a court or pursuant to a recoupment agreement, the department shall gradually recoup an overpayment from an assistance unit or spouse of an assistance unit, whether by installment payments or a reduction in benefit payments, on a monthly basis in an amount equal to ten per cent of such assistance unit's or spouse's present monthly assistance payment or, if such assistance unit or spouse is no longer receiving assistance pursuant to SAGA, in an amount equal to ten per cent of such assistance unit's or spouse's last assistance payment that was issued for a full month. The department shall recoup an overpayment of assistance only from that portion of such a monthly assistance payment attributable to SAGA benefits. Unless expressly requested by the assistance unit or spouse from whom recoupment is sought, the department shall not recoup an overpayment when the monthly SAGA benefit payment made to the assistance unit or spouse, as the case may be, is ten dollars or less. The case of an assistance unit whose monthly benefit payment is entirely eliminated pursuant to such an express request shall be considered active and open even while no benefit payments are issued to such assistance unit.

(5) The provisions of this subsection shall apply to overpayments resulting from benefits incorrectly issued during one month or during multiple months.

(d) Notice of corrective action. Prior to taking action to correct an underpayment or recoup an overpayment, the department shall provide notice to the assistance unit of its intent to make such correction or recoupment. Such notice shall include, at a minimum, the following information:

(1) The type of error that occurred;

(2) The amount of the overpayment or underpayment;

(3) The specific cause of the error based upon the department's investigation to date;

(4) The time period during which such error occurred;

(5) The amount of any offsetting done to reduce the error;

(6) The department's proposed method for correcting the error;

(7) A statement indicating that the assistance unit has a right to participate in the selection of the method that will be used to correct the error;

(8) A statement indicating that the assistance unit has a right to request a fair hearing to dispute the department's finding of benefit issuance error, the amount of such error and the selected method for correcting the error; and

(9) A statement indicating that the assistance unit has a right to be represented by legal counsel during any such fair hearing and whether free legal counsel is available.

(e) Classifying overpayments. (1) The department shall classify an overpayment of benefits as the result of department error in instances where the department is solely responsible for such overpayment, including, but not limited to, when the department:

(A) Fails to take timely action after an interim change adversely affecting an assistance unit's continued eligibility for assistance or the appropriate level of assistance is reported by such assistance unit;

(B) Incorrectly computes the assistance unit's income or needs;

(C) Fails to ensure that the assistance unit meets all eligibility criteria; or

(D) Makes a data entry or other processing error.

(2) The department shall classify an overpayment of benefits as the result of unintentional recipient error when:

(A) The assistance unit failed to timely report an interim change in circumstances that adversely affected such assistance unit's continued eligibility for assistance or the appropriate level of assistance, but verifies circumstances constituting good cause for such failure, as described in subsection (f) of section 17b-198-14 of the Regulations of Connecticut State Agencies;

(B) Either the department, through the administrative disqualification hearing process, or a court of appropriate jurisdiction determines that the assistance unit member was unaware of the need to report the information that adversely affected such assistance unit member's continued eligibility for assistance or the appropriate level of assistance had to be reported; or

(C) The department elects not to seek a penalty against an assistance unit member, either through a court procedure or the administrative disqualification hearing process, for what would otherwise constitute intentional recipient error pursuant to subdivision (3) of this section.

(3) The department shall classify an overpayment of benefits as the result of intentional recipient error when:

(A) The department makes a preliminary determination that:

(i) The assistance unit member failed, without good cause, as described in subsection (f) of section 17b-198-14 of the Regulations of Connecticut State Agencies, to timely report an interim change adversely affecting continued eligibility for assistance or the appropriate level of assistance;

(ii) The assistance unit member knowingly misinformed the department regarding information that would otherwise adversely affect such member's continued eligibility for assistance or the appropriate level of assistance; or

(iii) The assistance unit member committed an illegal or fraudulent act or omission that resulted in such overpayment, such as, but not limited to, falsely claiming circumstances that resulted in the department issuing a benefit replacement payment while such member maintained access to the initial benefit payment;

(B) A final determination that the overpayment was due to the assistance unit member's intentional act or omission either:

(i) Is made by a court of appropriate jurisdiction or the department through the administrative disqualification hearing process; or

(ii) Results by operation of law due to such member's waiver of his or her right to an administrative disqualification hearing on the department's preliminary determination; and

(C) The department elects to seek a penalty against the assistance unit member, either through a court procedure or the administrative disqualification hearing process.

(f) Preliminary determination of intentional recipient error. (1) When the department makes a preliminary determination of an intentional recipient error that resulted in an overpayment, as described in subdivision (3) of subsection (e) of this section, the department shall, regardless of overpayment size:

(A) Conduct an administrative disqualification hearing or consult with the Division of Criminal Justice to determine whether to refer the case to the Division of State Police within the Department of Emergency Services and Public Protection, the appropriate prosecuting authority for criminal prosecution or the office of the Attorney General for civil recovery; and

(B) Take immediate action to initiate recoupment of the overpayment and continue such recoupment process, regardless of whether the recipient error is ultimately classified as unintentional.

(2) The department shall conduct an administrative disqualification hearing whenever, after consultation with the Division of Criminal Justice, the department decides not to refer a case to the Division of State Police, the appropriate prosecuting authority or the office of the Attorney General, or, after any such referral, the Division of State Police, the appropriate prosecuting authority or the office of the Attorney General notifies the department that it will not take action on the referred case.

(3) The department shall not conduct an administrative disqualification hearing if, after a case is referred to an appropriate prosecuting authority, a legal action is commenced against the assistance unit member in a court of appropriate jurisdiction and such legal action results in any disposition other than a conviction or plea of guilty. The department shall classify the overpayment of benefits in any such case as unintentional recipient error.

(g) Eligibility pending completion of administrative disqualification hearing process. Whenever the department makes a preliminary determination that an assistance unit member committed intentional recipient error that, if corrected, would have an adverse impact on such assistance unit's eligibility for or appropriate level of assistance pursuant to SAGA, the department shall promptly provide advance notice of its intent to terminate or reduce such assistance in accordance with the provisions of section 17b-198-15 of the Regulations of Connecticut State Agencies. Any such termination or reduction of assistance shall be considered an interim change, subject to a fair hearing, and shall not be accompanied by a disqualification penalty or recoupment action until such time as a final determination regarding intentional recipient error is made.

(h) Notice of an administrative disqualification hearing. Right to a pre-hearing interview. Upon making a preliminary determination that an assistance unit member committed intentional recipient error, the department shall provide notice to such member of the department's intent to hold an administrative disqualification hearing. Such notice shall be sent not later than thirty days prior to the date scheduled by the department for such hearing and shall include, at a minimum:

(1) A statement explaining the assistance unit member's right to participate in, and the date, time and place of, a pre-hearing interview at which such member will have an opportunity to:

(A) Discuss and review the evidence supporting the department's preliminary determination of intentional recipient error;

(B) Receive an explanation of the administrative disqualification hearing process;

(C) Receive a detailed explanation of the assistance unit's right to waive such a hearing and the ramifications of doing so; and

(D) Discuss repayment arrangements, if such member intends to waive his or her right to such a hearing;

(2) The date, time and place of such hearing;

(3) An explanation of the reasons for such hearing;

(4) A warning that a final decision regarding whether the assistance unit member committed intentional recipient error will be based solely upon the information and evidence gathered by the department if such member fails to appear and participate at such hearing;

(5) An explanation of the assistance unit member's legal rights with respect to the administrative disqualification hearing;

(6) A statement that the administrative disqualification hearing does not preclude additional civil or criminal action against the assistance unit member;

(7) A statement concerning the availability of free legal representation;

(8) Information about the circumstances under which the department will reschedule the administrative disqualification hearing for good cause; and

(9) The department's contact information and a statement that the assistance unit member may contact the department to request additional information.

(i) Waiver of administrative disqualification hearing. (1) The notice required pursuant to subsection (h) of this section shall be accompanied by a form that the assistance unit member may use to waive his or her right to an administrative disqualification hearing. An assistance unit member may waive the right to an administrative disqualification hearing by completing, signing and returning such form to the department. Such waiver shall be equivalent to and carry with it all the penalties associated with a finding of intentional recipient error made by a court or by the department following an administrative disqualification hearing, regardless of whether such member admits guilt. An assistance unit member who waives the right to an administrative disqualification hearing may withdraw such waiver in writing not later than ten days after the date on which the waiver form was signed.

(2) The waiver form described in subdivision (1) of this subsection shall include, at a minimum, the following:

(A) The date by which the waiver must be signed by the assistance unit member and received by the department to avoid the administrative disqualification hearing process;

(B) A statement explaining the assistance unit member's right to remain silent and avoid self-incrimination;

(C) A space for the assistance unit member to either admit or deny the allegation of intentional recipient error;

(D) A space for the assistance unit member's signature;

(E) A statement explaining that waiving the right to an administrative disqualification hearing will result in the assistance unit member being disqualified for the applicable period, as set forth in subsection (l) of this section, even if such member does not admit guilt;

(F) A statement explaining that the department will take measures to recoup the overpayment;

(G) A statement explaining that the assistance unit member may withdraw his or her waiver not later than ten days after the date he or she signs the waiver form; and

(H) Contact information for requesting additional information or free legal services, if available.

(j) Format of the administrative disqualification hearing. Content of decision. (1) The hearing official assigned to the administrative disqualification hearing shall conduct such hearing in the same manner as a fair hearing and shall fulfill the same duties expected of a hearing official in a fair hearing. The hearing official shall advise the assistance unit member or such member's representative of the right to remain silent and avoid self-incrimination during the administrative disqualification hearing. If the assistance unit member or such member's representative fails to appear at the scheduled administrative disqualification hearing, the hearing official shall conduct such hearing in the absence of such member or representative, and shall base his or her decision on the evidence before him or her. A finding of intentional recipient error shall be supported by clear and convincing evidence.

(2) Following the administrative disqualification hearing, the hearing official shall issue a notice of decision explaining his or her final determination of whether the assistance unit member committed intentional recipient error. Such notice shall:

(A) Specify the reasons for the final determination;

(B) Identify the evidence upon which such determination is based;

(C) Cite any applicable statute or regulation upon which such determination is based;

(D) Respond to any reasoned arguments submitted by the assistance unit member or such member's representative; and

(E) Specify the effective date and length of any period of disqualification of eligibility for assistance pursuant to SAGA, if the assistance unit member is determined to have committed intentional recipient error.

(k) Processing standards for the administrative disqualification hearing process. (1) Except as provided in subdivisions (2) and (3) of this subsection, the department shall conduct the administrative disqualification hearing, make a final determination regarding whether the assistance unit member committed intentional recipient error and issue the notice of decision required pursuant to subsection (j) of this section not later than ninety days after the notice required under subsection (h) of this section is sent to the assistance unit.

(2) The assistance unit member or such member's representative may, not later than ten days prior to the date scheduled by the department for the administrative disqualification hearing, request and receive a postponement of such hearing not to exceed thirty days. The department shall grant not more than one postponement. Whenever such a postponement is granted, the deadline for completing the administrative disqualification hearing process set forth in subdivision (1) of this subsection shall be extended by a period equivalent to the duration of the postponement.

(3) If an assistance unit member fails to appear at a scheduled administrative disqualification hearing, such member may, not later than ten days after the date such hearing was scheduled to take place, request a new hearing. Such request shall be accompanied by an explanation of the reasons such member did not attend the scheduled hearing and any evidence such member wishes to submit in support of such request. Such request shall be reviewed by the hearing official assigned to conduct the administrative disqualification hearing and shall be granted only for good cause. For purposes of this subsection, good cause shall exist whenever the hearing official determines that the assistance unit member failed to appear at the administrative disqualification hearing due to: (A) An illness that afflicted such member or a person in his or her immediate family; (B) such member's incarceration; (C) the death of a person in such member's immediate family; (D) a catastrophic fire, flood or other natural or man-made disaster; (E) the unavoidable loss of such member's planned transportation, provided no alternative transportation was immediately available; and (F) any other circumstances beyond such member's control that the hearing official determines justified such member's failure to appear at such hearing. If a request for a new administrative disqualification hearing is timely submitted and the hearing official determines that there was good cause for the assistance unit member's failure to appear at the originally scheduled hearing, any final determination that such member committed intentional recipient error shall be rendered null and void and a new administrative disqualification hearing shall be scheduled. The department may assign the same hearing official to conduct the new administrative disqualification hearing or may assign a different hearing official to conduct such hearing. Whenever a new administrative disqualification hearing is scheduled pursuant to this subdivision, the deadline for completing the administrative disqualification hearing process set forth in subdivision (1) of this subsection shall be extended by a period equivalent to the number of days that elapsed between the originally scheduled hearing and the rescheduled hearing.

(l) Disqualification due to intentional recipient error. When a final determination of intentional recipient error is rendered by the department or a court, the assistance unit member who is found to have committed such error shall be disqualified from receiving assistance pursuant to SAGA for (1) six months after the first offense, (2) one year after the second offense, and (3) permanently after the third offense, unless such period of disqualification is contrary to a court order. If such member is presently receiving assistance pursuant to SAGA, such period of disqualification shall begin on the date a court issues an order finding intentional recipient error, if applicable, or the date a notice of decision finding intentional recipient error is provided to such member following an administrative disqualification hearing or such member's waiver of his or her right to such a hearing. If such member is not presently receiving assistance pursuant to SAGA, such period of disqualification shall be deferred until such time as such member requests and becomes eligible for such assistance. Any person found by a court of appropriate jurisdiction to have knowingly assisted an assistance unit member in committing intentional recipient error shall be disqualified from receiving assistance pursuant to SAGA for one year from the date of such court order, unless such order provides otherwise.

(m) Fair hearing prohibited in cases involving intentional recipient error. Appeal to the Superior Court. (1) Notwithstanding any regulatory provision to the contrary, an assistance unit member disqualified from receiving assistance pursuant to SAGA following a final determination of intentional recipient error shall not be entitled to a fair hearing to dispute the finding of intentional recipient error or the imposition of such disqualification penalty. The sole remedy for such a member who wishes to contest such matters shall be an appeal to the Superior Court. Any such appeal shall be filed not later than forty-five days after the date the hearing official issues the notice of decision in which such final determination was made, and shall be made in accordance with the procedures applicable to appeals to the Superior Court from decisions rendered following a fair hearing. This subsection shall not be construed to prohibit an assistance unit member from requesting a fair hearing to challenge the department's selected recoupment plan or any reduction or discontinuance of benefits based on error other than intentional recipient error.

(2) If, following an appeal to the Superior Court, said court issues an order reversing the department's finding that an assistance unit member committed intentional recipient error, such member's eligibility for assistance pursuant to SAGA shall be restored. If, based on the factual findings contained in such order and all other evidence available to the department, such member was otherwise eligible for assistance pursuant to SAGA during the assistance unit's period of disqualification, benefits not paid during such period shall be treated as an underpayment and a corrective payment shall be issued to the appropriate payee for such assistance unit.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-18 Methods of recovery

(a) Recovering from interests assigned to the department. (1) Subject to the provisions of subdivision (2) of this subsection, the department shall, pursuant to the assignment of interest required under subsection (f) of section 17b-198-6 of the Regulations of Connecticut State Agencies, recover an assistance unit's interest in:

(A) The settlement of a decedent's estate, provided the department shall recover from the assistance unit's interest in such estate an amount not to exceed the amount of SAGA benefits paid to such assistance unit as of the date the assistance unit became entitled to use assets from such estate for his or her benefit, or fifty per cent of the assets from the estate that are payable to such member, whichever is less;

(B) The net proceeds of any monetary damages or settlement received by such assistance unit in connection with a cause of action, provided the department shall recover such proceeds in an amount not to exceed the amount of SAGA benefits paid to such assistance unit as of the date of the award of such proceeds, or fifty per cent of such proceeds after payment of all expenses connected with such cause of action, whichever is less; and

(C) A retroactive SSI benefits award, provided that the portion of such award recovered by the department shall be prorated by the number of members in such assistance unit's SSI assistance unit and shall not exceed the amount of SAGA benefits paid during the period the retroactive SSI benefits award is intended to cover.

(2) In no event shall the department make a recovery under subdivision (1) of this subsection from a person who is under eighteen years of age. Notwithstanding the provisions of said subdivision, the department shall not recover (A) attorney's fees paid by the department on behalf of an assistance unit in connection with a successful appeal of a Social Security Administration denial of SSI benefits, or (B) any portion of a monetary award or settlement constituting a retroactive rent abatement, refund of a security deposit or relocation assistance following displacement from a condominium conversion.

(b) Recovery by lien. (1) The department shall place a lien on any property situated in Connecticut that is owned by the assistance unit member or such member's spouse. The effective date of such lien shall be the date of the initial award of benefits. Such lien shall be in an amount equal to the amount of benefits paid to the assistance unit pursuant to SAGA. If such property is jointly owned by such member or such member's spouse and another person, such lien shall be placed only on the share of the property owned by such member or such member's spouse. In addition, whenever the department pays for repairs to a property pursuant to subsection (d) of section 17b-198-11 of the Regulations of Connecticut State Agencies, the department shall place a lien on such property in an amount equal to the amount paid by the department for such repairs. Except as provided in subdivision (2) of this subsection, if the assistance unit member sells property used as his or her principal residence that is encumbered by a lien authorized pursuant to this subsection, the department shall collect an amount not to exceed the amount secured by such lien from the proceeds of such sale and release such lien. The department shall determine whether the assistance unit member remains eligible for assistance pursuant to SAGA following the sale of any such property.

(2) If an assistance unit member (A) sells property used as his or her principal residence that is encumbered by a lien authorized pursuant to this subsection, (B) intends to use the proceeds of such sale to purchase a different property to be used as his or her new principal residence, and (C) remains eligible for assistance pursuant to SAGA following such sale and purchase, the department shall release such lien, postpone collection of the amount secured by such lien and immediately place a separate lien on the newly purchased property in an amount calculated by adding to the amount of the former lien the amount of any additional benefits paid to or on behalf of such assistance unit pursuant to SAGA.

(c) Voluntary recovery. Legal action. The department may require an assistance unit member who (1) loses an exclusion for a previously excluded asset or form of income, (2) receives a lump-sum payment, such as, but not limited to, lottery winnings, or (3) converts a previously excluded asset to cash, to voluntarily repay the department in an amount not to exceed the total amount of SAGA benefits previously issued to or on behalf of such assistance unit if such asset, income or payment has not been assigned to the department or secured by a lien, as described in subsections (a) and (b) of this section. If such a member refuses to voluntarily repay the department, the department may, in conjunction with the Office of the Attorney General, initiate a legal action to recover from any such asset, income or payment an amount not to exceed the total amount of SAGA benefits previously issued to or on behalf of such member. In lieu of pursuing recovery pursuant to this subsection, the department may establish a period of ineligibility for such member.

(d) Recovery from former spouses obligated to provide alimony or support. If an assistance unit member's former spouse fails or refuses to make alimony or support payments to such member as required by a court order, the department shall recover from such former spouse an amount not to exceed (1) the amount of SAGA benefits paid to such member, or (2) the amount of alimony or support owed by such former spouse to such member, if less than the amount of SAGA benefits paid to such member. Whenever the department determines that, based on the financial information before it, a former spouse is able to contribute more to the assistance unit member than required by court order, the department shall assist such member in pursuing a modification of such order increasing the amount of alimony or support owed.

(e) Recovery from a beneficiary's estate. (1) Except as provided in subdivision (2) of this subsection, upon the death of any person who received assistance pursuant to SAGA, the department shall recover from the estate of such person an amount not to exceed the total amount of benefits paid to such person. The department shall pursue recovery from such person's estate by filing a claim in probate court against such estate. The department's claim against any such estate shall have priority over all claims except:

(A) Expenses of last sickness not to exceed an amount established by state law;

(B) Funeral and burial expenses not to exceed an amount established by state law, provided such amount shall be reduced by the amount of any revocable or irrevocable burial fund held by such person;

(C) Administrative expenses, including, but not limited to, probate fees and taxes, and fiduciary fees, in an amount not to exceed that permitted by state law; and

(D) Any other claim given priority by state or federal law in an amount not to exceed that permitted by applicable state or federal law.

(2) In no event shall the department make a recovery from a decedent's estate under subdivision (1) of this subsection:

(A) Of benefits paid to or on behalf of the decedent while he or she was under eighteen years of age;

(B) Of benefits previously issued to or on behalf of the decedent that were recovered by any other means during such decedent's lifetime;

(C) Of attorney's fees paid by the department on behalf of the decedent in connection with a successful appeal of a Social Security Administration denial of SSI benefits; and

(D) Of benefits paid to or on behalf of the decedent if the probate court administering such estate rules that the amount that would otherwise be recovered from the estate is necessary for the support of the decedent's dependent child who is under twenty-one years of age, surviving spouse or parent.

(f) Recovery of benefits obtained by fraud or improper transfer of assets. Whenever the department discovers that an assistance unit obtained SAGA benefits through fraud, the department shall act in conjunction with the Office of the Chief State’s Attorney to initiate a legal action to recover the full amount of such benefits. Whenever the department discovers that an assistance unit transferred an asset in order to establish eligibility for assistance pursuant to SAGA, as described in subsection (f) of section 17b-198-5 of the Regulations of Connecticut State Agencies, and the transferee refuses to return such asset to the assistance unit, the department, in conjunction with the Office of the Attorney General, shall initiate a legal action against such transferee seeking either to recover an amount not to exceed the amount of benefits paid on behalf of the assistance unit or to void the transfer of such asset.

History

• Effective October 11, 2016

Regs., Conn. State Agencies § 17b-198-19 Certain benefit levels maintained

Notwithstanding the provisions of sections 17b-198-9 and 17b-198-10 of the Regulations of Connecticut State Agencies, any married person receiving SAGA benefits at the time said sections become effective whose benefits would be reduced or terminated due to the implementation of subsections (a) and (b) of section 17b-198-10 of the Regulations of Connecticut State Agencies, shall continue to receive the same amount of SAGA benefits such person was receiving prior to the effective date of said sections, provided other circumstances affecting such person’s eligibility and appropriate level of assistance do not change.

History

• Effective October 11, 2016

17b-262 Requirements for Payment of Home Health Agencies

Regs., Conn. State Agencies § 17b-262-1 Scope

Sections 17b-262-2 to 17b-262-9 inclusive set forth the requirements for payment of Home Health services provided to individuals who are determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to Section 17b-262 of the Connecticut General Statutes.

History

• Effective June 4, 1996

Regs., Conn. State Agencies § 17b-262-2 Definitions

For the purpose of Sections 17b-262-1 through 17b-262-9 the following definitions apply:

(1) "Commissioner" means the Commissioner of the department of social services, or his representative.

(2) "Department" means the State of Connecticut department of social services, or its agent.

(3) "Home" means the recipient's place of residence which includes a boarding home or Home for the Aged. Home does not include a hospital, Skilled Nursing Facility, Intermediate Care Facility, or Intermediate Care Facility for the Mentally Retarded.

(4) "Home Health Care Agency" means the definition contained in subsection (d) of section 19a-490 of the Connecticut General Statutes (CGS).

(5) "Home Health Provider" means any home health care agency licensed by the Department of Public Health and who also meets the requirements for participation in Medicare. Providers shall also meet all departmental enrollment requirements.

(6) "Refusal to Serve" shall mean a refusal to accept a new client, a termination of service to an existing client, or an interruption of service to an existing client which lasts longer than 48 hours.

(7) "Service Area" means those cities or towns designated by zip codes on forms provided by the department.

(8) "Suspension of Service" shall mean an interruption of service to an existing client which lasts 48 hours or less.

History

• Effective June 4, 1996

Regs., Conn. State Agencies § 17b-262-3 Provider participation

In order to receive payment from the department for home health services, all Home Health Care Agencies shall be licensed by the Department of Public Health and shall meet the requirements for participation in Medicare. [Home Health Care Agency Licensure Regulations: Public Health Code Sections 19-13-D66 to D79 Inclusive and Federal Regulation: Sections 42 (Code of Federal Regulations) 440.70 and 42 (Code of Federal Regulations) 441.15]. Providers shall also meet all departmental enrollment requirements.

History

• Effective June 4, 1996

Regs., Conn. State Agencies § 17b-262-4 Eligibility

Payment for home health services is available to all persons eligible for Medicaid subject to the conditions and limitations which apply to these services.

History

• Effective June 4, 1996

Regs., Conn. State Agencies § 17b-262-5 Policy

No home health care agency enrolled as a Medicaid provider shall select a service area, or refuse to serve any person, based on the geographical location of the service to be provided unless the home health care agency has a legitimate, nondiscriminatory reason for its choice of service area or its refusal to serve. Referrals for service made to Medicaid enrolled home health care agencies shall not be refused if the patient's home is located within the home health care agency's designated service area. Any and all home health care agency refusals to serve shall be documented and based upon objective, legitimate, non-discriminatory reason(s). Upon receipt of a complaint of discriminatory action by a home health care agency, the home health care agency's proof of legitimate non-discriminatory purpose shall be evaluated to determine that it is not pretextual.

History

• Effective June 4, 1996

Regs., Conn. State Agencies § 17b-262-6 Designation of service area

(a) All home health care agencies shall designate their service area by identifying the zip codes of the areas which they serve on a form to be provided by the department. All changes in that service area shall be reported to the department on an annual basis. The designated service area shall not be smaller than that reported to the Department of Public Health. If an agency serves any zip code within a town or municipality, the agency shall serve all zip codes within such town.

(b) The department shall timely evaluate all such designations, and changes in designations, to determine that the service area has not been chosen in a pattern which suggests an intent to avoid, or has the effect of avoiding, areas with a high concentration of minority residents, based on census data and other objective information. If the department determines that the choice of service area is designed to or has the effect of avoiding areas with a high concentration of minority residents, the agency shall be notified in writing of such determination and shall be required, within ten days, to provide written justification of its choice of service area based upon legitimate non-discriminatory reasons in accordance with subsection 17b-262-8, Legitimate Non-Discriminatory Reason.

History

• Effective June 4, 1996

Regs., Conn. State Agencies § 17b-262-7 Refusal to serve

(a) All home health care agencies shall record each and every written or oral refusal to serve and suspension of service, including but not limited to discharges, including the date, the name and address of the patient or the reason why the name and address is unavailable, the reason for the refusal to serve, and identifying the support for this reason.

(b) If the stated reason for the refusal to serve is that there is an immediate danger to the health and safety of the home health care agency's personnel, the home health care agency shall, within 48 hours of the refusal to serve or discharge:

(1) Complete a form to be provided by the department detailing the timely, objective and substantial evidence on which the refusal to serve is based, the reasonable efforts taken to protect the home health care agency personnel, the geographic area covered by the refusal to serve, and the actual or expected duration of the refusal to serve;

(2) If the name and address of the client are known, send the client written notice of the refusal to serve in a form prescribed by the department, which notice shall include the reason for the refusal to serve, the timely, objective and substantial evidence on which the refusal to serve is based, the length of time during which service shall be refused, the right of the client to file a complaint with the department; and informing the client of his or her right to seek legal advice if he or she feels his or her rights have been violated; and

(3) Send the department a copy of the form with a copy of the notice to the client attached.

If the department determines that the agency has failed to comply with these requirements, the home health care agency shall be notified in writing of such determination, and shall be required, within ten days of receipt of the notice, to submit, in writing, justification for its failure to comply based on legitimate nondiscriminatory reasons in accordance with section 17b-262-8.

(c) The department shall review and monitor all forms prepared by home health care agencies pursuant to subsection (b) of section 17b-262-7, Refusal to Serve, to determine that the refusal to serve does not evidence a pattern which suggests an intent to avoid, or have the effect of avoiding, areas with a high concentration of minority residents, based on census data and other objective information. If the department determines that such a pattern exists, the home health care agency shall be notified of such determination, and shall be required, within ten days, to submit, in writing, justification for his refusals to serve based on legitimate non-discriminatory reasons in accordance with section 17b-262-8.

(d) The department shall conduct random inspections to ensure compliance with record-keeping requirements.

(e) The department shall respond to all complaints of refusal to serve by conducting a full investigation into the circumstances of the particular case, including but not limited to inspection of the home health care agency's records regarding refusals to serve.

(f) The department shall, in its discretion, conduct investigations into any refusals to serve or discharges which it determines warrant investigation, even in the absence of a specific complaint.

(g) If the department determines that a home health care agency has refused to serve a person located within its designated service areas, the agency shall be notified in writing of such determination and shall be required, within ten days, to submit, in writing, justification for its refusal to serve based upon legitimate non-discriminatory reasons in accordance with section 17b-262-8.

(h) All suspensions of service shall be justified by timely, objective and substantial evidence, and oral or written notice of the suspension shall be given to the client.

History

• Effective June 4, 1996

Regs., Conn. State Agencies § 17b-262-8 Legitimate non-discriminatory reason

(a) In any case in which a home health care agency is required to provide written justification based upon legitimate non-discriminatory reasons in accordance with this section, the home health care agency shall be afforded an opportunity to demonstrate, and shall have the burden of demonstrating, that it had a legitimate, nondiscriminatory reason for its actions, including but not limited to:

(1) The patient's non-compliance with the plan of care;

(2) Lack of staff qualified for the client's particular medical needs; and

(3) Immediate danger to the health or safety of home health care agency personnel.

(b) Immediate danger to the health or safety of home health care agency personnel shall not constitute a legitimate, non-discriminatory reason unless:

(1) There is timely, substantial and objective evidence demonstrating that the provider has a well-founded belief that there is an immediate danger to the health or safety of home health care agency personnel in providing services at the particular time and location at which the home health care services were requested, or in accessing such location, which prevents the agency from delivering services;

(2) All reasonable efforts to protect the home health care agency personnel have been made prior to refusing service, including but not limited to the use of escorts, coordination with community patrols, and coordination with public and housing authority law enforcement;

(3) The refusal to serve covers an area no larger than necessary to avoid the immediate danger to the health and safety of the home health care agency personnel; and

(4) The refusal to serve is limited in duration so as to be no longer than necessary to avoid the immediate danger to the health or safety of the home health care agency personnel.

(c) Proof of a legitimate non-discriminatory reason, including immediate danger to the health and safety of home health care agency personnel, shall be documented in writing and be based on timely, objective and substantial evidence. Such proof may include, but not be limited to, records maintained pursuant to Department of Public Health's regulations. Proof of immediate danger to the health and safety of home health care agency personnel, such as documented observation of significant drug dealing, criminal gang activity or threatening use of weapons or police department reports of ongoing criminal activity, shall relate to the particular location in question, or the means of access to that location.

(d) All proof of legitimate non-discriminatory purpose submitted pursuant to subsection (c) of section 17b-262-8, Legitimate Non-Discriminatory Reason, shall be investigated and evaluated by the department to ensure that they are not pretextual. For purposes of this section, an allegedly legitimate non-discriminatory purpose is pretextual when:

(1) The home health care agency is unable to offer timely, substantial and objective proof of its alleged legitimate non-discriminatory purpose; or

(2) Timely, substantial and objective evidence exists which demonstrates that there were alternative, neutral means of accomplishing the alleged purpose and that the home health care agency knew or should have known of the existence of such alternative, neutral means.

The department shall issue its findings and recommendations in writing at the conclusion of its investigation.

(e) If the home health care agency is unable to demonstrate a legitimate nondiscriminatory purpose, or if the department finds an alleged legitimate non-discriminatory purpose to be pretextual, the department shall issue a notice of violation and refer the case to the U.S. Department of Health and Human Services Office of Civil Rights.

History

• Effective June 4, 1996

Regs., Conn. State Agencies § 17b-262-9 Sanctions

If the department determines, in accordance with sections 17b-262-1 through 17b-262-9, that these regulations have been violated, the department shall provide the home health care agency a written notice of violation stating the basis of the department's determination and the sanctions to be imposed. Such sanctions may include any of the following, alone or in combination:

(a) Termination of provider agreement;

(b) Monitoring and/or reporting requirements;

(c) Public Notice; and

(d) Such other and further sanctions as the department deems appropriate.

History

• Effective June 4, 1996

Regs., Conn. State Agencies § 17b-262-10—17b-262-201 Reserved

Sec. 17b-262-10—17b-262-201. Reserved

Regs., Conn. State Agencies § 17b-262-202—17b-262-211 (Repealed)

Repealed August 28, 1998.

Regs., Conn. State Agencies § 17b-262-212 Reserved

Sec. 17b-262-212. Reserved

Regs., Conn. State Agencies § 17b-262-213 Scope

Sections 17b-262-213 to 17b-262-224 inclusive set forth the requirements for payment of school based child health services provided by or on behalf of Local Educational Agencies (LEAs) under section 10-76d of the Connecticut General Statutes (CGS), and Part B of the Individuals with Disabilities Education Act (IDEA) 20 U.S.C section 1411 et seq., to children determined eligible to receive such services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the CGS.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-214 Definitions

For purposes of section 17b-262-213 through 17b-262-224 the following definitions shall apply:

(1) "Allied Health Professional" means an individual who is licensed or certified by the Department of Public Health (DPH) or the SDE to provide school based child health services as defined within the context of this regulation.

(2) "Child" means an individual as defined in subsection (e) of section 10-76a of the Connecticut General Statutes (CGS).

(3) "Children Requiring Special Education" means an individual as defined in subsection (e) of section 10-76a of the CGS.

(4) "Department" means the State of Connecticut Department of Social Services (DSS) or its designated agent.

(5) "Diagnostic Services" means those services as defined in the Code of Federal Regulations (CFR) under 42 CFR, Part 440, subsection (a) of section 440.130, as amended from time to time.

(6) "Individualized Education Program (IEP)" means the ongoing plan of treatment services as defined in section 10-76d-11 of the Regulations of Connecticut State Agencies, and Part B of IDEA, as amended from time to time.

(7) "Evaluation" is the process defined under section 10-76d-9 of the Regulations of Connecticut State Agencies.

(8) "Licensed Practitioner of the Healing Arts" means those practitioners as defined in section 20-1 of the CGS.

(9) "Local Educational Agencies" or "Board of Education" means local or regional boards of education as defined in subsection (b) of section 10-76a-1 of the Regulations of Connecticut State Agencies and in Part B of IDEA, as amended from time to time.

(10) "Medical Appropriateness/Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate setting; and is the least costly of multiple, equally- effective, alternative treatments or diagnostic modalities.

(11) "Medically Necessary" means medical care provided to correct or diminish the adverse affects of a medical condition, assist an individual in attaining or maintaining an optimal level of well being, diagnose a condition or prevent a medical condition from occurring.

(12) "Planning and Placement Team" means the definition contained in subsection (p) of section 10-76a-1 of the Regulations of Connecticut State Agencies.

(13) "Provider" means the local educational agencies or boards of education that participate in the medicaid program as providers of school based child health ("SBCH") services.

(14) "Qualified SBCH Service Providers" include but, are not limited to: licensed physician, licensed osteopath, licensed optometrist, licensed chiropractor, licensed naturopath, licensed audiologist, speech therapy assistants working under the direction of licensed speech pathologists, licensed speech pathologist, licensed advanced practice registered nurse (APRN), licensed registered nurse (RN), licensed physician assistant, licensed practical nurse (LPN), licensed psychologist, certified family and marital counselors, SDE certified school psychologist, SDE certified school social worker, DPH certified independent social worker, DPH certified substance abuse counselor, DPH certified marital and family therapist, SDE certified school counselor, SDE certified guidance counselor, licensed occupational therapist, licensed occupational therapy assistant, licensed physical therapist, physical therapist assistant meeting requirements of section 20-66 of the CGS, licensed respiratory care practitioner and licensed optometrist.

(15) "Rehabilitative Services" are those services as defined under 42 CFR, Part 440, subsection (d) of section 440.130, as amended from time to time.

(16) "School Based Child Health Services" are those diagnostic and rehabilitative treatment services which are medically necessary and appropriate and which meet the needs of children as provided in accordance with Part B of IDEA, as amended from time to time, and section 10-76d of the CGS and supporting regulations, and are recommended in writing by a licensed practitioner of the healing arts within each respective practitioner's scope of practice as defined under state law in accordance with 42 CFR, Part 440, subsections (a) and (d) of section 440.130, as amended from time to time.

(17) "Triennial Reevaluation" is the process of reevaluation at least once every three years as described under section 10-76d-9 of the Regulations of Connecticut State Agencies.

(18) "Type of Placement" means, for the purposes of this regulation, the type of setting in which the child receives special education services. These settings include, but are not limited to: in-district, out-of-district public residential, out-of-district private residential, out-of-district public day and out-of-district private day.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-215 Provider participation

In order to participate in the Connecticut Medical Assistance Program and provide SBCH Services eligible for Medicaid reimbursement from the Department, the provider shall meet the following requirements:

(1) Enroll with the Department, and have on file, a valid provider agreement. This agreement shall be updated annually in order to continue billing the Department for services.

(2) Ensure that all professionals employed by or under contract arrangements with a LEA to provide school based child health services meet all applicable federal and state licensing and certification requirements.

(3) Comply with all Medicaid documentation and other requirements, including, but not limited to those delineated in the provider agreement.

(4) Follow all laws, rules, regulations, policies and amendments which govern Medicaid reimbursement for services provided pursuant to Part B of IDEA, as amended from time to time, and section 10-76 of the CGS, and which are specified by the federal government and the State of Connecticut.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-216 Eligibility

Medicaid funding is available for SBCH Services under section 17b-262-218 below on behalf of all children who are Medicaid recipients.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-217 Need for services

Medicaid shall reimburse for SBCH Services provided the following requirements are met:

(a) The diagnostic and evaluation services recommended by the PPT and a licensed practitioner of the healing arts in the initial evaluation or triennial reevaluation of the child are supported by reports containing recommendations by licensed or certified practitioners within the scope of their practice as defined by state law.

(b) The ongoing treatment services, as recommended by the PPT and a licensed practitioner of the healing arts, are specified in the child's IEP on file with the respective LEA. The IEP shall include, either in the IEP document itself or in an attachment to the IEP, but is not limited to:

(1) applicable medical diagnoses in a format acceptable to the department;

(2) anticipated treatment goals;

(3) a description of the type, amount, frequency and duration of the services to be furnished;

(4) identification of the type(s) of service providers(s); and

(5) signature(s) of licensed practitioner(s) of the healing arts, within their scope of practice as defined by state law, recommending the plan of medical services.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-218 Services covered

The Department shall pay for the following services:

(a) Audiology

Audiology services include, but are not limited to: (1) identification of children with hearing loss; (2) determination of the range, nature and degree of hearing loss, including referral for medical or other professional attention for the treatment of hearing; (3) provision of treatment activities, such as language habilitation, auditory training, speech reading (lip reading), hearing evaluation and speech conservation; (4) creation and administration of programs for the prevention of hearing loss; (5) counseling and guidance of children, parents and teachers regarding hearing loss; and (6) determination of the child's need for individual or group amplification, selecting and fitting an appropriate aid and evaluating the effectiveness of amplification, provided that these services are within the scope of practice set forth in subsection (3) of section 20-408 of the CGS.

(b) Clinical Diagnostic Laboratory Services

Clinical diagnostic laboratory services means services recommended by the PPT such as simple diagnostic tests and procedures performed in the school. These services include, but are not limited to: (1) blood sugar by a finger stick, (2) urine dipstick and (3) hematocrit.

(c) Durable Medical Equipment, Other Medical Supplies and Devices

Durable medical equipment means the purchase or rental of medically necessary and appropriate assistive devices such as: (1) augmentative communication device; (2) crouch screen voice synthesizer; (3) prone stander; (4) corner chair; (5) wheelchair; (6) crutches; (7) walkers; (8) auditory trainers; and (9) suctioning machines. Other medical supplies and devices means supplies and devices necessary, and incidental to, IEP related services.

(d) Medical Services

Medical services means medical diagnostic and evaluative services recommended by the PPT to determine the child's medically related disability as approved by the licensed practitioner of the healing arts as defined in section 20-1 of the CGS and provided by the qualified SBCH service provider.

(e) Medical Transportation

Medical transportation means the transportation of a child identified as requiring special education and related services to sites of medically appropriate and necessary services. This includes the cost of staff required to accompany the child, as prescribed in the IEP, in order to transport the child to and from school and other sites of medically appropriate and necessary services.

(f) Mental Health Services (Psychological & Counseling Services)

Mental health services means diagnostic and treatment services involving mental, emotional or behavioral problems and disturbances and dysfunctions, or the diagnosis and treatment of substance abuse. These services include, but are not limited to: (1) mental health evaluations; (2) psychological testing such as the (A) administering of psychological tests and other assessment procedures; (B) interpreting of assessment results; (C) obtaining, integrating and interpreting of information about child behavior and conditions related to learning; (D) planning and managing of a program of psychological services including psychological counseling for children and parents; and (3) counseling services such as individual, group or marital and family counseling or psychotherapy for the treatment of a mental, emotional, behavioral or substance abuse condition to alleviate the condition and encourage growth and development, as performed by qualified SBCH providers, provided these services are within the scope of practice set forth in subsection (a) of section 20-74o, section 20-187a, subsections (a) and (b) of section 20-195, subsection (a) of section 20-195a, subsection (a) of section 20-195m, and subsection (b) of section 20-195q of the CGS, and sections 10-145d-555 through 10-145d-566, inclusive, of the Regulations of Connecticut State Agencies.

(g) Nursing Services

Nursing services include, but are not limited to: (1) health assessment and development of individualized health care plans; (2) nursing procedures including suctioning, tracheostomy care, catherterization, toileting, ostomy management and care; (3) monitoring of health status, for example, monitoring of shunt functioning or respiratory status; and individual health counseling and instruction and emergency interventions, provided that these services are within the scope of practice set forth in subsections (a), (b) and (c) of section 20-87a of the CGS.

(h) Occupational Therapy

Occupational therapy services means those services as defined in subsection (1) of section 20-74a of the CGS.

(i) Physical Therapy

Physical therapy services means those services as defined in subsection (2) of section 20-66 of the CGS.

(j) Respiratory Care Services

Respiratory care services means those services as defined in subsection (b) of section 20-162n of the CGS.

(k) Speech/Language

Speech pathology services include, but are not limited to: (1) identification of children with speech and language impairments; (2) diagnosis and appraisal of specific speech and language impairments; (3) referrals for medical or other professional attention necessary for the treatment of speech or language impairments; (4) provision of speech or language services for the treatment or prevention of communicated impairments; and (5) counseling or guidance of parents, children and teachers regarding speech and language impairments, provided that these services are within the scope of practice set forth in subsection (1) of section 20-408 of the CGS and sections 10-145d-543 through 10-145d-546, inclusive, of the Regulations of Connecticut State Agencies.

(l) Optometric Services

Optometric services include, but are not limited to: (1) assessment for visual acuity, color blindness, near vision and strabismus; and (2) diagnosis of abnormalities related to the eye and optic nerves, provided that these services are within the scope of practice set forth in subsection (2) of section 20-127 of the CGS.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-219 Limitations

(a) No payments shall be made by Medicaid:

(1) directly to health professionals or organizations under contract to a LEA for medically appropriate and necessary services covered under section 17b-262-218 above;

(2) for services of an unproven, experimental, cosmetic or research nature or for any diagnostic, therapeutic or treatment procedures in excess of those deemed medically appropriate and necessary by the Department to treat the child's condition;

(3) for any immunizations, biological products and other products or examinations and laboratory tests for preventable diseases available free of charge from the Department of Public Health;

(4) for speech services involving non-diagnostic, non-therapeutic, routine, repetitive and reinforced procedures or services for the child's general good and welfare (e.g., the practicing of word drills which are not planned and performed or supervised by a licensed speech pathologist);

(5) for services which are provided free of charge to all students such as routine screenings; or

(6) for cancelled visits or appointments not kept.

(b) Services may be provided to an individual until the end of the school year in which a student reaches twenty-one (21) years of age.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-220 Documentation and record retention requirements

(a) A permanent service record documenting each SBCH Service provided to each medicaid eligible child shall be maintained by the LEA at which the child is enrolled at the time of service. The permanent service record shall include, but is not limited to:

(1) the written evaluation and the results of any diagnostic tests;

(2) the diagnosis(ses), in a manner acceptable to the Department;

(3) the IEP signed by a licensed practitioner of the healing arts in a manner acceptable to the Department; and

(4) the actual service delivery record including: the type of service; the date of the service; the units of service; the name and discipline of the person performing services and, for persons affiliated with an organization under contract to the LEA, the name of the organization; the signature of the individual performing the service; and progress notes signed by a licensed or certified allied health professional who performed or supervised the services within the scope of his or her practice under state law.

(b) The Local Educational Agency (LEA) shall maintain a current record of the applicable licenses or certificates of practice of all licensed or certified persons performing SBCH Services.

(c) The Local Educational Agency (LEA) shall maintain all supporting records of costs reported for SBCH Services.

(d) All records shall be maintained for at least six (6) years.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-221 Billing requirements

(a) All SBCH Services performed on behalf of Medicaid-eligible children shall be recorded on the required claim forms for the SBCH provider and submitted to the Department in accordance with the billing instructions provided by the Department.

(b) All claims submitted to the Department for payment of services covered under section 17b-262-218 above shall be substantiated by documentation in the eligible child's permanent service record pursuant to section 17b-262-220 above.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-222 Establishment of rates

(a) The Department shall establish payment rates for three (3) types of service specific to type of placement for SBCH Services:

(1) a per month per child unit rate for SBCH treatment services, specific to type of placement;

(2) a rate for initial evaluations and triennial reevaluations, specific to type of placement; and

(3) a rate for Durable Medical Equipment, Other Medical Supplies and Devices. Rates shall be determined based upon annual cost and utilization filings made on forms prescribed by the Commissioner of the Department, except that for the July 1, 1999 through June 30, 2000 rate period, such rates shall be determined based upon the July 1, 1996 through June 30, 1997 cost reports inflated by the increase in the consumer price index (urban-all items). Rates shall be based on cost and utilization data for all children referred for special educational services. The Commissioner may establish interim rates for the billing periods.

(b) On an annual basis, except for the July 1, 1999 through June 30, 2000 period, the participating local educational agencies (LEA), shall provide to the Commissioner of the Department of Social Services, for all Medicaid eligible and non-Medicaid eligible children receiving SBCH services through such agencies, the following information and supporting documentation including, but not limited to:

(1) the average monthly unduplicated count of children receiving initial evaluations for special education services by type of placement;

(2) the costs of providing initial evaluations for special education services by type of placement;

(3) the average monthly unduplicated count of children receiving triennial reevaluations and diagnostic testing for special education services by type of placement;

(4) the costs of providing triennial reevaluations and diagnostic testing for special education services by type of placement;

(5) the average monthly unduplicated count of children receiving ongoing special education-related health treatment services independent of initial evaluations and triennial reevaluations by type of placement; and

(6) the costs of providing ongoing special education-related health treatment services independent of initial evaluations and triennial reevaluations by type of placement.

(c) Cost and utilization data provided to the Department by the State Department of Education shall be audited in accordance with Generally Accepted Government Auditing Standards (GAGAS).

Cost and utilization data shall be maintained for a minimum of six (6) years from the billing period by the LEA.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-223 Audit/compliance review

All supporting accounting and business records, statistical data, the child's permanent service record and all other records relating to the provision of SBCH Services paid for by the Department shall be subject to audit or compliance review by authorized personnel. If an audit discloses discrepancies in the accuracy or allowability of actual direct or indirect costs or statistical data as submitted for each state fiscal year by the Department of Education and its LEAs, the Department's rates for said period shall be subject to adjustment. All documentation shall be made available to authorized personnel upon request in accordance with 42 CFR, Part 431. SDE shall take full responsibility for any Medicaid claims disallowed due to inadequate documentation by any LEA or failure to comply with requirements set forth in statute or regulations.

History

• Effective January 31, 1996; Amended May 10, 2000

Regs., Conn. State Agencies § 17b-262-224—17b-262-298 Reserved

Sec. 17b-262-224—17b-262-298. Reserved

Regs., Conn. State Agencies § 17b-262-299 Scope

Sections 17b-262-299 to 17b-262-311, inclusive, of the Regulations of Connecticut State Agencies set forth the requirements for payment of services provided by Intermediate Care Facilities for the Mentally Retarded to clients eligible to receive such services under Medicaid pursuant to section 17b-262 of the Connecticut General Statutes.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-300 Definitions

As used in sections 17b-262-299 to 17b-262-311, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:

(1) "Active treatment" means the treatment as described in 42 CFR 483.440(a), as amended from time to time;

(2) "Applied income" means the amount of income that each client receiving ICF/MR services is expected to pay each month toward the cost of his or her care, calculated according to the DSS Uniform Policy Manual, section 5045.20;

(3) "Client" means a person eligible for services under the Connecticut Medicaid program;

(4) "DMR" means the Department of Mental Retardation or its agent;

(5) "DPH" means the Department of Public Health or its agent;

(6) "Department" or "DSS" means the Department of Social Services or its agent;

(7) "Discharge" means the movement of a client out of an ICF/MR;

(8) "Home leave" means an overnight absence from the ICF/MR for any reason other than admission to a hospital. It is taken at the discretion of the client;

(9) "Hospital" means a general hospital, special hospital or chronic disease hospital as defined in section 19-13-D1(b) of the Regulations of Connecticut State Agencies;

(10) "Interdisciplinary team" or "IDT" means a group of persons, as described in 42 CFR 483.440(c)(2), as amended from time to time;

(11) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for the mentally retarded licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified and enrolled to participate in Medicaid as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(12) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and, is the least costly of multiple, equally-effective, alternate treatments or diagnostic modalities;

(13) "Medicaid" means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(14) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist a client in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring;

(15) "Objective information" means an estimate of the client's projected length of hospital stay obtained by the ICF/MR from a hospital staff person. This prognosis may be obtained from the client's record or the overall plan of service (OPS) or given by a physician or other health professional under his or her direction or by another qualified professional such as a social worker or discharge planner;

(16) "Overall plan of services" or "OPS" means a document that specifies a strategy to guide the delivery of services to a client for up to one year. It is the document required for a client that meets the federal requirements for a plan of care as outlined in 42 CFR 456.380, as amended from time to time, and an individual program plan as outlined in 42 CFR 483.440, as amended from time to time; and

(17) "Provider" means an ICF/MR that is enrolled in the Medicaid program.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-301 Provider participation

In order to enroll in Medicaid and receive payment from the department, providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies and be certified, in accordance with federal regulations, to participate in the Medicaid program.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-302 Eligibility

Payment to Intermediate Care Facilities for the Mentally Retarded is available on behalf of all clients who are determined to be in need of ICF/MR care by the Department of Mental Retardation and the Department of Social Services, subject to the conditions and limitations set forth in sections 17b-262-299 to 17b-262-311, inclusive, of the Regulations of Connecticut State Agencies. Clients shall be receiving active treatment as described in 42 CFR 483.440(a), as amended from time to time.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-303 Services covered and limitations

(a) Services Covered

(1) The department shall pay an all-inclusive per diem rate, computed in accordance with section 17b-340 of the Connecticut General Statutes and sections 17-311-1 to 17-311-120, inclusive, of the Regulations of Connecticut State Agencies, to the ICF/MR for each client. This rate represents an inclusive payment for all services and items that are required to be provided by the facility as a condition for participation as an ICF/MR, including but not necessarily limited to the following:

(A) services provided by qualified staff engaged by the ICF/MR, as described in 42 CFR 483.430, as amended from time to time;

(B) active treatment services as described in 42 CFR 483.440, as amended from time to time;

(C) client behavior and facility practice as described in 42 CFR 483.450, as amended from time to time;

(D) health care services as described in 42 CFR 483.460, as amended from time to time;

(E) physical environment management as described in 42 CFR 483.470, as amended from time to time;

(F) dietetic services as described in 42 CFR 483.480, as amended from time to time;

(G) routine personal hygiene items as defined in 42 CFR 483.10(c)(8)(i)(E), as amended from time to time;

(H) over the counter medications except insulin;

(I) durable medical equipment, except for those items listed in section 17b-262-676(a)(2) of the Regulations of Connecticut State Agencies where Medicaid payment is available directly to the supplier of durable medical equipment if the item is medically necessary;

(J) supplies used in the routine care of the client that are included on the department's medical and surgical fee schedule including:

(i) antiseptics and solutions;

(ii) bandages and dressing supplies;

(iii) catheters and urinary incontinent supplies;

(iv) diabetic supplies;

(v) diapers and underpads;

(vi) compression, burns and specialized medical garments;

(vii) ostomy supplies;

(viii) respiratory and tracheotomy supplies;

(ix) enteral and parenteral supplies; and

(x) miscellaneous supplies;

(K) services related to the provision or arrangement for provision of customized wheelchairs that are the responsibility of the ICF/MR as described in subsections 17-134d-46(m) and (n) of the Regulations of Connecticut State Agencies; and

(L) transportation services necessary to transport a client to and from any service included in the per diem rate as described in this section.

(2) The department shall pay to reserve a bed in an ICF/MR for a client during a temporary absence in a hospital as described in section 17b-262-306 of the Regulations of Connecticut State Agencies.

(3) The department shall pay to reserve a bed in an ICF/MR for home leave in accordance with section 17b-262-307 of the Regulations of Connecticut State Agencies.

(b) Limitations

(1) The department shall not pay for anything of an unproven, experimental or research nature or for services in excess of those deemed medically necessary by the department to treat the client's condition or for services not directly related to the client's diagnosis, symptoms or medical history.

(2) The department shall pay for the date of admission and not for the date of discharge. Exceptions to this are:

(A) the department shall pay for the date of death when the client dies in the ICF/MR. If the client dies while in the hospital or on home leave, the date of death is paid as a reserve bed day, provided all other bed reservation requirements as described in sections 17b-262-306 and 17b-262-307 of the Regulations of Connecticut State Agencies are met; and

(B) in the case of a client admitted and discharged on the same day, payment is authorized for one day of care.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-304 Need for services and authorization process

(a) The decision to admit and the subsequent admission to a facility must be made by the Department of Mental Retardation or the admitting ICF/MR in conjunction with the client's interdisciplinary team, subject to review by DSS.

(b) DSS shall evaluate and approve in writing the client's need for ICF/MR services ordered by the physician, as described in 42 CFR 456.372, as amended from time to time.

(c) In order for DSS to pay for ICF/MR services, the ICF/MR shall document the need for the admission by all of the following:

(1) certification of the need for care by a physician as described in 42 CFR 456.360(a), as amended from time to time;

(2) medical, psychological and social evaluations as described in 42 CFR 456.370, as amended from time to time;

(3) an admissions review as described in 42 CFR 483.440(b), as amended from time to time;

(4) exploration of alternative services as described in 42 CFR 456.371, as amended from time to time;

(5) an OPS; and

(6) a written report of each evaluation and OPS entered in the client's record, as described in 42 CFR 456.381, as amended from time to time.

(7) DSS written approval of the client's need for ICF/MR services in accordance with 42 CFR 456.372, as amended from time to time.

(d) Beginning no later than six months after admission, or earlier if indicated at the time of admission, the ICF/MR shall document the need for continued stay by all of the following:

(1) recertification of need for care as described in 42 CFR 456.360(b), as amended from to time, on forms prescribed by DSS;

(2) exploration of alternative services as described in 42 CFR 456.371, as amended from time to time;

(3) a continued stay review process in accordance with 42 CFR 456.431 to 42 CFR 456.438, inclusive, as amended from time to time;

(4) a review of the OPS as described in 42 CFR 456.380(c), as amended from time to time; and

(5) monitoring of the program plan as described in 42 CFR 483.440(f), as amended from time to time.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-305 Client's bill of rights

(a) An ICF/MR shall protect and promote the rights of each client as described in 42 CFR 483.420, as amended from time to time.

(b) Requirements for the administration of the patient's personal allowance shall be in accordance with sections 17-2-140 to 17-2-145, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-306 Bed reserve for hospitalization

(a) DSS shall pay to reserve a bed in an ICF/MR for a client during a temporary absence in a hospital for up to fifteen (15) days in accordance with subsection (e) of this section.

(b) The ICF/MR shall inform the client and guardian or other responsible person, upon admission to the ICF/MR and upon transfer of a client to the hospital, that the bed of a client shall be reserved if the conditions outlined in this section are met.

(c) The ICF/MR shall reserve the bed of any client who is absent from the ICF/MR due to hospitalization unless the ICF/MR has obtained objective information from the hospital that the client shall not return to the ICF/MR within the fifteen day period, including the day of admission, to the hospital.

(d) The ICF/MR shall not make the reserved bed available for use by any other person.

(e) DSS shall reimburse an ICF/MR at the per diem Connecticut Medicaid program rate of the ICF/MR for each day that the ICF/MR reserves the bed of a client in accordance with the following conditions:

(1) an ICF/MR shall be reimbursed for reserving the bed of a client who is hospitalized for a maximum of seven (7) days including the admission date of hospitalization, if on the date of admission the ICF/MR documents that it contacted the hospital and the hospital failed to provide objective information confirming that the person would be unable to return to the ICF/MR within fifteen (15) days of the date of hospitalization;

(2) the ICF/MR shall be reimbursed for a maximum of eight (8) additional days provided on or before the seventh day, but not before the third day of the hospitalization of a client, the ICF/MR contacts the hospital for an update on the client's status and the ICF/MR documents in the client's file that the information obtained through the contact does not indicate that the client shall be unable to return to the ICF/MR within fifteen (15) days of the hospital admission;

(3) documentation of the hospital contact described in subdivisions (1) and (2) of this subsection shall include the date of the contact, the hospital representative's name, the source of the information and the estimated length of stay;

(4) if at any time the ICF/MR is provided with information from the hospital that the client shall not return to the ICF/MR within fifteen (15) days of the hospital admission, the ICF/MR is not eligible to receive reimbursement for reserving the client's bed for any days after such information is received, including the day the information is received; and

(5) for the purposes of determining the beginning of the bed reservation period, admission to the hospital shall mean the time at which the client, on recommendation of a physician, is formally admitted as an inpatient to the hospital. When a client is transferred to the hospital and is not formally admitted, it shall not be considered a discharge, regardless of the length of the stay. It shall be considered a discharge from the ICF/MR only when the client is formally admitted by the hospital. Any other hospital stay, whether in the emergency room or otherwise shall be considered an outpatient visit.

(f) If the client's hospitalization exceeds the period of time that an ICF/MR is required to reserve the client's bed, the ICF/MR:

(1) shall provide the client the first available bed at the time notice is received of the client's discharge from the hospital;

(2) shall grant the client priority admission over applicants for new admission to the ICF/MR; and

(3) may charge a fee to reserve the bed if the client, his or her family or responsible party wishes to pay to reserve the bed. For hospital leave beyond fifteen (15) days per hospital admission, the facility shall reserve the bed as long as payment is available. The fee shall not exceed the per diem Connecticut Medicaid program rate for that bed.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-307 Bed reserve for home leave

(a) DSS shall pay to reserve a bed in an ICF/MR for a client during a temporary absence for home leave for up to thirty-six (36) days per calendar year. The ICF/MR shall not make the reserved bed available for use by any other person.

(b) The ICF/MR shall inform the client and guardian or other responsible person upon admission to the facility, that a bed shall be reserved for home leave if the conditions outlined in subsection (d) of this section are met.

(c) The ICF/MR shall reserve a client's bed for up to thirty-six (36) days per calendar year. No facility shall require, or request, a client to provide payment for authorized home leave.

(d) DSS shall reimburse an ICF/MR at the per diem Connecticut Medicaid program rate of the facility for each day that the facility reserves the bed in accordance with the following conditions:

(1) the client has not used more than thirty-six (36) days of home leave during the calendar year;

(2) the facility has not refused to take the client back during or upon completion of the authorized home leave. If so, no payment shall be made for the entire home leave; and

(3) the client has not failed to return to the ICF/MR. If the client has not returned, the liability for payment to the ICF/MR shall terminate on the date the ICF/MR is notified that the client will not be returning.

(e) If the client has used more than thirty-six (36) days of home leave in a calendar year the facility shall not be required to reserve the bed; however, the ICF/MR:

(1) shall provide the client the first bed available after notice is received that the client wishes to return;

(2) shall grant the client priority admission over applicants for new admission to the ICF/MR; and

(3) may charge a fee to reserve the bed if the client, his or her family or responsible party wishes to pay to reserve the bed. For home leave beyond thirty-six (36) days per calendar year, the facility shall reserve the bed as long as payment is available. The fee shall not exceed the per diem Connecticut Medicaid program rate for that bed.

(f) The ICF/MR shall document in the client's medical record:

(1) the contact person;

(2) the duration of the absence;

(3) the client's condition before leaving, and upon returning, to the facility; and

(4) the dates of home leave.

(g) The medical record does not need to be closed nor does the client need to be readmitted after home leave.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-308 Applied income

(a) DSS is responsible for calculating the applied income. DSS shall notify the ICF/MR of the amount of any applied income that the facility is responsible for collecting. Applied income shall be deducted from what otherwise would have been the DSS monthly payment to the ICF/MR on behalf of the client.

(b) The ICF/MR shall notify DSS of any errors in the amount of applied income processed against the claim using the form specified by DSS. Payment adjustments resulting from retroactive applied income corrections shall be processed periodically.

(c) In any month that a client returns to the community or dies, and the cost of care is less than the applied income, the department shall adjust the applied income as follows: the applied income shall equal the number of days that the client was in the ICF/MR multiplied by the per diem rate.

(d) Applied income shall not be pro rated. It shall be used to cover the cost of care until it is expended.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-309 Billing and payment procedures

(a) The ICF/MR shall submit claims to the department as described in section 17b-262-529 of the Regulations of Connecticut State Agencies and the billing instructions specific to ICFs/MR.

(b) The ICF/MR shall:

(1) complete the daily admission and discharge forms in accordance with DSS instructions;

(2) notify the DSS caseworker if the ICF/MR is aware that the ICF/MR client's asset level exceeds the established resource limit. The report shall be made on the form specified by DSS.

(3) notify the convalescent payment unit of DSS of any and all credits due DSS on the form specified by DSS.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-310 Rates

The per diem rates for an ICF/MR shall be determined annually, pursuant to section 17b-340 of the Connecticut general statutes and sections 17-311-1 to 17-311-120, inclusive, of the Regulations of Connecticut State Agencies. DSS shall reimburse the ICF/MR at the per diem rate minus the applied income.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-311 Documentation

(a) The ICF/MR shall maintain all documentation required for rate setting purposes for a minimum of 10 years pursuant to section 17-311-56 of the Regulations of Connecticut State Agencies, including all documentation required to support the billing for bed reserve days described in subsection (e)(4) of this section. This documentation shall be subject to review by the department.

(b) The ICF/MR shall maintain all other documentation required by this section for at least five (5) years or longer as required by statute or regulation, and shall be subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the ICF/MR shall maintain all documentation until the end of the dispute, for five (5) years, or for the length of time required by statute or regulation, whichever is longest.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the ICF/MR for which the required documentation is not maintained and provided to the department upon request. Documentation requirements are described in detail in the Provider Agreement for ICFs/MR and sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.

(d) An ICF/MR shall maintain fiscal and medical records to fully disclose services and goods rendered or delivered to Medicaid residents. Records shall be maintained in accordance with the department's Provider Agreement for ICFs/MR.

(e) Required documentation shall include:

(1) all reports, evaluations, certifications, reviews and approvals documenting the need for admission as described in subsection 17b-262-304(b) of the Regulations of Connecticut State Agencies;

(2) all certifications and reviews documenting the need for continued stay as described in subsection 17b-262-304(c) of the Regulations of Connecticut State Agencies;

(3) all admission and discharge forms required by DSS; and

(4) all documentation required to support the ICF's/MR billing for and the DSS payment of bed reserve days as described in sections 17b-262-306 and 17b-262-307 of the Regulations of Connecticut State Agencies.

(f) Providers shall maintain all medical records pursuant to sections 17a-227-17 and 17a-227-18 of the Regulations of Connecticut State Agencies.

History

• Adopted effective October 1, 2001

Regs., Conn. State Agencies § 17b-262-312—17b-262-336 Reserved

Sec. 17b-262-312—17b-262-336. Reserved

Regs., Conn. State Agencies § 17b-262-337 Scope

Sections 17b-262-337 to 17b-262-349, inclusive, of the Regulations of Connecticut State Agencies, set forth the Department of Social Services requirements for payment of accepted methods of treatment performed by or under the personal supervision of licensed physicians for clients who are determined eligible to receive services under Connecticut’s Medicaid Program pursuant to section 17b-261 of the Connecticut General Statutes.

History

• Adopted effective May 11, 1998; Amended January 31, 2008; Amended March 11, 2013

Regs., Conn. State Agencies § 17b-262-338 Definitions

For the purposes of sections 17b-262-337 to 17b-262-349, inclusive, of the Regulations of Connecticut State Agencies, the following definitions apply:

(1) “Accountable provider” means the maternity billing provider entity delivering services under the physicians’ services benefit category;

(2) “Acute” means having rapid onset, severe symptoms, and a short course;

(3) “Admission” means the formal acceptance by a hospital of a client who is to receive health care services while lodged in an area of the hospital reserved for continuous nursing services;

(4) “Advanced practice registered nurse” means a person licensed pursuant to section 20-94a of the Connecticut General Statutes;

(5) “Allied Health Professional” or “AHP” means a qualified individual other than a physician who: (A) Is qualified by special training, education, skills and experience in health care and treatment, (B) is certified or licensed by the Department of Public Health as one or more of the following: Psychologist, licensed clinical social worker, advanced practice registered nurse, nurse-midwife, physician assistant, licensed professional counselor, licensed marital and family therapist, licensed alcohol and drug counselor, physical therapist, occupational therapist, speech pathologist, audiologist, optician, optometrist, respiratory care practitioner, certified doula or such other category of licensed health care professional that the department permits to enroll individually as a Medicaid provider or meets other applicable qualifications approved in writing by the department and incorporated into the Medicaid State Plan or other applicable federally authorized state Medicaid document, (C) acts within the AHP’s scope of practice under state law and (D) complies with all requirements in 42 CFR 440, as amended from time to time, applicable to the AHP;

(6) “Audiologist” means a person licensed to practice audiology pursuant to section 20-395c of the Connecticut General Statutes;

(7) “Billing provider” means a physician, physician group or other entity enrolled in Medicaid that bills the department for physicians’ services;

(8) “Border provider” means a provider that is (A) located in a state bordering Connecticut in an area that allows the provider to generally serve Connecticut residents, (B) enrolled as and treated as a Medicaid provider, (C) certified, accredited or licensed by the applicable agency in their state and (D) deemed a border provider by the department on a case-by-case basis;

(9) “Case rate payments” means provider-specific monthly payments that reimburse a subset of services included in the maternity bundle episode and provided during the prenatal, labor and delivery, and postpartum periods;

(10) “Certified doula” means a doula who is certified pursuant to section 20-86bb of the Connecticut General Statutes;

(11) “Child” means a person who is under twenty-one years of age;

(12) “Chronic disease hospital” has the same meaning as provided in section 19a-490 of the Connecticut General Statutes;

(13) “Client” or “member” means a person eligible for goods or services under Medicaid;

(14) “Commissioner” means the Commissioner of Social Services;

(15) “Consultation” means those services rendered by a physician whose opinion or advice is requested by the client’s physician or agency in the evaluation or treatment of the client’s illness;

(16) “Department” means the Department of Social Services or its agent;

(17) “Early and Periodic Screening, Diagnostic and Treatment services” or “EPSDT services” means the services provided in accordance with section 1905(r) of the Social Security Act, as amended from time to time;

(18) “Emergency” means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client’s health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part;

(19) “Family planning services” means any medically approved diagnostic procedure, treatment, counseling, drug, supply or device that a provider prescribes or furnishes to individuals of childbearing age for the purpose of enabling such individuals to freely plan the number and spacing of their children;

(20) “Fees” means the payments for services, treatments and drugs administered by physicians which the commissioner establishes and includes in the department’s fee schedules;

(21) “General hospital” has the same meaning as provided in section 17-134d-80 of the Regulations of Connecticut State Agencies;

(22) “Home” means the client’s place of residence, which includes a boarding home, community living arrangement or residential care home. “Home” does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for individuals with intellectual disabilities or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(23) “Hysterectomy” has the same meaning as provided in 42 CFR 441.251, as amended from time to time;

(24) “Informed consent” has the same meaning as provided in 42 CFR 441.257, as amended from time to time;

(25) “Intermediate care facility for individuals with intellectual disabilities” or “ICF/IID” means a residential facility for individuals with intellectual disabilities licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in Medicaid as an intermediate care facility for individuals with intellectual disabilities pursuant to 42 CFR 442.101, as amended from time to time;

(26) “ICD” means the International Classification of Diseases established by the World Health Organization or such other disease classification system that the department currently requires providers to use when submitting Medicaid claims;

(27) “Institutionalized individual” has the same meaning as provided in 42 CFR 441.251, as amended from time to time;

(28) “Legend Device” has the same meaning as provided in section 20-571 of the Connecticut General Statutes;

(29) “Legend Drug” has the same meaning as provided in section 20-571 of the Connecticut General Statutes;

(30) “Licensed alcohol and drug counselor” means an individual licensed pursuant to section 20-74s of the Connecticut General Statutes;

(31) “Licensed clinical social worker” means an individual licensed pursuant to section 20-195n of the Connecticut General Statutes;

(32) “Licensed marital and family therapist” means an individual licensed pursuant to section 20-195c of the Connecticut General Statutes;

(33) “Licensed professional counselor” means an individual licensed pursuant to sections 20-195cc and 20-195dd of the Connecticut General Statutes;

(34) “Maternity bundle episode” or “bundle” or “episode” means a defined group of maternity-related Medicaid covered services provided to a specific patient over a specific period of time;

(35) “Medicaid” means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(36) “Medical necessity” or “medically necessary” has the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(37) “Medical record” has the same meaning as provided in section 19a-14-40 of the Regulations of Connecticut State Agencies;

(38) “Mentally incompetent individual” has the same meaning as provided in 42 CFR 441.251, as amended from time to time;

(39) “Nurse-midwife” has the same meaning as provided in section 20-86a of the Connecticut General Statutes;

(40) “Nursing facility” has the same meaning as provided in 42 USC 1396r(a), as amended from time to time;

(41) “Occupational therapist” means an individual licensed pursuant to section 20-74b or section 20-74c of the Connecticut General Statutes;

(42) “Optician” means a person licensed pursuant to section 20-146 of the Connecticut General Statutes;

(43) “Optometrist” means a person licensed pursuant to section 20-130 of the Connecticut General Statutes;

(44) “Out-of-state provider” means a provider that is located outside Connecticut and is not a border provider;

(45) “Panel or Profile Tests” means specified groups of tests performed on a single specimen or material derived from the human body that are related to a condition, disorder or family of disorders, and when combined mathematically or otherwise, comprise a finished identifiable laboratory study or studies;

(46) “Performing provider” means the physician or AHP who actually performs the service;

(47) “Performance year” means the specific time period during which the accountable provider’s performance is measured to determine financial incentives or penalties or both, and the first Performance Year (PY1) is defined as January 1, 2025 to December 31, 2025;

(48) “Physical therapist” means an individual licensed pursuant to 20-70 or 20-71 of the Connecticut General Statutes;

(49) “Physician” means a person who is: (A) Licensed pursuant to section 20-13 of the Connecticut General Statutes and (B) acting within the physician’s scope of practice under state law;

(50) “Physician assistant” means an individual licensed pursuant to section 20-12b of the Connecticut General Statutes;

(51) “Physicians’ services” or “physicians’ services benefit category” means services that are billed by the billing provider and are provided:

(A) By an individual physician who is also the billing provider;

(B) by a physician who is employed by or affiliated with the billing provider; or

(C) by an AHP working under the personal supervision of a physician who is employed by or affiliated with the billing provider;

(52) “Prior authorization” means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods;

(53) “Provider” means (A) a physician or a physician group enrolled in Medicaid or (B) an AHP who is providing physicians’ services;

(54) “Psychologist” means a person licensed pursuant to sections 20-188 or 20-190 of the Connecticut General Statutes;

(55) “Quality of care” means the evaluation of medical care to determine if it meets the professionally recognized standards of acceptable medical care for the client’s condition;

(56) “Quality performance criteria” means a provider’s achievement of Medicaid’s quality standards based upon quality measure performance results;

(57) “Respiratory care practitioner” means an individual licensed pursuant to section 20-162o of the Connecticut General Statutes;

(58) “Speech pathologist” means an individual licensed pursuant to section 20-411 of the Connecticut General Statutes;

(59) “Sterilization” has the same meaning as provided in 42 CFR 441.251, as amended from time to time;

(60) “Under the personal supervision” means the administrative and clinical responsibility personally assumed by the physician for the AHP’s services within the AHP’s scope of practice;

(61) “Under-service” means actions taken by or on behalf of a participating entity that have the result of limiting, excluding or discouraging one or more members from seeking or receiving medically necessary Medicaid covered services;

(62) “Usual and customary charge” means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases, except, if the provider varies the charges so that no one amount is charged in the majority of cases, “usual and customary charge” means the median amount that the provider charges for such service or procedure. “Usual and customary charge” does not include token charges for charity patients and other exceptional charges; and

(63) “Utilization review” has the same meaning as provided in section 17-134d-80 of the Regulations of Connecticut State Agencies.

History

• Adopted effective May 11, 1998; Amended January 31, 2008; Amended March 11, 2013; Amended December 24, 2025

Regs., Conn. State Agencies § 17b-262-339 Provider participation

(a) In order to enroll in Medicaid and for billing providers to receive payment from the department, performing providers and billing providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies and shall maintain their enrollment status pursuant to valid provider enrollment agreements on file with the department.

(b) Performing providers shall enroll in Medicaid as performing providers.

(c) Billing providers shall enroll in Medicaid as billing providers.

History

• Adopted effective May 11, 1998; Amended January 31, 2008; Amended March 11, 2013

Regs., Conn. State Agencies § 17b-262-340 Eligibility

Payment to a billing provider for physicians’ services billed by the billing provider shall be available on behalf of clients who have a need for such services, provided such services are medically necessary, subject to the conditions and limitations that apply to such services.

History

• Adopted effective January 31, 2008; Amended March 11, 2013

Regs., Conn. State Agencies § 17b-262-341 Goods and services covered and limitations

The department shall pay billing providers for the following physicians’ services:

(1) Those procedures that are medically necessary to treat the client’s condition;

(2) physicians’ services provided in an office a general hospital, the client’s home, a chronic disease hospital, nursing facility, ICF/IID or other medical care facility;

(3) laboratory services provided by a provider in compliance with 42 USC 263a to 42 USC 263a-7, inclusive;

(4) medical and surgical supplies for out-of-office use by the client;

(5) drugs and devices administered by a provider;

(6) a second opinion for surgery or any other treatment when requested voluntarily by the client or when required by the department. The department shall pay for a second opinion according to the established fees for consultation;

(7) family planning, abortion and hysterectomy services as described in section 17b-262-348(r) of the Regulations of Connecticut State Agencies;

(8) Early and Periodic Screening, Diagnostic and Treatment services, including treatment services which are indicated following screening not otherwise covered, provided that prior authorization is obtained;

(9) surgical services necessary to treat morbid obesity as defined by the ICD that causes or aggravates another medical illness, including illnesses of the endocrine system or the cardio-pulmonary system, or physical trauma associated with the orthopedic system;

(10) family planning services for clients of childbearing age, including minors who can be considered sexually active, and who desire the services;

(11) sterilization for clients who are at least 21 years of age at the time of informed consent; and

(12) a hysterectomy performed during a period of retroactive eligibility as described in 42 CFR 441.255(e).

History

• Adopted effective January 31, 2008; Amended March 11, 2013; Amended December 24, 2025

Regs., Conn. State Agencies § 17b-262-341a Physician Assistants

(a) The department shall pay the billing provider for physicians’ services provided by a physician assistant who:

(1) Provides services under the personal supervision of a physician;

(2) acts within the physician assistant’s scope of practice under state law and performs only functions delegated by the supervising physician in compliance with sections 20-12c and 20-12d of the Connecticut General Statutes and all applicable requirements of the Department of Public Health; and

(3) is employed by or affiliated with the billing provider.

(b) All relevant payment limits described in section 17b-262-348 of the Regulations of Connecticut State Agencies apply to physicians’ services provided by a physician assistant.

(c) Physician assistants shall enroll individually in Medicaid as performing providers.

History

• Effective March 11, 2013

Regs., Conn. State Agencies § 17b-262-342 Goods and services not covered

The department shall not pay for the following goods or services or goods or services related to the following:

(1) Immunizations, biological products and other products available to providers free of charge;

(2) Examinations and laboratory tests for preventable diseases that are furnished free of charge;

(3) Information or services provided to a client by a provider electronically or over the telephone;

(4) Cosmetic surgery;

(5) An office visit for the sole purpose of the client obtaining a prescription where the provider previously determined the need for the prescription;

(6) Cancelled services and appointments not kept;

(7) Services provided in a general hospital if the department determines the admission does not, or retrospectively did not, comply with the department’s utilization review requirements in section 17-134d-80 of the Regulations of Connecticut State Agencies;

(8) Infertility treatment;

(9) Sterilizations performed on mentally incompetent individuals or institutionalized individuals;

(10) More than one visit per day to the same provider by a client;

(11) Services to treat obesity other than those described in section 17b-262-341(9) of the Regulations of Connecticut State Agencies; and

(12) Any procedures or services of an unproven, educational, social, research, experimental or cosmetic nature; any diagnostic, therapeutic or treatment services in excess of those deemed medically necessary by the department to treat the client’s condition or services not directly related to the client’s diagnosis, symptoms or medical history.

History

• Adopted effective January 31, 2008; Amended March 11, 2013; Amended April 2, 2015

Regs., Conn. State Agencies § 17b-262-343 Need for service

Payment is available to billing providers for an initial office visit and continuing services that are medically necessary, provided that:

(a) The services are within the provider’s scope of practice; and

(b) the provider documents the services in the client’s medical record.

History

• Adopted effective January 31, 2008; Amended March 11, 2013

Regs., Conn. State Agencies § 17b-262-344 Prior authorization

(a) Prior authorization, on forms and in the manner specified by the department, is required in order for payment to be available for the following physicians’ services. Prior authorization is also required for services designated by the department and published on its website or by other means accessible to providers.

(1) Electrolysis epilation;

(2) physical therapy services in excess of two visits per calendar week per client per provider;

(3) physical therapy services in excess of nine visits per calendar year per client per provider, when the therapy being prescribed is for the treatment of:

(A) All mental disorders, including diagnoses related to mental retardation and specific delays in development covered by the ICD;

(B) musculoskeletal system disorders of the spine covered by the ICD; and

(C) symptoms related to nutrition, metabolism and development covered by the ICD;

(4) reconstructive surgery, including breast reconstruction following mastectomy;

(5) plastic surgery;

(6) transplant procedures;

(7) Early and Periodic Screening, Diagnostic and Treatment services that are identified during a periodic screening as medically necessary and that are not payable pursuant to the physician fee schedule; and

(8) any service or device that is not on the department’s fee schedule.

(b) Prior authorization is required for all hospital admissions pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies.

(c) The department shall make payment available to the billing provider only if the provider initiates the authorized procedure or course of treatment not more than six months after the date of authorization.

(d) The initial authorization period shall not exceed six months.

(e) If prior authorization is needed beyond the initial authorization period, the department shall consider requests for continued treatment beyond the initial authorization period for up to an additional six-month period per request or longer as determined by the department on a case-by-case basis.

(f) Except in emergency situations, the provider shall receive prior authorization before rendering services.

(g) In an emergency situation involving services that require prior authorization that occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval from the department on the next working day for the services provided.

(h) In order to receive payment from the department, a billing provider shall comply with all prior authorization requirements. The department, in its sole discretion, determines what information is necessary in order to approve a prior authorization request. Prior authorization does not guarantee payment unless all other requirements for payment are met.

History

• Adopted effective January 31, 2008; Amended March 11, 2013

Regs., Conn. State Agencies § 17b-262-345 Billing procedures

(a) Billing providers shall submit claims on a hard copy invoice or by electronic transmission to the department in a form and manner specified by the department, together with all information required by the department to process the claim for payment, including, but not limited to, identifying the performing provider on each claim.

(b) The amount billed to the department shall represent the billing provider’s usual and customary charge for the services delivered.

(c) When a client is referred to a provider for consultation, the consultant provider shall include the referring practitioner’s name on all applicable claims.

(d) When billing for anesthesia services, anesthesiologists shall include the name of the primary surgeon on the claim.

(e) The department shall pay the billing provider directly for laboratory services performed in the provider’s office and the billing provider shall bill the department for such services as separate line items. When a provider refers a client to a private laboratory for services, the laboratory shall bill the department directly and no laboratory charge shall be paid to the provider.

(f) When more than one member of a billing provider provides services, the billing provider shall submit prior authorization requests prior to billing in accordance with the billing instructions in the department’s provider manual.

History

• Adopted effective January 31, 2008; Amended March 11, 2013

Regs., Conn. State Agencies § 17b-262-346 Payment

(a) Fees shall be the same for in-state, border and out-of-state providers.

(b) Payment shall be made at the lowest of:

(1) The billing provider’s usual and customary charge;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department pursuant to section 4-67c of the Connecticut General Statutes; or

(4) the amount billed by the billing provider.

(c) Notwithstanding the provisions of the Regulations of Connecticut State Agencies or any provisions of the department’s Medical Services Policy, the department shall not pay any billing provider under sections 17b-262-337 to 17b-262-349, inclusive, of the Regulations of Connecticut State Agencies for a client seen at a freestanding clinic enrolled in Medicaid. Only the clinic may bill for such services, except that (1) a provider may bill for covered services for a client seen at an outpatient dialysis clinic or at an outpatient surgical facility and (2) a billing provider enrolled with Medicaid at a location separate from the clinic may bill the department for clients seen at the separate practice location.

(d) The department shall not pay interns or residents for their services, nor shall the department pay for assistant surgeons in general hospitals or chronic disease hospitals staffed by interns and residents, unless the procedure is sufficiently complicated that it is medically necessary for a full surgeon to act as an assistant, such as for open heart surgery. If the resident or intern performs the surgery and the supervising surgeon assists, the department shall pay only the assistant’s fee to the surgeon and shall not pay the regular surgical fee.

(e) If a resident or intern performs the surgery and the supervising surgeon is not present while the procedure is performed, the department shall not pay any fee to the surgeon even if the surgeon was on call during the surgery.

(f) When an AHP provides physicians’ services, the department shall pay the billing provider that employs or is affiliated with the AHP for such services at the rates applicable to the AHP’s provider type, including any percentage adjustment to the physician fee schedule for the AHP’s provider type.

History

• Adopted effective January 31, 2008; Amended March 11, 2013

Regs., Conn. State Agencies § 17b-262-347 Payment rate

The department shall establish and may periodically update the fees for covered physicians’ services in the department’s fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

History

• Adopted effective January 31, 2008; Amended March 11, 2013

Regs., Conn. State Agencies § 17b-262-348 Payment limitations

(a) The department shall pay only for physicians’ services performed by or under the personal supervision of a physician.

(b) The department shall pay the fee for an initial visit by a provider in an office, home, ICF/IID or nursing facility only once per client. Initial visits refer to the provider’s first contact with the client and reflect high fees for the additional time required for setting up records and developing past history. The only exception to this is when the provider-client relationship has been discontinued for three or more years and is then reinstated.

(c) The department shall pay non-hospital-based providers for evaluation and management services provided to the provider’s private practice clients in the emergency room.

(d) The department shall pay fees to a consultant provider only when another provider or other appropriate referral source requests the opinions and advice of the consultant provider. The consultant provider shall document such provider’s opinion and any services ordered or performed by the consulting provider in the client’s medical record and submit a written report describing such opinion and services to the requesting physician or other appropriate referral source. The referring provider remains responsible for carrying out the plan of care after seeking a consultation.

(e) If a client is referred to a provider for treatment of a condition that the referring provider does not usually treat, the department shall pay the treating provider the fee for an office visit rather than the fee for a consultation.

(f) When the consultant provider assumes the continuing care of the client, the department shall pay the consultant provider for any subsequent service according to the fee listed for the procedure.

(g) If a client’s medical condition necessitates the concurrent services and skills of two or more providers, the department shall pay each provider the listed fee for the service that each provider provides.

(h) When a provider examines a Medicaid applicant for the purpose of substantiating whether a medical condition exists that would enable the department to determine eligibility for Medicaid disability, the department shall pay the billing provider only for the tests required to establish eligibility as requested by the department. The department shall not pay the billing provider for any other procedures.

(i) Surgery

(1) When a billing provider submits a claim for multiple surgical procedures performed on the same date, the department shall pay the listed fee for the primary surgical procedure. THE department shall pay for additional surgical procedures performed on that day at 50% of the listed fee.

(2) When an assistant surgeon, in addition to staff provided by the general hospital or chronic disease hospital, is required, the department shall pay the assistant surgeon 20% of the listed fee for the surgery.

(3) The department shall not pay for related evaluation and management encounters on the same day of surgery.

(4) The listed fees for all surgical procedures include the surgery and typical postoperative follow-up care provided to clients in a general hospital or chronic disease hospital. The department shall pay for follow-up visits after a client is discharged from the general hospital or chronic disease hospital as office visits.

(5) The listed fees for surgery on the musculoskeletal system includes payment for the application of the first cast or traction device.

(j) Anesthesia

(1) The listed fees for anesthesia services include pre- and post-operative visits, the administration of the anesthetic and the administration of fluids and blood incident to the anesthesia or surgery.

(2) The department shall pay the listed fees for anesthesia services only when the anesthesia is administered by or under the supervision of a provider who remains in constant attendance during the procedure for the sole purpose of rendering anesthesia services.

(3) The department shall not pay for local infiltration or digital block administered by the operating surgeon.

(k) Radiology

(1) The listed fees for all diagnostic radiology procedures, including nuclear medicine, magnetic resonance imaging, computerized axial tomography and diagnostic ultrasound, include consultation and a written report to the referring provider.

(2) The listed fees for all diagnostic radiology procedures shall apply only when the provider’s own equipment is used. If a general hospital or chronic disease hospital or a related entity directly or indirectly owns the equipment used to perform the procedure, or if a hospital includes the operating expenses of the equipment in its cost reports, the department shall not pay the billing provider for the technical component of the listed fee.

(l) Radiotherapy

(1) The provider fee for radiological treatment includes one year of follow-up care unless otherwise specified.

(2) The provider fee for treatment includes the concomitant office visits, but does not include surgical, radiological or laboratory procedures performed on the same day.

(3) The fees listed for therapeutic procedures involving the use of radium and radioisotopes do not include the radioactive drug used or preliminary and follow-up diagnostic tests. Radioactive drugs may be billed separately.

(4) The fees listed for diagnostic procedures involving the use of radium and radioisotopes do not include the radioactive drugs used. Radioactive drugs may be billed separately.

(m) Laboratory

(1) The following routine laboratory tests shall be included in the physician fee for an office visit and shall not be billed on the same date of service: urinalysis without microscopy, hemoglobin determination and urine glucose determination.

(2) The department shall not pay for tests provided free of charge.

(3) The department shall pay for panel or profile tests according to the listed fees for panel tests and not according to the fee for each separate test included in the panel or profile.

(4) The department shall pay only for laboratory physicians’ services that the provider is authorized to perform and are performed in the provider’s office. The department shall not pay the referring provider for laboratory services performed in a laboratory or in any setting other than the provider’s office.

(n) Drugs

(1) The department shall pay up to the actual acquisition costs for oral medications incident to an office visit as billed by the provider.

(2) The department shall pay for injectables, legend drugs and legend devices administered by the provider based on a fee schedule determined by the department.

(3) The department shall not pay for drugs provided free of charge.

(o) Newborn Care

(1) The provider fee for routine care of a normal newborn infant in the general hospital includes history and examination of the infant, initiation of diagnostic and treatment programs, preparation of hospital records, history and physical examination of the baby and conferences with the parents. The department pays per day for subsequent hospital care for evaluation and management of a normal newborn.

(2) When a newborn requires other than routine care following delivery, the provider shall bill for the appropriate critical care. The department shall not pay both the critical care and the routine or subsequent newborn care for the same child.

(3) The provider may bill for newborn resuscitation in addition to billing for routine care or critical care of a newborn.

(p) Payment for assessments and subsequent care for clients in a nursing facility, ICF/IID or chronic disease hospital

(1) The department shall pay providers for evaluation and management only when performed in a nursing facility, ICF/IID or chronic disease hospital.

(2) The department shall pay for a maximum of one annual assessment per client per year.

(q) Admission to a General Hospital

If the department determines either prospectively or retrospectively pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies, that a general hospital admission was not medically necessary or did not fulfill the accepted professional criteria for appropriateness of setting or quality of care, the department shall not pay for the admitting provider’s services in a general hospital.

(r) Family planning, abortion and hysterectomy

(1) The department shall pay the provider for sterilization only if the client is at least age 21 and has given informed consent in accordance with 42 CFR 441.257 and 42 CFR 441.258, as amended from time to time.

(2) The department shall pay for hysterectomies and related laboratory and hospital services that are medically necessary only if the client is at least age 21 and the physician or physician’s representative has obtained:

(A) A consent form that complies with 42 CFR 441.257 and 42 CFR 441.258, as amended from time to time, or

(B) a physician’s certification that complies with 42 CFR 441.255(d), as amended from time to time.

(3) The department shall pay the billing provider for all abortions that a physician certifies as medically necessary whether or not the woman’s life would be endangered by carrying the fetus to term and whether or not the pregnancy is the result of rape or incest. For the purposes of abortion coverage and payment, a physician determines medical necessity.

(4) The provider shall maintain all forms required by section 19a-116-1 of the Regulations of Connecticut State Agencies and section 19a-601 of the Connecticut General Statutes.

(s) Maternity Bundled Payment. This subsection sets forth the rules for bundle payment methodology for maternity care to improve maternal health and birth outcomes and, to the extent applicable, includes payment to the billing provider for the services of certified doulas, lactation consultants, community health workers and any other non-licensed provider included in the bundle payment methodology.

(1) General Provisions for Maternity Bundled Payment.

(A) The department may pay for maternity services using monthly case rate payments for certain services included in the maternity bundle episode, as defined under the Medicaid State Plan, for services across all phases of the perinatal period (including prenatal, labor and delivery, and postpartum), which focuses on the accountability and quality of care for providers.

(B) The department may provide incentive payments to maternity providers, as identified in subparagraph (C) of this subdivision, who deliver high-quality, cost-effective services throughout the episode. Providers shall be eligible for incentive payments when: (i) the provider’s target price, which is the expected total cost of care for a bundle based on the statewide average cost and the provider’s historical cost, is not exceeded, (ii) the provider meets quality performance criteria, and (iii) the provider complies with the department’s goals to monitor and prevent under-service, such as risk-based patient selection as well as decreased utilization of services.

(C) This subsection shall apply to the following performing providers: Physicians, advanced practice registered nurses, physician assistants, and nurse-midwives with obstetrician-gynecology board certification or equivalent credential and expertise in maternity services.

(2) Provider Participation Requirements for Maternity Bundled Payment.

(A) All qualified maternity provider practices meeting the qualifications in subdivision (1) of this subsection shall participate in the bundle payment methodology.

(B) Providers who do not meet the minimum episode volume threshold, as set by the department, shall not be eligible to participate in the bundle payment methodology and shall be reimbursed fee-for-service (FFS) with no opportunity to earn incentive payments.

(3) Case Rate Payments for Maternity Bundled Payment.

(A) The department’s bundle accountability methodology shall determine the accountable provider.

(B) Prior to the establishment of bundle accountability, the department shall pay all maternity claims on an FFS basis.

(C) After the establishment of bundle accountability, the department shall pay a monthly case rate to the accountable provider for a subset of services, as outlined under the Medicaid State Plan. All other covered services not included in the monthly case rate shall be paid FFS.

(D) In accordance with the Medicaid State Plan, the case rate payment amount shall be based on the maternity provider’s historical cost, and the case rate shall be reassessed not more frequently than once every twelve months.

(E) Payment to the maternity provider practice meeting the qualifications in subdivision (1) of this subsection may also include payment for services provided by non-licensed professionals as designated by the department, including, but not limited to, certified doulas, community health workers, and lactation consultants.

(F) The bundled payment shall not change any reimbursement methodology for any provider other than as described in this subsection.

(4) Incentive Payments for Maternity Bundled Payment.

(A) Providers meeting the qualifications in subdivision (1) of this subsection shall be eligible to receive incentive payments in accordance with the applicable bundled payment methodology. The accountable provider meeting the qualifications in subdivision (1) of this subsection shall be eligible to earn incentive payments but shall not be subject to returning any portion of increased program expenditures accountable to the provider.

(B) Except for exclusions listed under the Medicaid State Plan, all Medicaid claim costs for covered services related to maternity care shall be included in the incentive payment calculations of the bundle. The incentive payment calculation shall be based on the difference between the expected costs and the actual costs of all applicable covered services provided to the birthing member, regardless of the specific maternity provider who performed each service.

(C) The distribution of incentive payments for savings for Medicaid shall be adjusted based upon the accountable provider’s performance of the quality measures established by the department. The distribution of incentive payments shall also be subject to clinical and social risk adjustment.

(D) Not later than fifteen months after each performance year, the department shall provide each accountable provider with a written description of the accountable provider’s results regarding performance on quality measures, applicable Medicaid expenditures for maternity bundled payment members assigned to the accountable provider and calculation of incentive payments, as applicable, for said members. After receiving said description from the department, the accountable provider may respond to any calculations, results, or decisions contained therein. Such response shall be in writing, be received by the department not later than thirty days after the accountable provider receives the written description from the department and include all supporting documentation. The department shall issue a written decision not later than thirty days after receiving the accountable provider’s response. There shall be no further right to review the department’s decisions regarding the written description described in this subparagraph, other than as described in this subparagraph. There shall be no right to review the final distribution of incentive payments for the maternity bundled payment.

History

• Adopted effective January 31, 2008; Amended March 11, 2013; Amended December 24, 2025

Regs., Conn. State Agencies § 17b-262-349 Documentation and audit requirements

(a) Providers shall maintain a specific record for all services provided to each client including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, treatment notes signed by the provider, documentation of services provided and the dates the services were provided.

(b) The provider shall maintain all required documentation in its original form for at least five years or longer in accordance with statute or regulation, subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the provider shall maintain the documentation until the end of the dispute, five years or the length of time required by statute or regulation, whichever is longest.

(c) The department may disallow and recover any amounts paid to the provider for which the required documentation is not maintained and not provided to the department upon request.

(d) The department may audit all relevant records and documentation and may take any other appropriate quality assurance measures it deems necessary to assure compliance with all regulatory and statutory requirements.

(e) If the provider bills for a service based on the time spent during the encounter, the provider shall document the length of the encounter.

History

• Adopted effective January 31, 2008; Amended March 11, 2013

Regs., Conn. State Agencies § 17b-262-350—17b-262-439 Reserved

Sec. 17b-262-350—17b-262-439. Reserved

Regs., Conn. State Agencies § 17b-262-440—17b-262-449 (Repealed)

Repealed January 31, 2008.

Regs., Conn. State Agencies § 17b-262-450—17b-262-451 Reserved

Sec. 17b-262-450—17b-262-451. Reserved

Regs., Conn. State Agencies § 17b-262-452 Scope

Sections 17b-262-452 through 17b-262-463 inclusive set forth the Department of Social Services requirements for payment of: (a) medical and clinical services provided by licensed psychiatrists in private or group practice, and (b) clinical procedures performed by allied health professionals in the employ of the psychiatrist in private or group practice for clients who are determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-453 Definitions

For the purposes of sections 17b-262-452 through 17b-262-463 the following definitions shall apply:

(1) "Acute" means having rapid onset, severe symptoms, and a short course.

(2) "Acute Care" means medical care needed for an illness, episode, or injury which requires short-term, intense care, and hospitalization for a short period of time.

(3) "Allied Health Professional (AHP)" means a professional or paraprofessional individual who is qualified by special training, education, skills, and experience in mental health care and treatment and shall include, but is not limited to: psychologists, social workers, psychiatric nurses, and other qualified therapists.

(4) "By or Under the Supervision" means the psychiatrist shall assume professional responsibility for the service performed by the allied health professional, overseeing or participating in the work of the allied health professional including, but not limited to:

(A) availability of the psychiatrist to the allied health professional in person and within five minutes;

(B) availability of the psychiatrist on a regularly scheduled basis to review the practice, charts, and records of the allied health professional and to support the allied health professional in the performance of services; and

(C) a predetermined plan for emergency situations, including the designation of an alternate psychiatrist in the absence of the regular psychiatrist.

(5) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.

(6) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.

(7) "Consultation" means those services rendered by a psychiatrist whose opinion or advice is requested by another physician or an agency in the evaluation and treatment of a client's illness.

(8) "Department" means the Department of Social Services or its agent.

(9) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(10) "Estimated Acquisition Cost (EAC)" means the department's best estimate of the price generally and currently paid by providers for a drug marketed or sold by a particular manufacturer.

(11) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.

(12) "HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with subdivision (5) of subsection (r) of section 1905 of the Social Security Act, and are:

(A) services not covered under the State Plan or contained in a fee schedule published by the department; or

(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.

(13) "Home" means the client's place of residence which includes a boarding home or home for the aged. Home does not include a hospital or long-term care facility; long-term care facility includes a nursing facility, chronic disease hospital, and intermediate care facility for the mentally retarded (ICF/MR).

(14) "Interperiodic Encounter" means any medically necessary visit to a Connecticut Medical Assistance provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(15) "Legend Drug" means the definition contained in section 20-571 of the Connecticut General Statutes.

(16) "Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(17) "Long-Term Care Facility" means a medical institution which provides, at a minimum, skilled nursing services or nursing supervision and assistance with personal care on a daily basis. Long-term care facilities include:

(A) nursing facilities,

(B) chronic disease hospitals—inpatient, and

(C) intermediate care facilities for the mentally retarded (ICFs/MR).

(18) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(19) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes (CGS) and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(20) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring.

(21) "Medical Record" means the definition contained in section 19a-14-40 of the Regulations of Connecticut State Agencies, which is part of the Public Health Code.

(22) "Prior Authorization" means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods.

(23) "Provider" means a psychiatrist.

(24) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(25) "Psychiatric Services" means services provided to individuals, groups, and families, by or under the supervision of a licensed psychiatrist in private or group practice. In such a setting the psychiatrist retains the primary medical and clinical responsibility for work up of the initial evaluation, diagnosis, and prescription of the treatment plan, rehabilitation, and discharge of the client. Such services include the diagnosis of specific mental and social problems which disrupt an individual's daily functioning and provide treatment to reduce the symptoms and signs associated with these disturbances.

(26) "Psychiatrist" means a physician licensed pursuant to section 20-10 of the Connecticut General Statutes who specializes in the study, diagnosis, treatment, and prevention of mental and social disorders.

(27) "State Plan" means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with Part 430, Subpart B, of Title 42 of the Code of Federal Regulations (CFR).

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-454 Provider participation

In order to enroll in the Medical Assistance Program and receive payment from the department, providers shall:

(a) meet and maintain all applicable licensing, accreditation, and certification requirements;

(b) meet and maintain all departmental enrollment requirements; and

(c) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-455 Eligibility

Payment for psychiatrists' services shall be available on behalf of all persons eligible for the Medical Assistance Program subject to the conditions and limitations which apply to these services.

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-456 Services covered and limitations

Except for the limitations and exclusions listed below, the department shall pay for the professional services of a licensed psychiatrist which conform to accepted methods of diagnosis and treatment, but shall not pay for anything of an unproven, educational, social, research, experimental, or cosmetic nature; for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history.

(a) The department shall pay for:

(1) psychiatric evaluation;

(2) psychotherapy, including: individual, group, family, hypnosis, and electroshock;

(3) psychiatric consultation;

(4) drugs, as limited in subsection (b) of section 17b-262-456;

(5) all admitting and inpatient services performed by the admitting psychiatrist in an acute care hospital after the psychiatrist has received prior authorization for the admission pursuant to the department's utilization review program as delineated in section 17-134d-80 of the Regulations of Connecticut State Agencies; and

(6) HealthTrack Services and HealthTrack Special Services.

(b) Limitations on covered services shall be as follows:

(1) a psychiatric evaluation shall be limited to one evaluation in any twelve month period per client per provider;

(2) only one unit of therapy of the same type shall be paid for on the same day:

(3) group psychiatric sessions shall be limited in size to a maximum of eight persons per group session regardless of the payment source of each participant;

(4) services covered shall be limited to those listed in the department's applicable fee schedule; and

(5) hypnosis and electroshock therapy shall be personally provided by a psychiatrist.

(c) Services Not Covered

The department shall not pay for the following psychiatric services:

(1) Information or services furnished by the provider to the client over the telephone;

(2) Concurrent services for the same client involving the same services or procedure;

(3) Office visits to obtain a prescription, the need for which has already been ascertained; and

(4) Cancelled office visits or appointments not kept.

History

• Adopted effective May 11, 1998; Amended April 2, 2015

Regs., Conn. State Agencies § 17b-262-457 Need for service

The department shall pay for medically necessary and medically appropriate psychiatric services for Medical Assistance Program eligible clients which are provided by a licensed physician who specializes in the study, diagnosis, treatment, and prevention of mental and social diseases.

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-458 Prior authorization

(a) Prior authorization, on forms and in a manner as specified by the department, is required for all clients, including clients originally referred by another state agency for:

(1) treatment services in excess of thirteen visits in a calendar quarter;

(2) treatment services to hospitalized clients from the date of admission; and

(3) HealthTrack Special Services. HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis. The request for HealthTrack Special Services shall include:

(i) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service requested;

(ii) a description of the outcomes of any alternative measures tried; and

(iii) if applicable and requested by the department, any other documentation required in order to render a decision.

(b) The procedure or course of treatment authorized shall be initiated within six months of the date of authorization. The form shall include the progress made to date and the future gains expected through additional treatment.

(c) Initial authorization for outpatient services shall be up to six months.

(d) Initial authorization for hospital inpatient services shall be authorized for up to forty-two days from the date of initial admission for a specific episode of illness.

(e) Requests for continued treatment beyond the initial authorized period shall be submitted prior to the onset of services for which authorization is requested. The form shall include the progress made to date and the future gains expected through additional treatment.

(f) Outpatient services beyond the initial authorized period shall be extended up to six months.

(g) One extension of hospital inpatient services for the same episode of illness shall be allowed up to an additional twenty one days unless the client requires hospitalization for a concurrent medical problem.

(h) Clients who require hospitalization for a concurrent medical problem shall receive hospital inpatient psychiatric services until hospital inpatient treatment for the concurrent medical problem is no longer necessary.

(i) The authorization request form shall include the name of the physician, person, or agency making the referral.

(j) In emergency or urgent situations involving services which require prior authorization, the provider of the service may request verbal approval by the department during normal working hours, or no later than the next business day if the emergency or urgent situation occurs outside of the department's normal working hours, when such authorization may be given. However, approval in such a manner shall be limited to psychiatric services that are immediately necessary and vital to the health and safety of the client.

(k) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-459 Billing procedures

(a) Claims from psychiatrists shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) The amount billed to the department shall represent the psychiatrist's usual and customary charge for the services delivered.

(c) When a Medical Assistance Program client is referred to a psychiatrist for consultation, the consultant psychiatrist shall include the referring practitioner's provider number and name. If no provider number has been assigned, the consultant psychiatrist shall enter the entire name as well as the state license number of the referring physician on the billing form.

(d) Psychiatric consultations in the hospital, home, or long-term care facility shall be billed as a comprehensive consultation.

(e) All charges billed for supplies and materials provided by a psychiatrist, except glasses, shall be reviewed by the department.

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-460 Payment

(a) Payment shall be made at the lowest of:

(1) the provider's usual and customary charge to the general public;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount billed by the provider; or

(5) the lowest price charged or accepted for the same of substantially similar goods or services by the provider from any person or entity.

(b) A psychiatrist who is fully or partially salaried by a general hospital, public or private institution, physicians' group, or clinic shall not receive payment from the department unless the psychiatrist maintains an office for private practice at a location separate from the hospital, institution, physicians' group, or clinic in which the psychiatrist is employed. Psychiatrists who are solely hospital, institution, physicians' group, or clinic-based, either on a full- or part-time salary are not entitled to payment from the department for services rendered to Medical Assistance Program clients.

(c) A psychiatrist who maintains an office for private practice separate from the hospital, institution, physicians' group, or clinic shall be able to bill for services provided at the private practice location or for services provided to the psychiatrist's private practice clients in the hospital, institution, physicians' group, or clinic only if the client is not a patient of the hospital, institution, physicians' group, or clinic.

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-461 Payment rate

The commissioner establishes the fees contained in the psychiatrists' and allied health professionals' fee schedules pursuant to section 4-67c of the Connecticut General Statutes.

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-462 Payment limitations

(a) Psychiatrists' services shall be performed at the psychiatrist's private or group practice location, hospital, long-term care facility, clinic, or the client's home.

(b) The psychiatrist who employs allied health professionals shall personally conduct the evaluation and, accordingly, develop the treatment plan in all cases.

(c) In situations where the psychiatrist employs allied health professionals on a salary or fee-for-service basis, the psychiatrist shall be paid at the psychiatrists' rate only under the following conditions:

(1) for clients personally being treated by the psychiatrist; and

(2) when the psychiatrist personally interviews the client as part of the psychiatrist's supervisory responsibilities, but only at that rate which corresponds to the time or service he or she actually provides to the client.

(d) Services provided by allied health professionals shall be billed at the rate for allied health professionals established by the department and not at the scheduled rate for psychiatrists.

(e) Fees for psychiatric evaluations include an allowance for the preparation of a full written report.

(f) When a psychiatrist renders consultation services and thereafter assumes the continuing care of the client, any subsequent services rendered by the psychiatrist or the psychiatrist's staff shall no longer be considered as a consultation and shall be billed at the rate applicable for the ongoing service.

(g) The fee for any procedure, as stipulated in the fee schedule for psychiatric services published by the department, represents the maximum amount payable per day regardless of the time it takes to complete the procedure.

(h) Payment for hospital inpatient services shall be limited to admissions to acute care hospitals.

(i) Payment for services provided by the admitting psychiatrist in an acute care hospital shall not be made, or shall be recouped, if it is determined by the department's utilization review program, either prospectively or retrospectively, that the admission did not fulfill the accepted professional criteria for medical necessity, medical appropriateness, appropriateness of setting, or quality of care.

(j) The department shall pay psychiatrists for drugs which are administered or dispensed directly to a client under the following conditions:

(1) excluding oral medications, payment shall be made to a psychiatrist for the estimated acquisition cost as determined by the department for drugs which are administered directly to the client; and

(2) for legend drugs which must be administered by a psychiatrist, the department shall reimburse the psychiatrist for the estimated acquisition cost as determined by the department for the amount of the drug which is administered.

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-463 Documentation

(a) Psychiatrists shall maintain a specific record for all services received for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, a current treatment plan signed by the psychiatrist, documentation of services provided, and the dates the services were provided.

(b) All required documentation shall be maintained for at least five years in the psychiatrist's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the psychiatrist for which the required documentation is not maintained or provided to the department upon request.

History

• Adopted effective May 11, 1998

Regs., Conn. State Agencies § 17b-262-464—17b-262-466 Reserved

Sec. 17b-262-464—17b-262-466. Reserved

Regs., Conn. State Agencies § 17b-262-467 Scope

Psychologists' services provide professional therapeutic intervention relating to mental, emotional, and social problems involving individuals or groups, taking into consideration the sum of actions, traits, attitudes, thoughts, and mental state of an individual. Sections 17b-262-467 through 17b-262-478 inclusive set forth the Department of Social Services requirements for payment of accepted methods of treatment by licensed psychologists for clients who are determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-468 Definitions

For the purposes of sections 17b-262-467 through 17b-262-478 the following definitions shall apply:

(1) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.

(2) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.

(3) "Department" means the Department of Social Services or its agent.

(4) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.

(5) "HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with subdivision (5) of subsection (r) of section 1905 of the Social Security Act, and are:

(A) services not covered under the State Plan or contained in a fee schedule published by the department; or

(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.

(6) "Interperiodic Encounter" means any medically necessary visit to a Connecticut Medical Assistance provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(7) "Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(8) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(9) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes (CGS) and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(10) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring.

(11) "Prior Authorization" means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods.

(12) "Provider" means a psychologist.

(13) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(14) "Psychologist" means a health professional, licensed by the Board of Examiners of Psychologists of Connecticut pursuant to section 20-186 and under Chapter 383 of the Connecticut General Statutes, who is engaged in private practice and has clinical training and experience approved by the department to provide psychological services to clients eligible under Connecticut's Medical Assistance Program.

(15) "Psychologists' Services" that are permitted means clinical, diagnostic, and remedial services personally performed by a psychologist. Services include:

(A) counseling and psychotherapy to individuals who are experiencing problems of a mental or behavioral nature; and

(B) measuring and testing of personality, aptitudes, emotions, and attitudes.

(16) "Qualified Neuropsychologist" means a psychologist who:

(A) documents completion of a Ph.D. or Psy.D. degree in clinical psychology from a program approved by the American Psychological Association with extensive pre- or post-doctoral coursework in basic neurosciences, neuroanatomy, neuropathol-ogy, clinical neurology, psychological assessment, clinical neuropsychological assessment, psychopathology and psychological intervention; and either

(B) has completed one year of full-time supervised clinical neuropsychological experience at the post-doctoral level and at least one year of independent professional experience as a clinical neuropsychologist, or, in lieu of (B), has

(C) the equivalent of three years of unsupervised post-doctoral experience as a clinical neuropsychologist within the past ten years.

(17) "Neuropsychological Evaluation" means a full battery of tests used to develop a diagnosis. The evaluation is the sum of all the testing and diagnostic interview sessions. The components of the neuropsychological evaluation are: patient history; assessment of perceptual motor functions; language functions; attention; memory, learning, intellectual processes and level; and emotional, behavioral, and personality functioning. The evaluation must be accomplished by means of appropriate psychological procedures administered by a qualified neuropsychologist.

(18) "State Plan" means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with Part 430, Subpart B, of Title 42 of the Code of Federal Regulations (CFR).

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-469 Provider participation

In order to enroll in the Medical Assistance Program and receive payment from the department, providers shall:

(a) meet and maintain all applicable licensing, accreditation, and certification requirements;

(b) meet and maintain all departmental enrollment requirements; and

(c) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-470 Eligibility

Payment for psychologists' services shall be available on behalf of all persons eligible for the Medical Assistance Program subject to the conditions and limitations which apply to these services.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-471 Services covered and limitations

Except for the limitations and exclusions listed below, the department shall pay for the professional services of a licensed psychologist which conform to accepted methods of diagnosis and treatment, but shall not pay for anything of an unproven, educational, social, research, experimental, or cosmetic nature; for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history.

(a) The department shall pay for the following psychological services:

(1) Psychodiagnostic Evaluations

(A) Intellectual Evaluation - Individual

Evaluation of intellectual functioning by means of appropriate psychological procedures, such as the Wechsler Adult Intelligence Scale, Wechsler Intelligence Scale for Children, and Stanford-Binet Intelligence Scale;

(B) Scholastic Achievement or Group Intelligence

(i) Scholastic Achievement: Determination of acquired abilities in areas of educational achievement through the administration and evaluation of tests, California Reading Test, and Wide Range Achievement Test; and

(ii) Group Intellectual Evaluation: Determination of intellectual functioning by means of group intelligence tests such as the Lorge-Thorndike Intelligence Test, Otis Quick-Scoring Mental Ability Test, and California Short-Form Test of Mental Maturity;

(C) Personality Diagnosis and Evaluation

Study of personality dynamics, interpersonal relations, emotional adjustment, and stability, through the utilization of psychological procedures such as Rorschach, MMPI, Thematic Apperception Test, Children's Apperception Test, and Figure-Drawing;

(D) Evaluation of Organic Brain Involvement: Organicity

Assessment of functions requiring memory, concept formation, visual motor skills, by means of psychological procedures such as the Wechsler Memory Scale, Goldstein-Scheerer Battery Graham-Kendall Memory for Designs, and Bender Visual Motor Gestalt Test;

(E) Evaluation of Aptitudes, Interests, and Educational Adjustment

Assessment of vocational aptitudes and interests and educational achievement by means of such procedures as manipulation tests of dexterity and coordination, vocational aptitude tests, interest tests, and achievement tests; and

(F) Neuropsychological Evaluation

Assessment of perceptual or motor functions; attention; memory; and learning; intellectual processes; and emotion, behavior, and personality by means of appropriate psychological procedures administered by a qualified neuropsychologist, such as the Wechsler Adult Intelligence Scale, the Wide Range Achievement Test, the Wechsler Memory Scale, the Luria Nebraska Neuropsychological Battery, and the Halstead-Reitan Neuropsychological Battery.

(2) Counseling and Psychotherapy

(A) Diagnostic Interview

Initial contact, review of available records, and personal interview with subject. Applicable only when formal testing is not possible;

(B) Individual Counseling or Psychotherapy; and

(C) Group Counseling or Psychotherapy.

(3) Staff Consultation

Attendance at staff conferences to present and to discuss psychological findings in planning for the individual; and

(4) HealthTrack Services and HealthTrack Special Services.

(b) Limitations on covered services shall be as follows:

(1) a diagnostic interview or psychodiagnostic evaluation procedure is limited to one of each in any twelve month period per psychologist for the same client;

(2) only one unit of individual counseling or psychotherapy and one unit of group counseling or psychotherapy shall be paid for on the same day;

(3) the department shall not pay for more than one psychodiagnostic evaluation in any twelve month period when performed by the same psychologist for the same client;

(4) group psychotherapy sessions shall be limited in size to a maximum of eight persons per group session regardless of the payment source of each participant;

(5) only two staff consultations, as described in subdivision (3) of subsection (a) of section 17b-262-471, shall be allowed per year per client per psychologist; and

(6) services covered are limited to those listed in the department's published fee schedule.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-472 Services not covered

The department shall not pay for the following psychological services:

(a) information or services furnished by the psychologist to the client over the telephone;

(b) all evaluations, diagnostic interviews, and therapy services performed in hospital inpatient or outpatient settings;

(c) concurrent services involving similar treatment modalities for the same client by different health professionals;

(d) cancelled office visits or for appointments not kept; and

(e) psychological services which are primarily for vocational or educational guidance.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-473 Need for service and authorization process

(a) Need for Service

The department shall pay for psychological services which are provided by a licensed psychologist and are medically necessary and medically appropriate for the prevention, diagnosis, and treatment of intellectual functioning and mental illness.

(b) Prior Authorization

(1) Prior authorization, on forms and in a manner as specified by the department, is required for:

(A) all clients for all counseling and psychotherapy interviews in excess of thirteen visits in a calendar quarter, per type of treatment for the same provider and client; and

(B) HealthTrack Special Services. HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis. The request for HealthTrack Special Services shall include:

(i) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service requested;

(ii) a description of the outcomes of any alternative measures tried; and

(iii) if applicable and requested by the department, any other documentation required in order to render a decision.

(2) For services requiring prior authorization, the procedure or course of treatment shall be initiated within six months of the date of authorization.

(3) The initial authorization period shall be up to three months.

(4) All authorization request forms shall include an explanation of the need for additional treatment for services in excess of the limitations described in subparagraph (A) of subdivision (1) of subsection (b) of section 17b-262-473, and the future gains expected.

(5) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorized period shall be considered for up to six months per request.

(6) The provider shall determine as soon as possible whether the number of service visits necessary shall exceed thirteen visits in a calendar quarter. If the number of visits shall exceed the limit, authorization shall be obtained from the department prior to the onset of the service visits for which authorization is needed.

(7) The authorization request form shall include the name of the physician, person, or agency making the referral.

(8) In urgent situations involving services which require prior authorization, the provider of service may request verbal approval by the department during normal working hours, or no later than the next business day if the urgent situation occurs outside of the department's normal working hours, when such authorization may be given. However, approval in such a manner shall be limited to psychological services that are immediately necessary and vital to the health and safety of the client.

(9) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-474 Billing procedures

(a) Claims from psychologists shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) The amount billed to the department shall represent the psychologist's usual and customary charge for the services delivered.

(c) Claims submitted for services not requiring prior authorization shall include the name of the physician, person, or agency making the referral—if there was a referral.

(d) When a psychologist is requested to attend a staff conference for a Medical Assistance Program client, the name of the referring practitioner, clinic, or agency shall be entered in the appropriate section of the claim form.

(e) Neuropsychological evaluations shall be billed as one unit regardless of the number of sessions.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-475 Payment

(a) Psychologists who are fully or partially salaried by a general hospital, public or private institution, group practice, or clinic shall not receive payment from the department unless the psychologist maintains an office for private practice at a separate location from the hospital, institution, or clinic in which the psychologist is employed and bills for a service provided to the psychologist's private practice client at the psychologist's private practice location only.

(b) Payment for services directly performed by a psychologist in private practice shall be made at the lowest of:

(1) the provider's usual and customary charge to the general public;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount billed by the provider; or

(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-476 Payment rate

The commissioner establishes the fees contained in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-477 Payment limitations

(a) The psychologist's interview of the client's family during the course of treatment in the psychologist's office shall be paid at the rate for individual therapy regardless of the number of persons in attendance.

(b) The fees for evaluative and treatment services, as stipulated in the psychologist's fee schedule, represent one unit of service, and only one unit shall be billed per day per service regardless of the number of days to complete the unit billed.

(c) The department shall not reimburse the psychologist for services performed by allied health professionals or paraprofessionals who are in the employ of the psychologist. The psychologist shall be paid for services only to the clients personally being treated by the psychologist.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-478 Documentation

(a) Psychologists shall maintain a specific record for all services received for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, a current treatment plan signed by the psychologist, documentation of services provided, and the dates the services were provided.

(b) The evaluation report for psychodiagnostic tests, including the Aptitudes, Interests, and Education Adjustment Evaluation, shall be on file with the psychologist to justify medical necessity and medical appropriateness of treatment.

(c) All required documentation shall be maintained for at least five years in the psychologist's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(d) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the psychologist for which the required documentation is not maintained and provided to the department upon request.

History

• Effective June 8, 1998

Regs., Conn. State Agencies § 17b-262-479—17b-262-492 Reserved

Sec. 17b-262-479—17b-262-492. Reserved

Regs., Conn. State Agencies § 17b-262-493 Scope

Sections 17b-262-493 to 17b-262-498 inclusive, set forth the copayment requirements for clients who are eligible to receive prescription drugs, over-the-counter drugs, or refills covered under the Medicaid, General Assistance and State Administered General Assistance Programs and furnished by a pharmacy provider enrolled in the Connecticut Medical Assistance Program pursuant to section 17b-259a and section 17b-262 of the Connecticut General Statutes and subject to the exclusions as set forth in section 17b-262-496.

History

• Adopted effective November 13, 1997

Regs., Conn. State Agencies § 17b-262-494 Definitions

For the purposes of sections 17b-262-493 to 17b-262-498 inclusive, the following definitions shall apply:

(1) "Client" means a person eligible for services under the department's Medical Assistance Program.

(2) "Compounded Prescriptions" means two or more drugs mixed together in which at least one ingredient is a legend drug. A compounded prescription shall include the name, strength, and amount of each prescribed ingredient.

(3) "Copayment" means the set portion of the department's fee for prescription drugs, over-the-counter drugs, or refills which shall be the responsibility of the client to pay to the pharmacy provider for such services furnished to the client.

(4) "Department" means the department of social services.

(5) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319V of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(6) "Pharmacy" means a facility licensed by the Commission of Pharmacy in the Department of Consumer Protection under Section 20-594 of the Connecticut General Statutes or by the appropriate regulatory body of the state in which it is located.

(7) "Provider" means any individual or entity enrolled in the department's Medical Assistance Program and performing within the scope of his or her practice under state law and capable of furnishing services or goods to Medical Assistance clients under the terms of a provider agreement with the department.

(8) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

History

• Adopted effective November 13, 1997

Regs., Conn. State Agencies § 17b-262-495 Services requiring a copayment

Except for the exclusions specified in section 17b-262-496 below, a copayment shall be imposed on each prescription, over-the-counter drug, or refill which is furnished to a client and covered in the department's fee schedule for pharmacy providers.

History

• Adopted effective November 13, 1997

Regs., Conn. State Agencies § 17b-262-496 Copayment exclusions

The following list contains those clients and services not subject to a copayment:

(a) The categories of clients and services described in subsection (b) of section 1916 of the Social Security Act and Part 447, section 447.53, of Title 42 of the Code of Federal Regulations (CFR), are specifically excluded from the copayment requirement;

(b) Children who are at least 18 years of age but under 21 years of age; and

(c) Compounded prescriptions.

History

• Adopted effective November 13, 1997

Regs., Conn. State Agencies § 17b-262-497 Copayment responsibilities

(a) Each pharmacy provider shall collect the copayment amount from the client at the time of the service unless the pharmacy provider, in dispensing a prescription, over-the-counter drug, or refill, does not have face-to-face contact with the client, in which case, the pharmacy shall bill the client for the amount of the copayment;

(b) The copayment shall be automatically deducted from the maximum allowable amount paid by the department to the pharmacy provider for each prescription drug, over-the-counter drug, or refill;

(c) A pharmacy provider participating in the Connecticut Medical Assistance Program may not deny prescription drugs, over-the-counter drugs, or refills to any client because of the client's inability to pay the copayment amount. The client's inability to pay does not eliminate the client's liability for the copayment charge or prevent the provider from attempting to collect the copayment amount from the client at a later time;

(d) The client's own declaration that he or she is unable to pay the copayment amount at the time of the service is the basis for determining when a client is unable to pay; and

(e) No pharmacy provider may waive the copayment requirement or in any way compensate the client for the copayment amount.

History

• Adopted effective November 13, 1997

Regs., Conn. State Agencies § 17b-262-498 Copayment rate

The copayment amount shall be $1.00 for each prescription drug, over-the-counter drug or refill.

History

• Adopted effective November 13, 1997

Regs., Conn. State Agencies § 17b-262-499 Scope

Sections 17b-262-499 through 17b-262-510 inclusive set forth the Department of Social Services requirements for payment for Connecticut's Medical Assistance Program, when clients under age twenty-one and age sixty-five or over receive inpatient psychiatric hospital services in accordance with section 17b-262-499 through section 17b-262-510.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-500 Definitions

For the purposes of sections 17b-262-499 through 17b-262-510 the following definitions shall apply:

(1) "Active Treatment" means the definition contained in 42 Code of Federal Regulations (CFR), Part 441, section 441.154.

(2) "Acute" means having rapid onset, severe symptoms, and a short course.

(3) "Acute Care" means medical care needed for an illness, episode, or injury which requires short-term, intense care, and hospitalization for a short period of time.

(4) "Allied Health Professional (AHP)" means a professional or paraprofessional individual who is qualified by special training, education, skills, and experience in mental health care and treatment and shall include, but shall not be limited to: psychologists, social workers, psychiatric nurses, and other qualified therapists.

(5) "Certification of Need Review" means an evaluation process for clients under the age of twenty-one who are requesting inpatient admission to a psychiatric hospital. This evaluation is conducted by the department acting as the independent team.

(6) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.

(7) "Client Age Sixty-Five or Over" means the definition contained in 42 CFR, Part 441, section 441.100.

(8) "Client Under Age Twenty-One" means the definition contained in 42 CFR, Part 441, section 441.151.

(9) "Department" means the Department of Social Services or its agent.

(10) "Elective Admission" means any psychiatric admission to a psychiatric hospital or psychiatric facility that is nonemergency, including urgent admissions and transfers from one facility to another.

(11) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.

(12) "HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with subdivision (5) of subsection (r) of section 1905 of the Social Security Act, and are:

(A) services not covered under the State Plan or contained in a fee schedule published by the department; or

(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.

(13) "Independent Team" means the definition contained in 42 CFR, Part 441, section 441.153. In addition, the independent team may not include anyone who is related, in any way, to the admitting facility, or who is directly responsible for the care of patients whose care is being reviewed, or has a financial interest in the admitting facility. The department performs the functions of the independent team.

(14) "Inpatient" means the definition contained in 42 CFR, Part 440, section 440.2. The client must also be present in the hospital at midnight for the census count.

(15) "Interdisciplinary Team" for review of clients under the age of twenty-one, means the definition contained in 42 CFR, Part 441, section 441.156.

(16) "Interperiodic Encounter" means any medically necessary visit to a Connecticut Medical Assistance provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(17) "Joint Commission on Accreditation of Healthcare Organizations (JCAHO)" means a national, private, not-for-profit organization founded in 1951, which offers accreditation to health care organizations throughout the United States.

(18) "Leave of Absence" means a conditional release which is a period of time after admission and prior to the day of discharge, in which the client has been permitted by the attending physician to be absent from the facility premises.

(19) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(20) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes (CGS) and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(21) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring.

(22) "Medical Record" means the definitions contained in 42 CFR, Part 482, section 482.6l, and subsection (d) of section 19-13-D3 of the Regulations of Connecticut State Agencies, which is part of the Public Health Code.

(23) "Plan of Care" means the definitions contained in 42 CFR, Part 441, Subpart D, and Part 456, sections 456.180 through 456.181.

(24) "Preadmission Review" means a review prior to, or, in the case of an emergency admission, within fourteen days after a client's admission to an inpatient psychiatric facility with the purpose of determining the medical necessity, appropriateness, and quality of the health care services to be delivered, or in the case of an emergency, delivered in the hospital.

(25) "Prior Authorization" means approval for the provision of a service or delivery of goods from the department before the provider actually provides the service or delivers the goods.

(26) "Provider" means a psychiatric hospital or psychiatric facility.

(27) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(28) "Psychiatric Emergency" means a sudden onset of a psychiatric condition, as determined by a physician, that manifests itself by acute symptoms of such severity that the absence of immediate medical care and treatment in an inpatient psychiatric facility could reasonably be expected to result in serious dysfunction, disability, or death of the client or harm to self or another person by the client. Court commitments and clients admitted on a Physician Emergency Certificate are not automatically deemed to qualify as a psychiatric emergency.

(29) "Psychiatric Facility" means an institution which is not a hospital and is accredited by the Joint Commission on Accreditation of Hospitals and Healthcare Organizations (JCAHO), to provide inpatient psychiatric services under the direction of a physician to clients who are under the age of twenty-one or age sixty-five or over, and meets specific conditions contained at 42 CFR, Part 435, section 435.1009.

(30) "Psychiatric Hospital" means an accredited or state licensed institution which is engaged in providing hospital level psychiatric services, under the supervision of a physician, for the diagnosis and treatment of mentally ill persons. Specific conditions for psychiatric hospital contained at 42 CFR, Part 482, sections 482.60 through 482.62, and at 42 CFR, Part 435, section 435.1009, shall be implemented. Psychiatric units or beds in a general, acute care hospital are not included in this definition.

(31) "Quality of Care" means the evaluation of medical care to determine if it meets the professionally recognized standard of acceptable medical care for the condition and the client under treatment.

(32) "Retrospective Review" means the review conducted after services are provided to a client, to determine the medical necessity, appropriateness, and quality of the services provided.

(33) "State Plan" means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with Part 430, Subpart B, of Title 42 of the Code of Federal Regulations.

(34) "Transfer" means that an individual is discharged from the hospital or facility and directly admitted to another.

(35) "Under the Direction of a Physician" means that health services may be provided by allied health professionals whether or not the physician is physically present at the time that the services are provided. The physician shall:

(A) assume professional responsibility for the services provided;

(B) assure that the services are medically appropriate; and

(C) be readily available within five minutes but not necessarily on the premises.

(36) "Urgent Admission" means an elective, nonemergency admission.

(37) "Utilization Review" means the evaluation of the necessity, appropriateness, and quality of the use of medical services, procedures, and facilities. Utilization Review evaluates the medical necessity and medical appropriateness of admissions, the services performed or to be performed, the length of stay, and the discharge practices. It is conducted on a concurrent, prospective, or retrospective basis.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-501 Provider participation

In order to enroll in the Medical Assistance Program and receive payment from the department, providers shall meet the following requirements:

(a) General:

(1) meet and maintain all applicable licensing, accreditation, and certification requirements;

(2) meet and maintain all departmental enrollment requirements; and

(3) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

(b) Specific:

(1) providers of inpatient psychiatric services shall be licensed, when appropriate, by the state and accredited as a psychiatric hospital by the Joint Commission on Accreditation of Healthcare Organizations, and

(2) psychiatric hospitals outside of Connecticut shall meet all of the above provider requirements. They shall also be an enrolled Medical Assistance Program provider in their state of residence, when that state participates in the optional program of Medical Assistance Program psychiatric inpatient services provided to clients age twenty-one and under and age sixty-five and over.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-502 Eligibility

Payment for inpatient psychiatric hospital services shall be available on behalf of Medical Assistance Program clients under age twenty-one and age sixty-five or over under the conditions and limitations which apply to these services.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-503 Services covered

The department shall pay for the following:

(a) medically necessary and medically appropriate inpatient psychiatric services for clients under age twenty-one or age sixty-five or over when the need for services as stated in section 17b-262-499 through section 17b-262-511 are met and provided by an enrolled Medical Assistance Program provider;

(b) inpatient hospital tests when the tests are specifically ordered by the attending physician or other licensed practitioner who is responsible for the diagnosis and treatment of the client, and who is acting within the scope of practice as defined under state law;

(c) HealthTrack Services; and

(d) HealthTrack Special Services. HealthTrack Special Services require prior authorization on a case-by-case basis to determine that the services are medically necessary and medically appropriate.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-504 Services not covered

The department shall not pay for the following inpatient psychiatric hospital services which are not covered under the Medical Assistance Program:

(a) procedures or services of an unproven, educational, social, research, experimental, or cosmetic nature or for any diagnostic, therapeutic, or treatment procedures in excess of those deemed medically necessary and appropriate by the department to treat the client's condition;

(b) services that do not directly relate to the client's diagnosis, symptoms, or medical history;

(c) services or items furnished for which the provider does not usually charge;

(d) the day of discharge or transfer;

(e) an inpatient psychiatric hospital admission or a day of care that does not meet all the department's requirements for inpatient services;

(f) an inpatient psychiatric hospital admission or a day of care that is denied by the hospital's Utilization Review Committee;

(g) a day when the client, who is age sixty-five or over, is absent from the psychiatric hospital at the midnight census, even though the leave or transfer is medically authorized and part of the treatment plan;

(h) a day when the client, who is under age twenty-one, is absent from the psychiatric hospital at the midnight census, even though the leave or transfer is medically authorized and part of the treatment plan; or

(i) costs associated with the education or vocational training of the client which shall be excluded from Medical Assistance Program payments.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-505 Certification of need review requirements for inpatient psychiatric services for a client under age twenty-one in a psychiatric hospital

(a) In order to receive payment for inpatient psychiatric hospital services for individuals under age twenty-one, each individual admission, including elective and emergency admissions, shall have a certification of need review.

(b) The certification of need review shall be a part of the client's medical record, with written documentation certifying that:

(1) ambulatory care resources available in the community do not meet the treatment needs of the client;

(2) proper treatment of the client's psychiatric condition requires inpatient care under the direction of a physician; and

(3) the services shall reasonably be expected to improve the client's condition or prevent further regression so that inpatient services shall no longer be needed.

(c) When the admission of a Medical Assistance Program client is elective, an independent team is responsible to perform the certification of need review. The department shall act as the independent team.

(d) When the admission is an individual who is not Medical Assistance Program eligible and who applies for the Medical Assistance Program while in the hospital, the certification of need review shall be conducted at the time of application for Medical Assistance Program coverage or by the first day of Medical Assistance Program coverage. An interdisciplinary team conducts the certification of need review which shall cover any period prior to application for which Medical Assistance Program claims are made. In addition, this certification of need review shall be validated by the independent team.

(e) For emergency admissions, the certification of need review shall be completed by an interdisciplinary team within fourteen days after the emergency admission and validated by the independent team.

(f) When the client is transferred from a psychiatric hospital to an acute care hospital and upon discharge readmitted to the psychiatric hospital, a new certification of need review by the independent team is required.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-506 Individual plan of care requirements for inpatient psychiatric services for a client under age twenty-one in a psychiatric hospital

(a) Inpatient psychiatric services for clients under age twenty-one shall constitute active treatment, as documented in the professionally developed and supervised individual plan of care.

(b) Before admission or before authorization for payment, the interdisciplinary team shall establish a written plan of care for each applicant or client, designed to achieve the client's discharge from inpatient status at the earliest possible time. This plan shall:

(1) be based on a diagnostic evaluation that includes examinations of the medical, psychological, social, behavioral, and developmental aspects of the client's situation and thereby reflect the need for inpatient psychiatric care;

(2) be developed by the interdisciplinary team of professionals in consultation with the client, and his or her parents, legal guardian, or others into whose care he or she will be released after discharge;

(3) state the treatment objective;

(4) prescribe an integrated program of therapies, activities, and experiences designed to meet the treatment objectives;

(5) include, at an appropriate time, post-discharge plans and coordination of inpatient services with partial discharge plans and related community services to ensure continuity of care with the client's family, school, and community upon discharge; and

(6) be a recorded document which is maintained in the client's medical record.

(c) In addition, the individual plan of care shall be reviewed every thirty days by the interdisciplinary team, starting at the date of admission. The purpose of the review is to determine that services being provided are currently required or were required on an inpatient basis, and to recommend any changes to the plan that are indicated by the client's overall progress towards the treatment goals.

(d) The development and review of the plan of care shall satisfy the utilization control requirements for recertification and the establishment and periodic review of the plan of care.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-507 Individual plan of care for a client age sixty-five or over in a psychiatric hospital

(a) A written, individual plan of care shall be developed to ensure that institutional care maintains the client at, or restores them to, the greatest possible degree of health and independent functioning. The plan of care for an elective admission shall be completed by the attending or staff physician prior to admission. The plan of care for clients age sixty-five or over, in addition to the requirements specified in the definitions, shall also include:

(1) an initial review of the client's medical, psychiatric, and social needs;

(2) periodic review of the client's medical, psychiatric, and social needs;

(3) a determination, at least every ninety days, of the client's need for continuing institutional care and for alternative care arrangements;

(4) appropriate medical treatment in the institution; and

(5) appropriate social services.

(b) In the situation where an individual applies for Medical Assistance Program eligibility after an elective or emergency admission to the psychiatric hospital, the plan of care shall be completed at the same time that the Medical Assistance Program application is submitted to the department or by the first day of Medical Assistance Program coverage. It shall cover both the period prior to and after application for which Medical Assistance Program claims are made.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-508 Utilization review program for inpatient psychiatric services for clients under age twenty-one or age sixty-five or over

(a) The department's Utilization Review Program conducts utilization review activities for services delivered by the inpatient psychiatric hospital to clients where the Medical Assistance Program has been determined to be the appropriate payer.

(b) To determine that inpatient psychiatric services or admissions are medically necessary and medically appropriate, the department may:

(1) require preadmission review or prior authorization of each inpatient psychiatric hospital admission, including a certificate of need review, for clients under age twenty-one, unless the department notifies the providers that a specific admission, diagnosis, or procedure does not require such authorization; and

(2) perform retrospective reviews at the department's discretion which may be a random or targeted sample of the admissions and services delivered. The review may be focused on the appropriateness, necessity, or quality of the health care services provided.

(c) If the department decides to impose prior authorization or preadmission review requirements, all effected providers shall be notified at least thirty days in advance of date of implementation.

(d) All claims for payment for admission and all days of stay and services that are provided shall be documented. Lack of said documentation itself may be adequate ground for the department, in its discretion, to deny or recoup payment for the admission for some or all of the days of stay or services provided.

(e) The department shall conduct medical review and inspections of care in psychiatric hospitals.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-509 Billing procedures

Claims from inpatient psychiatric providers shall be submitted on the department's uniform billing form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-510 Documentation and record retention

(a) A provider shall meet the special medical record requirements for a psychiatric hospital and shall maintain records to support claims made for payment. All documentation shall be made available upon request by and to authorized department, state, or federal personnel in accordance with state and federal laws. Documentation shall be retained by the provider for a period of five years, or if any dispute arises concerning a service, until such dispute has been finally resolved.

(b) Failure to maintain all required documentation or to provide it to the department upon request, may result in the disallowance and recovery by the department of any amounts paid out for which the required documentation is not maintained or provided.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-511 Reserved

Sec. 17b-262-511. Reserved

Regs., Conn. State Agencies § 17b-262-512 Scope

Sections 17b-262-512 through 17b-262-520 inclusive set forth the Department of Social Services requirements for the payment of radiology services performed by an independent radiology or ultrasound center provided in a freestanding center, which is not part of a physician's office nor a hospital outpatient department or clinic, for clients who are determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-513 Definitions

For the purposes of sections 17b-262-512 through 17b-262-520 the following definitions shall apply:

(1) "Acute" means having rapid onset, severe symptoms, and a short course.

(2) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.

(3) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.

(4) "Department" means the Department of Social Services or its agent.

(5) "Electrocardiogram (EKG) Services" means diagnostic services derived from an electrocardiogram device which measures the electrical variations in heart muscles.

(6) "Electroencephalogram (EEG) Services" means diagnostic services derived from an electroencephalogram instrument which records the electrical activity of the brain.

(7) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(8) "Freestanding Radiology or Ultrasound Center" means those centers which offer radiology or ultrasound services but which are not part of a physician's office nor an inpatient or outpatient hospital service.

(9) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.

(10) "HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with subdivision (5) of subsection (r) of section 1905 of the Social Security Act, and are:

(A) services not covered under the State Plan or contained in a fee schedule published by the department; or

(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.

(11) "Interperiodic Encounter" means any medically necessary visit to a Connect-icut Medical Assistance provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(12) "Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(13) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective alternative treatments or diagnostic modalities.

(14) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(15) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring.

(16) "Prior Authorization" means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods.

(17) "Provider" means a radiology or ultrasound center which provides professional and technical services and which is independent of a physician's office or an inpatient or outpatient hospital department or clinic.

(18) "Provider Agreement" means the signed, written, contractual, agreement between the department and the provider of services or goods.

(19) "Radiology" means any diagnostic and treatment service administered through the use of radiant energy.

(20) "State Plan" means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with Part 430, Subpart B, of Title 42 of the Code of Federal Regulations (CFR).

(21) "Ultrasound Services" means diagnostic and therapeutic services administered by ultrasound equipment—equipment emitting inaudible sound frequencies in the approximately 20,000 to 10,000,000,000 cycles per second range.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-514 Provider participation

In order to enroll in the Medical Assistance Program and receive payment from the department, providers shall:

(a) meet and maintain all applicable licensing, accreditation, and certification requirements;

(b) meet and maintain all departmental enrollment requirements; and

(c) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-515 Eligibility

Payment for radiology or ultrasound center services shall be available on behalf of all persons eligible for the Medical Assistance Program subject to the conditions and limitations which apply to these services.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-516 Services covered

The department shall pay for:

(a) medically appropriate and medically necessary radiology or ultrasound center services as published in the department's fee schedule when ordered by a licensed physician or other licensed practitioner of the healing arts; and

(b) HealthTrack Services and HealthTrack Special Services.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-517 Need for service and authorization process

(a) Need for Service

The department shall pay for independent radiology and ultrasound center services which are ordered by a duly licensed physician or other licensed practitioner of the healing arts and which the department deems to be medically necessary and medically appropriate.

(b) Prior Authorization

Prior authorization, on forms and in a manner as specified by the department, shall be required for HealthTrack Special Services:

(1) HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis; and

(2) the request for HealthTrack Special Services shall include:

(A) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service requested;

(B) a description of the outcomes of any alternative measures tried; and

(C) if applicable and requested by the department, any other documentation required in order to render a decision.

(c) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-518 Billing procedures

(a) Claims from independent radiology or ultrasound center providers shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) The payment for radiology or ultrasound center services includes all consultation services as well as the written report to the referring physician.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-519 Payment rate and limitations

(a) The commissioner shall establish the fees contained in the department's published fee schedule for independent radiology and ultrasound centers pursuant to section 4-67c of the Connecticut General Statutes.

(b) The payment rate shall be made at the lowest of:

(1) the provider's usual and customary charge to the general public;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount billed by the provider; or

(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

(c) When emergency services are rendered after normal posted business hours, a fee as indicated on the provider's fee schedule shall be reimbursed to the provider per patient.

(d) Actual allowable procedures billable to the Medical Assistance Program are negotiated individually by provider.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-520 Documentation

(a) Independent radiology or ultrasound center providers shall maintain a specific record for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, documentation of the services provided, and the dates the services were provided.

(b) All required documentation shall be maintained for at least five years in the provider's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained and provided to the department by request.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-521 Reserved

Sec. 17b-262-521. Reserved

Regs., Conn. State Agencies § 17b-262-522 Scope

Sections 17b-262-522 through 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services general requirements to which providers of Medical Assistance Program goods and services shall adhere in order to participate in, and receive payment from, the Connecticut Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-523 Definitions

For the purposes of sections 17b-262-522 through 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies the following definitions apply:

(1) "Acute" means symptoms that are severe and have a rapid onset and a short course;

(2) "Border provider" means a provider located in a state bordering Connecticut, in an area that allows it to generally serve Connecticut residents, and that is enrolled as and treated as a Connecticut Medical Assistance Program provider. Such providers are certified, accredited, or licensed by the applicable agency in their state and are deemed border providers by the department on a case by case basis;

(3) "Claim" means a request for payment submitted by a provider to the department, or its fiscal agent, in accordance with the billing requirements set forth by the department;

(4) "Client" means a person eligible for goods or services under the department's Medical Assistance Program;

(5) "Commissioner" means the commissioner of the Connecticut Department of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes;

(6) "Copayment" means a nominal fee, chargeable to the client and not payable from the department, for specified goods or services and which meets the requirements of section 1916 of the Social Security Act and 42 CFR 447.15 and 42 CFR 447.50 to 42 CFR 447.58, inclusive;

(7) "Coverable Medical Assistance Program good or service" means any good or service which is payable by the Medical Assistance Program under its regulations;

(8) "Department" means the Connecticut Department of Social Services or its agent;

(9) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part;

(10) "Free of charge" means a good or service for which no individual client has an obligation to pay and for which no third party payment is ever sought;

(11) "Lock-in" means the department's restriction of a client to a specific provider for certain Medical Assistance Program goods or services under the authority of section 17-134d-11 of the Regulations of Connecticut State Agencies;

(12) "Medical appropriateness or medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate [medical ]setting; and is the least costly of multiple, equally-effective alternative treatments or diagnostic modalities;

(13) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid;

(14) "Medical Assistance Program goods or services" means medical care or items that are furnished to a client to meet a medical necessity in accordance with applicable statutes or regulations that govern the Medical Assistance Program;

(15) "Medical necessity or medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; assist an individual in attaining or maintaining an optimal level of health; diagnose a condition; or prevent a medical condition from occurring;

(16) "Medicare" means the federal health care program authorized by Title XVIII of the Social Security Act;

(17) "Out-of-state provider" means a provider who is licensed, certified, or accredited in a state other than Connecticut; has a business address outside of Connecticut; and does not meet the definition of "border provider";

(18) "Overpayment" means any payment that represents an excess over the allowable payment under state law including, but not limited to, amounts obtained through fraud and abuse;

(19) "Point of sale or POS" means the department's on-line, real time pharmacy electronic claims transmission. This process also includes prospective drug utilization review;

(20) "Prior authorization" means approval for the provision of a service or delivery of goods from the department before the provider actually provides the service or delivers the goods;

(21) "Prospective drug utilization review or pro-DUR" means a client-specific drug utilization review prior to dispensing;

(22) "Provider" means any individual or entity that furnishes Medical Assistance Program goods or services pursuant to a provider agreement with the department and is duly enrolled and in good standing or, as the context may require, an individual or entity applying for enrollment in the Medical Assistance Program;

(23) "Provider agreement" means the signed, written, contractual agreement between the department and the provider of services or goods;

(24) "Provider enrollment or reenrollment form" means the department's form which requests the provider's data such as, but not limited to: name, address, licensure or certification information, service protocols, and any other information required by the department to assess provider eligibility for participation in the Medical Assistance Program;

(25) "Suspension" means limiting program participation of providers who, although not convicted of program-related crimes, are found by the department to have violated rules, regulations, standards or laws governing any such program;

(26) "Termination" means precluding medical assistance program participation by providers that have been convicted of a crime involving medicaid or medicare;

(27) "Third party" means any individual, private or public organization, or entity that is or may be liable to pay all or part of the medical costs of injury, disease, or disability for a client pursuant to 42 CFR 433.136;

(28) "Third party liability" as it applies to Medical Assistance Program claims processing, means payment resources available from both private and public health insurance that can be applied toward Medical Assistance Program clients' medical and health benefit expenses. A pending tort recovery or cause of action, worker's compensation or accident insurance settlement is not a third party liability; and

(29) "Type and specialty" means the department's categorization of Medical Assistance Program providers according to the type and specialty of the goods or services furnished by the provider.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-524 Provider participation

(a) To enroll in the Medical Assistance Program and receive payment from the department for the provision of goods or services to Medical Assistance Program clients, providers shall:

(1) Meet and maintain all applicable licensing, accreditation and certification requirements;

(2) meet and maintain all departmental enrollment requirements including the timely submission of a completed provider enrollment or reenrollment form and submission of all enrollment information and such affidavits as the department may require; and

(3) have a valid provider agreement on file which is signed by the provider and the department. This agreement, which shall be periodically updated, shall continue to be in effect for the duration specified in the agreement. The provider agreement specifies conditions and terms that govern the program and to which the provider is mandated to adhere in order to participate in the program.

(b) Additionally, the department shall at its discretion:

(1) Require documentation or other information necessary to ensure that requirements for enrollment in a type of service and specialty have been met pursuant to all applicable statutes and regulations;

(2) require that an out-of-state or border provider submit such supplemental documentation as it requires in the event their licenses, certificates, permits or other credentials do not disclose the required information, or if the criteria for attainment of such credentials is different from similarly situated in-state providers;

(3) require submission of a schedule of charges to the general public or any other pertinent data or information necessary to facilitate review of new or existing services;

(4) approve or disapprove enrollment or reenrollment of any provider based upon the department's requirements. The department in its sole discretion shall determine whether the provider meets the requirements for enrollment;

(5) deny initial enrollment or reenrollment of any provider when such enrollment or reenrollment is determined not to be in the best interests of the Medical Assistance Program;

(6) deny enrollment or reenrollment of any provider who does not offer coverable Medical Assistance Program goods or services regardless of whether the provider meets all other enrollment requirements; and

(7) enroll out-of-state providers if they provide services to clients who are out-of-state in accordance with section 17b-262-532 of the Regulations of Connecticut State Agencies.

(c) At the discretion of the department, out-of-state providers shall be eligible for enrollment or reenrollment into the Medical Assistance Program based on documentation of current enrollment in the Medical Assistance Program in another state.

(d) Failure by the provider to submit any required documents or information for reenrollment, at such times and in such a manner as the department shall require, may result in the loss of the provider's eligibility to participate in the Medical Assistance Program.

(e) Specific enrollment requirements for provider types and specialties are set forth in the Regulations of Connecticut State Agencies dealing with the specific provider type and specialty. The department in accordance with the governing Regulations of Connecticut State Agencies shall, in its sole discretion, determine the category of provider type and specialty into which a provider falls.

(f) For purposes of this section, the terms "institution" or "general hospital" include (1) any wholly or partially owned subsidiary of the institution or general hospital; (2) any entity that is related to the institution or general hospital, including, but not limited to, a parent company, or wholly or partially owned subsidiary of the institution or general hospital; and (3) any other entity, such as a partnership, that is established by (A) the institution or general hospital or (B) any entity related to the institution or general hospital, including a parent company and its wholly or partially owned subsidiaries.

(g) Notwithstanding any provisions of the Regulations of Connecticut State Agencies or any medical services policy, any provider who is (1) compensated directly or indirectly by an institution or general hospital or (2) located within an institution or general hospital, which includes being located in an institution or general hospital complex, campus or auxiliary or satellite location, may bill the department for services rendered to the provider's medical assistance program private practice clients who receive services at the institution or general hospital location if all of the following criteria are met:

(1) The provider maintains a practice at a location other than the location which is within the institution or general hospital complex, campus or auxiliary or satellite location;

(2) the provider is enrolled as a medical assistance program provider at the location that is separate from the institution or general hospital location and actively bills, as determined by the department, the Medical Assistance Program for services rendered at that separate location;

(3) the operations of the provider are entirely separate and independent from the institution or general hospital. The department considers the operations of a provider as entirely separate and independent if the following criteria are met:

(A) the provider does not utilize space that is directly or indirectly owned by the institution or general hospital unless the space is rented at fair market value;

(B) the provider and provider staff do not receive compensation in any form from the institution or general hospital for any reason for clinical services at the institution or general hospital;

(C) the provider and the institution or general hospital do not share administrative and support staff; and

(D) the provider and the institution or general hospital have no direct or indirect relationship relative to ownership or control;

(4) any direct and indirect costs associated with the services performed by the provider or provider staff are not included in the annual cost report of the institution or general hospital; and

(5) the provider has performed an evaluation and management service for the client at its separate location within the previous year.

(h) Notwithstanding the criteria identified in subdivision (3) of subsection (g) of this section, the provider may bill if the provider can demonstrate to the satisfaction of the department that the arrangements between the provider and the institution or general hospital do not result in duplication of payments. Evidence of lack of duplication of payments may include, but is not limited to, a copy of the provider-facility contract.

(i) Notwithstanding the requirements of subsections (g) and (h) of this section, a medical foundation established pursuant to sections 33-182aa to 33-182ff, inclusive, of the Connecticut General Statutes may bill the department for goods or services provided to Medical Assistance Program clients only after obtaining the department's approval. In order to obtain such approval, and as requested by the department from time to time, the medical foundation shall demonstrate, to the department's satisfaction, that mechanisms are in place to ensure that there will be no duplicate billing to or payment by the department relating to the provision of such goods or services. Not later than three months after the medical foundation begins billing the department, and as requested by the department from time to time, the medical foundation shall demonstrate to the department that no such duplicate billing in fact occurs. Duplicate billing includes, but is not limited to, claims for costs associated with related party transactions among the medical foundation, the hospital and any other related party, as defined in subsection (o) of section 17b-262-531 of the Regulations of Connecticut State Agencies.

History

• Adopted effective February 8, 1999; Amended April 1, 2003; Amended June 5, 2012

Regs., Conn. State Agencies § 17b-262-525 Termination or suspension of provider agreement

(a) Providers shall be subject to all of the conditions contained in section 17b-99 of the Connecticut General Statutes and sections 17-83k-1 through 17-83k-7 of the Regulations of Connecticut State Agencies.

(b) A provider agreement may be terminated by mutual consent or without cause by either the department or the provider by giving a thirty day written notification to the affected party, or as otherwise provided by federal or state law.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-526 General provider requirements

To maintain enrollment in the Connecticut Medical Assistance Program, a provider shall abide by all federal and state statutes regulations and operational procedures promulgated by the department which govern the Medical Assistance Program and shall:

(1) abstain from discriminating or permitting discrimination against any person or group of persons on the basis of race, color, religious creed, age, marital status, national origin, sex, mental or physical disability, or sexual orientation pursuant to 45 CFR 80.3 and 45 CFR 80.4;

(2) accept as payment in full either the department's payment or a combination of department, third party payment, and any authorized client copayment which is no more than the department's schedule of payment, except with regard to the department's obligations for payment of Medicare coinsurance and deductibles;

(3) agree to pursue and exhaust all of a client's third party resources prior to submitting claims to the department for payment; to report any and all third party payments; to acknowledge the department as the [payor] payer of last resort; and to assist in identifying other possible sources of third party liability for which a legal obligation for payment of all or part of the Medical Assistance Program goods or services furnished exists;

(4) be qualified to furnish Medical Assistance Program goods or services; be currently certified and enrolled in the Medicare program if required by any federal or state statutes or regulations which govern the Medical Assistance Program goods or services furnished by a provider under the provider's assigned type and specialty;

(5) meet and adhere to all applicable licensing, accreditation, and certification requirements and all applicable state and local zoning and safety requirements pertaining to the provider's assigned type and specialty in the jurisdiction where the Medical Assistance Program goods or services are furnished;

(6) meet and adhere to any additional department requirements, after enrollment, promulgated in conformance with federal and state statutes, regulations and operational procedures which govern the provider's assigned provider type and specialty;

(7) maintain a specific record for each client eligible for Medical Assistance Program payment including, but not limited to: name; address; birth date; Medical Assistance Program identification number; pertinent diagnostic information and x-rays; current and all prior treatment plans prepared by the provider; pertinent treatment notes signed by the provider; documentation of the dates of service; and other requirements as provided by federal and state statutes and regulations pursuant to 42 CFR 482.61, and, to the extent such requirements apply to a provider's licensure category, record requirements set forth in chapter iv of the Connecticut Public Health Code (sections 19-13-D1 to 19-13-D105 of the Regulations of Connecticut State Agencies). Such records and information shall be made available to the department upon request;

(8) maintain all required documentation for at least five years or longer as required by state or federal law or regulation in the provider's file subject to review by authorized department personnel. In the event of a dispute concerning goods or services provided, documentation shall be maintained until the end of the dispute,for five years, or the length of time required by state or federal law or regulation, whichever is greatest. Failure to maintain and provide all required documentation to the department upon request shall result in the disallowance and recovery by the department of any future or past payments made to the provider for which the required documentation is not maintained and not provided to the department upon request, as permitted by state and federal law;

(9) notify the department in writing of all substantial changes in information which were provided on the application submitted to the department for provider enrollment or reenrollment in the Medical Assistance Program;

(10) disclose, in accordance with 42 CFR 455.106, any information requested by the department regarding the identity of any person who has ownership or a controlling interest in the provider's business who has been convicted of a criminal offense related to that person's involvement in Medicare or the Medical Assistance Program;

(11) furnish all information relating to the provider's business ownership, as well as transactions with subcontractors, in accordance with federal and state statutes and regulations;

(12) not deny goods or services to a client solely on the basis of the client's inability to meet a copayment; and

(13) agree to participate in studies of access, quality and outcome conducted by the department or its agents. The department shall reimburse providers for costs above and beyond nominal costs incurred by such participation.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-527 Need for goods or services

The department shall review the medical appropriateness and medical necessity of medical goods and services provided to Medical Assistance Program clients both before and after making payment for such goods and services.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-528 Prior authorization

(a) Prior authorization, to determine medical appropriateness and medical necessity, shall be required as a condition of payment for certain Medical Assistance Program goods or services as set forth in the regulations of the department governing specific provider types and specialties. The department shall not make payment for such goods and services when such authorization is not obtained by the provider of the goods or services.

(b) Prior authorization shall be granted by the department to a provider to furnish specified goods or services within a defined time period as set forth in the regulations of the department governing specific provider types and specialties.

(c) Payment for medical goods or services provided to a client, for which prior authorization is given, is contingent upon the client's eligibility at all times such goods and services are furnished.

(d) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

(e) Coverable Medical Assistance Program goods or services requiring prior authorization may be so identified on the department's applicable fee schedule or identified in regulation.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-529 Billing procedures

(a) Claims from providers shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent within twelve months of the date the service was provided or the good was delivered and shall include all information required by the department to process the claim for payment, as set forth in the Regulations of Connecticut State Agencies and specified in the department's provider billing manuals. The date of service is the actual date on which the service was provided.

(b) Exceptions to the procedures set forth in subsection (a) of section 17b-262-529 of the Regulations of Connecticut State Agencies shall be as follows:

(1) when an individual is an applicant of the Medical Assistance Program or an applicant for a categorically related program which qualifies the individual for the Medical Assistance Program, and the determination of eligibility comes after the last date of service and eligibility is retroactive, the provider shall submit claims for goods or services received within one year of the effective date of the determination of eligibility or effective date of award, whichever comes later;

(2) when there is an issue related to Medical Assistance Program eligibility or to payment for goods or services which is subject to the grievance process, the provider shall submit claims within the guidelines in subsection (a) of section 17b-262-529 of the Regulations of Connecticut State Agencies or within twelve months of the effective date of the resolution in favor of Medical Assistance Program payments for goods or services, whichever is later; and

(3) when a provider has submitted a claim to a third party insurer and has not received a response within a reasonable time, the one year shall begin twelve months from the date of receipt of the explanation of benefits form. The provider shall be responsible for any followup to the third party insurers.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-530 Payment rates

(a) All schedules of payment for coverable Medical Assistance Program goods and services shall be established by the commissioner and paid by the department in accordance with all applicable federal and state statutes and regulations.

(b) A provider whose rates are established by the department based on the provider's cost may be required to submit data in a format prescribed by the department which may include but not be limited to, the following:

(1) a copy of the provider's financial statement and an independent auditor's report for the most recently completed fiscal year, or anticipated costs if the program or service is new;

(2) a copy of the provider's financial statement for the current year to date;

(3) a current copy of the provider's usual and customary charges to the general public; and

(4) the provider's most recent Medicare cost report, if one is required to be filed by the provider.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-531 Payment limitations

Payment, by the department, to all providers shall be limited to medically appropriate and medically necessary goods or services furnished to Medical Assistance Program clients. The following payment limitations shall also apply:

(a) the department shall not make payment for any claim for Medical Assistance Program goods or services for persons not eligible for the Medical Assistance Program on the date the good or service is provided, except for those medical services required and requested by the department to determine a person's eligibility for the program;

(b) the department shall not make payment for any Medical Assistance Program goods or services which are not covered under, and furnished in accordance with federal and state statutes and regulations including 42 USC 1396b(f);

(c) the department shall not make an additional payment when a third party payment is equal to or greater than the department's schedule of payment for the same Medical Assistance Program good or service, except to meet the department's obligations as defined by federal and state laws and regulations;

(d) the department shall not make payment for Medical Assistance Program goods or services furnished by a provider after the date of termination of the provider, or during a period of suspension, from the Medical Assistance Program, except as may be determined by the commissioner;

(e) the department shall make payment only to a duly enrolled provider;

(f) the department shall not pay for goods or services that are furnished to providers or clients free of charge;

(g) the department shall not pay for any procedures, goods, or services of an unproven, educational, social, research, experimental, or cosmetic nature; for any diagnostic, therapeutic, or treatment goods or services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history;

(h) the department shall not pay for cancelled office visits and appointments not kept;

(i) the department shall make payment only to the provider to whom a client is locked-in, pursuant to section 17-134d-11 of the Regulations of Connecticut State Agencies, except in an emergency;

(j) a provider shall not charge an eligible Medical Assistance Program client, or any financially responsible relative or representative of that individual, for any portion of the cost of goods or services which are covered and payable under the Connecticut Medical Assistance Program. If a client or representative has paid for the goods or services and the client subsequently becomes eligible for the medical assistance program, payment made by or on behalf of the client shall be refunded by the provider to the payer. The provider then may bill the Medical Assistance Program for the goods or services provided. The provider shall obtain appropriate documentation that the payment was refunded prior to the submission of the claim and shall maintain said documentation;

(k) a provider shall not charge for medical goods or services for which a client would be entitled to have payment made, but for the provider's failure to comply with the requirements for payment established by these regulations;

(l) a provider shall only charge an eligible Medical Assistance Program client, or any financially responsible relative or representative of that individual, for goods or services which are not coverable under the Medical Assistance Program, when the client knowingly elects to receive the goods or services and enters into an agreement in writing for such goods or services prior to receiving them;

(m) Refunds by vendors to persons eligible for the medical assistance program shall be in acordance with section 17b-103 of the Connecticut General Statutes. The provider shall obtain and maintain appropriate documentation that the payment was refunded prior to submission of the claim;

(n) a provider shall charge a client a copayment for Medical Assistance Program goods or services only when the department specifically authorizes the provider to collect such copayment from the client;

(o) Any cost used to establish the amount to be reimbursed by the medical assistance program which was incurred by a provider through a related party transaction shall not include any amount in excess of the cost to the related party. Only the actual cost of the product or service to the related party may be used to establish reimbursement by the Medical Assistance Program. Such related party cost shall also meet all other requirements for reimbursement, including, but not limited to, being reasonable and directly related to patient care. For purposes of this section, "related party" is defined as persons or organizations related through an ability to control, ownership, family relationship or business association, and includes persons related through marriage; and

(p) The provider shall be prohibited from reassigning claims in accordance with 42 CFR 447.10.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-532 Payment for out-of-state goods or services

(a) Pursuant to 42 CFR 431.52, payment for Medical Assistance Program goods or services furnished to clients while they are out-of-state shall be made by the department to the same extent as payment is made to in-state providers, unless otherwise specified in state statutes or regulations which govern the provider's assigned type and specialty, only when any of the following conditions is met:

(1) Medical Assistance Program goods or services are needed by a client because a medical emergency occurred while the client was outside of the state;

(2) Medical Assistance Program goods or services are needed because a client's health would be endangered if required to travel to Connecticut;

(3) the department determines that the Medical Assistance Program goods or services are[more readily] available only in another state and prior authorization was granted to the provider; or

(4) it is general practice for clients in a particular locality of Connecticut to use the medical resources in a bordering state. The department shall allow providers, who are designated by the department to be border providers, to be treated in the same manner as in-state providers.

(b) In addition, payment for Medical Assistance Program goods or services furnished to clients while they are out-of-state shall be made to the same extent as payment is made to in-state providers when:

(1) enrollment is for copayment or deductible of a Medicare claim; and

(2) a child for whom the department makes adoption assistance or foster care maintenance payment resides outside of Connecticut, or an individual approved to attend school out-of-state resides in Connecticut.

(c) In order to be paid for goods or services, out-of-state providers shall enroll in the Connecticut Medical Assistance Program.

(d) Out-of-state pharmacies rendering services in-state to clients shall:

(1) participate in on-line point of sale and prospective drug use review claims processing; and

(2) pursuant to section 20-627 of the Connecticut General Statutes, out-of-state pharmacy providers shall, when doing business in Connecticut, receive a certificate of registration from the Department of Consumer Protection, upon approval of the Commission of Pharmacy, and provide a toll-free telephone number disclosed on labels for drugs dispensed in Connecticut.

(e) For payment for emergency services, providers shall be required to submit a claim and applicable medical emergency room reports, discharge summaries, or other documentation as determined by the department which confirms the emergency.

(f) In most cases, enrollment shall be for dates of service or provision of goods only. An exception to this rule may apply to providers of goods or services to children for whom the department makes adoption assistance or foster care maintenance payments who reside outside of Connecticut, or individuals approved to attend school out-of-state who reside in Connecticut. In these situations, a provider shall not be required to submit a claim to initiate the enrollment process. The provider shall indicate the name of the child or individual for whom it shall be providing services at the time of enrollment.

(g) Timely filing requirement shall be the same for out-of-state providers as for in-state providers except that the date of first contact with the department's fiscal agent to become enrolled in the Medical Assistance Program or to submit a claim shall be within twelve months of the date of provision of the service or delivery of the good.

(h) Pursuing other third party liabilities shall be the same for out-of-state providers as for in-state providers.

(i) Out-of-state independent laboratories, border hospitals, and physician groups having admitting privileges in a border hospital shall be exempt from the out-of-state criteria delineated in subsection (a) of section 17b-262-532 of the Regulations of Connecticut State Agencies. All other border providers shall be considered for enrollment in the Medical Assistance Program on a case-by-case basis.

(j) The Medical Assistance Program shall not cover out-of-state long-term care services unless such services are not available in the state of Connecticut and receive prior authorization from the department.

(k) Out-of-state providers shall, upon request of authorized department representatives, make available fiscal and medical records as required by applicable Medical Assistance Program regulations and the provider agreement. Such records shall be made available for review by authorized department representatives at a location within the State of Connecticut.

History

• Adopted effective February 8, 1999; Amended April 1, 2003

Regs., Conn. State Agencies § 17b-262-533 Sums paid in excess of the authorized schedules of payment or for other reasons of ineligibility for payment

Any payment, or part thereof, for Medical Assistance Program goods or services which represents an excess over the payment authorized, or a violation due to abuse or fraud, shall be payable to the department. Any such sum not returned to the department by a provider may be recovered in an action brought by the department against the provider. Such sums may also be recouped from current payment due the provider in accordance with law.

History

• Adopted effective February 8, 1999

Regs., Conn. State Agencies § 17b-262-534 Reserved

Sec. 17b-262-534. Reserved

Regs., Conn. State Agencies § 17b-262-535 Scope

Sections 17b-262-535 through 17b-262-545 inclusive set forth the Department of Social Services requirements for payment of chiropractic services, performed by licensed practitioners of chiropractic in private or group practices, for clients who are determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-536 Definitions

For the purposes of sections 17b-262-535 through 17b-262-545 the following definitions shall apply:

(1) "Acute" means having rapid onset, severe symptoms, and a short course.

(2) "Chiropractic" means the services described in Title 42 of the Code of Federal Regulations (CFR), Part 440, section 440.60, and subsection (1) of section 20-24 of the Connecticut General Statutes.

(3) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.

(4) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.

(5) "Department" means the Department of Social Services or its agent.

(6) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(7) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.

(8) "HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with subdivision (5) of subsection (r) of section 1905 of the Social Security Act, and are:

(A) services not covered under the State Plan or contained in a fee schedule published by the department; or

(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.

(9) "Interperiodic Encounter" means any medically necessary visit to a Connecticut Medical Assistance provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(10) "Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(11) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(12) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes (CGS) and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(13) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or prevent a medical condition from occurring.

(14) "Medical Record" means the definition contained in section 19a-14-40 of the Regulations of Connecticut State Agencies, which is also the Public Health Code.

(15) "Prior Authorization" means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods.

(16) "Provider" means one who is licensed to practice chiropractic.

(17) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(18) "State Plan" means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with Part 430, Subpart B, of Title 42 of the Code of Federal Regulations (CFR).

(19) "Subluxation" means an incomplete dislocation, off centering, misalignment fixation of a joint or abnormal spacing of a vertebra as used by the practitioner of chiropractic.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-537 Provider participation

In order to enroll in the Medical Assistance Program and receive payment from the department, providers shall:

(a) meet and maintain all applicable licensing, accreditation, and certification requirements;

(b) meet and maintain all departmental enrollment requirements; and

(c) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-538 Eligibility

Payment for chiropractic services shall be available on behalf of all persons eligible for the Medical Assistance Program subject to the conditions and limitations which apply to these services.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-539 Services covered and limitations

(a) Except for the limitations and exclusions listed below, the department shall pay for the following:

(1) the manual manipulation of the spine, but not for any procedures or services of an unproven, educational, social, research, experimental, or cosmetic nature; for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history;

(2) services provided in the provider's office, client's home, hospital, nursing facility, rest home, home for the aged, boarding home, or intermediate care facility for the mentally retarded (ICF/MR); and

(3) HealthTrack Services and HealthTrack Special Services.

(b) Limitations on covered services shall be as follows:

(1) those services listed in the department's fee schedule and within the scope of the provider's practice;

(2) the department shall pay for no more than one visit per day per client per provider; and

(3) the department shall pay for a maximum of four exams or treatments in a single visit to a home, hospital, nursing facility, rest home, home for the aged, boarding home, or intermediate care facility for the mentally retarded (ICF/MR).

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-540 Services not covered

The department shall not pay for the following chiropractic services which are not covered under the Medical Assistance Program:

(1) chiropractic practice does not include the prescription or administration of any medication or drug or the performance of any surgery;

(2) x-rays furnished by a practitioner of chiropractic;

(3) manipulation of other parts of the body, such as the shoulder, arm or knee, even when for subluxation of the spine;

(4) lab work ordered by a practitioner of chiropractic;

(5) for information or services provided to a client over the telephone; and

(6) for cancelled office visits or appointments not kept.

History

• Adopted effective March 6, 1998; Amended September 20, 2024

Regs., Conn. State Agencies § 17b-262-541 Need for service

The department shall pay for medically necessary and medically appropriate treatment only when:

(a) provided by a licensed practitioner of chiropractic and the services are within the scope of practice of the practitioner, and

(b) the services are made part of the client's medical record.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-542 Prior authorization

(a) Prior authorization, on forms and in a manner as specified by the department, is required for:

(1) manipulation of the spine in excess of five per client per provider per month; and

(2) HealthTrack Special Services. HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis. The request for HealthTrack Special Services shall include:

(A) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service required;

(B) a description of the outcomes of any alternative measures tried; and

(C) if applicable and requested by the department, any other documentation required in order to render a decision.

(b) The procedure or course of treatment authorized shall be initiated within six months of the date of authorization.

(c) The initial authorization period shall be up to three months.

(d) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be considered up to six months per request.

(e) For services requiring prior authorization, a provider shall be required to provide pertinent medical or social information adequate for evaluating the client's medical need for services. Except in emergency situations, or when authorization is being requested for more than one visit in the same day, approval shall be received before services are rendered.

(f) In an emergency situation which occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval on the next working day for the services provided. This applies only to those services which normally require prior authorization.

(g) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-543 Billing procedures

(a) The amount billed to the department shall represent the practitioner of chiropractic's usual and customary charge for the services delivered.

(b) Claims from practitioners of chiropractic shall be submitted on a hard copy invoice or electronically transmitted to the department's fiscal agent, in a form and manner as specified by the department, and shall include all information required by the department to process the claim.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-544 Payment

(a) Payment shall be made at the lowest of:

(1) the provider's usual and customary charge to the general public;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount billed by the provider; or

(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

(b) Payment Rate

(1) The commissioner establishes the fees contained in the practitioner of chiropractic's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

(2) Payment rates, as established by the commissioner, are the same for in- and out-of-state providers.

(c) Payment Limitations

The fee paid by the department for visits to a home, hospital, nursing facility, rest home, home for the aged, boarding home, or intermediate care facility for the mentally retarded (ICF/MR) shall include payment for travel and all such incidental expenses.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-545 Documentation

(a) Practitioners of chiropractic shall maintain a specific record for all services received for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, a current treatment plan signed by the provider, documentation of services provided, and the dates the services were provided.

(b) All required documentation shall be maintained for at least five years in the practitioner of chiropractic's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained or provided to the department upon request.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-546 Reserved

Sec. 17b-262-546. Reserved

Regs., Conn. State Agencies § 17b-262-547 Scope

Sections 17b-262-547 through 17b-262-557 inclusive set forth the Department of Social Services requirements for payment of natureopathic services provided by licensed natureopaths for clients who are determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-548 Definitions

For the purposes of sections 17b-262-547 through 17b-262-557 the following definitions shall apply:

(1) "Acute" means having rapid onset, severe symptoms, and a short course.

(2) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.

(3) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.

(4) "Department" means the Department of Social Services or its agent.

(5) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily part or organ.

(6) "HealthTrack Services" means the services described in subsection (r) of section 1905 of the Social Security Act.

(7) "HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with subdivision (5) of subsection (r) of section 1905 of the Social Security Act, and are:

(A) services not covered under the State Plan or contained in a fee schedule published by the department; or

(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.

(8) "Interperiodic Encounter" means any medically necessary visit to a Connecticut Medical Assistance provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(9) "Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(10) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(11) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes (CGS) and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(12) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or prevent a medical condition from occurring.

(13) "Medical Record" means the definition contained in section 19a-14-40 of the Regulations of Connecticut State Agencies, which is also the Public Health Code.

(14) "Natureopathy" means the practice of natureopathy as defined in subsections (a) and (b) of section 20-34 of the Connecticut General Statutes.

(15) "Prior Authorization" means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods.

(16) "Provider" means one who is licensed to practice natureopathy.

(17) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(18) "State Plan" means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with Part 430, Subpart B, of Title 42 of the Code of Federal Regulations (CFR).

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-549 Provider participation

In order to participate in the Medical Assistance Program and receive payment from the department, providers shall:

(a) meet and maintain all applicable licensing, accreditation, and certification requirements,

(b) meet and maintain all departmental enrollment requirements, and

(c) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-550 Eligibility

Payment for natureopathic services shall be available on behalf of all persons eligible for the Medical Assistance Program subject to the conditions and limitations which apply to these services.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-551 Services covered and limitations

Except for the limitations and exclusions listed below, the department shall pay for the professional services of a licensed natureopath which conform to accepted methods of diagnosis and treatment, but shall not pay for any procedures or services of an unproven, educational, social, research, experimental, or cosmetic nature; for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history.

(a) The department shall pay for the following:

(1) services provided in the provider's office or client's home, hospital, nursing facility, rest home, home for the aged, boarding home, or intermediate care facility for the mentally retarded (ICF/MR), and

(2) HealthTrack Services and HealthTrack Special Services.

(b) Limitations on covered services shall be as follows:

(1) services covered shall be limited to those listed in the department's fee schedule and within the scope of the provider's practice;

(2) only one visit per day per client per provider shall be paid for; and

(3) the department shall pay for a maximum of four exams or treatments in a single visit to a home, hospital, nursing facility, rest home, home for the aged, boarding home, or intermediate care facility for the mentally retarded (ICF/MR).

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-552 Services not covered

The department shall not pay for the following natureopathic services:

(a) the administration of internal medication or substances simulating medicine, or the form of medicine;

(b) the administration of dehydrated foods;

(c) for information or services provided to a client over the telephone; and

(d) for cancelled office visits or appointments not kept.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-553 Need for service

The department shall pay for medically necessary and medically appropriate treatment only when:

(a) provided by a licensed natureopath and the services are within the scope of the natureopath's scope of practice, and

(b) the services are made part of the client's medical record.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-554 Prior authorization

(a) Prior authorization, on forms and in a manner as specified by the department, shall be required for:

(1) professional office or home visits in excess of five per client per provider per month, and

(2) HealthTrack Special Services. HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis. The request for HealthTrack Special Services shall include:

(i) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service requested;

(ii) a description of the outcomes of any alternative measures tried; and

(iii) if applicable and requested by the department, any other documentation required in order to render a decision.

(b) The procedure or course of treatment authorized shall be initiated within six months of the date of authorization.

(c) The initial authorization period shall be up to three months.

(d) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be considered up to six months per request.

(e) For services requiring prior authorization, a provider shall be required to provide pertinent medical or social information adequate for evaluating the client's medical need for services. Except in emergency situations, or when authorization is being requested for more than one visit in the same day, approval shall be received before services are rendered.

(f) In an emergency situation which occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval on the next working day for the services provided. This applies only to those services which normally require prior authorization.

(g) Eligibility for Medical Assistance Program coverage must be verified at every visit even though prior authorization has been received for the entire number of visits.

(h) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-555 Billing procedures

(a) Claims for natureopathic services shall be submitted on hard copy invoice or electronically transmitted to the department's fiscal agent, in a form and manner as specified by the department, and shall include all information required by the department to process the claim.

(b) The amount billed to the department shall represent the provider's usual and customary charge for the services delivered.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-556 Payment

(a) Payment shall be made at the lowest of:

(1) the provider's usual and customary charge to the general public;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount billed by the provider; or

(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

(b) Payment Rate

(1) The commissioner establishes the fees contained in the natureopath's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

(2) Payment rates, as established by the commissioner, are the same for in- and out-of-state providers.

(c) Payment Limitations

The fee issued by the department for visits to a home, hospital, nursing facility, rest home, home for the aged, boarding home, or intermediate care facility for the mentally retarded (ICF/MR) shall include payment for travel and all such incidental expenses.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-557 Documentation

(a) Natureopathic care providers shall maintain a specific record for all services received for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, a current treatment plan signed by the provider, documentation of services provided, and the dates the services were provided.

(b) All required documentation shall be maintained for at least five years in the natureopathic care provider's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained or provided to the department upon request.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-558 Reserved

Sec. 17b-262-558. Reserved

Regs., Conn. State Agencies § 17b-262-559 Scope

Sections 17b-262-559 through 17b-262-571, inclusive, set forth the Department of Social Services requirements for payment of accepted methods of treatment provided by an ophthalmologist, optometrist, or optician for clients who are determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-560 Definitions

For the purposes of sections 17b-262-559 through 17b-262-571 the following definitions shall apply:

(1) "Acute" means having rapid onset, severe symptoms, and a short course.

(2) "Client" means a person eligible for goods or services under the department's Medical Assistance Program.

(3) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.

(4) "Department" means the Department of Social Services or its agent.

(5) "Doctor of Osteopathy" means a doctor of osteopathy licensed pursuant to section 20-17 of the Connecticut General Statutes.

(6) "Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT)" means the services described in subsection (r) of section 1905 of the Social Security Act.

(7) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

(8) "Fees" means the rates for services, treatments, and drugs administered by ophthalmologists, optometrists, and opticians which shall be established by the commissioner of the department and contained in the department's fee schedules.

(9) "Incomplete Eye Exam" means an annual eye exam which is not completed since the preliminary findings reveal that visual analysis is not indicated.

(10) "Interperiodic Encounter" means any medically necessary visit to a Connect-icut Medical Assistance provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(11) "Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(12) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(13) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes (CGS) and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(14) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or prevent a medical condition from occurring.

(15) "Medical Record" means the definition contained in section 19a-14-40 of the Regulations of Connecticut State Agencies, which is also the Public Health Code.

(16) "Modified Lens Prescription" means a prescription given to a client because of:

(A) a radical change in the prescription;

(B) a large initial prescription; or

(C) amblyopia, latent hyperopia, or inadequate care previously received.

(17) "Ophthalmologist" means a physician licensed pursuant to Chapter 370 of the Connecticut General Statutes, who within his or her scope of practice as defined by state law, specializes in the branch of medicine dealing with the structure, functions, pathology, and treatment of the eyes. The practice includes the use of surgery, x-ray, photocoagulation, ionizing radiation, and drugs for examination of the eyes.

(18) "Optician" means an individual licensed pursuant to section 20-145 of the Connecticut General Statutes having a knowledge of optics and is skilled in the technique of producing and reproducing ophthalmic lenses and kindred products and who, within his or her scope of practice as defined by state law, prepares and dispenses ophthalmic lenses and products to correct visual defects.

(19) "Optometrist" means an individual licensed pursuant to Chapter 380 of the Connecticut General Statutes to practice optometry as delineated in subsections (a) (1) and (2) of section 20-127 of the Connecticut General Statutes.

(20) "Physician" means a physician licensed pursuant to section 20-10 of the Connecticut General Statutes.

(21) "Prior Authorization" means approval for the provision of a service or delivery of goods from the department before the provider actually provides the service or delivers the goods.

(22) "Progressive Myopia" means a known progressive myopia, changing .75 diopters in the past six months.

(23) "Provider" means a licensed ophthalmologist, optometrist, or optician.

(24) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(25) "State Plan" means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with Part 430, Subpart B, of Title 42 of the Code of Federal Regulations (CFR).

(26) "Usable Lens" means a lens which is not scratched or otherwise defective so as to impair use or endanger the wearer.

(27) "Usual and Customary Charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, usual and customary shall be defined as the median charge. When calculating the median charge, token charges for charity patients and other exceptional charges are to be excluded.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-561 Provider participation

In order to enroll in the Medical Assistance Program and receive payment from the department, providers shall:

(a) meet and maintain all applicable licensing, accreditation, and certification requirements;

(b) meet and maintain all departmental enrollment requirements; and

(c) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies the conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-562 Eligibility

Payment for vision care services shall be available on behalf of all persons eligible for the Medical Assistance Program subject to the conditions and limitations which apply to these services.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-563 Services covered and limitations

(a) Except for the limitations and exclusions listed below, the department shall pay for the professional services of a licensed ophthalmologist, optometrist, or optician which conform to accepted methods of diagnosis and treatment, but shall not pay for anything of an unproven, educational, social, research, experimental, or cosmetic nature; for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history.

(b) The department shall pay providers for:

(1) only those procedures listed in the provider's fee schedule and within the scope of the provider's practice;

(2) services provided in the provider's office, client's home, hospital, nursing facility, rest home, intermediate care facility for the mentally retarded (ICF/MR), chronic disease hospital, boarding home, state-owned or state-operated institution, or home for the aged;

(3) two pairs of eyeglasses, distance and near, permitted in lieu of bifocals, when need for same is substantiated in the client's medical record by clinical data from the provider; and

(4) Early periodic screening, diagnostic and treatment services.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-564 Services not covered

The department shall not pay for the following:

(a) information or services provided to a client by a provider over the telephone;

(b) cancelled office visits and appointments not kept;

(c) a spare pair of eyeglasses; and

(d) visual analysis within forty-two consecutive days from the date of an eye examination.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-565 Need for service

The department shall pay for medically necessary and medically appropriate vision care services for Medical Assistance Program eligible clients, in relation to the diagnosis for which care is required, provided that:

(a) the services are within the scope of the provider's practice;

(b) the services are made part of the client's medical record; and

(c) for contact lenses, glasses, or vision training, only when prescribed by a physician, doctor of osteopathy, or optometrist.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-566 Early periodic screening, diagnostic and treatment services

(a) Prior authorization for EPSDT services not on the Vision Care fee schedule or which are on such fee schedule but for which there are limitations in the amount, frequency or circumstances under which such services can be used, either in the fee schedule or in the Regulations of Connecticut State Agencies published by the department, may be obtained using the following procedures:

(1) Services not on the fee schedule, or for which there are limitations on their use, may be authorized on a case-by-case basis. Requests for prior authorization to provide services shall be made on forms and in a manner as specified by the department.

(2) Providers requesting prior authorization to provide services shall be required to provide pertinent medical or social information adequate for evaluating the client's medical need for services. This information shall include: (A) a written statement from the prescribing physician, or other practitioner of the healing arts, performing such services within such practitioner's respective scope of practice as defined under state law, justifying the need for the item or service requested; (B) a description of the outcomes of any alternative measures tried; and (C) if applicable and requested by the department, any other documentation required in order to render a decision.

(3) Except in emergency situations, or when authorization is being requested for more than one visit in the same day, approval shall be received before services are rendered. In an emergency situation which occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval on the next working day for the services provided.

(b) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department, in its sole discretion determines what information is necessary in order to approve an authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-567 Billing procedures

(a) Claims from providers shall be submitted on the department's designated form or electronically submitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) Claims for a full or partial eye examination in a nursing facility or a state-owned or state-operated institution shall contain the name of the prescribing practitioner.

(c) The amount billed to the department shall represent the provider's usual and customary charge for the services delivered.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-568 Payment

(a) Payment rates shall be the same for in-state and out-of-state providers.

(b) Payment for professional services shall be made at the lowest of:

(1) the provider's usual and customary charge;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department; or

(4) the amount billed by the provider.

(c) Payment for supplies and equipment shall be made at the lowest of:

(1) the provider's usual and customary charge;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department; or

(4) the amount billed by the provider.

(d) The department shall pay for lenses for clients who own their own frames and are eligible for lenses.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-569 Payment rate

The commissioner establishes the fees contained in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-570 Payment limitations

(a) Contact lenses shall be covered, when such lenses provide better management of a visual or ocular condition than can be achieved with spectacle lenses, including, but not limited to the diagnosis of: Unilateral Aphakia, Keratoconus, Corneal Transplant, and High Anisometropia.

(b) Prescription sunglasses shall be covered when light sensitivity which will hinder driving or seriously handicap the outdoor activity of a client is evident.

(c) Trifocals shall be covered only when the client has a special need due to a job training program or extenuating circumstances.

(d) Oversize lens shall be covered only when needed for physiological reasons, and not for cosmetic reasons.

(e) Services and materials covered shall be limited to those listed in the department's fee schedule.

(f) Extended wear contact lenses shall be covered for aphakia and for clients whose coordination or physical condition makes daily usage of contact lenses impossible.

(g) When the preliminary findings of an eye examination reveal that a visual analysis cannot or should not be completed, payment shall be made only for an incomplete eye exam.

(h) Providers shall be limited to a maximum of six full or partial eye examinations in a chronic disease hospital, boarding home, home for the aged, nursing facility, ICF/MR, or state-owned or state-operated institution in any one day, in any one home or institution.

(i) A written request shall be provided by the provider from the prescribing practitioner of a nursing facility and state-owned or state-operated institution, for a full or partial eye examination, to be performed on a client in the facility or institution.

(j) Payment for ocular prosthesis shall be made only to the provider performing the actual fitting.

(k) The payment limitations set forth in section 17b-262-448 of the department's regulations governing physicians' services are hereby incorporated by reference and made applicable to services provided by ophthalmologists.

(l) The department shall pay for eyeglasses for a client, as long as the client was eligible on the date the eyeglasses were ordered or requested by the client.

(m) The department shall pay for eyeglass frames when the client meets all eligibility requirements. The Medical Assistance Program published fee shall be considered maximum payment in full. A provider shall not bill the Medical Assistance Program for eyeglass frames and receive payment from the client for the difference in cost.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-571 Documentation

(a) Vision care providers shall maintain a specific record for all services and supplies received for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, a current treatment plan signed by the provider, documentation of services and supplies provided, and the dates the services or supplies were provided.

(b) All required documentation in its original form shall be maintained for at least five years in the vision care provider's file subject to review by authorized department personnel. In the event of a dispute concerning a service or supply provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the vision care provider for which the required documentation is not maintained and not provided to the department upon request.

History

• Adopted effective March 6, 1998; Amended June 11, 2003

Regs., Conn. State Agencies § 17b-262-572 Reserved

Sec. 17b-262-572. Reserved

Regs., Conn. State Agencies § 17b-262-573 Scope

Sections 17b-262-573 through 17b-262-585 inclusive set forth the Department of Social Services requirements for payment of nurse-midwifery services performed by licensed nurse-midwifes for clients who are determined eligible to receive such services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-574 Definitions

For the purposes of sections 17b-262-573 to 17b-262-585, inclusive, of the Regulations of Connecticut State Agencies, the following definitions apply:

(1) “Accountable provider” means the maternity billing provider entity delivering services under the physicians’ services benefit category;

(2) “Acute” means having rapid onset, severe symptoms, and a short course;

(3) “Admission” means the formal acceptance by a hospital of a client who is to receive health care services while lodged in an area of the hospital reserved for continuous nursing services;

(4) “Advanced practice registered nurse” means a person licensed pursuant to section 20-94a of the Connecticut General Statutes;

(5) “Allied Health Professional” or “AHP” means a qualified individual, other than a physician, who: (A) Is qualified by special training, education, skills and experience in health care and treatment, (B) is certified or licensed by the Department of Public Health as one or more of the following: Psychologist, licensed clinical social worker, advanced practice registered nurse, nurse-midwife, physician assistant, licensed professional counselor, licensed marital and family therapist, licensed alcohol and drug counselor, physical therapist, occupational therapist, speech pathologist, audiologist, optician, optometrist, respiratory care practitioner, certified doula or such other category of licensed health care professional that the department permits to enroll individually as a Medicaid provider or meets other applicable qualifications approved in writing by the department and incorporated into the Medicaid State Plan or other applicable federally authorized state Medicaid document, (C) acts within the AHP’s scope of practice under state law and (D) complies with all requirements in 42 CFR 440, as amended from time to time, applicable to the AHP;

(6) “Billing provider” means a physician, physician group or other entity enrolled in Medicaid that bills the department for physicians’ services;

(7) “Case rate payments” means provider-specific monthly payments that reimburse a subset of services included in the maternity episode and provided during the prenatal, labor and delivery, and postpartum periods;

(8) “Certified doula” means a doula who is certified pursuant to section 20-86bb of the Connecticut General Statutes;

(9) “Child” means a person who is under twenty-one years of age;

(10) “Client” or “member” means a person eligible for goods or services under Medicaid;

(11) “Commissioner” means the Commissioner of Social Services;

(12) “Department” means the Department of Social Services or its agent;

(13) “Early and Periodic Screening, Diagnostic and Treatment services” or “EPSDT services” means the services provided in accordance with section 1905(r) of the Social Security Act, as amended from time to time;

(14) “Emergency” means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part;

(15) “Essentially Normal” means a philosophic view of childbirth as a natural, normal process. Essentially normal means that if a client develops complications, the nurse-midwife either consults or collaborates with the physician in the management of care of the client or, depending on the severity of the complication, refers the client to the physician. This reflects again the team relationship with the physician, because normal is defined by the nurse-midwifes and physicians in a particular practice setting;

(16) “Family planning services” means any medically approved diagnostic procedure, treatment, counseling, drug, supply or device that a provider prescribes or furnishes to individuals of childbearing age for the purpose of enabling such individuals to freely plan the number and spacing of their children;

(17) “Fees” means the payments for services, treatments, and drugs administered by nurse practitioners which the commissioner establishes and includes in the department’s fee schedules;

(18) “Licensed Practitioner of the Healing Arts” means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH);

(19) “Long-Term Care Facility” means a medical institution which provides, at a minimum, skilled nursing services or nursing supervision and assistance with personal care on a daily basis. Long-term care facilities include:

(A) nursing facilities,

(B) chronic disease hospitals—inpatient, and

(C) intermediate care facilities for individuals with intellectual disabilities (ICF/IID);

(20) “Maternity bundle episode” or “bundle” or “episode” means a defined group of maternity-related Medicaid covered services provided to a specific patient over a specific period of time;

(21) “Maternity Cycle” means a period limited to:

(A) pregnancy

(B) labor,

(C) birth, and

(D) the postpartum period as defined by the Department;

(22) “Medicaid” means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(23) “Medical necessity” or “medically necessary” have the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(24) “Medical record” has the same meaning as provided in section 19a-14-40 of the Regulations of Connecticut State Agencies;

(25) “Nurse-midwife” has the same meaning as provided in section 20-86a of the Connecticut General Statutes;

(26) “Nurse-midwifery Services” means the services described in subdivision (1) of section 20-86a and section 20-86b of the Connecticut General Statutes;

(27) “Performing provider” means the physician or AHP who actually performs the service;

(28) “Performance year” means the specific time period during which the accountable provider’s performance is measured to determine financial incentives or penalties or both, and the first Performance Year (PY1) is defined as January 1, 2025 to December 31, 2025;

(29) “Physician” means a person who is: (A) Licensed pursuant to section 20-13 of the Connecticut General Statutes and (B) acting within the physician’s scope of practice under state law;

(30) “Prior Authorization” means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods;

(31) “Provider” means a licensed nurse-midwife;

(32) “Referral” means the nurse-midwife's request for a consultation and collaboration with the physician on a client which results in the physician providing the care for the client; and

(33) “State Plan” means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with 42 CFR 430, Subpart B, as amended from time to time.

History

• Adopted effective March 6, 1998; Amended December 24, 2025

Regs., Conn. State Agencies § 17b-262-575 Provider participation

In order to enroll in the Medical Assistance Program and receive payment from the department, a nurse-midwife shall:

(a) meet all applicable licensing, accreditation, and certification requirements;

(b) meet and maintain all departmental enrollment requirements; and

(c) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies the conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-576 Eligibility

Payment for nurse-midwifery services shall be available on behalf of all women and newborns, only throughout the maternity cycle, eligible for the Medical Assistance program subject to the conditions and limitations which apply to these services.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-577 Services covered and limitations

Except for the limitations and exclusions listed below, the department shall pay for the professional services of a licensed and certified nurse-midwife which conform to accepted methods of diagnosis and treatment, but shall not pay for any procedures or services of an unproven, educational, social, research, experimental, or cosmetic nature; for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client’s condition; or for services not directly related to the client’s diagnosis, symptoms, or medical history.

(a) The department shall pay for the following:

(1) services provided in the provider’s office, client’s home, hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities (ICF/IID), chronic disease hospital, boarding home, state-owned or -operated institution, or home for the aged; and

(2) family planning services as described in the Regulations of Connecticut State Agencies.

(b) Limitations on covered services shall be as follows:

(1) services concerned with the care and management of the care of essentially normal mothers and newborns, only throughout the maternity cycle, and well-woman gynecological care, including family planning services; and

(2) services covered shall be limited to these listed in the department’s applicable fee schedule.

History

• Adopted effective March 6, 1998; Amended December 24, 2025

Regs., Conn. State Agencies § 17b-262-578 Services not covered

The department shall not pay for the following:

(a) nurse-midwifery services to newborns occurring beyond the maternity cycle;

(b) any examinations, laboratory tests, biological products, immunizations, or other products which are furnished free of charge;

(c) information or services provided to a client by a provider over the telephone;

(d) an office visit for the sole purpose of the client obtaining a prescription where the need for the prescription has already been determined; and

(e) cancelled office visits and appointments not kept.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-579 Need for service

The department shall pay for medically necessary and appropriate nurse-midwifery services for Medical Assistance Program eligible clients:

(a) requiring care during an essentially normal maternity cycle or requiring well-woman gynecological care;

(b) of child-bearing age who indicate a need for family planning services and are free from coercion or mental pressure and are free to choose the method of family planning to be used;

(c) provided by a licensed and certified nurse-midwife within the scope of the nurse-midwife's practice; and

(d) if the services are made part of the client's medical record.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-580 Prior authorization

(a) Prior authorization, on forms and in a manner as specified by the department, is required for:

(1) more than one visit per day per client; and

(2) HealthTrack Special Services.

(A) HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis; and

(B) the request for HealthTrack Special Services shall include:

(i) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or services required;

(ii) a description of the outcomes of any alternative measures tried; and

(iii) if applicable and requested by the department, any other documentation required in order to render a decision.

(b) The procedure or course of treatment authorized shall be initiated within six months of the date of authorization.

(c) The initial authorization period shall be up to three months.

(d) If prior authorization is needed beyond the initial authorization period, request for continued treatment beyond the initial authorization period shall be considered up to six months per request.

(e) For services requiring prior authorization, a nurse-midwife shall be required to provide pertinent medical or social information adequate for evaluating the client's medical need for services. Except in emergency situations, or when authorization is being requested for more than one visit in the same day, approval shall be received before services are rendered.

(f) In an emergency situation which occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval on the next working day for the services provided. This applies only to those services which normally require prior authorization.

(g) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-581 Billing procedures

(a) Claims from nurse-midwifes shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) If a provider assumes the continuing care of a client or provides services to a client as a result of a referral by a nurse-midwife because the services cannot be provided by the nurse-midwife, an obstetrical-gynecological surgical procedure as an example, this procedure would be billed as a separate procedure, by any provider giving this service.

(c) When a Medical Assistance Program client is referred to a provider for consultation, the consultant provider shall include the referring practitioner's provider number and name. If no provider number has been assigned, the consultant provider shall enter the entire name as well as the state license number of the referring provider on the billing form.

(d) The fee for routine care of a newborn in the hospital shall be all inclusive and shall be billed only once per child. The fee includes initiation of diagnostic and treatment programs, preparation of hospital records, history and physical examination of the baby, and conferences with the parents. Subsequent hospital care for evaluation and management of a normal newborn is paid per day.

(e) The following routine laboratory tests shall be included in the fee for an office visit and shall not be billed on the same date of service: urinalysis without microscopy, hemoglobin determination, and urine glucose. Payment for these tests is included in the fee for a routine workup.

(f) Laboratory services performed in the nurse-midwife's office are payable to the nurse-midwife. Nurse-midwife's shall bill for these services as separate line items. When a nurse-midwife refers a client to a private laboratory for services, the laboratory shall bill directly. No laboratory charge shall then be paid to the nurse-midwife.

(g) Payment for laboratory services shall be limited to services provided by Medical Assistance providers who are in compliance with the provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA).

(h) When a newborn requires other than routine care following delivery, the provider shall bill for the appropriate critical care. The department shall not pay both the critical care and routine care for the same child.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-582 Payment

Payment shall be made at the lowest of:

(a) the provider's usual and customary charge to the general public;

(b) the lowest Medicare rate;

(c) the amount in the applicable fee schedule as published by the department;

(d) the amount billed by the provider; or

(e) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-583 Payment rate

(a) The commissioner establishes the fees contained in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

(b) Payment rates shall be the same for in-state and out-of-state providers.

(c) Nurse-midwifery rates for each procedure shall be set at 90% of the department's fee for physician procedure codes.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-584 Payment limitations

(a) The department shall pay for an initial visit by a nurse-midwife only once per client. Initial visits refer to the nurse-midwife's first contact with the client and reflect higher fees for the additional time required for setting up records and developing past history. The only exception to this is when the nurse-midwife-client relationship has been discontinued for three or more years and is then reinstated.

(b) The department shall pay for an initial visit once per inpatient hospitalization.

(c) Nurse-midwifes who are fully or partially salaried by a general hospital, public or private institution, group practice, or clinic shall not receive payment from the department unless the nurse-midwife maintains an office for private practice at a separate location from the hospital, institution, group, or clinic in which the nurse-midwife is employed. Nurse-midwifes who are solely hospital, institution, group, or clinic based, either on a full- or part-time salary are not entitled to payment from the department for services rendered to Medical Assistance Program clients.

(d) A nurse-midwife who maintains an office for private practice separate from the hospital, institution, group, or clinic, shall be able to bill for services provided at the private practice location or for services provided to the nurse-midwife's private clients in the hospital, institution, group, or clinic only if the client is not a client of the hospital, institution, group, or clinic.

(e) Fees for medical procedures shall include the fee for an emergency room visit. The department shall not pay a provider at a higher rate for any medical procedure which is performed in an emergency room.

(f) Payment for the total obstetric care procedure, shall include office visits for maternity care six months prior to delivery and six weeks after delivery.

(g) If antepartum care, vaginal delivery, or postpartum care are billed as separate procedures, total payment shall not exceed the fee for the total obstetric care procedure.

(h) If a client's medical problem necessitates the concurrent services and skills of two or more providers, each provider shall be entitled to the listed fee for the service.

(i) There shall be no payment for consultation and collaborative management services with an obstetrician-gynecologist when functioning as part of the health care team in the evaluation and treatment of a client.

(j) Although a nurse-midwife shall always function within a health care system in a team relationship with a physician which is directed and shall never be independent of physician back-up for consultation and collaborative management, or referral, directed does not necessarily imply the physical presence of the physician when care is being given by a certified and licensed nurse-midwife.

(k) Maternity Bundled Payment. This subsection sets forth the rules for bundle payment methodology for maternity care to improve maternal health and birth outcomes and, to the extent applicable, includes payment to the billing provider for the services of certified doulas, lactation consultants, community health workers and any other non-licensed provider included in the bundle payment methodology.

(1) General Provisions for Maternity Bundled Payment.

(A) The department may pay for maternity services using monthly case rate payments for certain services included in the maternity bundle episode, as defined under the Medicaid State Plan, for services across all phases of the perinatal period (including prenatal, labor and delivery, and postpartum), which focuses on the accountability and quality of care for providers.

(B) The department may provide incentive payments to maternity providers, as identified in subparagraph (C) of this subdivision, who deliver high-quality, cost-effective services throughout the episode. Providers shall be eligible for incentive payments when: (i) the provider’s target price, which is the expected total cost of care for a bundle based on the statewide average cost and the provider’s historical cost, is not exceeded, (ii) the provider meets quality performance criteria, and (iii) the provider complies with the department’s goals to monitor and prevent under-service, such as risk-based patient selection as well as decreased utilization of services.

(C) This subsection shall apply to the following performing providers: Physicians, advanced practice registered nurses, physician assistants, and nurse-midwives with obstetrician-gynecology board certification or equivalent credential and expertise in maternity services.

(2) Provider Participation Requirements for Maternity Bundled Payment.

(A) All qualified maternity provider practices meeting the qualifications in subdivision (1) of this subsection shall participate in the bundle payment methodology.

(B) Providers who do not meet the minimum episode volume threshold, as set by the department, shall not be eligible to participate in the bundle payment methodology and shall be reimbursed fee-for-service (FFS) with no opportunity to earn incentive payments.

(3) Case Rate Payments for Maternity Bundled Payment.

(A) The department’s bundle accountability methodology shall determine the accountable provider.

(B) Prior to the establishment of bundle accountability, the department shall pay all maternity claims on an FFS basis.

(C) After the establishment of bundle accountability, the department shall pay a monthly case rate to the accountable provider for a subset of services, as outlined under the Medicaid State Plan. All other covered services not included in the monthly case rate shall be paid FFS.

(D) In accordance with the Medicaid State Plan, the case rate payment amount shall be based on the maternity provider’s historical cost, and the case rate shall be reassessed not more frequently than once every twelve months.

(E) Payment to the maternity provider practice meeting the qualifications in subdivision (1) of this subsection may also include payment for services provided by non-licensed professionals as designated by the department, including, but not limited to, certified doulas, community health workers, and lactation consultants.

(F) The bundled payment shall not change any reimbursement methodology for any provider other than as described in this subsection.

(4) Incentive Payments for Maternity Bundled Payment.

(A) Providers meeting the qualifications in subdivision (1) of this subsection shall be eligible to receive incentive payments in accordance with the applicable methodology. The accountable provider meeting the qualifications in subdivision (1) of this subsection shall be eligible to earn incentive payments but shall not be subject to returning any portion of increased program expenditures accountable to the provider.

(B) Except for exclusions listed under the Medicaid State Plan, all Medicaid claim costs for covered services related to maternity care shall be included in the incentive payment calculations of the bundle. The incentive payment calculation shall be based on the difference between the expected costs and the actual costs of all applicable covered services provided to the birthing member, regardless of the specific maternity provider who performed each service.

(C) The distribution of incentive payments for savings for Medicaid shall be adjusted based upon the accountable provider’s performance of the quality measures established by the department. The distribution of incentive payments shall also be subject to clinical and social risk adjustment.

(D) Not later than fifteen months after each performance year, the department shall provide each accountable provider with a written description of the accountable provider’s results regarding performance on quality measures, applicable Medicaid expenditures for maternity bundled payment members assigned to the accountable provider and calculation of incentive payments, as applicable, for said members. After receiving said description from the department, the accountable provider may respond to any calculations, results, or decisions contained therein. Such response shall be in writing, be received by the department not later than thirty days after the accountable provider receives the written description from the department and include all supporting documentation. The department shall issue a written decision not later than thirty days after receiving the accountable provider’s response. There shall be no further right to review the department’s decisions regarding the written description described in this subparagraph, other than as described in this subparagraph. There shall be no right to review the final distribution of incentive payments for the maternity bundled payment.

History

• Adopted effective March 6, 1998; Amended December 24, 2025

Regs., Conn. State Agencies § 17b-262-585 Documentation

(a) Nurse-midwifes shall maintain a specific medical record for all services rendered to each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, a current treatment plan signed by the nurse-midwife, documentation of services provided, and the dates the services were provided.

(b) All required documentation shall be maintained for at least five years in the nurse-midwife's file subject to review by the authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the nurse-midwife for which the required documentation is not maintained or provided to the department upon request.

History

• Adopted effective March 6, 1998

Regs., Conn. State Agencies § 17b-262-586 Reserved

Sec. 17b-262-586. Reserved

Regs., Conn. State Agencies § 17b-262-587 Purpose and scope

Sections 17b-262-587 through 17b-262-596b, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment of personal care assistance services for adults. The Department operates the Personal Care Assistance Waiver Program that assists eligible disabled adults by paying for personal care assistance services. The purpose of sections 17b-262-587 through 17b-262-596b, inclusive, of the Regulations of Connecticut State Agencies is to describe the program requirements, services available and limitations under (1) the Personal Care Assistance Waiver Program, which is conducted under a federal waiver under section 1915(c) of the Social Security Act to the Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-588 Definitions

For the purposes of sections 17b-262-587 through 17b-262-596b, inclusive, of the Regulations of Connecticut State Agencies, the following definitions shall apply:

(1) "Activities of Daily Living" means hands-on activities or tasks, which are essential for a consumer's healthful and safe existence and include, but are not limited to: bathing, dressing, eating, transfers, and bowel and bladder care.

(2) "Adult" means a person 18 through 64 years of age inclusive.

(3) "Applicant" means a person who directly or through a representative completes a Personal Care Assistance Request Form and submits it to the department.

(4) "Assessment" means a comprehensive written evaluation conducted by non-medical department personnel which uses a standard assessment form and which consists of:

(A) an identification of the consumer's limitations in activities of daily living;

(B) the identification of the personal care assistance services required by the consumer and a determination that such services are appropriate for the consumer and, in the non-medical opinion of the department can reasonably be expected to meet the health and safety needs of the consumer;

(C) identification of the training and support needs of the consumer for personal care assistance services;

(D) a face-to-face interview with the consumer;

(E) documentation of the number of hours needed by the consumer to complete the activities of daily living and instrumental activities of daily living with the help of a personal care assistant;

(F) a determination confirming that the consumer would otherwise require institutional care in a nursing facility;

(G) development of a total cost of care plan for the consumer; and

(H) development of a consumer personal care services plan.

(5) "Average nursing facility cost" means a weighted average calculated by multiplying the nursing facility Medical Assistance Program rates in effect on July 1 of each calendar year for each facility by their respective number of days, adding the products and then dividing that total by the total patient days, and reducing the result by the average applied income for nursing facility patients.

(6) "Consumer" means an applicant or eligible person.

(7) "Commissioner" means the chief executive officer of the department appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.

(8) "Cost Effective" means the Department's payments for the consumer's total costs of care do not exceed the average nursing facility cost.

(9) "Cost-of-Care Plan" means a plan, which specifies all costs to the State of Connecticut that are associated with the care of the consumer.

(10) "Department" means the Department of Social Services or its agent.

(11) "Eligible Person" means an applicant who meets the criteria to receive personal care assistance services in accordance with section 17b-262-589 of the Regulations of Connecticut State Agencies and who meets all the eligibility requirements for participation in the Medicaid program as set forth in the Department's regulations that are contained in its Uniform Policy Manual.

(12) "Fiscal Intermediary" means an organization selected by the department to perform the payroll function for the administration of this program including but not limited to the fulfillment of all household employer tax obligations.

(13) "Instrumental Activities of Daily Living" means household maintenance activities and tasks, which are essential for a consumer's healthful and safe existence and include, but are not limited to: cooking, cleaning, and shopping.

(14) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319v of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time.

(15) "Nursing Facility" means an institution as defined in section 1919 of the Social Security Act, as amended from time to time, that participates in Connecticut's Title XIX medical assistance program pursuant to the terms of a provider agreement with the Department.

(16) "Personal Care Assistance Request Form" means a department form used to screen a consumer for financial and functional eligibility for personal care assistance services.

(17) "Personal Care Assistant" means any person, excluding the consumer's spouse, and excluding the consumer's conservator and any person related to the consumer's conservator who is employed by the consumer or the consumer's conservator and is qualified to assist the consumer in carrying out the tasks required in the personal care services plan.

(18) "Personal Care Assistance Services" or "Services" means physical assistance to enable the consumer to carry out activities of daily living and instrumental activities of daily living.

(19) "Personal Care Services Plan" or "Service Plan" means an individualized written plan documenting all necessary personal care assistance services, hours, costs, and training requirements for the consumer as determined by an assessment.

(20) "Personal Emergency Response System" (PERS)- means an electronic device that enables consumers to secure help in an emergency. The system is connected to the person's phone and programmed to signal a response center once the help button is activated. PERS service providers shall be enrolled as performing providers under Medicaid.

(21) "Representative" means a person designated by the consumer to act for the consumer and under the consumer's direction for purposes such as completing paperwork, making phone calls, advertising for personal care assistants, assisting with interviewing or scheduling, and sending paperwork to the fiscal intermediary. When the consumer has a court appointed conservator that person shall act as the consumer's representative in all matters. The conservator cannot also be employed as the consumer's personal care assistant or be related to any person employed as the consumer's personal care assistant.

(22) "Uniform Policy Manual" means department regulations promulgated pursuant to section 17b-10 of the Connecticut General Statutes governing eligibility for public assistance and special programs, and maintained in policy manual form including the Department's Title XIX medical assistance program.

(23) "Waiting List" means a record maintained by the department, which includes the names of the consumers seeking personal care assistance services, and specifies the date the Personal Care Assistance Request Form was received.

(24) "Waiver Program" means the program described in the federal waiver approved pursuant to section 1915(c) of the Social Security Act, as amended from time to time, by the Secretary of the United States Department of Health and Human Services for the provision of personal care assistance services to adults, as a partially federally reimbursed service that may be provided under Connecticut's Medicaid program.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-589 Eligibility and determination of need

(a) In order to be eligible to receive coverage for the cost of personal care assistance services under the Department's Personal Care Assistance Waiver Program, an individual shall either have already been determined eligible to participate in the Department's Title XIX medical assistance program and also be determined to meet the additional programmatic requirements for coverage of personal care assistance services that are specified in this section or qualify for personal care assistance services by meeting all of the technical, special financial, and programmatic requirements stated in this section.

(b) An individual who has not previously been determined eligible for medical assistance and who receives personal care assistance services after meeting the requirements of this section is thereby automatically determined eligible for the medical assistance program and for all other medically necessary services that are covered by the program.

(c) The technical requirements for eligibility are:

(1) A recipient of medical assistance benefits who applies for coverage of personal care assistance services and applicants for personal care assistance services shall meet all requirements for eligibility in the Department's medical assistance program that are applicable to disabled adults as stated in the regulations promulgated by the Department and contained in its Uniform Policy Manual pursuant to Section 17b-10 of the Connecticut General Statutes, including, without limitation, all regulations establishing medical assistance eligibility requirements related to the filing of applications for assistance, verifications, redeterminations, existence of a disabling condition, citizenship status, residency, institutional status, assistance unit composition and income and asset limits.

(2) Applicants for personal care assistance services are treated as if they were institutionalized and all medical assistance eligibility rules that apply to institutionalized applicants or recipients of medical assistance benefits are also applied in the same way to applicants or recipients of personal care assistance services. Specifically, without limiting the scope of this subsection, applicants and recipients for personal care assistance services are subject to the same rules that govern eligibility related to the transfer of assets and to the treatment of the resources and income of spouses of institutionalized applicants for assistance.

(d) The special financial eligibility rules are:

(1) A recipient of medical assistance benefits who applies for personal care assistance services or an applicant for personal care assistance services who meets all other technical requirements for eligibility may only be found eligible for personal care assistance services if his or her countable income is less than the special institutional income limit of 300 percent of the benefit amount that would be payable under the federal Supplemental Security Income ("SSI") program to an individual in his or her own home who has no income or resources. Income eligibility for personal care assistance services under this section is determined solely by reference to the individual's countable income, and does not involve consideration of the incurred medical expenses or any other liabilities that may have been incurred by the applicant for assistance. Except as noted below, the applicant's countable income for purposes of this subsection is determined by reference to the same methodologies that are employed by the Department in determining the countable income of an institutionalized applicant for assistance. Individuals who qualify for medical assistance related to the treatment of income under other optional coverage groups, including the medically needy, but who do not qualify for personal care assistance services under the 300 percent of the SSI income limit, may receive coverage of medically necessary services to the extent such services are available generally to recipients of medical assistance, but may not receive coverage for those services that are only provided to individuals who are covered under this or any other waiver of federal Medicaid requirements.

(2) An applicant or recipient of assistance may not reduce his or her income, or fail to pursue potential sources of income in order to obtain or retain eligibility for assistance under the special institutional income limit of 300 percent of the SSI benefit amount.

(e) The programmatic requirements for eligibility are:

In addition to meeting all technical and special financial eligibility requirements stated above in subsections (c) and (d) of this section, an applicant for coverage of personal care assistance services shall meet all of the following programmatic requirements for eligibility:

(1) the consumer shall be 18 through 64 years of age inclusive;

(2) the consumer shall have a primary medical diagnosis that is a chronic, severe, and permanent physical disability which results in a significant need for physical assistance with two or more of the following activities of daily living: bathing, dressing, eating, transfers, bowel and bladder care; and the consumer shall be in a condition that would otherwise require institutionalization in a nursing facility without such services. An individual whose primary disability is mental retardation, mental illness or whose need for personal care assistance is the result of a degenerative neurologically based dementia, including but not limited to Alzheimer's disease, is not eligible for personal care assistance services. In the case of dual diagnosis, the Department may request an assessment, made by a qualified medical provider, to determine which disabling condition is primary;

(3) the consumer shall have the cognitive ability to be the essential participant in the development of his or her personal care services plan and to hire, direct, and fire his or her personal care assistants unless the consumer has a conservator who acts on his or her behalf and fulfills the foregoing requirements;

(4) the consumer shall lack family and community supports to meet his or her needs for personal care assistance services;

(5) the consumer shall wish to live in the community by utilizing personal care assistance services;

(6) the consumer shall be capable of understanding and shall acknowledge that there is risk inherent in his or her living in the community, that his or her safety cannot be guaranteed, and shall accept full liability if he or she chooses to live in the community and absolve the Department of responsibility for anything that might result from this choice;

(7) the consumer shall acknowledge that he or she is the employer of his or her personal care assistants and shall sign a written document accepting full responsibility as the employer of his or her personal care assistants;

(8) the consumer, in order to insure his or her health and safety, shall have a back-up plan which shall be documented in the department's record identifying how he or she will provide for personal care assistance service needs in the event that a personal care assistant is not available to provide the services as scheduled;

(9) the consumer shall file such forms as may be necessary with the Internal Revenue Service and the State Department of Labor designating the fiscal intermediary as the consumer's agent for the purpose of managing employment benefit accounts for the personal care assistants and shall provide all other documentation needed by the fiscal intermediary in order to process payroll;

(10) the consumer shall have a personal care assistance plan that is cost effective; (refer to section 17b-262-594)

(11) the consumer shall replace state funded homemaker, companion, and personal care assistance services provided by the Department under the Community Based Services Program or Personal Care Assistance Working Person's Program with personal care assistance services under this waiver program;

(12) the consumer shall replace home health aide services provided under the Medicaid program with personal care services funded under the waiver program unless the provision of both services is otherwise determined necessary by the Department. If any home health aide services are approved, there shall be no duplication of services provided by the personal care assistance plan;

(13) if an applicant is eligible for, or receiving, comparable services under Section 101 (a)(8) of the Rehabilitation Act as amended in 1992, such applicant is ineligible for personal care assistance services under this Personal Care Assistance Waiver program. The applicant may be eligible for additional services through the waiver as long as those services are not related to attendance at school or employment. A plan, which is developed for a consumer in these circumstances, shall be developed jointly by appropriate staff from the Department's Social Work Services Division and the consumer;

(14) the consumer shall hire qualified personal care assistants within three months of approval of the service plan and a determination of Medicaid eligibility or the application shall be denied and the consumer will not maintain his or her slot on the waiting list. The application and eligibility determination process can be resumed at any time in the future;

(15) the consumer shall pursue and accept comparable services from other resources when requested by the Department.

(f) If a cost of care plan that is both cost effective and reasonably ensures the health and safety of the consumer in the non-medical opinion of the Department cannot be developed, the consumer is not eligible for personal care assistance waiver services. If the consumer requires full time acute care hospitalization he or she is not eligible for waiver services if unable to receive them for a period of thirty days or more due to such hospitalization. A new application and assessment shall be completed for such consumer.

(g) A disabled individual who is determined eligible for and who receives personal care assistance services under this Title XIX Medical Assistance Personal Care Assistance Waiver program as an alternative to institutionalization is subject to the same rights and responsibilities as an institutionalized recipient of medical assistance, including, without limitation, those requirements relating to third party liability, securing support, recovery, and liens that are applicable to institutionalized recipients of public assistance.

(h) Any consumer who is found by the Department to have knowingly signed a time sheet authorizing payment for services that were not provided may be discharged from the Personal Care Assistance Waiver program. Any consumer discharged under this subsection shall be ineligible for personal care assistance services under the Personal Care Assistance Waiver program for a period of not more than two years.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-590 Application process

(a) The application process consists of:

(1) a financial eligibility determination by the Department in accordance with the eligibility standards for participation in the Department's Title XIX medical assistance program that are contained in the Uniform Policy Manual;

(2) a preliminary determination by central office administrative staff as to the consumer's needs and financial eligibility based on a review of the information provided on the "Personal Care Assistance Request" form; and

(3) a referral to the appropriate regional office when an assessment for services is indicated to determine if a cost effective plan of services can be developed to provide services to the person in the community.

(b) A determination as to whether the consumer needs services without which the consumer would otherwise require institutionalization shall be made by non-medical Department staff based upon an assessment conducted in collaboration with the consumer.

(c) A determination of the personal care assistance services required by the consumer shall consist of:

(1) completion of an assessment by the department; and

(2) development of a personal care services plan by the department in consultation with the consumer. The plan shall be reviewed annually or more often when a change in the consumer's condition has occurred or when other circumstances may warrant; and

(3) a determination documented on a cost of care plan of whether the personal care assistance services combined with all other state administered services are cost effective; and

(4) authorization for personal care assistance services in the community if appropriate and cost effective.

(d) Eligibility shall be redetermined annually for each recipient.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-591 Waiting list

(a) As a result of the limitation of the number of slots and/or funding, the Department shall establish and maintain a statewide waiting list for the Personal Care Assistance Waiver program when the Department has filled its maximum allocation of slots or reached the funding level in the approved waiver. Names shall be placed on the waiting list in the same order as the "Personal Care Assistance Request" form is received in Central Office.

(b) When an opening occurs, applications shall be solicited by contacting consumers in the order their names appear on the waiting list.

(c) A consumer is removed from the waiting list if he or she:

(1) asks to be removed;

(2) moves out of state;

(3) reaches age 65; or

(4) is deceased.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-592 Limitations

(a) The Department does not offer Personal Care Assistance Waiver services to more than the number of consumers specified in the federally approved Personal Care Assistance Waiver or to more than the number of consumers who can be served within the funding limitations established in the approved waiver.

(b) In order to be eligible for a personal care services plan that, combined with all other state administered home care and community based services, exceeds 60% of the average nursing facility cost, the consumer shall require physical assistance with three or more of the following activities of daily living: bathing, dressing, eating, transferring and bowel and bladder care.

(c) In order to be eligible for a personal care services plan that, combined with all other state administered home care and community based services, exceeds 80% of the average nursing facility cost, the consumer shall require assistance with all of the following activities of daily living: bathing, dressing, eating, transferring and bowel and bladder care.

(d) In addition, any plan exceeding 60% of the average nursing facility cost shall meet the following requirements:

(1) there shall be documentation of any changes in the consumer's needs or other circumstances which affect the plan if the cost of care plan exceeds the costs of services provided prior to application to this program; and

(2) the projected overall program costs for the total personal care assistance services population shall not be exceeded as a result of the approval of this consumer's personal care services plan; and

(3) all informal and family supports shall have been explored and documented in the record. It is not the intent of the program to displace services that have been provided free of charge by family members and relatives, and may reasonably be expected to continue in the future, and a personal care services plan shall not be developed which substitutes the paid services of a personal care assistant for voluntary services provided by family members.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-593 Services covered

(a) Services covered are:

(1) personal care assistance services provided in accordance with a personal care services plan which enable the consumer to carry out activities of daily living and instrumental activities of daily living in a community living arrangement; and

(2) as a result of being determined eligible for Medicaid, any other covered service to the extent that it is necessary, in accordance with Title XIX contained in the Social Security Amendments of 1965 and state and federal regulations adopted pursuant thereto.

(3) personal care assistance services up to 25.75 hours per week provided by a single personal care assistant and up to 40 hours per week provided by a single personal care assistant if the consumer documents, to the department's satisfaction, that the consumer has obtained and maintained worker's compensation insurance for the single personal care assistant and that such insurance shall remain in full force and effect for at least one year from the date the personal care assistant begins providing personal care assistance services to the consumer. Personal care assistance services beyond 25.75 hours per week shall not be covered without the submission of such documentation. The social worker shall verify the continuation of the worker's compensation insurance coverage at the time of the annual review.

(4) up to 10 additional hours of personal care assistance services beyond those already included in the approved service plan for the purpose of communicating with medical providers during a crisis or an emergency for those consumers who have difficulty communicating verbally their needs to medical providers, as determined by the social worker during the assessment process.

(5) for those consumers who either live alone or who remain at home alone with no available caregiver, a personal emergency response system (PERS) may be provided. The department social worker shall determine the need for the PERS as part of the assessment process.

(b) Services not covered are:

(1) services that are not in the consumer's approved cost of care plan;

(2) personal care assistance services provided either in a health care institution that is licensed by the Department of Public Health or in a living arrangement funded by the department which includes funding for the purpose of assisting clients to meet their daily needs as a component in the rate of reimbursement;

(3) personal care assistance services provided by the consumer's spouse, the consumer's conservator or any person related to the conservator;

(4) personal care assistance services which are duplicative of home health services which the consumer will receive concurrently while participating in the program;

(5) scheduled hours which a personal care assistant does not keep;

(6) transportation of the personal care assistant to and from the consumer's home;

(7) services in excess of those deemed necessary by the department to serve the consumer;

(8) services not related to the condition of the consumer or the consumer's physical limitations in performing activities of daily living and instrumental activities of daily living;

(9) any service that is required by state law to be provided by licensed staff;

(10) services in excess of 25.75 hours per week provided by a single personal care assistant, except as otherwise provided in subdivision (3) of subsection (a) of this section;

(11) services provided by an individual who formerly performed such services at no cost;

(12) personal care services provided at school or in the workplace;

(13) personal care services when the consumer is eligible to receive comparable services that are available from another resource;

(14) services performed by someone other than the provider designated in the service plan; and

(15) services performed by a provider who does not meet the qualifications outlined in the federally approved waiver.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-594 Determining the cost effectiveness of the service plan

In order to determine the cost effectiveness of the consumer's service plan, the Department shall do all of the following:

(1) Obtain the monthly average nursing facility cost; and

(2) Determine the monthly cost of the service plan; and

(3) Determine the monthly cost of other medical services that the consumer will require in order to live in the community. These other medical services include: home health care, nursing services, physical therapy, occupational therapy and/or speech therapy. These costs are based on the consumer's expected utilization of these services, multiplied by the Medicaid rates established by the Department for such services; and

(4) Determine the monthly cost of other state administered home and community based services. These other home and community based services costs include but are not limited to those services provided by the department's Community Based Services Program and all funds provided by programs administered by any other state agency which help to maintain the consumer in the community; and

(5) Add the cost of other medical services and other state administered home and community based services to the costs of the service plan to obtain the consumer's total cost of care; and

(6) Compare the consumer's total cost of care to the average nursing facility cost.

The Department may not approve a personal care assistance plan when the cost of all of the foregoing services exceeds the cost of care in a nursing facility.

If due to a temporary acute condition the consumer requires personal care assistance services that exceed the monthly average nursing facility cost for a period that is not expected to exceed four months, the Department, at its discretion, may approve a plan that provides such additional personal care assistance services provided that the annualized cost of personal care assistance services and other services does not exceed the annualized cost of nursing facility services.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-595 Payment

(a) Payment for personal care assistance services for adults is made at the lowest of:

(1) the maximum rate determined by the department for personal care assistance services;

(2) a rate below the maximum based on an amount the consumer has negotiated with the personal care assistant; or

(3) the amount billed.

(b) Payment is made directly to the fiscal intermediary who, on behalf of the consumer, shall pay all required employment taxes and issue paychecks to the consumer made out in the names of the personal care assistants or directly to the personal care assistants.

(c) The fiscal intermediary shall inform consumers about the requirement that they obtain worker's compensation insurance for those single personal care assistants who provide the consumer with more than 25.75 hours per week of personal care assistance services, as set forth in subdivision (3) of subsection (a) of section 17b-262-593 of the Regulations of Connecticut State Agencies, and shall not issue payment for personal care assistance services in excess of 25.75 hours per week by a single personal care assistant unless the consumer has complied with this requirement.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-596 Personal care assistant qualifications

(a) The consumer is responsible for ensuring that his or her personal care assistants meet all of the following qualifications:

(1) be at least 16 years of age except that, if the consumer chooses to hire an individual who is 16 or 17 years old, the consumer shall comply with specific standards and restrictions imposed by state and federal law;

(2) be able to understand and carry out directions given by the consumer or conservator;

(3) be physically able to perform all duties delineated in the service plan;

(4) be willing to receive training from the consumer or conservator in performance of all personal care assistance services delineated in the service plan;

(5) be able to handle emergencies; and

(6) demonstrate competencies in effective employer/employee relationships, disability awareness, use of equipment, and activities of daily living.

(b) The Commissioner shall require any person providing personal care assistance services to a consumer to submit to a criminal background check.

(c) The Commissioner shall have the discretion to refuse payments for personal care assistance services if the personal care assistant performing the services has been convicted in this state or any other state of a felony, as defined in section 53a-25 of the Connecticut General Statutes, involving forgery under section 53a-137 of the Connecticut General Statutes, robbery under section 53a-133 of the Connecticut General Statutes, larceny under sections 53a-119, 53a-122, 53a-123 and 53a-124 of the Connecticut General Statutes, or of a violation of section 53a-290 to 53a-296, inclusive involving vendor fraud, section 53-20 of the Connecticut General Statutes involving cruelty to persons, sections 53a-70, 53a-70a, 53a-70b, 53a-71, 53a-72a, 53a-72b, or 53a-73a of the Connecticut General Statutes involving sexual assault, section 53a-59 of the Connecticut General Statutes involving assault, section 53a-59a of the Connecticut General Statutes involving assault of an elderly, blind, disabled, pregnant or mentally retarded person, and sections 53a-320 to 53a-323, inclusive, of the Connecticut General Statutes involving abuse of elderly, blind, disabled or mentally retarded persons.

(d) A personal care assistant may be suspended from participation in the program if he or she has accepted payment for services that were never provided to the consumer or otherwise violates the rules, regulations, standards or laws governing the program, in accordance with sections 17-83k-1 to 17-83k-7, inclusive, of the Regulations of Connecticut State Agencies.

(e) The department may deny coverage of services performed by a personal care assistant who does not meet the department's qualifications as set forth in this section.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-596a Fair hearings

Applicants for and recipients of services under the Personal Care Assistance program may request and receive a fair hearing, in accordance with the rules of the Department's Medicaid program when the Department:

(1) did not offer the choice of home and community-based services as an alternative to institutional care in a nursing facility; or

(2) does not reach a determination of financial eligibility within the Department's standard of promptness; or

(3) denies the application for any reason other than the limitations on the number of individuals who can be served and/or funding limitations as established in the approved waiver; or

(4) disapproves the consumer's service plan; or

(5) denies or terminates payment to a qualified personal care assistant of the consumer's choice; or

(6) discharges the consumer from the waiver program.

History

• Adopted effective February 8, 1999; Amended March 9, 2006

Regs., Conn. State Agencies § 17b-262-596b (Repealed)

Repealed March 9, 2006.

Regs., Conn. State Agencies § 17b-262-597 Scope

Sections 17b-262-597 through 17b-262-605 inclusive set forth the Department of Social Services (DSS) requirements for payment of early intervention services provided by the Department of Mental Retardation (DMR), or another state agency, and their funded contractors, to children age Birth to Three years with developmental delays who are determined eligible for Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes.

History

• Effective August 28, 1998

Regs., Conn. State Agencies § 17b-262-598 Definitions

For the purposes of section 17b-262-597 through 17b-262-605 the following definitions shall apply:

(1) "Allied Health Professional or AHP" means an individual who is licensed or certified or who is qualified by special training, education, skills, and experience to provide early intervention services. Such individuals include, but are not limited to: nurses, physician assistants, masters level social workers, special education teachers, speech therapy assistants, nutritionists, and family therapists.

(2) "Assessment" means the definition contained in Part H of the Individuals with Disabilities Education Act (IDEA), Title 20 United States Code (USC), section 1477(a), and at Title 34 Code of Federal Regulations (CFR), Part 303, subdivisions (1) and (2) of subsection (a) of section 303.322, and at subdivision (2) of subsection (b) of section 303.322.

(3) "Assessment Team" means a multidisciplinary team of qualified, as defined in Title 34 CFR, Part 303, section 303.21, service providers selected by the performing provider, based on results of the child's evaluation, to perform an assessment to determine the service needs of the child based on the diagnosis of the evaluation team.

(4) "Assistive Technology Devices" means the assistive technology devices as defined in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (1) of subsection (d) of section 303.12.

(5) "Assistive Technology Services" means the assistive technology services defined in Part H of IDEA, 20 USC et seq., and at Title 34 CFR, Part 303, subdivision (1) of subsection (d) of section 303.12.

(6) "Audiology" means the definition contained in Part H of IDEA, Title 20 USC et seq., and at Title 34 CFR, Part 303, subdivision (2) of subsection (d) of section 303.12.

(7) "Audiologist" means one who is licensed to practice audiology pursuant to Chapter 399 of the Connecticut General Statutes.

(8) "Billing Provider" means DMR or another state agency responsible for coordinating and delivering early intervention services to Birth to Three eligible children. Billing providers may also be responsible for service coordination and may be a performing provider.

(9) "Birth to Three Eligible Child" means a child from birth to age three who is:

(A) experiencing a significant developmental delay as measured by standardized diagnostic test or clinical opinion in one or more of the following areas:

(i) cognitive development;

(ii) physical development, including vision or hearing;

(iii) communication development; or

(iv) adaptive skills; or

(B) diagnosed as having a physical or mental condition that has a high probability of resulting in developmental delay; and

(C) qualified to receive services under the Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes.

(10) "Birth to Three System" means a statewide, comprehensive, coordinated, multidisciplinary, interagency program of early intervention services for infants and toddlers with disabilities.

(11) "Child" means a person who is under twenty-one years of age.

(12) "Commissioner" means the Commissioner of Social Services appointed pursuant to subsection (a) of section 17b-1 of the Connecticut General Statutes.

(13) "Department" means the Department of Social Services or its agent.

(14) "Developmental Delay" means a significant delay in one or more of the following areas: cognitive development; communication development; physical development, including vision or hearing; social or emotional development; or adaptive skills or development.

(15) "Developmental Therapy" means special instruction.

(16) "DMR" means the Department of Mental Retardation.

(17) "Early Intervention Record" means the written record maintained for both the eligible child and the noneligible child for the Birth to Three System.

(18) "Early Intervention Services" means services which are defined in Part H of IDEA, Title 20 USC 1471 et seq., and those listed explicitly in Title 34 CFR, Part 303, subsection (d) of section 303.12.

(19) "Evaluation" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivisions (1) and (2) of subsection (a) of section 303.322, and subdivision (1) of subsection (b) of section 303.322, and as defined in section 17a-248 of the Connecticut General Statutes.

(20) "Evaluation Team" means two or more qualified allied health professionals, as defined in Title 34 CFR, Part 303, section 303.21, selected by the performing provider, from different disciplines matched to the needs of the child based on available information, to perform an evaluation.

(21) "Family Training, Counseling, and Home Visits" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (3) of subsection (d) of section 303.12.

(22) "Health Care Financing Administration or HCFA" means the federal agency within the Department of Health and Human Services which administers both the Medicaid and Medicare programs.

(23) "Health Services" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (4) of subsection (d) of section 303.13.

(24) "Individualized Family Service Plan (IFSP)" means the definition contained under Part H of IDEA, Title 20 USC 1471 et seq., and Title 20 USC, section 1477(d), and at Title 34 CFR, Part 303, subsection (b) of section 303.340.

(25) "Lead Agency" means the Department of Mental Retardation (DMR) pursuant to Title 34 of the CFR, Part 303, section 303.500.

(26) "Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(27) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(28) "Medical Assistance Program" means the medical assistance provided pursuant to Chapter 319V of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act. The program is also referred to as Medicaid.

(29) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or prevent a medical condition from occurring.

(30) "Medical Services" means the definition contained in Part H of IDEA and at Title 34 CFR, Part 303, subdivision (5) of subsection (d) of section 303.12.

(31) "Multidisciplinary Team" means the definition contained in Part H of IDEA, Title 20 USC, and at Title 34 CFR, Part 303, section 303.17, and a team of two or more persons from different disciplines, one of whom shall be an allied health professional.

(32) "Natural Environments" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subsection (b) of section 303.12.

(33) "Nursing Services" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (6) of subsection (d) of section 303.12.

(34) "Nutrition Services" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (7) of subsection (d) of section 303.12.

(35) "Occupational Therapy" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (8) of subsection (d) of section 303.12.

(36) "Part H of IDEA" means Part H of the Individuals with Disabilities Education Act (IDEA), Title 20 United States Code (USC), section 1471 et seq.

(37) "Performing Provider" means:

(A) any billing provider;

(B) any independent provider under contract with a billing provider; or

(C) any state agency under contract with a billing provider providing diagnostic services or treatment services recommended by a licensed practitioner of the healing arts and in accordance with the IFSP.

(38) "Physician" means an individual licensed under Chapter 370 or 371 of the Connecticut General Statutes as a doctor of medicine or osteopathy.

(39) "Physical Therapy" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (9) of subsection (d) of section 303.12, and section 20-74 of the Connecticut General Statutes.

(40) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(41) "Psychological Services" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (10) of subsection (d) of section 303.12.

(42) "Service Coordination" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34, CFR Part 303, subdivision (11) of subsection (d) of section 303.12.

(43) "Service Coordinator" means the person from the profession most immediately relevant to the child's or family's needs who is employed or contracted by the performing provider to provide service coordination as defined in Title 34 CFR, Part 303, subsection (g) of section 303.344.

(44) "Service Page" means the section of the Individualized Family Service Plan (IFSP) which specifies service information as delineated in Part H of IDEA, Title 20 of the USC, section 1477 (d) (4), (5), and (6).

(45) "Social Work Services" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (d) of subsection (12) of section 303.12.

(46) "Special Instruction" means the services described in Part H of IDEA, Title 20 of the USC, and at Title 34 CFR, Part 303, subdivision (13) of subsection (d) of section 303.12, when delivered by a multidisciplinary team.

(47) "Speech-Language Pathology" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (14) of subsection (d) of section 303.12.

(48) "Transportation and Related Costs" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (15) of subsection (d) of section 303.12.

(49) "Vision Services" means the definition contained in Part H of IDEA, Title 20 USC 1471 et seq., and at Title 34 CFR, Part 303, subdivision (16) of subsection (d) of section 303.12.

History

• Effective August 28, 1998

Regs., Conn. State Agencies § 17b-262-599 Provider participation

(a) Billing Provider

In order to enroll in the Medical Assistance Program and receive payment from the department for early intervention services rendered, the billing provider shall:

(1) meet and maintain all departmental enrollment requirements;

(2) have a valid billing provider agreement on file which is signed by the billing provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the billing provider is mandated to adhere in order to participate in the program;

(3) ensure that an individual employed or contracted by the performing provider shall be selected as service coordinator for each child to serve as the person responsible for compliance with the duties as defined in Title 34 CFR, Part 303, section 303.22;

(4) provide early intervention services directly or by means of a contract with qualified allied health professionals pursuant to all applicable federal and state statutes and regulations and ensure that all performing providers are enrolled with the Medical Assistance Program prior to provision of service;

(5) select one or more performing providers through a competitive or non-competitive bidding process;

(6) process all claims submitted by all other performing providers under contract for provision of early intervention services in the Birth to Three System; and

(7) comply with all Medical Assistance Program documentation and other requirements.

(b) Performing Provider

In order to enroll in the Medical Assistance Program as a performing provider the provider shall:

(1) have a contract with the billing provider;

(2) meet and maintain all departmental enrollment requirements;

(3) have a valid performing provider agreement on file which is signed by the performing provider and the department;

(4) provide all early intervention services directly with allied health professionals pursuant to all applicable provisions of federal and state statutes and regulations; and

(5) comply with all Medical Assistance Program documentation and other requirements.

History

• Effective August 28, 1998

Regs., Conn. State Agencies § 17b-262-600 Eligibility

(a) Payment for early intervention services shall be available for all children eligible for the Medical Assistance Program subject to the conditions and limitations which apply to early intervention services as provided by these regulations.

(b) Payment for early intervention services shall be available only for evaluations, assessments, and services that are contained in an IFSP and by consent of a parent or other person authorized to consent to such activities on behalf of an eligible child.

(c) Significant delay shall be demonstrated with scores on an appropriate norm-referenced standardized diagnostic instrument or other procedures, such as formal observations and informed clinical opinion, to substantiate:

(1) a score two standard deviations below the mean in one area of development; or

(2) scores one and one-half standard deviations below the mean in two areas of development.

(d) Other procedures shall be used to demonstrate significant delay when the use of the standardized diagnostic instrument is not appropriate due to a child's age or when a child requires significant adaptation to perform on a standardized instrument.

History

• Effective August 28, 1998

Regs., Conn. State Agencies § 17b-262-601 Services covered and limitations

(a) The department shall pay for the following:

(1) evaluations and assessments;

(2) early intervention services, which are medically appropriate and medically necessary as follows:

(A) assistive technology devices and assistive technology services;

(B) audiology;

(C) family training, counseling, and home visits;

(D) health services;

(E) medical services;

(F) nursing services;

(G) nutrition services;

(H) occupational therapy;

(I) physical therapy;

(J) psychological services;

(H) service coordination;

(I) social work services;

(J) special instruction;

(K) speech-language pathology;

(L) transportation and related costs; and

(M) vision services; and

(3) services provided in the child's natural environment to the maximum extent appropriate to the needs of the child.

(b) Limitations on covered services shall be as follows:

(1) DMR, or another state agency, shall be the agencies eligible for enrollment with the department to bill for early intervention services to Birth to Three eligible children and their families and to enter into a billing provider agreement with the department for the provision of such services;

(2) services shall be limited to those early intervention services authorized, by a parent or other person empowered to consent on behalf of an eligible child, in the IFSP;

(3) effective July 1, 1996, service coordination shall become part of the early intervention services fee;

(4) special instruction, developmental therapy, requires a signature by a licensed practitioner of the healing arts documenting the existence of a multidisciplinary team, and stating that he or she has periodically reviewed the child's progress and has recommended appropriate techniques, activities, and strategies during discussions with the child's early intervention teacher. Documentation of this requirement in a format and manner to be described by the department shall be signed and dated quarterly;

(5) treatment services are limited to a maximum of one per day of the same type of treatment service per child;

(6) evaluation services are limited to a maximum of one per month, per child;

(7) services are limited to those listed in the department's fee schedule;

(8) services of an unproven, educational, social, experimental, research, or cosmetic nature are not covered;

(9) immunizations, biological products, and other products or examinations and laboratory tests for preventable diseases available free of charge are not covered;

(10) speech services involving nondiagnostic, nontherapeutic, routine, repetitive, and reinforced procedures or services for the child's general welfare that are not planned and performed or supervised by a licensed speech pathologist are not covered;

(11) payment for services by an AHP whose scope of practice is defined under state law when the service that was provided is not within said scope of practice; and

(12) payment for services by an AHP whose scope of practice is not defined under state law when the service that was provided is not within the accepted standard in his or her respective profession or the AHP is otherwise prohibited under state law from providing said service.

History

• Effective August 28, 1998

Regs., Conn. State Agencies § 17b-262-602 Billing procedures

All claims submitted to the department for payment of evaluation and early intervention services including assessments and assistive technology devices, shall be substantiated by documentation in the Birth to Three eligible child's early intervention record.

History

• Effective August 28, 1998

Regs., Conn. State Agencies § 17b-262-603 Payment

(a) The department shall establish payment rates effective July 1, 1996.

(b) The rate period shall be the state fiscal year.

(c) Interim rates shall be issued for each rate period and such rates shall be replaced by rates computed on the basis of actual cost and service volume submitted to the department by the billing provider by December 31 each year for the immediately preceding state fiscal year.

(d) Payment shall not be made directly to AHPs or organizations under contract to a performing provider or a billing provider.

(e) Payment limitations shall be as follows:

(1) payment for evaluations; early intervention services, which includes assessments; and assistive technology devices shall not duplicate payments made under the Medical Assistance Program for other services which are covered under the Program;

(2) any Medical Assistance Program Birth to Three eligible child is qualified to be evaluated for eligibility for Part H of IDEA;

(3) payment shall be made for early intervention services only for the period covered by the written authorized IFSP;

(4) once a child is determined ineligible for Part H of IDEA, payment shall not be made for assessment and early intervention services;

(5) claims for payment shall be submitted to the department only by the billing provider or its designated agent;

(6) payment for early intervention services, excluding evaluations, shall not be made unless one or more of the individual services pursuant to section 17b-262-601 are rendered in a calendar month;

(7) payment shall be made for evaluations regardless of whether the child becomes eligible for the Birth to Three System;

(8) evaluations shall be based on a cost per evaluation basis;

(9) other early intervention services, including assessments, shall be no more than two units per child per calendar month;

(10) rates for early intervention services shall include assistive technology devices having a cost equal to or less than two hundred and fifty dollars; and

(11) rates for assistive technology devices having a cost of more than two hundred and fifty dollars, shall be based on the applicable Medical Assistance Program durable medical equipment fee schedule.

History

• Effective August 28, 1998

Regs., Conn. State Agencies § 17b-262-604 Documentation requirements

Early intervention services shall be paid by the department only when the lead agency ensures compliance of the following documentation requirements on file with the performing provider, as appropriate:

(a) Evaluation

(1) A copy of the evaluation report which shall meet the requirements of Part H of IDEA, Title 20 USC 1471 et seq., Title 20 USC section 1477(a), and at Title 34 CFR, Part 303, subdivision (1) of subsection (b) of section 303.322, shall be on file, recommending the specific medical diagnosis or diagnoses according to the International Classification of Diseases (ICD) in a form and manner specified by the department, and signed by all members of the evaluation team.

(2) The evaluation shall include:

(A) for eligible Birth to Three children, a signature on a form and manner to be specified by the department, by the physician who recommended the evaluation and stated diagnosis or diagnoses; which authorizes the development of the IFSP, and

(B) for ineligible children, a signature by a physician within forty-five days of the date the evaluation was completed and signed.

(b) Assessment

(1) A copy of the assessment which shall meet the requirements of Part H of IDEA, Title 20 USC 1471 et seq., Title 20 USC, section 1477(a), and at Title 34 CFR, Part 303, subdivisions (1) and (2) of subsection (a) of section 303.322 and subdivision (2) of subsection (b) of section 303.322, shall be on file.

(2) The assessment shall be a multidisciplinary team assessment of the child's and child's family's unique needs and the identification of services appropriate to meet such needs.

(3) The written assessment report shall be signed by all members of the multidisciplinary team recommending the type of services appropriate for the child as listed in the IFSP.

(4) If any member of the multidisciplinary team does not attend the IFSP meeting, that member shall provide a written report regarding recommended services appropriate to their scope of practice.

(c) Individualized Family Service Plan (IFSP)

(1) The IFSP shall meet the requirements of Part H of IDEA, Title 20 USC 1471 et seq., Title 20 USC, section 1477(b), (c), and (d), and at Title 34 CFR, Part 303, sections 303.340 through 303.346, and be provided in accordance with the Birth to Three eligible child's service page as delineated in the IFSP. The IFSP shall be evaluated not less than once a year and the family shall be provided a review of the plan at six month intervals, or more often where appropriate, based on infant and toddler and family needs.

(2) At a minimum, the IFSP shall:

(A) be developed by the multidisciplinary team, of which the service coordinator shall be a member, within forty-five days of referral for early intervention services and indicate that the Birth to Three eligible child, his or her family or their representative has participated in, or been given the opportunity to participate in, the development of the child's plan of services service page of the IFSP;

(B) include a signature by a physician functioning within his or her scope of practice as defined in state law recommending the diagnostic and treatment services contained in the IFSP and the ICD diagnosis code. The physician shall sign the document within forty-five days of the date the IFSP was completed and signed by the parent;

(C) be based on an assessment of a Birth to Three eligible child's and child's family's needs which include, but are not limited to, assessments of medical, clinical, social, educational, or other needs;

(D) include a statement of the major outcomes expected to be achieved for the Birth to Three eligible child and the family, and the criteria, procedures, and timelines used to determine the degree to which progress toward achieving the outcomes is being made and whether modifications or revisions of the outcomes or services are necessary;

(E) include a statement of specific early intervention services necessary to meet the unique needs of the Birth to Three eligible child and the family, including the frequency, intensity, and the method of delivering services;

(F) include the name of the service coordinator from the profession most immediately relevant to the Birth to Three eligible child's or family's needs who shall be responsible for the implementation of the plan and coordination with other agencies and persons;

(G) include the steps to be taken supporting the transition of the Birth to Three eligible child to other appropriate services; and

(H) develop and implement an interim IFSP for a Birth to Three eligible child whose developmental status requires early intervention services while the evaluation and assessment are being completed such as a Birth to Three eligible child discharged from a hospital and who needs immediate continuation of care. Interim IFSPs may be developed and implemented if written parental consent is obtained, the name of the service coordinator and the early intervention services that are needed immediately for the child and the child's family are included in the interim IFSP, and the initial evaluation is completed within forty-five days after the performing provider receives the referral.

(d) Progress Notes

(1) Progress notes shall be kept in a form and manner as specified by the department. They shall provide a comprehensive treatment narrative of the contacts with the child and family throughout the month, highlighting activities, nature and extent of the contacts, and relationship of activities to the medical necessity and medical appropriateness of the early intervention services in relation to the outcomes specified in the evaluation, assessment reports, and the service page as delineated in the IFSP.

(2) Any changes or differences in treatment shall be noted and related to the dates of services. Any increases in services shall meet signature requirements contained in these regulations. If a child is seen more than once during the same week, a summary and progress note for the month is acceptable if any changes in progress or treatment are documented each time they occur with the specific date that they occurred. The progress notes at a minimum shall:

(A) include a summary of progress made according to the IFSP;

(B) include a summary statement of service delivered noting any significant changes in the child's condition;

(C) be kept by the performing provider or the state agency in a form and manner to be determined, as specified by the department; and

(D) include the signature of the AHP providing the service.

(e) Medical Expertise

(1) Records of services provided by individuals who are AHPs but do not have a scope of practice defined by state law, such as a special education teacher, shall include written documentation of the involvement of a licensed practitioner of the healing arts in the delivery of service.

(2) Except for service coordination, the documentation required by this subsection shall be updated and signed, and in the child's early intervention record at least quarterly. This documentation shall include:

(A) identifying information about the child;

(B) the name of the AHP; and

(C) a signed statement by a licensed practitioner of the healing arts who shall be a member of the multidisciplinary team.

(f) Early Intervention Record

(1) An early intervention record for a child eligible for the Birth to Three System shall be maintained as provided by these regulations. At a minimum, the record shall contain the following:

(A) the initial written referral, all evaluations, all assessments, and reassessments, as necessary, to determine needed services;

(B) the Birth to Three eligible child's name, date of birth, address, social security or medical assistance number, and other relevant historical and financial information;

(C) all IFSPs;

(D) a statement by a physician recommending diagnostic or treatment services;

(E) all records of actual service delivery indicating the dates of service, type of service, location of service, units of service, and dated signature of the individual AHP providing the service;

(F) all records of service entries of service coordination indicating the date, place of service, the name of the service coordinator, and type of ongoing service coordination provided, and a signature, by an AHP, confirming monthly data; and

(G) a transition plan, as appropriate, and an exit form.

(2) For a child who is determined ineligible for the Birth to Three System, the early intervention record shall include at a minimum:

(A) a written review of the diagnostic services by a physician;

(B) the ineligible child's name, date of birth, address, social security or medical assistance number, and other relevant historical and financial information; and

(C) all evaluations and ICD code.

(g) Other Documentation Requirements

(1) A contract establishing the independent provider as a Birth to Three performing provider for a particular type of service at a particular rate shall be available and include the following:

(A) any relevant terms and conditions associated with being a Birth to Three performing provider including the agreement not to bill the Medical Assistance Program for these services provided to Birth to Three children; and

(B) the performing provider shall be responsible for the development, maintenance, and monitoring of current and updated lists of the names and credentials of all employed and contracted Birth to Three performing providers and their employees, and the effective dates they were eligible to provide Birth to Three services. The list shall:

(i) include the performing provider's certification number, license number, and the Medical Assistance Program number, if applicable; and

(ii) be kept by the performing providers, in a central location, and be available upon request to authorized persons such as the Health Care Financing Administration (HCFA) or the department.

(2) The billing provider may choose to require performing providers which employ more than twenty people qualified to provide services under the contract, when contracted for service provision, to maintain and update the necessary list of persons providing services, their credentials, and their Medical Assistance Program billing number if they are enrolled with the Medical Assistance Program as a billing provider. A statement to this effect shall be part of the contract between the billing provider and the performing provider and shall be signed and dated:

(A) the contract shall also provide for the transfer of employee lists, should the organization subsequently go out of business; and

(B) each state agency shall be responsible for maintaining the licensure and certification document on each state employee providing direct service in the Birth to Three System.

(3) The performing provider shall be responsible for maintaining fiscal and medical records which fully disclose services and goods rendered or delivered to all persons receiving services in the Birth to Three System:

(A) these records and information shall be made available to authorized representatives of the department and billing provider upon request;

(B) all documentation shall be entered in ink and incorporated into the early intervention record in a complete, prompt, and accurate manner; and

(C) all documentation shall be made available to authorized department personnel upon request in accordance with Title 42 CFR, Part 431, section 431.17.

(4) The procedural safeguards required by Part H of IDEA, Title 20, USC 1471 et seq., Title 20. USC, section 1480, and specifically Title 34 CFR, Part 303, section 303.400 et seq., shall be developed and implemented by the lead agency. In addition to these safeguards, any child who is a Birth to Three eligible child and is also a Medical Assistance Program client may avail themselves of the department's fair hearing process pursuant to section 17b-60 of the Connecticut General Statutes.

History

• Effective August 28, 1998

Regs., Conn. State Agencies § 17b-262-605 Audit and record retention

(a) All supporting accounting and business records, statistical data, early intervention records, and other records relating to the provision of evaluation, assessment, service coordination, and early intervention services paid for by the department shall be subject to audit.

(b) Documentation as required for the Birth to Three System, including census and accounting records, shall be maintained for the longer of:

(1) six years from the end of the billing period; or

(2) six years from the date of services by the performing provider; or

(3) until such time as the department audit of documented services is completed and said audit is approved or disallowed as the case may be by the commissioner.

History

• Effective August 28, 1998

Regs., Conn. State Agencies § 17b-262-606 Reserved

Sec. 17b-262-606. Reserved

Regs., Conn. State Agencies § 17b-262-607 Scope

Sections 17b-262-607 through 17b-262-618 inclusive set forth the Department of Social Services requirements for payment of nurse practitioner services provided by licensed advanced practice registered nurses for clients who are determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Effective August 10, 1998

Regs., Conn. State Agencies § 17b-262-608 Definitions

For the purposes of sections 17b-262-607 to 17b-262-618, inclusive, of the Regulations of Connecticut State Agencies, the following definitions apply:

(1) “Accountable provider” means the maternity billing provider entity delivering services under the physicians’ services benefit category;

(2) “Acute” means having rapid onset, severe symptoms, and a short course;

(3) “Admission” means the formal acceptance by a hospital of a client who is to receive health care services while lodged in an area of the hospital reserved for continuous nursing services;

(4) “Advanced practice registered nurse” or “APRN” means a person licensed pursuant to section 20-94a of the Connecticut General Statutes;

(5) “Allied Health Professional” or “AHP” means a qualified individual, other than a physician, who: (A) Is qualified by special training, education, skills and experience in health care and treatment, (B) is certified or licensed by the Department of Public Health as one or more of the following: Psychologist, licensed clinical social worker, advanced practice registered nurse, nurse-midwife, physician assistant, licensed professional counselor, licensed marital and family therapist, licensed alcohol and drug counselor, physical therapist, occupational therapist, speech pathologist, audiologist, optician, optometrist, respiratory care practitioner, certified doula or such other category of licensed health care professional that the department permits to enroll individually as a Medicaid provider or meets other applicable qualifications approved in writing by the department and incorporated into the Medicaid State Plan or other applicable federally authorized state Medicaid document, (C) acts within the AHP’s scope of practice under state law and (D) complies with all requirements in 42 CFR 440, as amended from time to time, applicable to the AHP;

(6) “Audiologist” means a person licensed to practice audiology pursuant to section 20-395c of the Connecticut General Statutes;

(7) “Billing provider” means a physician, physician group or other entity enrolled in Medicaid that bills the department for physicians’ services;

(8) “Border provider” means a provider that is (A) located in a state bordering Connecticut in an area that allows the provider to generally serve Connecticut residents, (B) enrolled as and treated as a Medicaid provider,

(C) certified, accredited or licensed by the applicable agency in their state, and (D) deemed

a border provider by the department on a case-by-case basis;

(9) “By or Under the Supervision” means the nurse practitioner shall assume professional responsibility for the service performed by the allied health professional, overseeing or participating in the work of the allied health professional including, but not limited to:

(A) availability of the nurse practitioner to the allied health professional in person and within five minutes;

(B) availability of the nurse practitioner on a regularly scheduled basis to review the practice, charts, and records of the allied health professional and to support the allied health professional in the performance of services; and

(C) a predetermined plan for emergency situations, including the designation of an alternate nurse practitioner in the absence of the regular nurse practitioner;

(10) “Case rate payments” means provider-specific monthly payments that reimburse a subset of services included in the maternity episode and provided during the prenatal, labor and delivery, and postpartum periods;

(11) “Certified doula” means a doula who is certified pursuant to section 20-86bb of the Connecticut General Statutes;

(12) “Child” means a person who is under twenty-one years of age;

(13) “Chronic disease hospital” has the same meaning as provided in section 19a-490 of the Connecticut General Statutes;

(14) “Client” or “member” means a person eligible for goods or services under Medicaid;

(15) “Commissioner” means the Commissioner of Social Services;

(16) “Consultation” means those services rendered by a nurse practitioner whose opinion or advice is requested by the client’s nurse practitioner or agency in the evaluation or treatment of the client’s illness;

(17) “Department” means the Department of Social Services or its agent;

(18) “Early and Periodic Screening, Diagnostic and Treatment services” or “EPSDT services” means the services provided in accordance with section 1905(r) of the Social Security Act, as amended from time to time;

(19) “Emergency” means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client’s health in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part;

(20) “Family planning services” means any medically approved diagnostic procedure, treatment, counseling, drug, supply or device that a provider prescribes or furnishes to individuals of childbearing age for the purpose of enabling such individuals to freely plan the number and spacing of their children;

(21) “Fees” means the payments for services, treatments, and drugs administered by nurse practitioners that the commissioner establishes and includes in the department’s fee schedules;

(22) “General hospital” has the same meaning as provided in section 17-134d-80 of the Regulations of Connecticut State Agencies;

(23) “Home” means the client’s place of residence, which includes a boarding home, community living arrangement or residential care home. “Home” does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for individuals with intellectual disabilities or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(24) “Hysterectomy” has the same meaning as provided in 42 CFR 441.251, as amended from time to time;

(25) “Informed consent” has the same meaning as provided in 42 CFR 441.257, as amended from time to time;

(26) “Institutionalized individual” has the same meaning as provided in 42 CFR 441.251, as amended from time to time;

(27) “Intermediate care facility for individuals with intellectual disabilities” or “ICF/IID” means a residential facility for individuals with intellectual disabilities licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in Medicaid as an intermediate care facility for individuals with intellectual disabilities pursuant to 42 CFR 442.101, as amended from time to time;

(28) “ICD” means the International Classification of Diseases established by the World Health Organization or such other disease classification system that the department currently requires providers to use when submitting Medicaid claims;

(29) “Legend Device” has the same meaning as provided in section 20-571 of the Connecticut General Statutes;

(30) “Legend Drug” has the same meaning as provided in section 20-571 of the Connecticut General Statutes;

(31) “Licensed Practitioner” means any Connecticut medical professional granted prescriptive powers within the scope of his or her professional practice as defined and limited by federal or state law;

(32) “Licensed Practitioner of the Healing Arts” means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH);

(33) “Long-Term Care Facility” means a medical institution which provides, at a minimum, skilled nursing services or nursing supervision and assistance with personal care on a daily basis. Long-term care facilities include:

(A) nursing facilities,

(B) chronic disease hospitals--inpatient, and

(C) intermediate care facilities for individuals with intellectual disabilities (ICF/IID);

(34) “Maternity bundle episode” or “bundle” or “episode” means a defined group of maternity-related Medicaid covered services provided to a specific patient over a specific period of time;

(35) “Medicaid” means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(36) “Medical necessity” or “medically necessary” has the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(37) “Medical record” has the same meaning as provided in section 19a-14-40 of the Regulations of Connecticut State Agencies;

(38) “Nurse-midwife” has the same meaning as provided in section 20-86a of the Connecticut General Statutes;

(39) “Panel or Profile Tests” means specified groups of tests performed on a single specimen or material derived from the human body that are related to a condition, disorder or family of disorders, and when combined mathematically or otherwise, comprise a finished identifiable laboratory study or studies;

(40) “Performing provider” means the physician or AHP who actually performs the service;

(41) “Performance year” means the specific time period during which the accountable provider’s performance is measured to determine financial incentives or penalties or both, and the first Performance Year (PY1) is defined as January 1, 2025 to December 31, 2025;

(42) “Physical therapist” means an individual licensed pursuant to 20-70 or 20-71 of the Connecticut General Statutes;

(43) “Physician” means a person who is: (A) Licensed pursuant to section 20-13 of the Connecticut General Statutes and (B) acting within the physician’s scope of practice under state law;

(44) “Physician assistant” means an individual licensed pursuant to section 20-12b of the Connecticut General Statutes;

(45) “Plan of Care” means plans described in 42 CFR 441.102, 42 CFR 441.103, 42 CFR 441.155 and 42 CFR 441.156, as amended from time to time;

(46) “Prior Authorization” means approval for the provision of a service or delivery of goods from the department before the provider actually provides the service or delivers the goods;

(47) “Provider” means a nurse practitioner who is enrolled in the Medical Assistance Program;

(48) “Quality of Care” means the evaluation of medical care to determine if it meets the professionally recognized standards of acceptable medical care for the client’s condition;

(49) “Quality performance criteria” means a provider’s achievement of Medicaid’s quality standards based on quality measure performance results;

(50) “Respiratory care practitioner” means an individual licensed pursuant to section 20-162o of the Connecticut General Statutes;

(51) “Speech pathologist” means an individual licensed pursuant to section 20-411 of the Connecticut General Statutes;

(52) “Sterilization” has the same meaning as provided in 42 CFR 441.251, as amended from time to time;

(53) “Under the personal supervision” means the administrative and clinical responsibility personally assumed by the APRN for the AHP’s services within the APRN and AHP’s scope of practice;

(54) “Under-service” means actions taken by or on behalf of a participating entity that have the result of limiting, excluding, or discouraging one or more members from seeking or receiving medically necessary Medicaid covered services;

(55) “Usual and customary charge” means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases, except, if the provider varies the charges so that no one amount is charged in the majority of cases, “usual and customary charge” means the median amount that the provider charges for such service or procedure. “Usual and customary charge” does not include token charges for charity patients or other exceptional charges; and

(56) “Utilization review” has the same meaning as provided in section 17-134d-80 of the Regulations of Connecticut State Agencies.

History

• Effective August 10, 1998; Amended December 24, 2025

Regs., Conn. State Agencies § 17b-262-609 Provider participation

In order to enroll in the Medical Assistance Program and receive payment from the department, providers shall meet the following requirements:

(a) General:

(1) meet and maintain all applicable licensing, accreditation, and certification requirements;

(2) meet and maintain all departmental enrollment requirements; and

(3) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medical Assistance Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

(b) Specific:

In order to qualify for payment under the Medical Assistance Program for laboratory procedures, a nurse practitioner shall be in compliance with the provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA), as amended from time to time.

History

• Effective August 10, 1998

Regs., Conn. State Agencies § 17b-262-610 Eligibility

Payment for nurse practitioner services shall be available on behalf of all persons eligible for the Medical Assistance Program subject to the conditions and limitations which apply to these services.

History

• Effective August 10, 1998

Regs., Conn. State Agencies § 17b-262-611 Services covered and limitations

(a) Except for the limitations and exclusions listed below, the department shall pay for:

(1) medically necessary and medically appropriate professional services of a nurse practitioner which conform to accepted methods of diagnosis and treatment;

(2) services provided in the practitioner's office, client's home, hospital, long-term care facility, or other medical care facility;

(3) family planning services as described in the Regulations of Connecticut State Agencies;

(4) unless defined elsewhere, CPT descriptive terms used by the department as standards;

(5) medical and surgical supplies used by the provider in the course of treatment of a client;

(6) injectable drugs which are payable by the department and administered by a provider; and

(7) HealthTrack Services and HealthTrack Special Services.

(b) Limitations on covered services shall be as follows:

(1) The department reserves the right to review the medical necessity and medical appropriateness of visits and to disallow payment for those visits it determines are not medically necessary or medically appropriate.

(2) A nurse practitioner who is fully or partially salaried by a general hospital, public or private institution, group practice, or clinic shall not receive payment from the department unless the nurse practitioner maintains an office for private practice at a separate location from the hospital, institution, group, or clinic in which the nurse practitioner is employed. Nurse practitioners who are solely hospital, institution, group, or clinic based, either on a full- or part-time salary are not entitled to payment from the department for services rendered to Medical Assistance Program clients.

(3) Nurse practitioners who maintain an office for private practice separate from the hospital, institution, group, or clinic, shall be able to bill for services provided at the private practice location or for services provided to the nurse practitioner's private practice clients in the hospital, institution, group, or clinic.

(4) The department shall pay nurse practitioners for drugs or devices which are administered or dispensed directly to a client under the following conditions:

(A) excluding oral medications, payment shall be made to a nurse practitioner for the estimated acquisition cost as determined by the department for the amount of the drugs or devices which are administered directly to the client; and

(B) for legend drugs or legend devices which shall be administered by a nurse practitioner, the department shall pay the nurse practitioner for the estimated acquisition cost as determined by the department for the amount of the drug or device which is administered.

(5) The fee for routine care of a newborn in the hospital shall be all inclusive and shall be billed only once per child. The fee includes initiation of diagnostic and treatment programs, preparation of hospital records, history and physical examination of the baby, and conferences with the parents. Subsequent hospital care for evaluation and management of a normal newborn is paid per day.

(6) Admission or annual exams for long-term care facility residents shall meet the following criteria:

(A) the exam shall be performed in the facility;

(B) the admission examination shall be performed within forty-eight hours of admission to the facility and shall be limited to one per client, per provider, regardless of the number of admissions. However, if the nurse practitioner who attended the client in an acute or chronic care hospital is the same nurse practitioner who shall attend the client in the facility, a copy of a hospital discharge summary completed within five working days of admission and accompanying the client may serve in lieu of this requirement. An additional admission exam shall be performed only when a new medical record is opened for the client; and

(C) the annual comprehensive medical examination shall be limited to one per client per calendar year.

(7) When billing allergy procedures the nurse practitioner shall bill for followup visits which include intracutaneous tests only if subsequent visits require testing. If follow-up visits do not include testing, regular office visit codes for established clients shall be used.

(8) Payment for panel or profile tests shall be made according to the fees listed in the department's fee schedule for panel tests and not at the rate for each separate test included in the panel or profile.

(9) Payment for any laboratory service shall be limited to services provided by Medical Assistance Program providers who are in compliance with the provisions of the Clinical Laboratory Improvement Amendments of 1988 (CLIA).

(10) The fees listed in the department's fee schedule shall be payable only when these services are provided by or under the supervision of a nurse practitioner.

(11) The department shall not pay a higher rate for any procedure which is performed in an emergency department.

(12) The department shall pay for an initial visit by a nurse practitioner in the office, home, or long-term care facility only once per client. Initial visits refer to the provider's first contact with the client and reflect higher fees for the additional time required for setting up records and developing past history. The exception to this is when the nurse practitioner-client relationship has been discontinued for three or more years and is then reinstated.

(13) The department shall pay for an initial visit once per inpatient hospitalization.

(14) The fee for a consultation shall apply only when the opinions and advice of a consultant nurse practitioner are requested by the client's nurse practitioner or agency in the evaluation or treatment of the client's illness. In a consultation the client's nurse practitioner carries out the plan of care. In a referral a second provider provides direct service to the client.

(15) When the consultant nurse practitioner assumes the continuing care of the client, any service subsequent to the initial consultation rendered by the consultant provider shall no longer be a consultation and shall be paid according to the fee listed for the procedure.

(16) A consultation initiated by a client or family, and not requested by a nurse practitioner, shall not be billed as an initial consultation, but shall be billed as a confirmatory consultation or as an office visit, whichever is appropriate.

(17) If a consultant nurse practitioner, subsequent to the consultation, assumes responsibility for management of a portion, or all of the client's medical condition, consultation codes shall not be billed. A specifically identifiable procedure, identified with a specific CPT code, performed on, or subsequent to the date of the initial consultation, shall be billed separately.

(18) When a newborn requires other than routine care following delivery, the nurse practitioner shall bill for the appropriate critical care. The department shall not pay both critical care and routine care for the same child.

History

• Effective August 10, 1998

Regs., Conn. State Agencies § 17b-262-612 Services not covered

The department shall not pay for the following:

(a) Any procedures or services of an unproven, educational, social, research, experimental or cosmetic nature; for any diagnostic, therapeutic or treatment procedures in excess of those deemed medically necessary by the department to treat the client's condition; or for services not directly related tothe client's diagnosis, symptoms or medical history;

(b) Any examinations, laboratory tests, biological products, immunizations or other products which are furnished free of charge;

(c) Information or services provided to a client by a provider over the telephone;

(d) An office visit for the sole purpose of the client obtaining a prescription where the need for the prescription has already been determined;

(e) Cancelled office visits and appointments not kept;

(f) Cosmetic surgery;

(g) Services provided in an acute care hospital if the department determines the admission does not, or retrospectively did not, fit the department's utilization review requirements pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies;

(h) Services provided by the admitting provider in an acute care hospital shall not be made or costs for such services may be recouped if it is determined by the department's utilization review, either prospectively or retrospectively, that the admission did not fulfill the accepted professional criteria for medical necessity, appropriateness of setting or quality of care;

(i) A laboratory charge for laboratory services performed by a laboratory outside of the nurse practitioner's office. The laboratory shall bill the department for services rendered when a nurse practitioner refers a client to a private laboratory; and

(j) The following routine laboratory tests which shall be included in the fee for an office visit and shall not be billed on the same date of service: urinalysis without microscopy,hemoglobin determination and urine glucose.

History

• Effective August 10, 1998; Amended April 2, 2015

Regs., Conn. State Agencies § 17b-262-613 Need for service

The department shall pay for an initial office visit and continuing services which the department deems are medically necessary and medically appropriate, in relation to the diagnosis for which care is required, provided that:

(a) the services are within the scope of the provider's practice, and

(b) the services are made part of the client's medical record.

History

• Effective August 10, 1998

Regs., Conn. State Agencies § 17b-262-614 Prior authorization

(a) Prior authorization, on forms and in a manner as specified by the department, is required for the following services:

(1) more than one visit on the same day for the same client by the same provider. Authorization for additional visits need not be submitted in advance of the service, but providers shall submit the authorization request prior to billing for the second or subsequent visits;

(2) admissions to acute care hospitals pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies;

(3) electrolysis epilation;

(4) physical therapy services in excess of two treatments per calendar week per client per provider;

(5) physical therapy services in excess of nine treatments per calendar year per client per provider, involving the following primary diagnoses:

(A) all mental disorders including diagnoses related to mental retardation and specific delays in development covered by the International Classification of Diseases (ICD), as amended from time to time;

(B) cases involving musculoskeletal system disorders covered by ICD, as amended from time to time; and

(C) cases involving symptoms related to nutrition, metabolism, and development covered by ICD, as amended from time to time;

(6) reconstructive surgery, including breast reconstruction following mastectomy;

(7) plastic surgery;

(8) transplant procedures; and

(9) HealthTrack Special Services.

(A) HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis; and

(B) the request for HealthTrack Special Services shall include:

(i) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service required;

(ii) a description of the outcomes of any alternative measures tried; and

(iii) if applicable and requested by the department, any other documentation required in order to render a decision.

(b) The procedure or course of treatment authorized shall be initiated within six months of the date of authorization.

(c) The initial authorization period shall be up to three months.

(d) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be considered up to six months per request.

(e) For services requiring prior authorization, a nurse practitioner shall be required to provide pertinent medical or social information adequate for evaluating the client's medical need for services. Except in emergency situations, or when authorization is being requested for more than one visit in the same day, approval shall be received before services are rendered.

(f) In an emergency situation which occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval on the next working day for the services provided. This applies only to those services which normally require prior authorization.

(g) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Effective August 10, 1998

Regs., Conn. State Agencies § 17b-262-615 Billing procedures

(a) Claims from nurse practitioners shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) The amount billed to the department shall represent the nurse practitioner's usual and customary charge for the services delivered.

(c) When a Medical Assistance Program client is referred to a provider for consultation, the consultant provider shall include the referring practitioner's provider number and name. If no provider number has been assigned, the consultant provider shall enter the entire name as well as the state license number of the referring provider on the billing form.

(d) Injectables shall be billed according to the number of units administered to the client by the nurse practitioner.

(e) When billing for anesthesia services, providers shall include the name of the primary surgeon on the bill and enter the total number of minutes in units.

(f) Providers shall bill for drugs or devices which are dispensed directly to the client as separate line items.

(g) All charges billed for supplies and materials provided by a provider, except glasses, shall be reviewed by the department.

History

• Effective August 10, 1998

Regs., Conn. State Agencies § 17b-262-616 Payment

(a) Payment rates shall be the same for in-state and out-of-state providers.

(b) Payment shall be made at the lowest of:

(1) the provider's usual and customary charge to the general public;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount billed by the provider; or

(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

History

• Effective August 10, 1998

Regs., Conn. State Agencies § 17b-262-617 Payment rate and limitations

(a) The commissioner establishes the fees contained in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

(b) Nurse practitioner rates for each procedure shall be set at 90% of the department's fees for physician procedure codes.

(c) The fees listed apply only when services are directly performed by the nurse practitioner or provided under the supervision of the nurse practitioner.

(d) Payment shall be made for panel or profile tests according to the fees listed in the department's fee schedule for panel tests and not at the rate for each separate test included in the panel or profile.

(e) Fees for surgical and medical procedures shall include the fee for an emergency room visit. The department shall not pay a provider at a higher rate for any surgical or medical procedure which is performed in an emergency room.

(f) The department shall pay nonhospital based providers for evaluation and management services provided to the provider's private practice clients in the emergency room.

(g) If a client is referred to a provider for advice and treatment of a condition which the referring provider does not usually treat, the fee for a consultation shall not be paid.

(h) If a client's medical condition necessitates the concurrent services and skills of two or more providers, each nurse practitioner provider shall be entitled to the listed fee for the service.

(i) When a Medical Assistance Program applicant visits a provider for the purpose of determining eligibility, the department shall pay only for the test required to establish eligibility as requested by the department. No other procedures shall be paid.

(j) Newborn resuscitation may be billed in addition to billing for routine care of a newborn or billing for critical care.

(k) The admission and annual comprehensive medical examination, in a long-term care facility, shall be performed by or under the direct supervision of a provider.

(l) The admission examination, in a long-term care facility, shall be performed within forty-eight hours of admission to the long-term care facility and shall be limited to one per client, per provider, regardless of the number of admissions.

(m) Maternity Bundled Payment. This subsection sets forth the rules for bundle payment methodology for maternity care to improve maternal health and birth outcomes and, to the extent applicable, includes payment to the billing provider for the services of certified doulas, lactation consultants, community health workers and any other non-licensed provider included in the bundle payment methodology.

(1) General Provisions for Maternity Bundled Payment.

(A) The department may pay for maternity services using monthly case rate payments for certain services included in the maternity bundle episode, as defined under the Medicaid State Plan, for services across all phases of the perinatal period (including prenatal, labor and delivery, and postpartum), which focuses on the accountability and quality of care for providers.

(B) The department may provide incentive payments to maternity providers, as identified in subparagraph (C) of this subdivision, who deliver high-quality, cost-effective services throughout the episode. Providers shall be eligible for incentive payments when: (i) the provider’s target price, which is the expected total cost of care for a bundle based on the statewide average cost and the provider’s historical cost, is not exceeded, (ii) the provider meets quality performance criteria, and (iii) the provider complies with the department’s goals to monitor and prevent under-service, such as risk-based patient selection as well as decreased utilization of services.

(C) This subsection shall apply to the following performing providers: Physicians, advanced practice registered nurses, physician assistants, and nurse-midwives with obstetrician-gynecology board certification or equivalent credential and expertise in maternity services.

(2) Provider Participation Requirements for Maternity Bundled Payment.

(A) All qualified maternity provider practices meeting the qualifications in subdivision (1) of this subsection shall participate in the bundle payment methodology.

(B) Providers who do not meet the minimum episode volume threshold, as set by the department, shall not be eligible to participate in the bundle payment methodology and shall be reimbursed fee-for-service (FFS) with no opportunity to earn incentive payments.

(3) Case Rate Payments for Maternity Bundled Payment.

(A) The department’s bundle accountability methodology shall determine the accountable provider.

(B) Prior to the establishment of bundle accountability, the department shall pay all maternity claims on an FFS basis.

(C) After the establishment of bundle accountability, the department shall pay a monthly case rate to the accountable provider for a subset of services, as outlined under the Medicaid State Plan. All other covered services not included in the monthly case rate shall be paid FFS.

(D) In accordance with the Medicaid State Plan, the case rate payment amount shall be based on the maternity provider’s historical cost, and the case rate shall be reassessed not more frequently than once every twelve months.

(E) Payment to the maternity provider practice meeting the qualifications in subdivision (1) of this subsection may also include payment for services provided by non-licensed professionals as designated by the department, including, but not limited to, certified doulas, community health workers, and lactation consultants.

(F) The bundled payment shall not change any reimbursement methodology for any provider other than as described in this subsection.

(4) Incentive Payments for Maternity Bundled Payment.

(A) Providers meeting the qualifications in subdivision (1) of this subsection shall be eligible to receive incentive payments in accordance with the applicable methodology. The accountable provider meeting the qualifications in subdivision (1) of this subsection shall be eligible to earn incentive payments but shall not be subject to returning any portion of increased program expenditures accountable to the provider.

(B) Except for exclusions listed under the Medicaid State Plan, all Medicaid claim costs for covered services related to maternity care shall be included in the incentive payment calculations of the bundle. The incentive payment calculation shall be based on the difference between the expected costs and the actual costs of all applicable covered services provided to the birthing member, regardless of the specific maternity provider who performed each service.

(C) The distribution of incentive payments for savings for Medicaid shall be adjusted based upon the accountable provider’s performance of the quality measures established by the department. The distribution of incentive payments shall also be subject to clinical and social risk adjustment.

(D) Not later than fifteen months after each performance year, the department shall provide each accountable provider with a written description of the accountable provider’s results regarding performance on quality measures, applicable Medicaid expenditures for maternity bundle payment members assigned to the accountable provider and calculation of incentive payments, as applicable, for said members. After receiving said description from the department, the accountable provider may respond to any calculations, results, or decisions contained therein. Such response shall be in writing, be received by the department not later than thirty days after the accountable provider receives the written description from the department and include all supporting documentation. The department shall issue a written decision not later than thirty days after receiving the accountable provider’s response. There shall be no further right to review the department’s decisions regarding the written description described in this subparagraph, other than as described in this subparagraph. There shall be no right to review the final distribution of incentive payments for the maternity bundled payment.

History

• Effective August 10, 1998; Amended December 24, 2025

Regs., Conn. State Agencies § 17b-262-618 Documentation

(a) Nurse Practitioners shall maintain a specific record for all services rendered for each client eligible for Medical Assistance Program payment including, but not limited to: name, address, birth date, Medical Assistance Program identification number, pertinent diagnostic information, a current treatment plan signed by the nurse practitioner, documentation of services provided, and the dates the services were provided.

(b) All required documentation shall be maintained for at least five years in the nurse practitioner's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the nurse practitioner for which the required documentation is not maintained or provided to the department upon request.

History

• Effective August 10, 1998

Regs., Conn. State Agencies § 17b-262-619 Scope

Sections 17b-262-619 to 17b-262-629, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment of podiatric services on behalf of clients who are determined eligible to receive services under the Connecticut Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-620 Definitions

As used in section 17b-262-619 to section 17b-262-629, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Acute" means symptoms that are severe and have a rapid onset and short course;

(2) "Admission" means the formal acceptance by a hospital of a client who is to receive health care services while lodged in an area of the hospital reserved for continuous nursing services;

(3) "Border provider" means an out-of-state provider who routinely serves clients and is deemed a border provider by the department on a provider by provider basis;

(4) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(5) "Client" means a person eligible for goods or services under the department's Medicaid program;

(6) "Commissioner" means the Commissioner of Social Services or his or her designee;

(7) "Consultation" means those services rendered by a podiatrist or other practitioner whose opinion or advice is requested by the client's podiatrist or other appropriate source in the evaluation or treatment of the client's illness;

(8) "Customized item" means an item or material adapted through modification to meet the specific needs of a particular client;

(9) "Department" means the Department of Social Services or its agent;

(10) "Early and Periodic Screening, Diagnostic and Treatment services" or "EPSDT" means the services provided in accordance with section 1905(r) of the Social Security Act, as amended from time to time;

(11) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part;

(12) "Freestanding clinic" means "freestanding clinic" as defined in section 171B of the department's Medical Services Policy for clinic services;

(13) "General hospital" means "general hospital" as defined in section 17-134d-80 of the Regulations of Connecticut State Agencies;

(14) "Home" means the client's place of residence, including, but not limited to, a boarding home, community living arrangement or residential care home. "Home" does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for the mentally retarded (ICFs/MR) or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(15) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for persons with mental retardation licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in the Medicaid program as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(16) "Legend device" means "legend device" as defined in section 20-571 of the Connecticut General Statutes;

(17) "Legend drug" means "legend drug" as defined in section 20-571 of the Connecticut General Statutes;

(18) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(19) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate setting; and is the least costly of multiple, equally-effective alternative treatments or diagnostic modalities;

(20) "Medical necessity" or "medically necessary" means health care provided; to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring;

(21) "Medical record" means "medical record" as defined in section 19a-14-40 of the Regulations of Connecticut State Agencies;

(22) "Nursing facility" means "nursing facility" as defined in 42 USC 1396r(a), as amended from time to time;

(23) "Out-of-state provider" means a provider that is located outside Connecticut and is not a border provider;

(24) "Physician" means a person licensed pursuant to chapter 370 of the Connecticut General Statutes;

(25) "Podiatric Services" means services provided by a podiatrist within the scope of practice as defined by state law, including chapter 375 of the Connecticut General Statutes;

(26) "Podiatrist" means a doctor of podiatric medicine licensed pursuant to section 20-54 of the Connecticut General Statutes;

(27) "Prior authorization" means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods;

(28) "Provider" means a podiatrist or a podiatrist group enrolled in Medicaid;

(29) "Quality of care" means the evaluation of medical care to determine if it meets the professionally recognized standards of acceptable medical care for the condition and the client under treatment;

(30) "Routine foot care" means clipping or trimming of normal or mycotic toenails; debridement of the toenails that do not have onychogryposis or onychauxis; shaving, paring, cutting or removal of keratoma, tyloma or heloma; and nondefinitive shaving or paring of plantar warts except for the cauterization of plantar warts;

(31) "Simple foot hygiene" means self-care including, but not limited to: observation and cleansing of the feet; use of skin creams to maintain skin tone of both ambulatory and bedridden patients; nail care not involving professional attention; and prevention and reduction of corns, calluses and warts by means other than cutting, surgery or instrumentation;

(32) "Systemic condition" means the presence of a metabolic, neurologic, or peripheral vascular disease, including, but not limited to: diabetes mellitus, arteriosclerosis obliterans, Buerger's disease, chronic thrombophlebitis and peripheral neu-ropathies involving the feet, which would justify coverage of routine foot care;

(33) "Usual and customary charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, "usual and customary" shall be defined as the median charge. Token charges for charity patients and other exceptional charges are to be excluded; and

(34) "Utilization review" means the evaluation of the necessity and appropriateness of medical services and procedures as defined in section 17-134d-80 of the Regulations of Connecticut State Agencies.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-621 Provider participation

To enroll in Medicaid and receive payment from the department, providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-622 Eligibility

Payment for podiatric services shall be available on behalf of all persons eligible for Medicaid subject to the conditions and limitations that apply to these services.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-623 Services covered and limitations

Subject to the limitations and exclusions identified in sections 17b-262-619 to 17b-262-629, inclusive, of the Regulations of Connecticut State Agencies, the department shall pay providers for podiatric services provided by podiatrists:

(1) for only for those procedures listed in the provider's fee schedule that are medically necessary and medically appropriate to treat the client's condition;

(2) for podiatric services provided in an office, a general hospital, the client's home, a chronic disease hospital, nursing facility, ICF/MR or other medical care facility;

(3) for laboratory services provided by a podiatrist in compliance with the provisions of the Clinical Laboratory Improvement Amendments (CLIA) of 1988;

(4) for medical and surgical supplies used by the podiatrist in the course of treatment of a client;

(5) for drugs and supplies administered by a podiatrist;

(6) for a second opinion for surgery when requested voluntarily by the client or when required by the department. The department shall pay for a second opinion according to the established fees for consultation; and

(7) for EPSDT services including, but not limited to, treatment services which are indicated following screening but not otherwise covered, provided that prior authorization is obtained.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-624 Services not covered

The department shall not pay a podiatrist:

(1) for information or services provided to a client by a podiatrist over the telephone;

(2) for any product available to podiatrists free of charge;

(3) for more than one visit per day per client to the same podiatrist;

(4) for cosmetic surgery;

(5) for simplified tests requiring minimal time or equipment and employing materials nominal in cost, including, but not limited to, urine testing for glucose, albumin and blood;

(6) for simple foot hygiene;

(7) for repairs to devices judged by the department to be necessitated by willful or malicious abuse on the part of the client;

(8) for repairs to devices under guarantee or warranty. The podiatrist shall first seek payment from the manufacturer;

(9) for an office visit for the sole purpose of the client obtaining a prescription where the need for the prescription has already been determined;

(10) for cancelled services and appointments not kept;

(11) for services provided in a general hospital if the department determines the admission does not, or retrospectively did not, fit the department's utilization review requirements pursuant to section 17-134d-80 of the Regulations of Connecticut State Agencies; or

(12) for any procedures or services of an unproven, educational, social, research, experimental or cosmetic nature; for any diagnostic, therapeutic or treatment services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms or medical history.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-625 Need for service

Payment for an initial office visit and continuing services which the department deems medically necessary and medically appropriate, in relation to the diagnosis for which care is required, is available provided that:

(1) the services are within the scope of the podiatrist's practice; and

(2) the services are made part of the client's medical record.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-626 Prior authorization

(a) To receive payment from the department, a podiatrist shall comply with the prior authorization requirements described in section 17b-262-528 of the Regulations of Connecticut State Agencies. The department, in its sole discretion, shall determine what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

(b) Prior authorization, on forms and in the manner specified by the department, shall be required for:

(1) physical therapy services in excess of two visits per calendar week per client per podiatrist;

(2) physical therapy services in excess of nine visits per calendar year per client per podiatrist, when the therapy is for the treatment of the following diagnoses:

(A) cases involving musculoskeletal system disorders of the spine covered by the ICD, as amended from time to time; and

(B) cases involving symptoms related to nutrition, metabolism and development covered by the ICD, as amended from time to time;

(3) reconstructive surgery;

(4) plastic surgery;

(5) EPSDT services that are identified during a periodic screening as medically necessary and which are not listed on the existing fee schedule; and

(6) other services and supplies identified as requiring prior authorization on the fee schedule.

(c) Prior authorization is required for payment of all hospital admissions as required and described in section 17-134d-80 of the Regulations of Connecticut State Agencies.

(d) The authorization period shall be for a period not to exceed six months.

(e) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be considered for up to an additional six month period per request.

(f) Except in emergency situations, prior authorization shall be received before services are rendered.

(g) In an emergency situation that occurs after working hours or on a weekend or holiday, the podiatrist shall secure verbal prior authorization on the next working day for the services provided. This applies only to those services that normally require prior authorization.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-627 Billing procedures

(a) Claims from podiatrists shall be submitted on the department's designated form or electronically transmitted to the department, in a form and manner as specified by the department, and shall include all information required by the department to process the claim for payment.

(b) The amount billed to the department shall represent the podiatrist's usual and customary charge for the services delivered.

(c) When a client is referred to a podiatrist for consultation, the consultant podiatrist shall include the referring practitioner's name.

(d) Laboratory services performed in the podiatrist's office shall be payable to the podiatrist and shall be billed as separate line items. When a podiatrist refers a client to a private laboratory for services, the laboratory shall bill directly and no laboratory charge shall be paid to the podiatrist.

(e) All charges billed for supplies and materials provided by a podiatrist may be reviewed by the department.

(f) When services are provided by more than one member of a group, the authorization request shall be submitted prior to billing as described in the billing instructions in the provider manual.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-628 Payment

(a) The commissioner shall establish, and may periodically update, the fees for covered services in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

(b) Fees shall be the same for in-state, border and out-of-state podiatrists.

(c) Payment shall be made at the lowest of:

(1) the podiatrist's usual and customary charge;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department pursuant to section 4-67c of the Connecticut General Statutes; or

(4) the amount billed by the podiatrist.

(d) Notwithstanding the provisions of the regulations of connecticut state agencies or any of the Medical Services Policies to the contrary, the department shall not pay any podiatrist under sections 17b-262-619 through 17b-262-629, inclusive, of the regulations of connecticut state agencies for a client seen at a freestanding clinic enrolled in Medicaid. Only the clinic may bill for such services. As an exception to the foregoing, a podiatrist may bill for covered services for a client seen at an outpatient surgical facility. a podiatrist who is enrolled with medicaid at a location separate from the clinic may bill the department for clients seen at the separate practice location.

(e) The department shall not pay interns or residents for their services nor shall the department pay for assistant surgeons in general or chronic disease hospitals staffed by interns and residents, unless the procedure is significantly complicated to justify a full surgeon acting as an assistant. If the surgery is performed by a resident or intern and the supervising surgeon assists, only the assistant's fee shall be paid to the surgeon. The regular surgical fee shall not be paid.

(f) If a resident or intern performs the surgery and the supervising surgeon is not present while the procedure is performed, no fee shall be paid to the surgeon even when the surgeon is on call.

(g) Payment limitations

(1) Fees for initial fittings and adjustments shall be included in the cost of the item or device.

(2) The department shall pay a podiatrist for physical therapy only if the podiatrist personally provides the physical therapy.

(3) Payment shall be made for a customized item for a client who dies, or is not otherwise eligible on the date of delivery, provided the client was eligible:

(A) on the date prior authorization was given by the department; or

(B) on the date the client ordered the item, if the item does not require prior authorization. For purposes of this section, the date the client orders the item means the date on which the podiatrist presents the order to the manufacturer or supplier. The podiatrist shall verify to the department the date the client ordered the item.

(4) The department shall pay for routine foot care only if the client has a systemic condition. Services are limited to one treatment every sixty days.

(5) The fees listed in the department's fee schedule shall be payable only when the services are performed by the podiatrist.

(6) The department shall pay for an initial visit by a podiatrist in an office, home, ICF/MR or nursing facility visit only once per client. Initial visits refer to the podiatrist's first contact with the client and reflect higher fees for the additional time required for setting up records and developing past history. The only exception to this is when the podiatrist-client relationship has been discontinued for three or more years and is then reinstated.

(7) Fees for consultations shall apply only when the opinions and advice of a consultant podiatrist are requested by the referring provider or other appropriate source in the evaluation and treatment of the client's illness. After the consultation is provided, the consultant shall prepare a written report of his or her findings and provide a copy of the report to the referring podiatrist or physician. In a consultation, the client's referring provider carries out the plan of care. In a referral, a second provider provides direct service to the client.

(h) Surgery

(1) When a claim is submitted by a podiatrist for multiple surgical procedures performed on the same date of service, the department will pay for the primary surgical procedure at the Medicaid allowed amount for podiatrists or the billed amount, whichever is lower. The department shall pay for additional surgical procedures performed on that day at fifty percent of the Medicaid allowed amount for podiatrists.

(2) When an assistant surgeon, in addition to staff provided by the hospital, is required, the amount payable by the department to the assistant surgeon shall be as indicated on the fee schedule.

(3) Subsequent to the decision for surgery, fees for surgical procedures include one related evaluation and management encounter on the date immediately prior to, or on, the date of the procedure, including history and physical.

(4) The listed fees for all surgical procedures include the surgery and typical postoperative follow-up care while in the general or chronic disease hospital. Followup visits related to the surgery shall not be payable as office visits.

(5) The listed fees for surgery on the musculoskeletal system shall include payment for the application of the first cast or traction device.

(i) Radiology

(1) The listed fees for all diagnostic radiology procedures shall include consultation and a written report to the referring provider.

(2) The listed fees for all diagnostic radiology procedures shall apply only when the podiatrist's own equipment is being used. If the equipment used to perform the procedure is owned directly or indirectly by the general or chronic disease hospital or a related entity, or if a hospital includes the operating expenses of the equipment in its cost reports, the podiatrist shall not be paid for the technical component of the listed fee.

(j) Laboratory

(1) The following routine laboratory tests shall be included in the fee for an office visit and shall not be payable on the same date of service: urinalysis without microscopy, hemoglobin determination and urine glucose determination.

(2) No payment shall be made for tests which are provided free of charge.

(3) Payment shall be made for panel or profile tests according to the fees listed in the department's fee schedule for panel tests and not according to the fee for each separate test included in the panel or profile.

(k) Drugs

(1) The department shall pay the actual acquisition costs for oral medications incident to an office visit as billed by the podiatrist.

(2) The department shall pay for legend drugs and legend devices administered by the podiatrist based on a fee schedule determined by the department.

(3) No payment shall be made for drugs provided free of charge.

(l) Admission to a general hospital

Payment for services provided by the admitting podiatrist in a general hospital shall not be made available if it is determined by the department's utilization review program, either prospectively or retrospectively, that the admission did not fulfill the accepted professional criteria for medical necessity, medical appropriateness, appropriateness of setting or quality of care. Specific requirements are described in section 17-134d-80 of the Regulations of Connecticut State Agencies.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-629 Documentation and audit requirements

(a) Podiatrists shall maintain a specific record for all services received by each client eligible for Medicaid payment including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, a current treatment plan and treatment notes signed by the podiatrist, documentation of services provided and the dates the services were provided and a signed receipt for all devices dispensed. The receipt for any dispensed device, regardless of the format used, shall, at a minimum, contain the following elements:

(1) the podiatrist's name;

(2) the client's name;

(3) the delivery address;

(4) the date of delivery; and

(5) itemization of the device delivered, including:

(A) a product description;

(B) a brand name;

(C) a model name and number, if applicable;

(D) a serial number, if applicable;

(E) the quantity delivered; and

(F) the amount billed per device.

(b) All required documentation shall be maintained in its original form for at least five years or longer by the podiatrist in accordance with statute or regulation, subject to review by the department. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute, five years or the length of time required by statute or regulation, whichever is longest.

(c) Failure to maintain and provide all required documentation to the department upon request shall result in the disallowance and recovery by the department of any future or past payments made to the podiatrist for which the required documentation is not maintained and not provided to the department upon request.

(d) The department retains the right to audit any and all relevant records and documentation and to take any other appropriate quality assurance measures it deems necessary to assure compliance with these and other regulatory and statutory requirements.

(e) Podiatrists shall maintain documentation supporting all prior authorization requests.

History

• Adopted effective February 11, 2009

Regs., Conn. State Agencies § 17b-262-630 Scope

Sections 17b-262-630 to 17b-262-640, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment of services provided by independent licensed audiologists, physical therapists, occupational therapists and speech pathologists for clients who are determined eligible to receive services under Connecticut's Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes. Sections 17b-262-630 to 17b-262-640, inclusive, of the Regulations of Connecticut State Agencies shall not apply to therapy services provided by home health agencies, clinics, rehabilitation centers, hospitals or other health care providers.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-631 Definitions

For the purposes of sections 17b-262-630 to 17b-262-640, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:

(1) "Advanced practice registered nurse" or "APRN" means a person licensed pursuant to section 20-94a of the Connecticut General Statutes;

(2) "Audiologist" means a person licensed to practice audiology pursuant to chapter 397a of the Connecticut General Statutes and who meets the definition of "qualified audiologist" in 42 CFR 440.110(c)(3);

(3) "Audiology" means evaluation and treatment provided by an audiologist;

(4) "Border provider" has the same meaning as provided in section 17b-262-523 of the Regulations of Connecticut State Agencies;

(5) "Chronic disease hospital" has the same meaning as provided in section 19a-550 of the Connecticut General Statutes;

(6) "Client" means a person eligible for goods or services under Medicaid;

(7) "Commissioner" means the Commissioner of Social Services or the commissioner's agent;

(8) "Department" means the Department of Social Services or its agent;

(9) "Early and Periodic Screening, Diagnostic and Treatment Special Services" or "EPSDT Special Services" means services that are not otherwise covered under Medicaid but which are nevertheless covered as EPSDT services for Medicaid-eligible children pursuant to 42 USC 1396d(r)(5) when the service is medically necessary, the need for the service is identified in an EPSDT screen, the service is provided by a participating provider and the service is a type of service that may be covered by a state Medicaid agency and qualifies for federal reimbursement under 42 USC 1396d;

(10) "Home" means the client's place of residence, which includes a boarding home or residential care home. Home does not include a hospital or long-term care facility;

(11) "Hospital" means a "short-term hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies. It shall also include an out-of-state hospital or a hospital that is a border provider;

(12) "Independent therapist" means an audiologist, physical therapist, occupational therapist or speech pathologist practicing in the community independently and not associated with a hospital, long-term care facility, clinic, home health agency or any other health care provider;

(13) "Independent therapy" means those services provided by an independent therapist, a physical therapy assistant or an occupational therapy assistant;

(14) "Intermediate Care Facility for the Mentally Retarded" or "ICF/MR" means a residential facility for individuals with intellectual disabilities licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in Medicaid as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(15) "International Classification of Diseases" or "ICD" means the most recent system of disease classification established by the World Health Organization or such other disease classification system that the department requires providers to use when submitting Medicaid claims;

(16) "Licensed practitioner" means a physician, a physician assistant, an advanced practice registered nurse or a podiatrist providing services within the licensed practitioner's scope of practice under state law;

(17) "Long-term care facility" means a medical institution which provides, at a minimum, skilled nursing services or nursing supervision and assistance with personal care on a daily basis. Long-term care facilities include:

(A) nursing facilities;

(B) inpatient chronic disease hospitals; and

(C) intermediate care facilities for the mentally retarded;

(18) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(19) "Medical necessity" or "medically necessary" have the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(20) "Nursing facility" has the same meaning as provided in 42 USC 1396r(a) and is licensed pursuant to section 19-13-D8t of the Regulations of Connecticut State Agencies as a chronic and convalescent home or a rest home with nursing supervision;

(21) "Occupational therapist" has the same meaning as provided in section 20-74a(2) of the Connecticut General Statutes;

(22) "Occupational therapy" means services provided by an occupational therapist or an occupational therapy assistant and that meet the definition of occupational therapy in 42 CFR 440.110(b);

(23) "Occupational therapy assistant" has the same meaning as provided in section 20-74a(3) of the Connecticut General Statutes;

(24) "Physical therapist" has the same meaning as provided in section 20-66 of the Connecticut General Statutes;

(25) "Physical therapy assistant" has the same meaning as provided in section 20-66 of the Connecticut General Statutes;

(26) "Physical therapy" means the evaluation and treatment provided by a physical therapist or physical therapy assistant in accordance with 42 CFR 440.110(a);

(27) "Physician" means a person licensed pursuant to section 20-13 of the Connecticut General Statutes;

(28) "Physician assistant" has the same meaning as provided in section 20-12a(5) of the Connecticut General Statutes;

(29) "Podiatrist" means a person licensed to practice podiatric medicine pursuant to chapter 375 of the Connecticut General Statutes;

(30) "Prior authorization" means approval from the department for the provision of a service or the delivery of goods before the provider actually provides the service or delivers the goods;

(31) "Provider" means an independent therapist enrolled with Medicaid;

(32) "Provider agreement" means the signed, written agreement between the department and the provider for enrollment in Medicaid;

(33) "Speech pathologist" means a "licensed speech and language pathologist" as defined in section 20-408 of the Connecticut General Statutes;

(34) "Speech pathology services" means the evaluation and treatment provided by a speech pathologist in accordance with 42 CFR 440.110(c); and

(35) "Usual and customary charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, "usual and customary" means the median charge. Token charges for charity patients and other exceptional charges shall be excluded when calculating the usual and customary charge.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-632 Provider participation

In order to participate in Medicaid and receive payment from the department, providers shall:

(a) Comply with all applicable licensing, accreditation and certification requirements;

(b) comply with all departmental enrollment requirements, including sections 17b-262-522 to 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies;

(c) comply with sections 17b-262-630 to 17b-262-640, inclusive, of the Regulations of Connecticut State Agencies; and

(d) have a valid provider agreement on file with the department.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-633 Eligibility

Payment for independent therapy services prescribed by a licensed practitioner is available on behalf of all clients who have a need for such services and which are medically necessary subject to the conditions and limitations which apply to such services.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-634 Services covered and limitations

Subject to the limitations and exclusions in this section, the department shall pay for independent therapy which conforms to accepted methods of diagnosis and treatment, but shall not pay for anything of an unproven, educational, social, research, experimental or cosmetic nature; for services in excess of those deemed medically necessary by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms or medical history.

(a) The department shall pay for the following:

(1) Services provided in the provider's office or the client's home; and

(2) EPSDT Special Services.

(b) Limitations on covered services shall be as follows:

(1) Evaluation services for physical therapy, speech therapy, occupational therapy and audiology shall be limited to one of each type per day, per client regardless of the length of time it takes to complete the evaluation;

(2) for physical therapy and occupational therapy services, the department shall pay per modality as listed on the fee schedule;

(3) for speech therapy and audiology services, the department shall not pay for more than one and one half hours of treatment per day;

(4) the fee for evaluation shall include all treatment when evaluation and treatment are provided on the same day; and

(5) group speech therapy services shall include a maximum of three persons per group, per session regardless of each participant's payment source.

(c) The department shall not pay for the following independent therapy:

(1) Independent therapy when the client is concurrently receiving the same therapy services from a hospital, chronic disease hospital, clinic, rehabilitation clinic, home health agency or any other health care provider;

(2) services provided to clients who are residents of a hospital, long-term care facility or any other facility that is required to include independent therapy in its rates;

(3) cancelled office visits or appointments not kept; and

(4) information or services provided to a client by a provider electronically or over the telephone.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-635 Need for service

(a) The department shall pay for independent therapy that is medically necessary when a licensed practitioner prescribes the client's need for the service.

(b) A licensed practitioner shall reestablish the need for service by performing an evaluation not more than twelve months after the previous evaluation.

(c) The provider shall document the initial and subsequent need for service in the client's record.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-636 Prior authorization

(a) Prior authorization, on forms and in a manner as specified by the department, is required for:

(1) All audiology, physical therapy, occupational therapy and speech pathology evaluation services in excess of one evaluation per calendar year, per client, per provider;

(2) all audiology, physical therapy, occupational therapy and speech pathology treatment services in excess of nine treatments per calendar year per provider per client, involving the following primary diagnoses:

(A) All mental disorders including diagnoses relating to mental retardation and specific delays in development covered by the ICD;

(B) cases involving musculoskeletal system disorders of the spine covered by the ICD; and

(C) cases involving symptoms related to nutrition, metabolism and development covered by the ICD;

(3) all audiology, physical therapy, occupational therapy and speech pathology treatment services in excess of two services per calendar week, per client, per provider;

(4) EPSDT Special Services, as follows:

(A) EPSDT Special Services are determined medically necessary on a case-by-case basis; and

(B) the request for EPSDT Special Services shall include:

(i) A written statement from a licensed practitioner justifying the need for the item or services requested; and

(ii) any other documentation required by the department in order to render a decision; and

(5) any service that is not on the department's fee schedule.

(b) The length of the initial authorization period is at the department's discretion, but shall be for no longer than three months;

(c) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be considered up to six months per request or longer if determined appropriate by the department on a case- by-case basis.

(d) For services requiring prior authorization, a provider shall provide pertinent medical or social information adequate to evaluate the client's medical need for the services.

(e) In order to receive payment from the department, a provider shall comply with all prior authorization requirements. The department, in its sole discretion, determines what information is necessary in order to approve a prior authorization request. Prior authorization does not guarantee payment unless all other requirements for payment are met.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-637 Billing procedures

Providers shall submit claims on a hard copy invoice or by electronic transmission to the department in a form and manner specified by the department, together with all information required by the department to process the claim for payment.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-638 Payment

(a) Payment rates shall be the same for in-state, border and out-of-state providers.

(b) Payment shall be made at the lowest of:

(1) The provider's usual and customary charge;

(2) the lowest Medicare rate;

(3) the amount in the independent therapy fee schedule as published by the department;

(4) the amount billed by the provider; or

(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

(c) Notwithstanding the provisions of subsection (b)(5) of this section and subject to the approval of the department, a provider may charge or accept a lesser amount based on a showing by the provider of financial hardship to an individual without affecting the amount paid by the department for the same or substantially similar goods or services.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-639 Payment rates

The commissioner shall establish the fees contained in the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-640 Documentation

(a) Providers shall maintain a specific record for all services provided to each client including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, a current treatment plan and treatment notes signed by the provider, documentation of services provided and the dates the services were provided.

(b) The provider shall maintain all required documentation in its original form, paper or electronic, for at least five years or longer, as required by applicable statutes and regulations in the provider's file, subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the provider shall maintain the documentation until the end of the dispute or five years, whichever is greater.

(c) The department may disallow and recover any amounts paid to the provider for which the required documentation is not maintained and not provided to the department upon request.

(d) The department may audit any relevant records and documentation and take any other appropriate quality assurance measures it deems necessary to assure compliance with all regulatory and statutory requirements.

History

• Adopted effective December 1, 2000; Amended September 6, 2012

Regs., Conn. State Agencies § 17b-262-641 Scope

Sections 17b-262-641 through 17b-262-650, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment of laboratory services provided by licensed clinical laboratories, in settings other than hospital inpatient or outpatient departments or a physician's, nurse-midwife's, or nurse practitioner's office, for clients who are determined eligible to receive services under Connecticut's Medicaid Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-642 Definitions

For the purposes of sections 17b-262-641 through 17b-262-650, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:

(1) "Client" means a person eligible for goods or services under the department's Medicaid Program.

(2) "Commissioner" means the Commissioner of Social Services appointed pursuant to section 17b-1(a) of the Connecticut General Statutes.

(3) "Department" means the Department of Social Services or its agent.

(4) "HealthTrack Services" means the services described in section 1905(r) of the Social Security Act.

(5) "HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with section 1905(r)(5) of the Social Security Act, and are:

(A) services not covered under the State Plan or contained in a fee schedule published by the department; or

(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.

(6) "Interperiodic Encounter" means any medically necessary visit to a Connecticut Medicaid provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(7) "Laboratory" means a licensed clinical laboratory as defined in section 19a-30 of the Connecticut General Statutes and which is independent of a physician's, nurse-midwife's, or nurse practitioner's office, or an inpatient or outpatient hospital department or clinic.

(8) "Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(9) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(10) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act.

(11) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or prevent a medical condition from occurring.

(12) "Panel or Profile Tests" means certain multiple tests performed on a single specimen or material derived from the human body which are related to a condition, disorder, or family of disorders, which when combined mathematically or otherwise, comprise a finished identifiable laboratory study or studies.

(13) "Prior Authorization" means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods.

(14) "Provider" means a laboratory which provides testing and analysis services and which is independent of a physician's, nurse-midwife's, or nurse practitioner's office, or an inpatient or outpatient hospital department.

(15) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(16) "State Plan" means the document which contains the services covered by the Connecticut Medicaid Program in compliance with 42 CFR 430(B).

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-643 Provider participation

In order to enroll in the Medicaid Program and receive payment from the department, providers shall:

(1) be in compliance with the provisions of the Clinical Laboratories Improvement Amendments (CLIA) of 1988 for the procedures performed at the laboratory for which claims are submitted, including but not limited to, 42 CFR 493.1809;

(2) meet and maintain all applicable licensing, accreditation, and certification requirements;

(3) meet and maintain all departmental enrollment requirements; and

(4) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medicaid Program. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-644 Eligibility

Payment for independent clinical laboratory services shall be available on behalf of all persons eligible for the Medicaid Program subject to the conditions and limitations which apply to these services.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-645 Services covered and limitations

(a) The department shall pay for the following:

(1) medically appropriate and medically necessary clinical laboratory services, for which the laboratory holds certification according to the provisions of CLIA, which are listed in the department's fee schedule; and

(2) for HealthTrack and HealthTrack Special Services.

(b) Limitations on covered services shall be as follows:

(1) payment shall not be made for laboratory fees to the physician, nurse-midwife, nurse practitioner, or referring laboratories for services performed in a separate private laboratory;

(2) when laboratory services are performed in a private laboratory, billing for the service shall be made by the laboratory. Payment shall not be made to the referring physician, nurse-midwife, nurse practitioner, or to another laboratory which has referred the specimen to the performing laboratory for testing;

(3) payment shall not be made for testing and analysis which is available free of charge; and

(4) payment shall not be made for any procedures or services of an unproven, educational, social, research, experimental, or cosmetic nature; for services in excess of those deemed medically necessary and medically appropriate to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-646 Need for service

The department shall pay for medically necessary and medically appropriate testing and analysis services only when ordered by a licensed physician or other licensed practitioner of the healing arts.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-647 Prior authorization

(a) Prior authorization, on forms and in a manner as specified by the department, is required for HealthTrack Special Services. HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis. The request for HealthTrack Special Services shall include:

(1) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her respective scope of practice as defined under state law, justifying the need for the item or service requested;

(2) a description of the outcomes of any alternative measures tried; and

(3) if applicable and requested by the department, any other documentation required in order to render a decision.

(b) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-648 Billing procedures

(a) Claims from providers shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) Laboratory services performed in a physician's, nurse-midwife's, or nurse practitioner's office shall be payable pursuant to respective Regulations of Connecticut State Agencies which describe these services.

(c) Payment for services performed in a laboratory shall not be made to the referring physician, nurse-midwife, or nurse practitioner.

(d) Payment for the components of a panel or profile of tests consists of the following:

(1) the sum of any number of the components of a panel or profile of tests shall not exceed the total charged for the group offering, the panel or profile, whether done by automation or bench testing and whether or not the equipment is available in the facility where some Medicaid Program clients reside; and

(2) where multiple tests constitute a panel or profile, they shall be billed in that manner.

History

• Adopted effective May 10, 2000; Amended November 4, 2005

Regs., Conn. State Agencies § 17b-262-649 Payment

(a) Payment shall be made at the lowest of:

(1) the provider's usual and customary charge to the general public;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount billed by the provider; or

(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

(b) Notwithstanding the provisions of subsection (a) of this section and subject to the approval of the department, a provider may charge or accept a lesser amount based on a showing by the provider of financial hardship to an individual enrollee without affecting the amount paid by the department for the same or substantially similar goods or services.

(c) Payment Rate

The commissioner establishes the fees contained in the department's published fee schedule for independent clinical laboratories pursuant to section 4-67c of the Connecticut General Statutes.

(d) Payment Limitations

(1) A specimen collection fee by an independent clinical laboratory is limited to specimen collection by venipuncture or catherization.

(2) One specimen collection fee is permitted per encounter. A physician or duly authorized practitioner of the healing arts shall order the collection, and the order shall include the covered procedure or procedures from the independent clinical laboratory fee schedule. Payment shall be made to the provider performing the collection.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-650 Documentation

(a) Independent clinical laboratory providers shall maintain a specific record for all services received for each client eligible for Medicaid Program payment including, but not limited to: name, address, birth date, Medicaid Program identification number, pertinent diagnostic information, documentation of services provided, and the dates the services were provided.

(b) All required documentation shall be maintained for at least five years in the provider's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which required documentation is not maintained or provided to the department upon request.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-651 Scope

Sections 17b-262-651 through 17b-262-660, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment of dialysis services provided by physicians, general hospitals, and freestanding dialysis clinics for clients who are determined eligible to receive services under Connecticut's Medicaid Program pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-652 Definitions

For the purposes of sections 17b-262-651 through 17b-262-660, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:

(1) "Border Hospital" means an out-of-state general hospital which has a common medical delivery area with the State of Connecticut and is deemed a border hospital by the department on a hospital by hospital basis.

(2) "Client" means a person eligible for goods or services under the department's Medicaid Program.

(3) "Commissioner" means the Commissioner of Social Services appointed pursuant to section 17b-1(a) of the Connecticut General Statutes.

(4) "Department" means the Department of Social Services or its agent.

(5) "Dialysis" means dialysis as defined in 42 CFR 405.2102.

(6) "Freestanding Dialysis Clinic" means those centers licensed by the Department of Public Health (DPH) and certified, pursuant to section 19-13-D55a of the Regulations of Connecticut State Agencies, to provide dialysis services.

(7) "General Hospital" means a short-term acute care hospital having facilities, medical staff, and all necessary personnel to provide diagnosis, care, and treatment of a wide range of acute conditions, including injuries. This includes a children's general hospital. It shall also include a border hospital.

(8) "HealthTrack Services" means the services described in section 1905(r) of the Social Security Act.

(9) "HealthTrack Special Services" means medically necessary and medically appropriate health care, diagnostic services, treatment, or other measures necessary to correct or ameliorate disabilities and physical and mental illnesses and conditions discovered as a result of a periodic comprehensive health screening or interperiodic encounter. Such services are provided in accordance with section 1905(r)(5) of the Social Security Act, and are:

(A) services not covered under the State Plan or contained in a fee schedule published by the department; or

(B) services covered under the State Plan and contained in a fee schedule published by the department which exceed the limit on the amount of services established by the department that are contained in regulation.

(10) "Home" means the client's place of residence which includes a boarding home or residential care home. Home does not include a hospital, chronic disease hospital, nursing facility or intermediate care facility for the mentally retarded (ICF/MR).

(11) "Interperiodic Encounter" means any medically necessary visit to a Connecticut Medicaid provider, other than for the purpose of performing a periodic comprehensive health screening. Such encounters include, but are not limited to, physician's office visits, clinic visits, and other primary care visits.

(12) "Licensed Practitioner of the Healing Arts" means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH).

(13) "Medical Appropriateness or Medically Appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

(14) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act.

(15) "Medical Necessity or Medically Necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or prevent a medical condition from occurring.

(16) "Medical Record" means medical record as defined in section 19a-14-40 of the Regulations of Connecticut State Agencies, which is part of the Public Health Code.

(17) "Physician" means a physician licensed pursuant to section 20-1 of the Connecticut General Statutes or a doctor of osteopathy licensed pursuant to section 20-17 of the Connecticut General Statutes.

(18) "Prior Authorization" means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods.

(19) "Provider" means:

(A) a physician;

(B) a general hospital—inpatient or outpatient; or

(C) a freestanding dialysis clinic licensed by the Department of Public Health (DPH) and certified, pursuant to section 19-13-D55a of the Regulations of Connecticut State Agencies, to provide dialysis services.

(20) "Provider Agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

(21) "State Plan" means the document which contains the services covered by the Connecticut Medicaid Program in compliance with 42 CFR(430)(B).

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-653 Provider participation

In order to enroll in the Medicaid Program and receive payment from the department, providers shall:

(1) meet and maintain all applicable licensing, accreditation, and certification requirements;

(2) meet and maintain all departmental enrollment requirements; and

(3) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into the Medicaid Program. This agreement, which will be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-654 Eligibility

Payment for dialysis services shall be available on behalf of all persons eligible for the Medicaid Program subject to the conditions and limitations which apply to these services.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-655 Services covered and limitations

Subject to the limitations and exclusions listed below and those set forth in the Regulations of Connecticut State Agencies dealing with physicians, general hospitals, and freestanding dialysis clinics, the department shall pay for dialysis services which conform to accepted methods of diagnosis and treatment.

(a) The department shall pay for the following:

(1) for services provided by an enrolled provider in a home, clinic, hospital, or institution having an organized and approved dialysis program; and

(2) for HealthTrack Services and HealthTrack Special Services.

(b) The department shall not pay for the following:

(1) cancelled office visits and appointments not kept;

(2) information or services provided to a client by a provider over the telephone;

(3) any examinations, laboratory tests, biological products, immunizations, or other products which are furnished free of charge; and

(4) for any procedures or services of an unproven, educational, social, research, experimental, or cosmetic nature; for any diagnostic, therapeutic, or treatment services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms, or medical history.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-656 Need for service and authorization process

(a) The department shall pay for medically necessary and medically appropriate dialysis services for Medicaid Program clients, in relation to the diagnosis for which care is required, provided that:

(1) the services are within the scope of the provider's practice;

(2) a physician documents the need in writing and orders the service; and

(3) the services are made part of the client's medical record.

(b) Prior authorization, on forms and in a manner as specified by the department, is required for HealthTrack Special Services:

(1) HealthTrack Special Services are determined medically necessary and medically appropriate on a case-by-case basis; and

(2) the request for HealthTrack Services shall include:

(A) a written statement from the prescribing physician, or other licensed practitioner of the healing arts, performing such services within his or her scope of practice as defined under state law, justifying the need for the item or services requested;

(B) a description of the outcomes of any alternative measures tried; and

(C) if applicable and requested by the department, any other documentation required in order to render a decision.

(c) The procedure or course of treatment authorized shall be initiated within six months of the date of authorization.

(d) The initial authorization period shall be up to three months.

(e) If prior authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be considered up to six months per request.

(f) For services requiring prior authorization, a provider shall be required to provide pertinent medical or social information adequate for evaluating the client's medical need for services. Except in emergency situations, or when authorization is being requested for more than one visits in the same day, approval shall be received before services are rendered.

(g) In an emergency situation which occurs after working hours or on a weekend or holiday, the provider shall secure verbal approval on the next working day for the services provided. This applies to only those services which normally require prior authorization.

(h) In order to receive payment from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-657 Billing procedures

Claims from providers shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-658 Payment

(a) Payment shall be made at the lowest of:

(1) the provider's usual and customary charge to the general public;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount billed by the provider; or

(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

(b) Notwithstanding the provisions of subsection (a) of this section and subject to the approval of the department, a provider may charge or accept a lesser amount based on a showing by the provider of financial hardship to an individual enrollee without affecting the amount paid by the department for the same or substantially similar goods or services.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-659 Payment rate

(a) The commissioner establishes the fees contained in the provider's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

(b) Payment rates for physicians and physician groups are found in the department's fee schedule for physicians' services.

(c) Payment rates for dialysis services performed by freestanding dialysis clinics shall be based on the fee published by the department and contained in the department's fee schedule for clinics.

(d) Payment rates for dialysis services performed in a hospital on an inpatient basis are paid through the inpatient hospital interim per diem rate and published in the department's fee schedule for general hospital inpatient services.

(e) Payment rates for dialysis services performed in a hospital on an outpatient basis are paid as published in the department's fee schedule for general hospital outpatient services.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-660 Documentation

(a) Providers shall maintain a specific medical record for all services received for each client eligible for Medicaid Program payment including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, documentation of services provided, and the dates the services were provided.

(b) All required documentation shall be maintained for at least five years in the provider's file subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is greater.

(c) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained or provided to the department upon request.

History

• Adopted effective May 10, 2000

Regs., Conn. State Agencies § 17b-262-661—17b-262-671 Reserved

Sec. 17b-262-661—17b-262-671. Reserved

Regs., Conn. State Agencies § 17b-262-672 Scope

Sections 17b-262-672 through 17b-262-682 of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for the payment of durable medical equipment (DME) to providers, for clients who are determined eligible to receive services under Connecticut Medicaid pursuant to section 17b-262 of the Connecticut General Statutes (CGS).

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-673 Definitions

For the purposes of sections 17b-262-672 through 17b-262-682 of the Regulations of Connecticut State Agencies, the following definitions shall apply:

(1) "Chronic disease hospital" means an institution as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(2) "Client" means a person eligible for goods or services under the Medicaid program;

(3) "Certificate of Medical Necessity" or "CMN" means an approved Medicare form or a similar form which has been submitted to and approved by the department for use. This form shall contain all the documentation required for DME;

(4) "Commissioner" means the commissioner of social services;

(5) "Customized equipment" means devices or equipment prescribed by a licensed practitioner which is specifically manufactured to meet the special medical, physical, and psychosocial needs of the client. The equipment shall be individualized to preclude its use by any other person except the client for whom it was originally developed;

(6) "Department" means the department of social services or its agent;

(7) "Documented in writing" means that the prescription has been handwritten, typed, or computer printed;

(8) "Durable medical equipment" or "DME" means equipment that meets all of the following requirements:

(A) can withstand repeated use;

(B) is primarily and customarily used to serve a medical purpose;

(C) generally is not useful to a person in the absence of an illness or injury; and

(D) is nondisposable;

(9) "Equipment replacement" means any item that takes the place of original equipment lost, destroyed, or no longer medically useable or adequate;

(10) "Home" means the client's place of residence which includes a boarding home, community living arrangement, or residential care home. Home does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for the mentally retarded (ICFs/MR), or other facilities that are paid an all inclusive rate directly by Medicaid for the care of the client;

(11) "Hospital" means an institution as defined in Section 19-13-D1(b)(1) of the Regulations of Connecticut State Agencies;

(12) "Intermediate care facility for the mentally retarded" or "ICF/MR" means an institution licensed by, or operated by, the department of mental retardation (DMR) according to state law, and certified as a Medicaid intermediate care facility for the mentally retarded by the department of public health (DPH) to provide health or rehabilitative services for individuals with mental retardation or related conditions who, because of their mental or physical condition, require care and services, above the level of room and board, which can be made available to them only through a residential facility. Individuals residing in an ICF/MR shall be receiving active treatment pursuant to 42 CFR 483.440(a);

(13) "Licensed practitioner" means any person licensed by the state of Connecticut, any other state, District of Columbia, or the Commonwealth of Puerto Rico and authorized to prescribe treatments within the scope of his or her practice as defined and limited by federal and state law;

(14) "Manufactured" means constructed or assembled;

(15) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities;

(16) "Medicaid" means the program operated by the department of social services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(17) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring;

(18) "Nursing facility" or "NF" means an institution as defined in 42 USC 1396r(a);

(19) "Prescription" means an original order issued by a licensed practitioner that is documented in writing and signed by the practitioner issuing the order;

(20) "Prior authorization" or "PA" means approval for the service or the delivery of goods from the department before the provider actually provides the service or delivers the goods;

(21) "Provider" means the vendor or supplier of durable medical equipment who is enrolled with the department as a medical equipment, devices, and supplies supplier; and

(22) "Provider agreement" means the signed, written, contractual agreement between the department and the provider of services or goods.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-674 Provider participation

In order to enroll in the Medicaid program and receive payment from the department, providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-675 Eligibility

Payment for DME and related equipment is available for Medicaid clients who have a medical need for such equipment which meets the department's definition of DME when the item is prescribed by a licensed practitioner, subject to the conditions and limitations set forth in sections 17b-262-672 to 17b-262-682, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-676 Services covered and limitations

(a) Services Covered

(1) The department shall pay for the purchase or rental and the repair of DME, except as limited by sections 17b-262-672 to 17b-262-682, inclusive, of the Regulations of Connecticut State Agencies, that conforms to accepted methods of diagnosis and treatment and is medically necessary and medically appropriate.

(2) DME services are available to all clients who live at home. Additionally, the department shall pay for ventilators, customized wheelchairs, and Group 2 Pressure Reducing Support Surfaces for residents of nursing facilities and ICFs/MR.

(3) The department shall maintain a non-exclusive fee schedule of items which it has already determined meet the department's definition of DME and for which coverage shall be provided to eligible clients, subject to the conditions and limitations set forth in sections 17b-262-672 to 17b-262-682, inclusive, of the Regulations of Connecticut State Agencies. This fee schedule includes, but is not limited to:

(A) wheelchairs and accessories;

(B) walking aides, such as walkers, canes, and crutches;

(C) bathroom equipment such as commodes and safety equipment;

(D) inhalation therapy equipment such as IPPB machines, suction machines, nebulizers, and related equipment;

(E) hospital beds and accessories; and

(F) enteral/parenteral therapy equipment.

(4) When the item for which Medicaid coverage is requested is not on the department's fee schedule, prior authorization is required by the department. The recipient requesting Medicaid coverage for a prescribed item not on the list shall submit such prior authorization request to the department through an enrolled provider of DME. Such request shall include a signed prescription and shall include documentation showing the recipient's medical need for the prescribed item. If the item for which Medicaid coverage is requested is not on the department's fee schedule, the provider shall also include documentation showing that the item meets the department's definition of DME and is medically appropriate for the client requesting coverage of such item.

(5) In the last quarter of each calendar year, the department shall make modifications to its non-exclusive DME fee schedule. In deciding which items to add to this schedule, the department shall give consideration to:

(A) items requested for individual consideration through the process described in subdivision (4) of this subsection;

(B) input from the provider community; and

(C) input from the consumer community.

Providers and consumers who wish to provide input may make suggestions to the department's Medical Operations unit. Any suggestions shall be considered during the department's annual modification of its fee schedule.

(b) Limitations

(1) The department shall not pay for anything of an unproven, experimental or research nature or for services in excess of those deemed medically necessary by the department to treat the recipient's condition or for services not directly related to the recipient's diagnosis, symptoms, or medical history.

(2) Notwithstanding any other provisions of the Regulations of Connecticut State Agencies, the department shall pay for customized wheelchairs for clients of nursing facilities and ICFs/MR only when such customized wheelchairs are medically necessary in accordance with section 17-134d-46 or section 17-134d-47 of the Regulations of Connecticut State Agencies. The department shall pay for the purchase, modification or repair of these customized wheelchairs. The customized wheelchair may or may not be motorized. The need for the customized wheelchair shall be documented in accordance with section 17-134d-46 or section 17-134d-47 of the Regulations of Connecticut State Agencies.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-677 Services not covered

The Department shall not pay DME providers for:

(1) standard or stock DME items prescribed and ordered for a client who:

(A) dies prior to delivery of the item, or

(B) is not otherwise eligible on the date of delivery. It shall be the provider's responsibility to verify that the client is eligible on the date the item is delivered;

(2) the purchase or repair of DME necessitated by inappropriate, willful, or malicious misuse on the part of the client as determined by the department;

(3) the repairs and maintenance of DME furnished on a rental basis. The rental fee shall cover the services necessary to maintain the equipment in working order;

(4) DME supplied to clients in hospitals or chronic disease hospitals; and

(5) any service or item not identified as covered in sections 17b-262-672 to 17b-262-682, inclusive, of the Regulations of Connecticut State Agencies, unless it is approved in accordance with section 17b-262-676(a)(4) of the Regulations of Connecticut State Agencies.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-678 Prior authorization

(a) In order to receive reimbursement from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements are met.

(b) The department requires prior authorization for: 1) any item identified on the department's published fee schedule as requiring prior authorization; and 2) any item requested under section 17b-262-676(a)(4) of the Regulations of Connecticut State Agencies.

(c) A PA request, on forms and in a manner as specified by the department, shall include documentation of medical need and shall be signed by the prescribing licensed practitioner and the supplier. A copy of the prescription from the licensed practitioner may be attached to the completed PA request in lieu of the actual signature of the licensed practitioner on the PA request form. The licensed practitioner's original prescription shall be on file with the provider and subject to review by the department.

(d) A provider may FAX in prior authorization requests that are medically necessary to: 1) facilitate institutional discharge, or 2) avoid imminent hospitalization. Specifics that substantiate the nature of the request need to be clearly documented. Other PA requests for DME shall be submitted by mail.

(e) The initial authorization period for the rental of DME is determined by the department. If the medical need continues beyond the initial authorization period, a request for the extension of the authorization shall be submitted to the department with documentation by a licensed practitioner that service continues to be medically necessary. Such request and documentation shall arrive at the department prior to the start date of the extension or prior authorization shall be denied.

(f) Providers shall include an estimated delivery date when submitting a request for prior authorization, allowing for the department to take up to four weeks to process the request. The department shall share such estimated date with the client so that expectations for service delivery can be clear. Prior authorizations that do not include an estimated delivery date shall be denied.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-679 Billing procedure

(a) Claims from DME providers shall be submitted on a hard copy invoice or electronically transmitted to the department or its agent, in a form and manner as specified by the department, and shall include all information required by the department to process the claim for payment.

(b) Claims submitted for DME not requiring prior authorization shall include the name of the licensed practitioner or clinic making the referral. A licensed practitioner's original prescription for these items shall be on file with the provider and shall be subject to review by the department.

(c) DME providers shall bill and the department shall pay at the lowest of:

(1) the usual and customary charge to the general public;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount prior authorized in writing by the department; or

(5) the lowest price charged or accepted for the same or substantially similar goods or services by the provider from any person or entity.

(d) Notwithstanding the provisions of subsection (c)(5) of this section and subject to the approval of the department, a provider may charge or accept a lesser amount based on a showing by the provider of financial hardship to an individual without affecting the amount paid by the department for the same or substantially similar goods or services.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-680 Payment limitations

(a) Payment shall be made for customized DME for a client who dies or is not otherwise eligible on the date of delivery providing the client was eligible:

(1) on the date prior authorization was given by the department; or

(2) on the date the client ordered the item, if the item does not require prior authorization. For purposes of this section, the date the client orders the item means the date on which the written medical order for the item is presented to the provider. The provider shall verify to the department the date the client ordered the item.

(b) If the cost of repairs to any item exceeds its replacement cost, the item shall be replaced.

(c) The price for any item listed in the fee schedule published by the department shall include:

(1) fees for initial fittings and adjustments and related transportation costs;

(2) labor charges;

(3) delivery costs, fully prepaid by the provider, including any and all manufacturer's delivery charges with no additional charges to be made for packing or shipping;

(4) travel to the client's home, postage and handling, and set up or installation charges;

(5) technical assistance to the client to teach the client, or his or her family, the proper use and care of the equipment; and

(6) information furnished by the provider to the client over the telephone.

(d) Payment for servicing, repairs, or replacement of DME that are purchased by the department shall be contingent upon the exhaustion of any manufacturer's or dealer's warranty. The supplier shall first utilize existing warranties covering required servicing, repairs, and replacement.

(e) The department may pay for the rental of a wheelchair, for a period not to exceed three (3) months, in situations involving the pending delivery of a customized model to a client who resides in his or her own home.

(f) The department has the authority to determine the maximum rental period for DME, at which time the item shall be considered purchased. Such maximum rental periods shall be published on the fee schedule.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-681 Documentation

(a) All required documentation shall be maintained for at least five (5) years in the DME provider's file subject to review by the department. In the event of a dispute concerning a service or an item provided, documentation shall be maintained until the end of the dispute or five (5) years, whichever is greater.

(b) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the DME provider for the item or service for which the required documentation is not maintained or provided to the department upon request.

(c) The licensed practitioner's original prescription for DME shall be on file with the DME provider and shall be subject to review by the department. Such prescription shall specify the items ordered.

(d) The department requires that DME providers maintain fiscal and medical records to fully disclose services and goods rendered or delivered to Medicaid clients. A new prescription is required prior to replacement of DME.

(e) A signed receipt is required for all deliveries of DME, documenting that the client or, if the client is unable to sign, a designated representative other than the DME provider or the DME provider's employees, took delivery of the item. The receipt for DME, regardless of format used, shall, at a minimum, contain the following elements:

(1) provider's name;

(2) client's name;

(3) itemization of DME delivered, including:

(A) product description;

(B) brand name;

(C) model name and number;

(D) serial number (if applicable);

(E) quantity delivered;

(F) amount billed per item; and

(4) date of delivery.

(f) All prescriptions for DME regardless of format used (e.g., CMN, prescription pad, or letter) shall, at a minimum, contain the following elements:

(1) the client's name, address, and date of birth;

(2) diagnosis for which the DME is required;

(3) detailed description of the DME, including quantities and any special options or add-ons;

(4) length of need for the DME use;

(5) name and address of prescribing practitioner; and

(6) prescribing practitioner's signature and date signed.

(g) All requests for purchase of DME to replace an item shall be fully explained, documenting the continuing medical necessity and including reasons for the replacement and the reason that repairs are not feasible or are more costly than replacement.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-682 Other

(a) All equipment or devices purchased by the department shall be new and shall become the property of the client as of the date of delivery to the client.

(b) Where brand names or stock or model numbers are specified on the prescription or the PA, no substitution shall be permitted without the written approval of the department.

(c) Used equipment when rented shall be completely refurbished and in proper condition to meet the client's specific medical need.

(d) The provider shall instruct the client, or his or her family, on the proper use and care of the equipment. This instruction shall be provided as a part of the cost of the item. Additionally, the services and items shall be appropriate to both the environment and the client's current medical necessity.

(e) When the DME item is delivered, the provider shall ensure that proper assembly occurs and that the item meets the client's needs.

(f) DME providers shall notify the department of returns of DME items delivered to a client. Providers shall initiate necessary reimbursement adjustments resulting from such returns.

(g) It shall be the department's decision to rent or purchase DME, except in cases where the rental or payment option is determined by the primary payor source.

History

• Adopted effective August 22, 2000

Regs., Conn. State Agencies § 17b-262-683 Reserved

Sec. 17b-262-683. Reserved

Regs., Conn. State Agencies § 17b-262-684 Scope (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective January 1, 2002; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-262-685 Definitions (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective January 1, 2002; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-262-686 Provider participation (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective January 1, 2002; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-262-687 Eligibility (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective January 1, 2002; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-262-688 Services covered and limitations (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective January 1, 2002; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-262-689 Services not covered (Repealed)

Repealed June 11, 2014.

History

• Adopted effective January 1, 2002; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-262-690 Payment rate (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective January 1, 2002; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-262-691 Documentation (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective January 1, 2002; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-262-692 Manufacturer rebate program (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Adopted effective January 1, 2002; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-262-693 Scope (Repealed)

Repealed July 9, 2025.

History

• Adopted effective July 10, 2001; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-694 Definitions (Repealed)

Repealed July 9, 2025.

History

• Adopted effective July 10, 2001; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-695 Provider participation (Repealed)

Repealed July 9, 2025.

History

• Adopted effective July 10, 2001; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-696 Eligibility (Repealed)

Repealed July 9, 2025.

History

• Adopted effective July 10, 2001; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-697 Services covered and limitations (Repealed)

Repealed July 9, 2025.

History

• Adopted effective July 10, 2001; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-698 Services not covered (Repealed)

Repealed July 9, 2025.

History

• Adopted effective July 10, 2001; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-699 Payment rate and billing procedure (Repealed)

Repealed July 9, 2025.

History

• Adopted effective July 10, 2001; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-700 Documentation (Repealed)

Repealed July 9, 2025.

History

• Adopted effective July 10, 2001; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-701 Scope

Sections 17b-262-701 to 17b-262-711, inclusive, set forth the Department of Social Services requirements for payment to nursing facilities for services to clients eligible to receive such services under Connecticut's Medicaid program pursuant to section 17b-262 of the Connecticut General Statutes.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-702 Definitions

For the purposes of sections 17b-262-701 to 17b-262-711, inclusive, the following definitions shall apply:

(1) "Applied income" means the amount of income that each client receiving nursing facility services is expected to pay each month toward the cost of his or her care, calculated according to the department's Uniform Policy Manual, section 5045.20;

(2) "Client" means a person eligible for goods or services under the department's Medicaid program;

(3) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(4) "Commissioner" means the Commissioner of Social Services, or the commissioner's designee;

(5) "Department" means the Department of Social Services or its agent;

(6) "DMHAS" means the Department of Mental Health and Addiction Services or its agent;

(7) "DMR" means the Department of Mental Retardation or its agent;

(8) "Home leave" means an absence from the nursing facility for any reason other than admission to a hospital. It is taken at the discretion of the resident;

(9) "Hospital" means "hospital" as defined in section 19a-537 of the Connecticut General Statutes;

(10) "Institution for Mental Diseases" or "IMD" means "institution for mental diseases" as defined in 42 CFR 435.1009, as amended from time to time;

(11) "Licensed practitioner" means any person licensed by the state of Connecticut, any other state, District of Columbia, or the Commonwealth of Puerto Rico and authorized to prescribe treatments within the scope of his or her practice as defined and limited by federal and state law;

(12) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and, is the least costly of multiple, equally-effective, alternate treatments or diagnostic modalities;

(13) "Medicaid" means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(14) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring;

(15) "Nursing facility" or "NF" means "nursing facility" as defined in 42 USC 1396r(a), as amended from time to time;

(16) "Preadmission screening and resident review" or "PASRR" means the program defined in 42 USC 1396r(e)(7) and 42 CFR Part 483, Subpart C, as amended from time to time;

(17) "Preadmission MI/MR screen" means the level I screen required under the PASRR program and described in 42 CFR 483.106 and 42 CFR 483.128, as amended from time to time. It shall be completed on the forms and in the manner prescribed by the department;

(18) "Preadmission screening level II evaluation" means the level II screen as described in 42 CFR 483.112 and 42 CFR 483.128, as amended from time to time. It shall be completed on the forms and in the manner prescribed by the department;

(19) "Provider" means a nursing facility that is enrolled in the Medicaid program;

(20) "Provider agreement" means the signed, written, contractual agreement between the department and the provider;

(21) "Reserve bed day" means a day when a nursing facility client is temporarily absent from the nursing facility and for which payment is made by the department in accordance with section 19a-537 of the Connecticut General Statutes;

(22) "Resident" means a person living in a nursing facility; and

(23) "Usual and customary charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, usual and customary shall be defined as the median charge. Token charges for charity patients and other exceptional charges are to be excluded.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-703 Provider participation

In order to enroll in the Medicaid program and receive payment from the department, a nursing facility shall comply with sections 17b-262-522 through 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies. Licensing and certification requirements for nursing facilities referenced in sections 17b-262-701 to 17b-262-711, inclusive, of the Regulations of Connecticut State Agencies include, but are not limited to, the criteria described in section 19-13-D8t of the Regulations of Connecticut State Agencies and the criteria described in 42 CFR Part 483, subpart B, as amended from time to time.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-704 Eligibility

Payment for nursing facility services is available to all persons eligible for the Medicaid program subject to the conditions and limitations that apply to these services.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-705 Services covered and limitations

The department shall pay an all-inclusive per diem rate, computed in accordance with section 17b-340 of the Connecticut General Statutes and sections 17-311-1 to 17-311-120, inclusive, and sections 17-311-200 to 17-311-209, inclusive, of the Regulations of Connecticut State Agencies, to the provider for each Medicaid resident. This rate represents payment for the following goods and services:

(a) all services as required by section 19-13-D8t of the Regulations of Connecticut State Agencies and 42 CFR Part 483, subpart B, as amended from time to time, including, but not limited to:

(1) medical direction in accordance with sections 19-13-D8t(h) and (i) of the Regulations of Connecticut State Agencies;

(2) nursing service in accordance with 42 CFR 483.30, as amended from time to time, and sections 19-13-D8t(j),(k),(m) and (n) of the Regulations of Connecticut State Agencies;

(3) social services in accordance with 42 CFR 483.15(g), as amended from time to time, and section 19-13-D8t(s) of the Regulations of Connecticut State Agencies;

(4) therapeutic recreation in accordance with 42 CFR 483.15(f), as amended from time to time, and section 19-13-D8t(r) of the Regulations of Connecticut State Agencies;

(5) specialized rehabilitative services in accordance with 42 CFR 483.45, as amended from time to time;

(6) room and board in accordance with 42 CFR 483.10(c)(8)(i)(D), 42 CFR 483.35, and 42 CFR 483.70, as amended from time to time, and sections 19-13-D8t(q) and 19-13-D8t(v) of the Regulations of Connecticut State Agencies;

(7) consultation and assistance to residents in obtaining other needed services including:

(A) vision and hearing services in accordance with 42 CFR 483.25(b), as amended from time to time;

(B) services to address mental and psychosocial functioning in accordance with 42 CFR 483.25(f), as amended from time to time;

(C) dental services in accordance with 42 CFR 483.55, as amended from time to time; and

(D) pharmacy services in accordance with 42 CFR 483.60(b) and (c), as amended from time to time;

(b) routine personal hygiene items as defined in 42 CFR 483.10(c)(8)(i)(E), as amended from time to time;

(c) over the counter medications except insulin;

(d) durable medical equipment except those items listed in section 17b-262-676(a)(2) of the Regulations of Connecticut State Agencies that are payable separately for nursing facility clients;

(e) supplies used in the routine care of the Medicaid resident that are included on the department's medical and surgical fee schedule including:

(1) antiseptics and solutions;

(2) bandages and dressing supplies;

(3) catheters and urinary incontinent supplies;

(4) diabetic supplies;

(5) diapers and underpads;

(6) compression, burns and specialized medical garments;

(7) ostomy supplies;

(8) respiratory and tracheotomy supplies;

(9) enteral and parenteral supplies; and

(10) miscellaneous supplies;

Some of these supplies are covered by and should be billed to Part B of the Medicare program. Such supplies are not included in the per diem rate as per section 17b-340(f)(1) of the Connecticut General Statutes.

(f) services related to the provision or arrangement for provision of customized wheelchairs that are the responsibility of the nursing facility as described in sections 17-134d-46(m) and (n) of the Regulations of Connecticut State Agencies;

(g) oxygen concentrators as described in section 17b-281 of the Connecticut General Statutes and the regulations promulgated thereunder;

(h) prescription drugs for those providers that have approval from the department to include prescription drug costs in the per diem rate; and

(i) transportation services necessary to transport a client to and from any service included in the per diem rate as described in this section. Transportation to services listed in subdivision (a)(7) of this section, which the nursing facility shall help obtain but not provide directly, is not included in the per diem rate. Nursing facilities shall follow the customary authorization procedure in arranging for such transpor tation.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-706 Service limitations

(a) the department shall pay to reserve a bed in a nursing facility for a Medicaid resident during a temporary absence in a hospital or a temporary absence for home leave in accordance with the provisions of section 19a-537 of the Connecticut General Statutes.

(b) Payment shall be made for the date of admission and not for the date of discharge. Exceptions to this are:

(1) Payment may be made for the date of death when the resident dies in the nursing facility. If the resident dies while in the hospital or on home leave, the date of death may be paid as a reserve bed day, provided all other bed reservation requirements as described in section 19a-537 of the Connecticut General Statutes are met; and

(2) In the case of a resident admitted and discharged on the same day, payment shall be made for one day of care.

(c) The department shall not pay nursing facilities that are characterized as institutions for mental diseases (IMD) except for services to clients aged 65 and older or under age 22 in accordance with section 17-134d-68 of the Regulations of Connecticut State Agencies and 42 CFR 435.1008.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-707 Need for service and authorization process

(a) The department shall pay for an admission that is medically necessary and medically appropriate as evidenced by the following:

(1) certification by a licensed practitioner that a client admitted to a nursing facility meets the criteria outlined in section 19-13-D8t(d)(1) of the Regulations of Connecticut State Agencies. This certification of the need for care shall be made prior to the department's authorization of payment. The licensed practitioner shall use and sign all forms specified by the department;

(2) the department's evaluation and written authorization of the client's need for nursing facility services as ordered by the licensed practitioner;

(3) a health screen for clients eligible for the Connecticut Home Care Program for Elders as described in section 17b-342-4(a) of the Regulations of Connecticut State Agencies;

(4) a preadmission MI/MR screen signed by the department; or an exemption form, in accordance with 42 CFR 483.106(b), as amended from time to time, for any hospital discharge, readmission or transfer for which a preadmission MI/MR screen was not completed; and

(5) a preadmission screening level II evaluation for any individual suspected of having mental illness or mental retardation as identified by the preadmission MI/MR screen.

(b) The department shall pay a provider only when the department has authorized payment for the client's admission to that nursing facility.

(c) A nursing facility may admit a client on an emergency basis only if:

(1) the Office of Protection and Advocacy, established in accordance with section 46a-10 of the Connecticut General Statutes, in conjunction with DMHAS or DMR authorizes the emergency admission of a client with mental illness or mental retardation to a nursing facility for up to seven (7) days in accordance with 42 CFR 483.130(d)(5), as amended from time to time; or

(2) the commissioner of public health authorizes an emergency transfer as prescribed in section 19a-534 of the Connecticut General Statutes.

(d) if a client is admitted on an emergency basis, the nursing facility is not required to meet:

(1) the waiting list requirements of section 19a-533 of the Connecticut General Statutes and sections 17-311-200 to 17-311-209, inclusive, of the Regulations of Connecticut State Agencies, as long as emergency admissions are uniformly and consistently made without regard to source of payment; and

(2) the requirements of subsections (a)(3) to (a)(5) of this section.

(e) A client who requires admission after hours is not considered an emergency admission.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-708 Applied income

(a) The department is responsible for calculating the applied income. The department shall notify the nursing facility of the amount of any applied income that the nursing facility is responsible for collecting. Applied income shall be deducted from what otherwise would have been the department's monthly payment to the nursing facility.

(b) The nursing facility shall notify the department's caseworker of any errors in the amount of applied income processed against the claim using the form specified by the department. Payment adjustments resulting from retroactive applied income corrections shall be processed periodically.

(c) In any month that a resident returns to the community or dies, and the cost of care is less than the applied income, the department shall adjust the applied income as follows: the applied income shall equal the number of days that the resident was in the nursing facility multiplied by the per diem rate.

(d) Applied income is not pro rated. It is used to cover the cost of care until it is expended.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-709 Billing and payment procedures

(a) The nursing facility shall submit claims to the department as described in section 17b-262-529 of the Regulations of Connecticut State Agencies and the billing instructions specific to nursing facilities established by the department.

(b) The nursing facility is responsible for:

(1) completing the daily admission and discharge forms in accordance with the department's instructions;

(2) notifying the department caseworker if the nursing facility is aware that the Medicaid resident's asset level exceeds the established resource limit. The report shall be made on the form specified by the department;

(3) notifying the convalescent payment unit of the department of any and all credits due the department on the form specified by the department; and

(4) exhausting other payment sources of which the nursing facility is aware before billing the department.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-710 Rates

(a) The per diem rates for nursing facilities services are determined annually pursuant to section 17b-340 of the Connecticut general statutes and sections 17-311-1 to 17-311-209, inclusive, of the Regulations of Connecticut State Agencies.

(b) the department shall reimburse the nursing facility at the lower of:

(1) the per diem rate minus the applied income; or

(2) the usual and customary charge minus the applied income.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-711 Documentation

(a) The nursing facility shall maintain all documentation required for rate setting purposes in accordance with section 17-311-56 of the Regulations of Connecticut State Agencies, including all documentation required to support the billing for bed reserve days described in subsection (e)(5) of this section. This documentation is subject to review and audit by the department.

(b) The nursing facility shall maintain all other documentation required by this section for at least five (5) years or longer as required by statute or regulation, subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the nursing facility shall maintain all documentation until the end of the dispute, for five (5) years, or for the length of time required by statute or regulation, whichever is longest.

(c) Failure to maintain all required documentation may result in the disallowance and recovery by the department of any amounts paid to the nursing facility for which the required documentation is not maintained and provided to the department upon request. Documentation requirements are described in detail in the Provider Agreement for Nursing Facilities and sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.

(d) The department requires that nursing facilities maintain fiscal and medical records to fully disclose services and goods rendered or delivered to Medicaid residents. Records shall be maintained in accordance with the department's Provider Agreement for nursing facilities.

(e) Required documentation includes:

(1) certification for nursing facility admission as required by the department. The form shall be signed by the licensed practitioner;

(2) the department's written authorization of the client's need for nursing facility care;

(3) a health screen signed by the department for clients eligible for the Connecticut Home Care Program for Elders;

(4) all admission and discharge forms supporting the claim;

(5) all documentation required to support the nursing facility's billing for and the department's payment of bed reserve days as described in section 19a-537 of the Connecticut General Statutes;

(6) all documentation required by the PASRR process including:

(A) a preadmission MI/MR screen signed by the department or an exemption letter, in the form and manner prescribed by the department, for any hospital discharge, readmission or transfer for which a preadmission MI/MR screen is not on file; and

(B) a preadmission screening level II evaluation, signed by DMHAS or DMR, for any resident suspected of having mental illness or mental retardation, respectively, as identified on the preadmission MI/MR screen.

(7) medical records in accordance with section 19-13-D8t(o) of the Regulations of Connecticut State Agencies.

History

• Adopted effective March 1, 2002

Regs., Conn. State Agencies § 17b-262-712 Scope

Sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment to providers of medical and surgical supplies provided to eligible Medicaid clients residing at home.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-713 Definitions

As used in sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(2) "Client" means a person eligible for goods or services under the Medicaid program;

(3) "Commissioner" means the Commissioner of Social Services or his or her designee;

(4) "Department" means the Department of Social Services or its agent;

(5) "Documented in writing" means handwritten, typed or computer printed;

(6) "EPSDT (Early & Periodic Screening & Diagnostic Treatment) special services" means services provided in accordance with subdivision 1905 (r) of the Social Security Act;

(7) "Home" means the client's place of residence, including a boarding home, community living arrangement or residential care home. Home does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for the mentally retarded or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(8) "Hospital" means "short-term hospital" as defined in section 19-13-D1(b)(1) of the Regulations of Connecticut State Agencies;

(9) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for the mentally retarded licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in the Medicaid program as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(10) "Licensed practitioner" means an individual who is licensed by the Connecticut Department of Public Health, another state, District of Columbia or the Commonwealth of Puerto Rico and is acting within his or her scope of practice under Connecticut state law in prescribing a medical or surgical supply;

(11) "Medical and surgical supplies" or "supply" means treatment products that:

(A) are fabricated primarily and customarily to fulfill a medical or surgical purpose;

(B) are used in the treatment or diagnosis of specific medical conditions;

(C) are generally not useful in the absence of illness or injury; and

(D) are generally not reusable and are disposable.

(12) "Medicaid" means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(13) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities;

(14) "Medical necessity" or "medically necessary" means health care needed to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring;

(15) "Nursing facility" means "nursing facility" as defined in 42 USC 1396r(a), as amended from time to time;

(16) "Prescription" means an original order issued by a licensed practitioner that is documented in writing and signed and dated by the licensed practitioner issuing the order;

(17) "Prior authorization" or "PA" means approval from the department for the provision of a service or the delivery of goods before the provider actually provides the service or delivers the goods;

(18) "Provider" means a vendor or supplier of medical and surgical supplies who is enrolled with the department as a supplier of medical and surgical supplies;

(19) "Provider agreement" means the signed, written contractual agreement between the department and the provider; and

(20) "Usual and customary charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, usual and customary shall be defined as the median charge. Token charges for charity patients and other exceptional charges are to be excluded.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-714 Provider participation

To enroll in Medicaid and receive payment from the department, providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-715 Eligibility

Payment for medical and surgical supplies is available for clients who have a medical necessity for such supplies, when the supplies are prescribed by a licensed practitioner, subject to the conditions and limitations set forth in sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-716 Supplies covered and limitations

(a) Supplies covered

(1) The department shall pay for the purchase of medical and surgical supplies, except as limited by sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies, that conform to accepted methods of diagnosis and treatment and are medically necessary and medically appropriate.

(2) Payment for medical and surgical supplies is available only to clients who live at home.

(3) The department shall maintain a non-exclusive fee schedule of supplies which it has determined meet the department's definition of medical and surgical supplies and for which coverage shall be provided to eligible clients, subject to the conditions and limitations set forth in sections 17b-262-712 to 17b-262-722, inclusive, of the Regulations of Connecticut State Agencies.

(4) When the supply for which coverage is requested is not on the department's fee schedule, prior authorization is required for that supply. The provider requesting coverage for a prescribed supply not on the list shall submit a prior authorization request to the department through an enrolled provider of medical and surgical supplies. Such request shall include a prescription and documentation showing the client's medical necessity for the prescribed supply. The provider also shall include documentation showing that the supply meets the department's definition of a medical and surgical supply and is medically appropriate for the client requesting coverage of such supply.

(5) The department shall pay for medical and surgical supplies for EPSDT special services.

(b) Limitations

(1) The department shall not pay for anything of an unproven, experimental or research nature or for supplies in excess of those deemed medically necessary by the department to treat the client's condition or for supplies not directly related to the client's diagnosis, symptoms or medical history.

(2) A prescription shall be valid for no longer than one year.

(3) The department may set maximum allowable quantity limitations at levels that it determines to be reasonable.

(4) Automatic shipment of goods and products shall not be allowed. Any refills shall be made only at the request of the client or the client's authorized representative with a valid prescription.

(c) Medicaid Coverage for Donor Breast Milk.

(1) Pursuant to section 17b-277c of the Connecticut General Statutes, the department shall provide Medicaid coverage for pasteurized donor breast milk when determined medically necessary under section 17b-259b of the Connecticut General Statutes and in accordance with the provisions of this subsection.

(2) Practitioner Order. A licensed practitioner authorized by section 17b-277c of the Connecticut General Statutes shall issue a written order that documents that (A) donor breast milk is medically necessary for the infant, and (B) either (i) the infant is medically or physically unable to receive maternal breast milk or participate in breastfeeding due to maternal breast milk being unsuitable for infant consumption due to infectious disease, medication, or other maternal medical condition, or (ii) the infant’s mother is unable to produce sufficient quantities of breast milk to satisfy the infant’s nutritional requirements.

(3) Birth Weight and Health Conditions. The birth weight and health conditions that make the donor breast milk medically necessary for the infant may include, but are not limited to, one or more of the following:

(A) Birth weight below 1500 grams;

(B) Infant born at or below thirty-two weeks of gestation;

(C) Presence of a congenital or acquired condition that increases the risk of development of a necrotizing enterocolitis;

(D) Presence of an abdominal wall defect;

(E) An immunological deficiency;

(F) Presence of congenital heart disease that requires a repair in the first year of life;

(G) The infant is an organ transplant recipient or on an organ transplant waiting list; or

(H) Any other health condition not listed in this subdivision that is clinically determined by the department to make donor breast milk medically necessary.

(4) Time Frame. The infant may receive donor breast milk until the infant reaches six months of age, except (A) the infant may receive donor breast milk for up to two additional ninety day periods thereafter, provided a licensed practitioner provides documentation that the infant cannot meet his or her nutritional needs with the introduction of other forms of nutrition and the infant is not more than twelve months of age, and (B) donor breast milk for infants twelve months of age and older is covered only as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) special services approved by the department on a case-by-case basis.

(5) Prior Authorization. Prior authorization shall be required for donor breast milk for an infant receiving donor breast milk under this subsection in accordance with the provisions of section 17b-262-718 of the Regulations of Connecticut State Agencies.

(6) Provider Accreditation. The billing provider shall (A) be enrolled with the department as a human breast milk bank in accordance with the department’s enrollment requirements for the applicable provider type and specialty, and (B) obtain and maintain accreditation as a human breast milk bank from the Human Milk Banking Association of North America or another organization approved in writing by the department as qualified to accredit human breast milk banks.

History

• Adopted effective May 11, 2009; Amended March 14, 2024

Regs., Conn. State Agencies § 17b-262-717 Supplies not covered

The department shall not pay providers for:

(1) standard or stock medical and surgical supplies prescribed and ordered for a client who:

(A) dies prior to delivery of the supply; or

(B) is not otherwise eligible on the date of delivery. It shall be the provider's responsibility to verify that the client is eligible on the date the supply is delivered;

(2) medical and surgical supplies provided to clients in hospitals, chronic disease hospitals, nursing facilities or ICF/MRs;

(3) drugs and supplements, including, but not limited to, over-the-counter supplies such as cough medicines, herbal remedies and laxatives; and

(4) any supply routinely used for personal hygiene.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-718 Prior authorization

(a) To receive payment from the department, providers shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not guarantee payment unless all other requirements are met.

(b) The department requires prior authorization for any supply identified on the department's published fee schedule as requiring prior authorization or any supply not on the department's fee schedule.

(c) A prior authorization request, on forms and in a manner as specified by the department, shall include documentation of medical necessity and shall be signed by the prescribing licensed practitioner and the supplier. A copy of the prescription from the licensed practitioner may be attached to the completed PA request in lieu of the actual signature of the licensed practitioner on the PA request form. The licensed practitioner's original prescription shall be on file with the provider and be subject to review by the department.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-719 Billing procedure

(a) Claims from providers shall be submitted on a hard copy invoice or electronically transmitted to the department or its agent, in a form and manner that the department shall specify and shall include all information that the department shall require to process the claim for payment.

(b) Claims submitted for medical and surgical supplies not requiring prior authorization shall include the name of the licensed practitioner prescribing the supplies. A licensed practitioner's original prescription for the supplies shall be on file in the client's record with the provider and shall be subject to review by the department.

(c) Providers shall use the Healthcare Common Procedure Coding System (HCPCS), as maintained and distributed by the United States Department of Health and Human Services, for billing for medical and surgical supplies. Providers shall consult the Medicare SADMERC (Statistical Analysis Durable Medical Equipment Regional Carrier) if necessary to determine the proper billing code. A miscellaneous HCPCS code shall not be used unless a specific HCPCS code is not available for a supply. If a provider submits a prior authorization request to the department using a miscellaneous code for a supply that has a specific HCPCS code, the authorization request shall be denied.

(d) Providers shall bill the usual and customary charge.

(e) The department shall pay the lowest of:

(1) the lowest Medicare rate;

(2) the amount in the applicable fee schedule as published by the department;

(3) the provider's usual and customary charge; or

(4) the amount previously authorized in writing by the department.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-720 Payment limitations

The price for any supply listed in the fee schedule published by the department shall include and the department shall pay the lowest:

(1) fees for initial measurements, fittings and adjustments and related transportation costs;

(2) labor charges;

(3) delivery costs, fully prepaid by the provider, including any and all manufacturer's delivery charges with no additional charges to be made for packing or shipping;

(4) travel to the client's home;

(5) technical assistance to the client to teach the client, or his or her family, the proper use and care of the supplies;

(6) information furnished by the provider to the client over the telephone; and

(7) the provider shall accept the department's payment as payment in full.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-721 Documentation

(a) All required documentation shall be maintained for at least five years or the length of time required by statute in the provider's file subject to review by the department. In the event of a dispute concerning a service or a supply provided, documentation shall be maintained until the end of the dispute, five years or the length of time required by statute, whichever is longest.

(b) Failure to maintain all required documentation shall result in the disallowance of payment and recovery by the department of any amounts paid to the provider for supplies for which the required documentation is not maintained or provided to the department upon request.

(c) The licensed practitioner's original prescription for medical and surgical supplies shall be on file with the provider and shall be subject to review by the department.

(d) The department requires that providers maintain fiscal and medical records to fully disclose services and goods rendered or delivered to clients.

(e) A signed receipt is required for all deliveries of medical and surgical supplies documenting that the client or, if the client is unable to sign, a designated representative or adult other than the provider or the provider's employee, took delivery of the supply. The receipt for medical and surgical supplies, regardless of format used, shall, at a minimum, contain the following elements:

(1) provider's name;

(2) client's name;

(3) delivery address;

(4) date of delivery; and

(5) itemization of the medical and surgical supplies delivered, including:

(A) product description;

(B) brand name;

(C) quantity delivered; and

(D) amount billed per supply.

(f) All orders for medical and surgical supplies, regardless of format used, which includes verbal, telephone and faxed orders, shall, at a minimum, contain the following:

(1) client's name, address and date of birth;

(2) diagnosis for which the medical and surgical supplies are required;

(3) detailed description of the medical and surgical supplies, including quantities and directions for usage, when appropriate;

(4) length of need for the medical and surgical supplies prescribed;

(5) name and address of prescribing practitioner; and

(6) prescribing practitioner's signature and date signed.

(g) Original prescriptions for medical and surgical supplies shall be obtained from the prescribing practioner prior to submitting claims for payment.

(h) The department retains the right to audit any and all relevant records and documentation and to take any other appropriate quality assurance measures it deem necessary to assure compliance with these and other regulatory and statutory requirements.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-722 Other

(a) Where brand names or stock numbers are specified on the prescription or the PA, no substitution shall be permitted without the written approval of the department.

(b) The provider shall instruct the client or his or her family, designated representative or adult, on the proper use and care of the supply. This instruction shall be provided as a part of the cost of the supply.

(c) Providers shall notify the department of returns of medical and surgical supplies delivered to a client. Providers shall initiate necessary reimbursement adjustments resulting from such returns.

(d) The provider shall maintain a current usual and customary price list.

History

• Adopted effective May 11, 2009

Regs., Conn. State Agencies § 17b-262-723 Reserved

Sec. 17b-262-723. Reserved

Regs., Conn. State Agencies § 17b-262-724 Scope

Sections 17b-262-724 to 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for the payment of home health care services on behalf of clients who are determined eligible to receive services under the Connecticut Medicaid program pursuant to section 17b-262 of the Connecticut General Statutes.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-725 Definitions

As used in section 17b-262-724 to section 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Activity of daily living" or "ADL" means any activity necessary for self care including bathing, dressing, toileting, transferring and feeding;

(2) "Acute" means symptoms that are severe and have a rapid onset and a short course;

(3) "Care plan" means the patient care plan as set forth in section 19-13-D73 of the Regulations of Connecticut State Agencies;

(4) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1(b)(2) of the Regulations of Connecticut State Agencies;

(5) "Client" means a person eligible for goods or services under Medicaid;

(6) "Commissioner" means the Commissioner of Social Services or his or her designee;

(7) "Concurrent" means in the same time period covered by the care plan;

(8) "Department" means the Department of Social Services or its agent;

(9) "Early and periodic screening, diagnostic, and treatment services" or "EPSDT" means the services provided in accordance with section 1905(r) of the Social Security Act, as amended from time to time;

(10) "Emergency" means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client's health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part;

(11) "Extended nursing services" means nursing care services that are required for more than two continuous, consecutive hours on any given day;

(12) "Hands on care" means the assistance with activities of daily living provided most often, but not exclusively, by home health aides. The assistance includes the prompting and cueing necessary for a client to perform an activity of daily living;

(13) "Home" means the client's place of residence, including, but not limited to, a boarding home, residential care home or community living arrangement. "Home" does not include facilities such as hospitals, nursing facilities, chronic disease hospitals, intermediate care facilities for the mentally retarded (ICFs/MR) or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(14) "Home health aide" means "homemaker-home health aide" as defined in section 19-13-D66 of the Regulations of Connecticut State Agencies;

(15) "Home health care agency" means "home health care agency" as defined in section 19a-490 of the Connecticut General Statutes and which:

(A) is licensed by the Department of Public Health pursuant to sections 19-13-D66 to 19-13-D79, inclusive, of the Regulations of Connecticut State Agencies;

(B) meets the requirements of 42 CFR Parts 440, 441 and 484, as amended from time to time; and

(C) is enrolled in Medicaid;

(16) "Home health care services" means the services provided by a licensed home health care agency on a part-time or intermittent basis in the client's home;

(17) "Hospice" means "hospice" as defined in section 19-13-D1(b)(1)(C) of the Regulations of Connecticut State Agencies;

(18) "Hospital" means "short-term hospital" as defined in section 19-13-D1(b)(1) of the Regulations of Connecticut State Agencies;

(19) "Household" means a situation where two or more people are living: (A) in a group home, a residential care home or other group living situation; (B) at the same street address if it is a single family house that is not divided into apartments or units; or (C) at the same apartment number or unit number if clients live in a building that is divided into apartments or units;

(20) "Instrumental activity of daily living" or "IADL" means any activity related to a person's ability to function in the home, including, but not limited to, meal preparation, housework, laundry and use of the telephone;

(21) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for persons with mental retardation licensed pursuant to section 17a-227 of the Connecticut General Statutes, if applicable, and certified to participate in Medicaid as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(22) "Intermittent" means less than twenty-four hour care within a twenty-four hour period;

(23) "Licensed practical nurse" or "LPN" means "licensed practical nurse" as defined in chapter 378 of the Connecticut General Statutes;

(24) "Licensed practitioner" means a physician who orders home health care services in accordance with sections 19-13-D66 to 19-13-D79, inclusive, of the Regulations of Connecticut State Agencies;

(25) "Licensed practitioner order" means an order that directs the home health care agency to provide services according to the licensed practitioner's care plan;

(26) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(27) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate setting; and is the least costly of multiple, equally-effective alternative treatments or diagnostic modalities;

(28) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring;

(29) "Medical record" means "medical record" as defined in section 19a-14-40 of the Regulations of Connecticut State Agencies;

(30) "Medication administration" means the administration of oral, intramuscular or subcutaneous medication and also those procedures used to assess the client's medical or behavioral health status as ordered by the prescribing practitioner. Such procedures include, but are not limited to, glucometer readings, pulse rate checks, blood pressure checks or brief mental health assessments;

(31) "Normal life activities" means any activity that the client attends or in which he participates in the community including, but not limited to, school, work and day care;

(32) "Nursing care services" means the services provided by a registered nurse or a licensed practical nurse;

(33) "Nursing facility" means "nursing facility" as defined in 42 USC 1396r(a), as amended from time to time;

(34) "Occupational therapy" means the services provided by an occupational therapist or an occupational therapy assistant as set forth in section 20-74a of the Connecticut General Statutes;

(35) "Physical therapy" means the services provided by a physical therapist or a physical therapy assistant as set forth in section 20-66 of the Connecticut General Statutes;

(36) "Physician" means a physician or surgeon licensed pursuant to sections 20-8 to 20-14k, inclusive, of the Connecticut General Statutes;

(37) "Postpartum" means the sixty-day time period immediately following childbirth;

(38) "Prenatal" means the time period between the beginning of a pregnancy and the end of a pregnancy;

(39) "Prior authorization" or "PA" means the approval for the provision of a service or delivery of goods from the department before the provider actually provides the service or delivers the goods;

(40) "Provider" means a home health care agency;

(41) "Registered nurse" means "registered nurse" as defined in chapter 378 of the Connecticut General Statutes;

(42) "Speech therapy" or "speech pathology" means the services provided by a speech pathologist as set forth in section 20-408 of the Connecticut General Statutes;

(43) "Usual and customary charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, "usual and customary" shall be defined as the median charge. Token charges for charity patients and other exceptional charges are to be excluded; and

(44) "Week" means a calendar week beginning on Sunday and ending on Saturday.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-726 Provider participation

To enroll in Medicaid and receive payment from the department, providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, and sections 17b-262-1 to 17b-262-9, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-727 Eligibility

Payment for home health care services provided to persons eligible for Medicaid shall be available subject to the conditions and limitations that apply to these services as identified in sections 17b-262-724 to 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-728 Services covered and limitations

(a) Subject to the limitations and exclusions identified in sections 17b-262-724 to 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies, the department shall pay for medically necessary and medically appropriate home health care services provided by home health care agencies that are directly related to the client's diagnosis, symptoms or medical history. These services include:

(1) nursing care services limited to the following:

(A) physical nursing care or the teaching of nursing care, including, but not limited to, direct services such as enemas, irrigations, dressing changes, treatments and administration and supervision of medication;

(B) admission of clients to agency services; development of the initial care plan; and subsequent reviews of the care plan, no more than one every 60 days;

(C) diabetic teaching for thirty consecutive days per diabetic client;

(D) pregnancy-related preventive prenatal and postpartum nursing care services to women at high risk of negative pregnancy outcome that are performed during the prenatal or postpartum period of pregnancy for the purpose of, but not limited to:

(i) evaluation of medical health status, obstetrical history, present and past pregnancy related problems and psychosocial factors such as emotional status, inadequate resources, supportive helping networks and parenting skills; and

(ii) the provision of general health education and counseling, referral, instruction, suggestions, support or observation to monitor for any untoward changes in the condition of a prenatal or postpartum woman at high risk so that other medical or social services, if necessary, can be instituted during the prenatal or postpartum stage of childbearing;

(2) hands on care provided by a home health aide;

(3) home health aide assistance with an IADL provided in conjunction with hands on care;

(4) physical therapy services;

(5) speech therapy or speech pathology services;

(6) occupational therapy services; and

(7) EPSDT

(b) Limitations on covered services shall be as follows:

(1) The department shall pay for home health care services only when these services are provided in the client's home. However, the department shall pay for medically necessary and medically appropriate nursing care services for clients who leave their place of residence to engage in normal life activities. The total number of hours of nursing care services shall be limited to those hours to which the client would be entitled if services were provided exclusively at the client's place of residence. Such services shall not be provided in hospitals, nursing facilities, chronic disease hospitals, intermediate care facilities for the mentally retarded or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client.

(2) The department shall pay for only those services that are listed in the department's fee schedule for home health care services.

(3) The department shall pay for pregnancy-related preventive postpartum nursing care services only for high risk women as described in section 17b-262-731 of the Regulations of Connecticut State Agencies. Such payment shall be limited to services provided during the sixty-day time period immediately following childbirth.

(4) Home health aide services in excess of fourteen hours per week must be cost effective, as described in section 17b-262-730 of the Regulations of Connecticut State Agencies, for Medicaid payment to be available.

(5) Extended nursing services shall be cost effective as described in section 17b-262-730 of the Regulations of Connecticut State Agencies.

(6) The fee for medication administration shall include the administration of medication(s) while the nurse is present as well as the pre-pouring of additional doses, less than a one week supply, that the client will self administer at a later time and the teaching of self administration of the medication that has been pre-poured.

(7) When the purpose of the visit is to pre-pour medication for a week or more, the skilled nursing visit codes for either a registered nurse or a licensed practical nurse shall be used. The skilled nursing visit is provided for a client who has a documented need for this service because of his or her inability to correctly count out or draw up the medication for self-administration. Documentation shall include a full assessment of the client's medical and behavioral status as well as notes addressing the client's understanding of the drug therapy and his or her continued ability to self-administer the medications.

(8) If during the course of a scheduled medication administration visit, there is a change in the client's condition and the client's prescribing practitioner is notified, the medication administration visit may become a skilled nursing visit. This may occur even if a revision to the client's plan of care is not required. The client's medical record shall be fully updated to reflect the change in medical and behavioral health observed during the visit, the additional skilled services provided to the client and the revisions, if any, made to the plan of care. If this situation occurs and the services have been prior authorized, the provider shall contact the department to request modification of the prior authorization.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-729 Services not covered

The department shall not pay a home health care agency:

(1) for services provided to a client who is receiving the same service concurrently from an individual therapist, clinic, hospital, practitioner, rehabilitation center or other health care provider;

(2) for services provided by or through another agency or facility as part of its licensing requirements. For example, the department shall not pay for home health aide services if the client lives in a facility that provides home health aide services as part of its licensing requirements;

(3) when the client is in a hospital, nursing facility, chronic disease hospital, ICF/MR or other facility that is paid an all-inclusive rate directly by Medicaid for the care of the client;

(4) when the client is receiving the same home health care services concurrently from another home health care agency. This limitation does not preclude a home health care agency from contracting with another agency as described in section 19-13-D70 of the Regulations of Connecticut State Agencies;

(5) for well child care or for prenatal or postpartum care that is not high risk;

(6) for medical and surgical supplies or durable medical equipment used by the nurse, home health aide or therapist as part of the course of treatment for a client;

(7) for cancelled visits, appointments not kept or services not provided;

(8) for information or services provided to a client over the telephone; or

(9) for anything of an unproven, experimental or research nature or for services in excess of those deemed medically necessary and medically appropriate by the department to treat the client's condition or for services not directly related to the client's diagnosis, symptoms or medical history.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-730 Cost effectiveness test

(a) The department shall apply a cost effectiveness test for all prior authorization requests for: (1) home health aide services in excess of fourteen hours per week; and (2) all extended nursing services. The purpose of said test is to ensure that the services requiring PA, when combined with other services provided and within the home health care agency's scope of practice, whether or not provided by the home health agency, are not more expensive than the cost of the care would be for the client if the client were to be placed in the appropriate institution.

(b) In determining whether the home health care services are cost effective, the department shall compare the monthly cost of the home health care services with the monthly rate at the appropriate institution. The monthly cost of service in the appropriate institution means the average monthly Medicaid rate, calculated by the department, for a particular type of institution, for example, a nursing facility or ICF/MR. The monthly cost of home health care services is defined as the projected costs of providing these services for the client.

(c) The department shall total the costs of the following services to determine the cost of the home health care services: nursing, home health aide, physical therapy, speech therapy and occupational therapy. All costs of providing these services shall be included whether provided by a single home health care agency or multiple Medicaid providers including any other entity that the department reimburses for these services.

(d) The department shall determine whether a nursing facility, ICF/MR, chronic disease hospital or hospice is the appropriate institutional placement. Such determination shall depend on the criteria for admission to the institution and the client's care needs.

(e) The department shall approve PA requests for home health aide services for more than fourteen hours per week or extended nursing services only if:

(1) the total monthly cost of the home health care services as described in subsection (c) of this section is less than the monthly cost of services provided at the appropriate institution as described in subsection (d) of this section; and

(2) all other requirements of sections 17b-262-724 to 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies are met.

(f) Notwithstanding subsections (a) and (e) of this section, the department shall not apply the cost-effectiveness test for a PA request for home health aide services or extended nursing services provided during the first week after a hospital discharge. However, said services shall require prior authorization.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-731 Need for service

(a) The department shall pay for medically necessary and medically appropriate home health care services only under orders of a licensed practitioner as part of a care plan.

(b) The department shall pay for pregnancy-related preventive prenatal or postpartum nursing care services only if the woman has one, or a combination of, high risk indicators including, but not limited to, the following, which, in the opinion of her licensed practitioner, places the woman at high risk for negative pregnancy outcomes:

(1) an age under 20;

(2) an age over 39;

(3) a late registration for prenatal care that starts after the sixteenth week of gestation;

(4) no prenatal care;

(5) a serious weight loss or inadequate weight gain of seven pounds or less;

(6) a prenatal weight of more than eighty percent above the standard for height and age;

(7) more than one abortion, or an abortion within three months before the current pregnancy;

(8) a previous neonatal or fetal death;

(9) a previous preterm birth;

(10) an infant with a significant congenital anomaly or central nervous system damage;

(11) violence or deprivation that was abusive or damaging to the woman or her children;

(12) active substance abuse or an addiction, or a history of substance abuse or addiction, such as alcohol, drugs or nicotine;

(13) an active sexually transmitted disease or a history of such a disease;

(14) diseases or conditions including, but not limited to:

(A) human immunodeficiency virus (HIV), including related conditions such as acquired immune deficiency syndrome (AIDS) or AIDS related complex (ARC);

(B) cancer;

(C) acute or chronic cardiac disease;

(D) chronic renal disease;

(E) a seizure disorder;

(F) hypertension, either pre-existing or gestational;

(G) mental disorder without social or psychiatric supervision;

(H) mental retardation without supervision or support;

(I) endocrine or metabolic disorder;

(J) hepatitis;

(K) multiple sclerosis; or

(L) nutritional deficiency; and

(15) an infant up to sixty days of age with one or a combination of diseases or conditions such as:

(A) HIV, including related conditions such as AIDS or ARC;

(B) a birth before thirty-six weeks of gestation or a birth weight under two thousand five hundred grams;

(C) central nervous system damage;

(D) a failure to thrive or a significant infant feeding problem;

(E) an admission to a neonatal intensive care unit;

(F) a sibling who required treatment for recurring apnea or had sudden infant death syndrome;

(G) mental retardation;

(H) neonatal asphyxia;

(I) a seizure disorder;

(J) a significant congenital anomaly; or

(K) a supervising relative under sixteen years of age.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-732 Prior authorization

(a) To receive payment from the department the provider shall comply with the prior authorization requirements described in section 17b-262-528 of the Regulations of Connecticut State Agencies and this section. The department, in its sole discretion, shall determine what information is necessary to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

(b) Prior authorization, on forms and in a manner as specified by the department, shall be required for:

(1) nursing care services in excess of an initial evaluation and two visits per week;

(2) all extended nursing services;

(3) pregnancy-related preventive prenatal nursing care services in excess of two visits during the prenatal period;

(4) pregnancy-related preventive postpartum nursing care services in excess of two visits during the postpartum period;

(5) home health aide services in excess of fourteen hours per week;

(6) physical therapy services in excess of an initial evaluation and two visits per week;

(7) speech therapy services in excess of an initial evaluation and two visits per week;

(8) occupational therapy services in excess of an initial evaluation and one visit per week;

(9) physical therapy, occupational therapy or speech therapy services in excess of nine visits per therapy type per calendar year per provider per client, when the therapy is for the treatment of the following diagnoses:

(A) all mental disorders including diagnoses relating to mental retardation and specific delays in development covered by the International Classification of Diseases (ICD), as amended from time to time;

(B) cases involving musculoskeletal system disorders of the spine covered by the ICD, as amended from time to time; or

(C) cases involving symptoms related to nutrition, metabolism and development covered by the ICD, as amended from time to time; and

(10) Early and periodic screening, diagnostic and treatment services requested under section 1905(r)(5) of the Social Security Act, as amended from time to time.

(c) The provider shall obtain, and the department may give, the initial prior authorization either verbally or by mail. The length of the initial authorization is at the department's discretion, but shall be for no longer than a three-month period. The provider shall submit subsequent prior authorization requests in writing by mail at least thirty days in advance of providing services or delivering goods beyond the period of initial approval. If there is a need to change the prior authorization request, the provider shall notify the department not more than two working days after the modification was made. Any authorization period for home health aide services shall be for at least one month.

(d) If continued treatment is needed beyond an initial or subsequent authorization period, the department shall consider, and may approve, an additional prior authorization request that shall be for a period of up to twelve months. The provider shall submit subsequent prior authorization requests in writing by mail at least thirty days in advance.

(e) The provider shall present pertinent medical or social information adequate for evaluating the client's medical need for services when requesting prior authorization. The home health care agency shall maintain a valid practitioner's order on file. Except in emergency situations, the provider shall obtain approval from the department before services are rendered.

(f) In an emergency situation that occurs after working hours or on a weekend or holiday, the provider shall secure verbal authorization on the next working day for the services provided. This applies only to those services that normally require prior authorization. If verbal authorization is obtained, the provider shall submit a written request not more than ten days after the date of service.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-733 Billing procedures

(a) Claims from home health care agencies shall be submitted on the department's designated form or electronically transmitted to the department or its agent, in a form and manner as specified by the department, and shall include all information required by the department to process the claim for payment.

(b) The provider shall bill the usual and customary charge and the department shall pay the lowest of:

(1) the provider's usual and customary charge;

(2) the lowest non-managed care Medicare rate;

(3) the amount in the applicable fee schedule as published by the department; or

(4) the amount billed by the provider to the department.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-734 Payment

(a) Payment

(1) The commissioner shall establish the fees for home health care services in the department's fee schedule pursuant to section 17b-242 of the Connecticut General Statutes.

(2) The department shall pay for home health aide services based on each unit of service the aide spends providing the services as described in the fee schedule.

(3) The department shall pay therapists as described in the fee schedule.

(4) The department shall pay for nursing services based on each visit or unit of service the nurse spends providing the services as described in the fee schedule.

(b) Payment Limitations

(1) The department shall reimburse a provider when all of the requirements of sections 17b-262-726 to 17b-262-735, inclusive, of the Regulations of Connecticut State Agencies have been met.

(2) When two or more clients in the same household are receiving nursing care services, except extended nursing services, the department shall pay the full unit fee for the primary client and a reduced fee for each subsequent client. The procedure code and modifier used for billing shall reflect the purpose of the visit for each subsequent client.

(3) The following limitations shall apply when extended nursing services are required to care for multiple clients in the same household:

(A) If one nurse is required, the department shall pay the full unit fee for the primary client and a reduced unit fee for the unit of time during which the nurse is providing care to one subsequent client. No payment shall be made for additional subsequent clients. The billing instructions for home health agencies shall include a detailed description of the billing process. The care plans shall support the ability of one nurse to provide services safely to multiple clients.

(B) If more than one nurse is required, the department shall pay the fee as described in section 17b-262-734(b)(3)(A) of the Regulations of Connecticut State Agencies for each nurse. The care plans shall support the need for multiple nurses.

(4) When home health aides are caring for multiple clients in the same household, the department shall pay each aide the full unit fee. The department shall pay for the home health aide to care for one client for any one 15-minute unit of time.

(5) The fee for home health care services shall include transportation.

(6) The fee for home health aide services shall include supervision of the home health aide by a registered nurse.

(7) The department shall pay the same fee for out-of-state providers as for instate providers.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-735 Documentation

(a) All required documentation shall be maintained for at least five years, or longer by the provider in accordance with statute or regulation, subject to review by the department. Documentation as set forth in sections 19-13-D75 and 19-13-D77 of the Regulations of Connecticut State Agencies shall be maintained for seven years. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute, five years or the length of time required by statute or regulation, whichever is longest.

(b) Failure to maintain and provide all required documentation to the department upon request shall result in the disallowance and recovery by the department of any future or past payments made to the provider for which the required documentation is not maintained and not provided to the department upon request.

(c) The following information shall be documented in writing or electronically, consistent with the requirements described in the Provider Enrollment Agreement and maintained on file with the home health care agency for each Medicaid client:

(1) initial and subsequent care plans signed and dated by the licensed practitioner in accordance with section 19-13-D73 of the Regulations of Connecticut State Agencies;

(2) verbal and telephone orders signed and dated by a licensed practitioner in accordance with section 17b-242 of the Connecticut General Statutes;

(3) Medicaid identification number;

(4) pertinent diagnostic information;

(5) documentation of each service provided and its duration;

(6) dates of services provided;

(7) for pregnancy-related preventive prenatal or postpartum nursing care services, evidence that the client is high risk as described in section 17-262-731 of the Regulations of Connecticut State Agencies;

(8) time sheets documenting all home health aide hours worked and duties performed that are signed by the client or his or her representative. A client representative shall not be an employee of, or under contract to, the home health care agency. All signatures shall be accompanied by a printed name; and

(9) all information described in section 19-13-D75(b) of the Regulations of Connecticut State Agencies.

(d) Each home health care agency shall maintain fiscal and medical records that fully disclose services and goods rendered or delivered to Medicaid clients.

(e) The licensed practitioner order shall include the projected number of hours needed for home health care services. The actual number of hours provided may be less than, or the same as, the projected number of hours, but the actual number of hours provided may not exceed the projected number of hours.

(f) Providers shall maintain documentation supporting all prior authorization requests.

History

• Adopted effective March 7, 2007

Regs., Conn. State Agencies § 17b-262-736 Scope

Sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment to providers of orthotic and prosthetic devices that are prescribed by a licensed practitioner on behalf of clients who are determined to be eligible to receive such goods and services under Medicaid pursuant to section 17b-262 of the Connecticut General Statues.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-737 Definitions

As used in sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:

(1) "Chronic disease hospital" means a "chronic disease hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(2) "Client" means a person eligible for goods or services under the Medicaid program;

(3) "Customized orthotic or prosthetic device" means a device prescribed by a licensed practitioner that is specifically manufactured to meet the special medical, physical or psychosocial needs of a client. A customized orthotic or prosthetic device requires special construction, the plans for which are taken from an exact model of a particular client's body part;

(4) "Department" means the Department of Social Services or its agent;

(5) "Documented in writing" means that the prescription has been handwritten, typed or computer printed;

(6) "Home" means the client's place of residence and includes a boarding home, community living arrangement or residential care home. Home does not include a facility such as a hospital, chronic disease hospital, nursing facility, intermediate care facility for the mentally retarded (ICF/MR) or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(7) "Hospital" means a "short-term hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(8) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for the mentally retarded licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in the Medicaid program as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(9) "Licensed practitioner" means an individual who is either licensed by the Connecticut Department of Public Health, another state, District of Columbia or the Commonwealth of Puerto Rico and is acting within his or her scope of practice under Connecticut state law in prescribing an orthotic or prosthetic device;

(10) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally-recognized standards of acceptable medical care; is delivered in the appropriate setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities;

(11) "Medicaid" means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(12) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness, to assist an individual in attaining or maintaining an optimal level of health, to diagnose a condition or to prevent a medical condition from occurring;

(13) "Nursing facility" means an institution as defined in 42 USC 1396r(a), as amended from time to time;

(14) "Orthotic or prosthetic device" or "device" means a corrective or supportive device prescribed by a licensed practitioner, within the scope of his or her practice as defined by federal and state law, to:

(A) artificially replace a missing portion of the body;

(B) prevent or correct physical deformity or malfunction; or

(C) support a weak or deformed portion of the body;

(15) "Prescription" means an original order issued by a licensed practitioner that is documented in writing and signed and dated by the licensed practitioner issuing the order;

(16) "Prior authorization" or "PA" means approval from the department for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods;

(17) "Provider" means the vendor or supplier of an orthotic or prosthetic device who is enrolled with the department as a medical equipment, devices, and supplies supplier; and

(18) "Usual and customary charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, usual and customary shall be defined as the median charge. Token charges for charity patients and other exceptional charges are to be excluded.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-738 Provider participation

To enroll in the Medicaid program and receive payment from the department, providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-739 Eligibility

A provider may receive reimbursement from the department for the provision of an orthotic and prosthetic device to a client. No reimbursement shall be made unless a licensed practitioner has prescribed the orthotic or prosthetic device subject to the conditions and limitations set forth in sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-740 Services covered and limitations

(a) Services Covered

(1) The department shall pay for the purchase or repair of a medically necessary and medically appropriate orthotic or prosthetic device, except as limited by sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies, provided such device is prescribed by a licensed practitioner in conformance with accepted methods of diagnosis and treatment.

(2) The department shall pay for an orthotic or prosthetic device for a client who lives at home or in a nursing facility, ICF/MR, hospital or chronic disease hospital, except as limited by sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies.

(3) The department shall maintain a fee schedule for orthotic and prosthetic devices, subject to the conditions and limitations set forth in sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies. This fee schedule is designed to meet the needs of most Medicaid clients. An item is not covered unless it is on the fee schedule. A provider or client may request that an item be added to the fee schedule. The department, at its discretion, may decide to add requested items during its regular revisions to the fee schedule, as published by the department.

(4) The department shall pay for early and periodic screening, diagnostic and treatment services (EPSDT) described in subsection 1905(r) of the Social Security Act, as amended from time to time.

(b) Limitations

(1) The department shall pay for replacement of a device only if the device is lost, destroyed or is no longer medically usable or adequate due to a measurable change in the client's condition. A new prescription shall be required for a replacement item. All requests for purchases of orthotic or prosthetic devices to replace a device shall be fully explained, and shall document the continuing medical necessity and include reasons for the replacement and the reason that repairs are not feasible or are more costly than replacement.

(2) The department shall not pay for an orthotic or prosthetic device for a client in a nursing facility, ICF/MR, chronic disease hospital or hospital if the device is included in the facility's per diem Medicaid rate.

(3) The department shall not pay for an orthotic or prosthetic device that can be billed to another payor.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-741 Goods and services not covered

The department shall not pay providers for:

(1) any orthotic or prosthetic device that is of an unproven, experimental or research nature or for services in excess of those deemed medically necessary by the department to treat the client's condition or for services not directly related to the client's diagnosis, symptoms or medical history;

(2) any non-customized orthotic or prosthetic device that does not require prior authorization and that is prescribed and ordered for a client who:

(A) dies prior to delivery of the device; or

(B) is not otherwise eligible on the date of delivery. It shall be the provider's responsibility to verify that the client is eligible on the date the device is delivered; or

(3) the purchase or repair of an orthotic or prosthetic device necessitated by inappropriate, willful or malicious misuse on the part of the client as determined by the department.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-742 Prior authorization

(a) The department shall require PA for any orthotic or prosthetic device identified on the department's published fee schedule as requiring PA.

(b) To receive reimbursement from the department a provider shall comply with all prior authorization requirements. The department in its sole discretion shall determine what information is necessary to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements are met.

(c) A PA request, on a form and in a manner specified by the department, shall include documentation of medical necessity and shall be signed by the prescribing licensed practitioner and the provider. A copy of the prescription from the licensed practitioner may be attached to the completed PA request in lieu of the actual signature of the licensed practitioner on the PA request form. The licensed practitioner's original prescription shall be on file with the provider and be subject to review by the department.

(d) A provider may send a prior authorization request to the department via facsimile if the request is medically necessary to: (1) facilitate institutional discharge or (2) avoid imminent hospitalization. Specifics that substantiate the nature of the request shall be clearly identified in the facsimile. All other PA requests for an orthotic or prosthetic device shall be submitted by mail.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-743 Billing procedure

(a) Claims from providers shall be submitted on a hard copy invoice or electronically transmitted to the department or its agent in a form and in a manner specified by the department and shall include all information required by the department to process the claim for payment.

(b) A claim submitted for an orthotic or prosthetic device that did not require prior authorization shall include the name of the licensed practitioner prescribing the device. A licensed practitioner's original prescription for the device shall be on file with the provider and shall be subject to review by the department.

(c) Providers shall bill and the department shall pay at the lowest of:

(1) the usual and customary charge;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department;

(4) the amount billed by the provider to the department; or

(5) the amount the department indicates in writing in a prior authorization.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-744 Payment limitations

(a) The department shall reimburse a provider when all requirements of sections 17b-262-736 to 17b-262-746, inclusive, of the Regulations of Connecticut State Agencies have been met.

(b) The department shall pay for a customized orthotic or prosthetic device for a client who dies or is not otherwise eligible on the date of delivery provided the client was eligible:

(1) on the date prior authorization was given by the department; or

(2) on the date the client ordered the device, if the device does not require prior authorization. For purposes of this section, the date the client orders the device means the date on which the written medical order for the device is presented to or received by the provider. The provider shall verify to the department the date the client ordered the device.

(c) If the cost of repairs to any orthotic or prosthetic device exceeds its replacement cost, the device shall be replaced.

(d) The price for any device listed in the fee schedule published by the department shall include:

(1) fees for initial fittings and all related subsequent adjustments;

(2) labor charges;

(3) delivery costs, fully prepaid by the provider, including any manufacturer's delivery charges, postage, packing and shipping;

(4) all travel costs incurred by the provider associated with measurements, fittings, adjustments or repairs;

(5) technical assistance fees related to teaching the client, his or her family or the designated representative the proper use and care of the equipment; and

(6) fees for providing information to the client over the telephone.

(e) The department shall pay for the servicing, repair or replacement of an orthotic or prosthetic device that is purchased by the department, provided that any manufacturer's or dealer's warranty has been exhausted. The provider shall first utilize existing warranties that cover required servicing, repairs and replacement.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-745 Documentation

(a) All required documentation shall be maintained for at least five (5) years in the provider's primary place of business and shall be subject to review by the department. In the event of a dispute concerning a service or a device provided, documentation shall be maintained until the end of the dispute or five (5) years, whichever is longer.

(b) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for the device or service for which the required documentation is not maintained or provided to the department upon request.

(c) The licensed practitioner's original prescription for an orthotic or prosthetic device and documentation of all notes related to fittings and adjustments shall be kept at the provider's primary place of business and shall be subject to review by the department.

(d) Providers shall maintain all fiscal and medical records related to services and goods rendered or delivered to Medicaid clients.

(e) Providers shall require and retain a signed receipt for all deliveries of orthotic and prosthetic devices, documenting that the client or, if the client is unable to sign, a designated representative other than the provider or the provider's employee, took delivery of the device. The receipt for an orthotic or prosthetic device, regardless of the format used, shall, at a minimum, contain the following elements:

(1) the provider's name;

(2) the client's name;

(3) the delivery address;

(4) the date of delivery; and

(5) itemization of the orthotic and prosthetic devices delivered, including:

(A) a product description;

(B) a brand name;

(C) a model name and number, if applicable;

(D) a serial number, if applicable;

(E) the quantity delivered; and

(F) the amount billed per device.

(f) A prescription for an orthotic or prosthetic device, regardless of the format used, shall, at a minimum, contain the following elements:

(1) the client's name, address and date of birth;

(2) the diagnosis for which the orthotic or prosthetic device is required;

(3) a detailed description of the orthotic or prosthetic device, including the quantity and any special options or add-ons, and, if needed, directions for usage;

(4) the length of need for the orthotic or prosthetic device prescribed;

(5) the name and address of the prescribing licensed practitioner; and

(6) the prescribing licensed practitioner's signature and date of his or her signature.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-746 Other

(a) Where brand names or stock or model numbers are specified on the prescription or the PA, no substitution shall be permitted without the written approval of the department.

(b) The provider shall instruct the client, his or her family or a designated representative on the proper use and care of the device.

(c) Providers shall initiate necessary reimbursement adjustments to the department resulting from returns of non-customized orthotic and prosthetic devices delivered to a client.

(d) The provider shall maintain a written usual and customary price list that details individual product and service charges. This list, including updates along with any required manufacturer's list pricing, shall be available for review by authorized department personnel.

(e) An orthotic or prosthetic device purchased by the department shall be new and shall become the property of the client on the date of delivery to the client.

History

• Adopted effective January 1, 2003

Regs., Conn. State Agencies § 17b-262-747 Scope

Sections 17b-262-747 to 17b-262-757, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment of rehabilitative services provided by private non-medical institutions to children who are determined eligible for Connecticut's Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-748 Definitions

As used in sections 17b-262-747 through 17b-262-757, inclusive, of the Regulations of Connecticut State Agencies the following definitions shall apply:

(1) "Billing provider" means the Connecticut Department of Children and Families.

(2) "Child" means a person who is under twenty-one (21) years of age.

(3) "Department" or "DSS" means the Department of Social Services or its agent.

(4) "DCF" means the Department of Children and Families.

(5) "Individual treatment plan" means a written plan developed by the performing provider in accordance with section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies.

(6) "Licensed clinical staff" means:

(A) a doctor of medicine or osteopathy licensed under chapter 370 of the Connecticut General Statutes;

(B) a psychologist who is licensed under chapter 383 of the Connecticut General Statutes;

(C) a marriage and family therapist who is licensed under chapter 383a of the Connecticut General Statutes;

(D) a clinical social worker who is licensed under chapter 383b of the Connecticut General Statutes;

(E) an alcohol and drug counselor who is licensed under chapter 376b of the Connecticut General Statutes;

(F) an advanced practice registered nurse who is licensed under chapter 378 of the Connecticut General Statues; or

(G) a registered nurse who is licensed under chapter 378 of the Connecticut General Statutes and who has a minimum of one year of experience in the mental health field.

(7) "Medicaid" means the program operated by the department pursuant to Section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act.

(8) "Medically necessary" or "medically appropriate" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a medical condition or mental illness; or to prevent a condition from occurring.

(9) "Monthly rate" means the amount the department pays for each PNMI client for PNMI program services for each month of service.

(10) "Performing provider" means an entity that participates in the Medicaid program as a provider of PNMI children's rehabilitative services and that is a state licensed or approved (A) residential treatment facility; group home; maternity home; or similar institution; or (B) child placing agency that offers a therapeutic foster care or professional parent program.

(11) "PNMI client" or "client" means a client who is a child that (A) has been placed with a PNMI performing provider by a state agency and (B) determined by the department to be eligible for Medicaid.

(12) "Private Non-Medical Institution" or "PNMI" means an entity that is not a health insuring organization, hospital, nursing home, or a community health care center, but which (A) provides residential services for children and is licensed or approved by the state of Connecticut as (i) a residential treatment facility, group home, maternity home, or similar institution or (ii) a child placing agency that offers a therapeutic foster care or a professional parent program or (B) is an out-of-state facility determined by the Commissioner of the Department of Children and Families to meet comparable licensure standards or requirements.

(13) "Residential treatment facility" means a 24 hour mental health facility that is licensed or approved by the Department of Children and Families and that operates for the purpose of effecting positive change and normal growth and development for emotionally disturbed, behavior disordered and socially maladjusted children.

(14) "Group home" means a community based residential facility with a homelike environment that is licensed or approved by the Department of Children and Families; provides board and care, counseling, life-skill training and recreation; and arranges for or helps residents access educational, vocational and therapy services that are offered in the community.

(15) "Maternity home" means a maternity home that (A) is licensed by DCF as a group home; (B) is a 24 hour facility that provides board, care, treatment and the therapeutic environment required to promote positive change and growth in pregnant adolescents and young mothers; and (C) has neonatal and postnatal programs that are designed to assess client needs and develop skills in parenting, socialization and independent living.

(16) "Therapeutic foster care" means a program offered by a DCF approved or licensed child placing agency that recruits, trains and supports foster parents who provide family foster care to children with emotional and behavioral needs.

(17) "Professional parent program" means a program provided by a DCF approved or licensed child placing agency that (A) recruits, trains and supports foster parents who provide family foster care to children with multiple needs and (B) serves children who need a greater level of care than those children who are served in a therapeutic foster care agency program.

(18) "Provider agreement and contract" means the signed, written contractual agreement between the department and the performing provider and the billing provider of PNMI children's rehabilitative services.

(19) "Rehabilitative services" means those services described in 42 C.F.R. 440.130(d), as amended from time to time, and include those services identified in section 17b-262-752 of the Regulations of Connecticut State Agencies.

(20) "Title V Agency" means the Department of Public Health, which administers Title V of the Social Security Act, known as the Maternal and Child Health Services Block Grant.

(21) "PNMI program" means the component part of the state's Title V program, which is administered through agreement among the billing provider, the department and the Title V Agency.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-749 Provider and billing provider requirements

To participate in the Medicaid program and provide PNMI rehabilitative services that are eligible for Medicaid reimbursement from the department, the following requirements shall be met:

(1) The performing provider shall:

(A) Enroll with the department and have on file a valid provider agreement.

(B) Be licensed or approved by DCF or another state agency as (A) a residential treatment facility, group home, maternity home, or similar institution; or (B) a child placing agency that offers therapeutic foster care or a professional parent program.

(C) Comply with all Medicaid record keeping, documentation and other requirements, including, but not limited to, those delineated in the department's administrative manuals, provider agreements and memoranda of understanding.

(D) Follow all laws, rules, regulations, policies and amendments that govern the Medicaid program as they relate to reimbursement for PNMI rehabilitative services.

(E) Develop an individual treatment plan for each PNMI client in accordance with section 17a-145-94 of the Regulations of Connecticut State Agencies not later than thirty days after the PNMI client's admission to the program. The individual treatment plan shall be developed in conjunction with DCF, the child and the child's family, whenever possible, and shall be signed and dated by a licensed clinical staff member employed by or under contract with the performing provider. Such plan shall contain specific behavioral health goals and objectives that are based on an evaluation and diagnosis for the maximum reduction of a client's behavioral health problems and shall identify the type, amount, frequency and duration of services to be provided.

(F) Ensure that a licensed clinical staff member employed by or under contract with the performing provider reviews and signs the individual treatment plan within each six month calendar period following the date of a PNMI client's admission.

(G) Keep current service and progress notes in a permanent case record for each PNMI client in accordance with sections 17a-145-94 and 17a-145-98 of the Regulations of Connecticut State Agencies. Such entries shall be made on at least a monthly basis.

(H) Furnish information and documentation to the billing provider that is sufficient to allow the billing provider to prepare PNMI claims for rehabilitative services.

(I) Cooperate with the department and the billing provider in the rate setting process; licensing; or any quality assurance reviews or periodic audits to ensure compliance with PNMI program requirements.

(J) Assign billing responsibilities related to the claiming of federal financial participation for state PNMI Medicaid costs to the billing provider.

(2) The billing provider shall:

(A) Have a valid provider agreement and contract on file that is signed by the performing provider, the billing provider and the department that assigns responsibility for the claiming of federal financial participation to the department. The agreement shall be updated periodically in accordance with Medicaid requirements.

(B) Ensure that the performing provider meets and maintains all applicable licensing, accreditation and certification requirements in accordance with federal and state laws.

(C) Comply with all Medicaid record keeping, documentation, and other requirements, including, but not limited to, those delineated in department PNMI rehabilitative service administrative manuals, provider agreements and memoranda of understanding.

(D) Follow all laws, rules, regulations, policies and amendments that govern the Medicaid program as they relate to PNMI rehabilitative services.

(E) Carry out regular licensing and quality assurance reviews of performing providers.

(F) Assist the department in establishing PNMI rates that are based upon Medicaid eligible activities that are not otherwise being claimed for federal financial participation.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-750 Eligibility

Payment for PNMI rehabilitative services shall be subject to available appropriations and shall be available for services rendered to PNMI clients under the conditions and limitations that are set forth in sections 17b-262-747 to 17b-262-757, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-751 Need for services

Payment for PNMI rehabilitative services shall be made by the department only if all of the following conditions are met:

(1) The client shall be assessed by the billing provider or its agent to determine that the PNMI rehabilitative services are medically necessary or medically appropriate.

(2) For up to 30 days of a PNMI client's initial stay in a PNMI program, the PNMI rehabilitative services shall be provided in accordance with an initial assessmentof need that is completed by DCF and signed by a licensed clinical staff member of the performing provider. This assessment shall, for up to 30 days of a PNMI client's initial stay, be deemed to meet the PNMI requirements for an individual treatment plan set forth in section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies.

(3) After the first 30 days of a client's stay in a PNMI program, the PNMI rehabilitative services shall be provided in accordance with a written individual treatment plan developed in accordance with section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies. Within each 90 day period thereafter, the individual treatment plan shall be reviewed by the licensed, clinical staff employed by or under contract with the performing provider.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-752 Covered services

PNMI rehabilitative services shall include the following services:

(1) Assessment, treatment planning and support activities that assist the client in gaining access to authorized services. These services include:

(A) Intake and assessment, which means assessing and reassessing the client's behavioral health needs in the context of medical, social, educational and other needs through face-to-face contact with the client, the client's family and through consultation with other professionals; and

(B) Development of an individual treatment plan in accordance with sections 17b-262-749(a)(5) and 17b-262-751 of the Regulations of Connecticut State Agencies; and

(C) Care coordination, which means facilitating the child's access to behavioral health services identified in the individual treatment plan, including:

(i) Arranging for services;

(ii) Assuring that prescribed services are received;

(iii) Assessing the effectiveness of those services;

(iv) Attending case conferences to review and modify individual treatment plans as necessary; and

(v) Arranging home visits, discharge and aftercare services.

(2) Socialization skills development, which means client-centered activities that are provided to support the goals and objectives in the PNMI client's individual treatment plan and that are directed at reducing mental disabilities of children in care, restoring them to their best possible functioning level and assisting clients in becoming responsible for their own actions.

(3) Counseling and therapy, which includes (A) individual, group and family counseling and (B) therapy or consultation that is necessary to improve problems and to restore children to their optimal functioning level.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-753 Limitations

Coverage of PNMI rehabilitative services shall be subject to the following limitations:

(1) PNMI rehabilitative services shall be pre-authorized by DCF based on a written service recommendation.

(2) The PNMI rehabilitative service shall be based on the individual treatment plan developed pursuant to section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies and shall be performed by the performing provider or under the supervision of licensed clinical staff employed by or under contract to the performing provider.

(3) The department shall not pay for programs, services or components of services that are of an unproven, experimental, cosmetic or research nature.

(4) The department shall not pay for programs, services or components of services that do not relate to the client's diagnosis, symptoms or medical history.

(5) The department shall not pay for programs, services or components of services, which are not included in the fee schedule established by the department.

(6) The department shall not pay for programs, services that are academic in nature such as tutoring, study sessions or instruction in English, science, history, mathematics or foreign languages.

(7) The department shall not pay for programs, services or components of services that are intended solely to prepare individuals for paid or unpaid employment or for vocational equipment and uniforms.

(8) The department shall not pay for programs, services or components of services designed to provide socialization or recreational activities for clients unless such services are provided to meet a client's need for motivational, diversionary or behavior management activities for which specific goals and objectives are identified in the client's individual treatment plan.

(9) The department shall not pay for costs associated with room and board for clients.

(10) The department shall not pay PNMI rehabilitative services that are provided out-of-state unless the services are pre-authorized by a placing state agency and are not available within Connecticut.

(11) The department shall not pay any organization that is directly under contract to a performing provider for services covered under this regulation.

(12) The department shall not pay for care coordination services that are provided within a PNMI program if such services duplicate Medicaid-reimbursed case management services that are provided outside the facility. PNMI program staff providing care coordination services shall coordinate with any Medicaid-reimbursed case management services provided outside of the program so that such duplication does not occur.

(13) The department shall not pay other providers for services to PNMI clients that if the services are not part of a client's individual treatment plan developed pursuant to section 17b-262-749(a)(5) of the Regulations of Connecticut State Agencies.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-754 Documentation and record retention requirements

PNMI rehabilitative services shall be reimbursed by the department when documentation of compliance with the following requirements is on file with the billing provider or the performing providers:

(1) Individual treatment plan requirement.

(A) An individual treatment plan shall be maintained.

(B) An initial assessment of need completed by DCF in conformance with section 17b-262-751 of the Regulations of Connecticut State Agencies is maintained.

(2) Permanent case record requirement.

(A) A permanent case record, as required by section 17a-145-98 of the Regulations of Connecticut State Agencies, is maintained and includes, at a minimum, identifying information including the name of the client, date of birth, gender, Medicaid identification number, LINK person number; the client's family, social and health history; the reason for admission to the PNMI program; the individual treatment plan; identification of the care and services provided; the progress of the child in the program; and the plan for discharge and disposition of the PNMI client.

(B) All documentation shall be physically placed into the eligible PNMI client's permanent case record in a complete, prompt and accurate manner. All documents shall be made available to authorized Department personnel upon request.

(3) Other documentation and record retention requirements.

(A) The performing provider shall maintain a current record of the applicable licenses and certificates of practice of all licensed or certified individuals furnishing PNMI rehabilitative services.

(B) The performing provider shall be substantially in compliance with all documentation requirements in its most recent licensure review and relevant state agency quality assurance reviews.

(C) The performing provider shall maintain all required records for at least five (5) years or longer as required by statutes or regulation subject to review by the department. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five (5) years, whichever is greater.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-755 Billing requirements

(a) Claims for payment of PNMI rehabilitation services shall be submitted by the billing provider on the department's uniform billing form or electronically transmitted to the Department's fiscal agent and shall include all information required by the Department to process the claim for payment.

(b) All claims submitted to the department for payment of services covered under sections 17b-262-747 to 17b-262-757, inclusive, of the Regulations of Connecticut State Agencies shall be substantiated by documentation in the PNMI client's permanent case record.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-756 Payment

Payment by the department for PNMI rehabilitative services shall be made in accordance with the following provisions.

(1) The department shall make payments on the basis of monthly rates for each of three types of PNMI programs: (A) residential treatment centers, (B) group homes or maternity homes and (C) therapeutic foster care and professional parent programs. The Department shall establish interim PNMI rates each year based upon the cost to the public agency for the purchase of PNMI services during the most recently completed year. These rates shall be adjusted based upon actual cost experience of the public agency at the close of the fiscal year by adjusting the interim rate for the subsequent year accordingly. To identify costs not covered by the Medicaid program, the Department shall establish a method for cost allocation acceptable to the Centers for Medicare and Medicaid Services.

(2) The calculation of the PNMI rates shall not include any services that have been reimbursed by Medicaid under other service categories.

(3) The PNMI rates shall exclude payment for non-Medicaid covered services, such as room and board.

(4) Payments shall not be made if the recipient has been absent from the program for the entire calendar month.

(5) The billing provider shall seek payment from any other resources that are available for payment of rendered services prior to billing the Department.

(6) The billing provider shall provide the non-federal match funds required for the PNMI program.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-757 Audit and compliance review

All supporting accounting and business records, statistical data and all other records relating to the provision of PNMI rehabilitative services paid for by the department shall be subject to audit or compliance review by authorized personnel. All documentation shall be made available to authorized personnel upon request in accordance with 42 C.F.R. section 431. The Department of Children and Families shall take full financial responsibility for any Medicaid claims disallowed due to inadequate documentation by any performing provider or failure to comply with requirements set forth in statute or regulations.

History

• Adopted effective March 11, 2003

Regs., Conn. State Agencies § 17b-262-758 Scope

Sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment of rehabilitative services provided by private non-medical institutions to adults who are determined eligible for Connecticut's Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-759 Definitions

As used in sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Adult" means a person who is 18 years of age or older;

(2) "Department" or "DSS" means the Department of Social Services or its agent;

(3) "DMHAS" means the Department of Mental Health and Addiction Services;

(4) "DPH" means the Department of Public Health;

(5) "Group home" means a privately operated, community-based residential facility that serves sixteen or fewer adult clients, is licensed by the Department of Public Health as either a private freestanding mental health residential living center or a private freestanding community residence pursuant to sections 19a-495-551 or 19a-495-560 of the Regulations of Connecticut State Agencies, is certified by the Department of Mental Health and Addiction Services as a provider of mental health rehabilitation services pursuant to section 17a-485d of the Connecticut General Statutes, and meets the requirements of section 17b-262-760 of the Regulations of Connecticut State Agencies for participation in the Medicaid program as a provider of PNMI rehabilitative services;

(6) "Licensed clinician" means:

(A) a doctor of medicine or osteopathy licensed under chapter 370 of the Connecticut General Statutes;

(B) a psychologist who is licensed under chapter 383 of the Connecticut General Statutes;

(C) a marriage and family therapist who is licensed under chapter 383a of the Connecticut General Statutes;

(D) a clinical social worker who is licensed under chapter 383b of the Connecticut General Statutes;

(E) an advanced practice registered nurse who is licensed under chapter 378 of the Connecticut General Statutes;

(F) a registered nurse who is licensed under chapter 378 of the Connecticut General Statutes and who has a minimum of one year of experience in the mental health field; or

(G) a professional counselor who is licensed under chapter 383c of the Connecticut General Statutes;

(7) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(8) "Medically appropriate" means medical care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care and is delivered in the appropriate medical setting;

(9) "Medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a medical condition or mental illness; or to prevent a condition from occurring;

(10) "Monthly rate" means the amount the department pays for each PNMI client for PNMI program services for each month of service in which there is a qualifying billable unit of service provided;

(11) "Provider" means an entity that participates in the Medicaid program as a qualified group home provider of PNMI adult rehabilitative services as evidenced by an executed provider agreement with DSS;

(12) "PNMI client" or "client" means a Medicaid-eligible adult who resides in a participating group home and who receives covered PNMI rehabilitative services in accordance with sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies;

(13) "Prior authorization" means approval for the provision of service from the department before the provider actually provides the service;

(14) "Private Non-Medical Institution" or "PNMI" means an entity that is a qualified group home provider of adult rehabilitative services under sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies and is not a health insuring organization, hospital, nursing home, or a community health care center;

(15) "Provider agreement" means the signed, written contractual agreement between the department and the provider of PNMI rehabilitative services;

(16) "Qualifying billable unit of service" means forty hours of rehabilitative services during a calendar month or the prorated equivalent based on the number of days the client is in residence at the group home during that month. For purposes of calculation, the forty hours, or the prorated equivalent, may be made up of fifteen minute sub-units, using a rounding convention to be determined by the department;

(17) "Rehabilitative services" means those services identified in section 17b-262-763 of the Regulations of Connecticut State Agencies when provided by a qualified provider on behalf of a PNMI client;

(18) "Residential rehabilitation plan" means a written plan developed by the performing provider in accordance with section 17b-262-760(5) of the Regulations of Connecticut State Agencies; and

(19) "Under the supervision" means that a licensed clinician provides periodic supervision of the work performed by unlicensed clinical staff and accepts primary responsibility for the rehabilitative services performed by the unlicensed staff.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-760 Provider participation

In order to participate in the Medicaid program and provide PNMI rehabilitative services that are eligible for Medicaid reimbursement from the department, the provider shall:

(1) Enroll with the department and have on file a valid provider agreement;

(2) Be certified by DMHAS as a group home provider of rehabilitation services;

(3) Comply with all Medicaid record keeping, documentation and other requirements, including, but not limited to, those delineated in the department's administrative manuals, provider agreements and memoranda of understanding;

(4) Follow all laws, rules, regulations, policies and amendments that govern the Medicaid program as they relate to reimbursement for PNMI rehabilitative services;

(5) Develop an individual residential rehabilitation plan for each PNMI client in accordance with section 19a-495-551(k)(3) of the Regulations of Connecticut State Agencies not later than thirty days after the PNMI client's admission to the program. Such plan shall contain specific behavioral health goals and objectives that are based on each client's mental health diagnosis and diagnostic and functional evaluation and are targeted toward the maximum reduction of a client's behavioral health symptoms, restoration of functioning, and recovery, and shall identify the type, amount, frequency and duration of services to be provided;

(6) Ensure that a licensed clinician employed by, or under contract with, the performing provider reviews and signs the individual residential rehabilitation plan. The first review and signature shall occur not more than thirty days after admission;

(7) Keep current service and progress notes in a permanent case record for each PNMI client in accordance with section 19a-495-551(k)(3)(H) of the Regulations of Connecticut State Agencies;

(8) Cooperate with the department in the rate setting process including, but not limited to, time studies, licensing or any quality assurance reviews or periodic audits to ensure compliance with PNMI program requirements;

(9) Provide an initial orientation, training and periodic supervision to direct service staff related to the provision of rehabilitative services;

(10) Ensure that all group home staff are certified in first aid and cardiopulmonary resuscitation;

(11) Conduct ongoing assessment and service planning;

(12) Promote independent management of medication including the supervision and monitoring of self-administration as appropriate;

(13) Be licensed by the Department of Public Health as either a private freestanding mental health residential living center or a private freestanding community residence pursuant to sections 19a-495-551 or 19a-495-560 of the Regulations of Connecticut State Agencies;

(14) Ensure that the facility director holds a bachelor's degree in a human service discipline and a minimum of three years of experience in a mental health services related position;

(15) Ensure that the facility director (or other manager) is accessible after-hours, by telephone or pager, to staff on duty; and

(16) Ensure that direct service staff hold either a bachelor's degree in a behavioral health related specialty or have two years experience in the provision of mental health services.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-761 Eligibility

Payment for PNMI rehabilitative services shall be available for services rendered to PNMI clients under the conditions and limitations that are set forth in sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-762 Need for services

Payment for PNMI rehabilitative services shall be made by the department only if all of the following conditions are met:

(1) For up to thirty days of a PNMI client's initial stay in a PNMI program, the PNMI rehabilitative services shall be provided in accordance with an initial assessment of need that is completed and signed by a licensed clinician. This assessment shall, for up to thirty days of a PNMI client's initial stay, be utilized as the individual residential rehabilitation plan;

(2) After the first thirty days of a client's stay in a PNMI program, the PNMI rehabilitative services shall be provided in accordance with a written individual residential rehabilitation plan developed in accordance with section 17b-262-760(5) of the Regulations of Connecticut State Agencies. This plan shall be reviewed and signed by the licensed clinical staff employed by, or under contract with, the performing provider at least every ninety days thereafter;

(3) The group home has provided one qualifying billable unit of service for that month;

(4) The client's mental illness is so serious and disabling as to require care in a group home setting;

(5) The client is sufficiently stable to be able to function outside of a twenty-four hour medically managed setting and participate in community-based treatment services; and

(6) The client has functional disabilities secondary to serious and persistent mental illness and such disabilities are so great as to require that the client reside in a non-medical residential setting with rehabilitative services and supports.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-763 Covered services

PNMI rehabilitative services are services designed to assist individuals with a serious and persistent mental illness to achieve their highest degree of independent functioning and recovery. These services include the following services, depending upon the particular needs of each client and the individual rehabilitation plan:

(1) Intake and assessment, which means assessing and reassessing the client's behavioral health needs in the context of medical, social, educational and other needs through face-to-face contact with the client, the client's family and through consultation with other professionals;

(2) Development of an individual residential rehabilitation plan in accordance with sections 17b-262-760(5) and 17b-262-762 of the Regulations of Connecticut State Agencies;

(3) Socialization skills development, which means client-centered skills development activities that are provided to support the goals and objectives in the PNMI client's individual residential rehabilitation plan and that are directed at reducing mental disabilities of clients in care, restoring them to their best possible functioning level and assisting clients in becoming responsible for their own actions;

(4) Behavior management training and intervention;

(5) Supportive counseling directed at solving daily problems related to community living and interpersonal relationships;

(6) Psycho-educational groups pertaining to the alleviation and management of psychiatric disorders;

(7) Teaching, coaching and assisting with daily living and self-care skills such as the use of transportation, meal planning and preparation, personal grooming, management of financial resources, shopping, use of leisure time, interpersonal communication and problem solving;

(8) Assistance in developing skills necessary to support a full and independent life in the community;

(9) Support with connecting individuals to natural community supports;

(10) Orientation to, and assistance with, accessing self help and advocacy resources;

(11) Development of self-advocacy skills;

(12) Health education;

(13) Teaching of recovery skills in order to prevent relapse;

(14) Other rehabilitative support necessary to develop or maintain social relationships, to provide for independent participation in social, interpersonal or community activities and to achieve full community reintegration; and

(15) Individual, family, and group counseling.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-764 Limitations

Coverage of PNMI rehabilitative services shall be subject to the following limitations:

(1) PNMI rehabilitative services shall be pre-authorized by the department or its agent based on a written service recommendation.

(2) PNMI rehabilitative services shall be based on the individual residential rehabilitation plan developed pursuant to section 17b-262-760(5) of the Regulations of Connecticut State Agencies and the requirements of sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies, and shall be performed by, or under the supervision of, a licensed clinician employed by, or under contract to, the performing provider.

(3) The department shall not pay for programs, services or components of services that are of an unproven, experimental, cosmetic or research nature.

(4) The department shall not pay for programs, services or components of services that do not relate to the client's diagnosis, symptoms, functional limitations or medical history.

(5) The department shall not pay for programs, services or components of services that are not included in the fee established by the department.

(6) The department shall not pay for programs, services or components of services that are intended solely to prepare individuals for paid or unpaid employment or for vocational equipment and uniforms.

(7) The department shall not pay for programs, services or components of services designed to provide socialization or recreational activities for clients.

(8) The department shall not pay for time spent by the provider transporting clients.

(9) The department shall not pay for services that are solely, educational or vocational.

(10) The department shall not pay for costs associated with room and board for clients.

(11) The department shall not pay for PNMI rehabilitative services that are provided out-of-state unless the services are pre-authorized and are not available within Connecticut.

(12) The department shall not pay any organization or individual for services covered under sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies, if such organization or individual is directly under contract to a provider for services covered under sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-765 Prior authorization

(a) Prior authorization of the need for PNMI adult rehabilitative services is required in order for Medicaid payment to be available for the services. Prior authorization shall be obtained on forms and in the manner specified by the department.

(b) The initial authorization period shall be for up to six months.

(c) If authorization is needed beyond the initial authorization period, requests for continued treatment beyond the initial authorization period shall be submitted prior to the end of the existing authorization and shall be considered for up to six months per request.

(d) Except in emergency situations, approval shall be received before services are rendered.

(e) In an emergency situation that occurs after working hours or on a weekend or holiday, the provider shall secure approval on the next working day for the admission to the PNMI.

(f) In order to receive payment from the department, a provider shall comply with all prior authorization requirements. The department or its agent in its sole discretion determines what information is necessary in order to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-766 Documentation and record retention requirements

Providers shall comply with the following documentation and record retention requirements:

(1) An initial residential rehabilitation plan and all updated versions, including the current plan, shall be maintained.

(2) A case record, as required by section 19a-495-551(k) (3) of the Regulations of Connecticut State Agencies, shall be maintained and shall include, at a minimum: identifying information; social and health history; the reason for admission to the PNMI program; copies of the initial and all subsequent orders for PNMI rehabilitative services; the individual residential rehabilitation plan; identification of the care and services provided; a current list of all medications; and the plan for discharge and disposition of the PNMI client.

(3) Encounter notes shall be maintained for each rehabilitative service provided. The notes shall include the service rendered, actual time the service was rendered, location of service, the goal and objective that is the focus of the intervention, a general description of the content of the intervention to provide evidence that it is a rehabilitative service as described in section 17b-262-763 of the Regulations of Connecticut State Agencies and the client's response to the intervention. Encounter notes shall be signed, dated and indicate the credentials of the staff member who provided the service. Shift notes are not a substitute for encounter notes.

(4) At least monthly, a progress note shall be prepared that describes the services the client has received over the past month, the client's overall response, and the client's specific progress toward the goals and objectives listed on the residential rehabilitation plan. The note shall be signed or co-signed by the program director or the licensed clinician. The note shall discuss any variance between the services listed on the residential rehabilitation plan and the services actually delivered. The note shall also discuss suggested changes, if any, to the residential rehabilitation plan.

(5) Other documentation and record retention requirements:

(A) The provider shall maintain a current record of the applicable licenses and certificates of practice of all licensed or certified individuals furnishing PNMI rehabilitative services.

(B) The provider shall be substantially in compliance with all documentation requirements in its most recent licensure review and relevant state agency quality assurance reviews.

(C) The provider shall maintain all required records for at least five years or longer as required by statutes or regulation. All required records shall be subject to review by the department. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is longer.

(D) All documentation shall be physically placed into the eligible PNMI client's case record in a complete, prompt and accurate manner. All documents shall be made available to authorized personnel of the department upon request.

(6) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained and not provided to the department upon request.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-767 Billing requirements

(a) Claims for payment of PNMI rehabilitation services shall be on the department's uniform billing form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) All claims submitted to the department for payment of services covered under sections 17b-262-758 to 17b-262-769, inclusive, of the Regulations of Connecticut State Agencies shall be substantiated by documentation in the recipient's permanent case record.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-768 Payment

Payment by the department for PNMI rehabilitative services shall be made in accordance with the following provisions.

(a) The department shall make payments on the basis of monthly rates for PNMI programs.

(b) A statewide capitated monthly rate will be established annually and applied uniformly to all facility providers and to all Medicaid eligible recipients provided with a qualified billable unit of service.

(c) The statewide capitated rate shall be based upon annual audited cost reports filed by licensed and certified service providers to include cost allocations based upon semi-annual time studies of facility staff hours related to rehabilitative services.

(d) The Department shall establish interim PNMI rates for the first and second year of service coverage based upon estimated costs. The interim rates will be replaced based upon cost report filings for the period and related payment adjustments will be made accordingly.

(e) Prospective rates for subsequent periods will be based upon allowable costs for the cost period ending twelve months prior to the start of the rate period. These rates will be updated, within available appropriations, by the projected increase or decrease in the consumer price index for urban consumers for the twenty-four months between the mid-point of the cost period and the mid-point of the rate year.

(1) Allowable costs for purposes of establishing the statewide capitated rate are the reasonable and necessary costs attributable to the provision of rehabilitative services covered under this regulation but shall exclude any other costs such as transportation, recreation or vocational services that are not part of rehabilitative services. Allowable costs will be determined based on a survey of all group homes covered under this regulation.

(f) The calculation of the PNMI rates shall not include any services that have been reimbursed by Medicaid under other service categories.

(g) The PNMI rates shall exclude payment for non-Medicaid covered services, such as room and board.

(h) Payments shall not be made if the recipient has been absent from the program for the entire calendar month.

(i) The provider shall seek payment from any other resources that are available for payment of rendered services prior to billing the Department.

(j) Claims for payment shall be supported by documentation of required services.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-769 Audit and compliance review

All supporting accounting and business records, statistical data and all other records relating to the provision of PNMI rehabilitative services paid for by the department shall be subject to audit or compliance review by authorized personnel. All documentation shall be made available, upon request, to authorized representatives of DPH, DMHAS, and DSS.

History

• Adopted effective December 1, 2005

Regs., Conn. State Agencies § 17b-262-770 Scope

Sections 17b-262-770 to 17b-262-773, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for the establishment by Medicaid entities of policies and procedures for the education of employees regarding false claims recoveries and methodologies for oversight of entities' compliance with these requirements.

History

• Adopted effective August 30, 2007

Regs., Conn. State Agencies § 17b-262-771 Definitions

As used in sections 17b-262-770 to 17b-262-773, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Entity" means a government agency, organization, unit, corporation, partnership, or other business arrangement, including any Medicaid managed care organization, irrespective of the form of business structure or arrangement by which it exists, whether for-profit or not-for profit, which furnishes directly, or otherwise authorizes the furnishing of, the delivery of Medicaid health services where payments made with respect to those services are received, or made, under a State Plan approved under Title XIX, or under any waiver of such plan totaling at least $5,000,000 annually. If an entity furnishes items or services at more than a single location, or under more than one contractual or other payment arrangement, the provisions of sections 17b-262-770 to 17b-262-773, inclusive, of the Regulations of Connecticut State Agencies apply if the aggregate payments to that entity meet the $5,000,000 annual threshold whether the entity submits claims for payments using one or more provider identification or tax identification numbers. An entity meets the $5,000,000 annual threshold as of January 1, 2007, if it received or made payments in that amount in federal fiscal year 2006. Future determinations regarding an entity's responsibility stemming from the requirements of section 1902(a)(68) of the Social Security Act, P.L. 109-171, § 6032, will be made by January 1 of each subsequent year, based upon the amount of payments an entity either received or made under the State Plan under Title XIX of the Social Security Act during the preceding federal fiscal year. A government component serving as a provider for which Medicaid payments are made (e.g., a state mental health facility or school district providing school-based health services) is an "entity" as defined in this subsection. A government agency which merely administers the Medicaid program, in whole or in part (e.g., managing the claims processing system or determining beneficiary eligibility), is not an "entity" as defined in this subsection;

(2) "Employee" means any officer or employee of an entity and includes management;

(3) "Contractor" or "agent" means any contractor, subcontractor, agent or other person which or who, on behalf of the entity, furnishes, or otherwise authorizes the furnishing of, the delivery of Medicaid health care items or services, performs billing or coding functions, or is involved in the monitoring of health care provided by the entity;

(4) "Department" means the Department of Social Services or its agent; and

(5) "Medicaid" means the program operated by the Department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time.

History

• Adopted effective August 30, 2007

Regs., Conn. State Agencies § 17b-262-772 Provider participation

To receive payment from the Department for the provision of goods or services to Medicaid clients, entities shall comply with sections 17b-262-770 to 17b-262-773, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective August 30, 2007

Regs., Conn. State Agencies § 17b-262-773 Establishment and dissemination of written policies

(a) An entity shall establish and disseminate written policies, which shall also be adopted by its contractors or agents. Written policies may be on paper or in electronic form, but shall be readily available to all employees, contractors and agents. An entity need not create an employee handbook if none already exists.

(b) An entity shall establish written policies for all employees and for any contractor or agent of the entity, that includes, but is not limited to, detailed information about the federal False Claims Act and other provisions named in section 1902(a)(68)(A) of the Social Security Act and detailed information about the entity's policies and procedures for detecting and preventing waste, fraud and abuse. An entity shall include in any employee handbook a specific discussion of the laws described in the written policies, the rights of employees to be protected as whistleblowers and a specific discussion of the entity's policies and procedures for detecting and preventing fraud, waste and abuse.

(c) In addition to the education requirements concerning the federal laws set forth above, an entity shall reference in its written polices and handbook the following sections of the Connecticut General Statutes: 53a-290 et seq. (Vendor Fraud); 53-440 et seq. (Health Insurance Fraud); 53a-118 et seq. (Larceny); 53a-155 (Tampering with or Fabricating Physical Evidence); 53a-157b (False Statement Intending to Mislead Public Servant); 17b-25a (Toll Free Vendor Fraud Telephone Hotline); 17b-99 (Vendor Fraud); and 17b-102 (Financial Incentive for Reporting Vendor Fraud); 4-61dd (Whistleblowing); 31-51m (Protection of Employee Who Discloses Employer's Illegal Activities or Unethical Practices); and 31-51q (Liability of Employer for Discipline or Discharge of Employee on Account of Employee's Exercise of Certain Constitutional Rights).

(d) An entity shall reference in its written policies and handbook the following sections of the Regulations of Connecticut State Agencies: 17-83k-1 et seq. (Administrative Sanctions); 17b-102-01 et seq. (Financial Incentive for Reporting Vendor Fraud and Requirements for Payment for Reporting Vendor Fraud); and 4-61dd-1 et seq. (Rules of Practice for Contested Case Proceedings under the Whistleblower Protection Act).

(e) The Department shall require that all entities, upon re-enrollment or contract amendment subsequent to January 1, 2007, include an addendum to their Medicaid Provider Agreement or contract which describes the requirements of this section. All entities that met the $5,000,000 threshold in federal fiscal year 2006 and annually thereafter must provide an attestation of their compliance with this section to the Department's Office of Quality Assurance by August 31st of each year. The Department's Office of Quality Assurance shall verify compliance with this section.

History

• Adopted effective August 30, 2007

Regs., Conn. State Agencies § 17b-262-774—17b-262-778 Reserved

Sec. 17b-262-774—17b-262-778. Reserved

Regs., Conn. State Agencies § 17b-262-779 Scope

Sections 17b-262-779 to 17b-262-791, inclusive, of the Regulations of Connecticut State Agencies, set forth the department of social services' requirements for payment to chronic disease hospitals for services to clients who are determined eligible to receive services under the Connecticut Medicaid program pursuant to section 17b-262 of the Connecticut General Statutes.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-780 Definitions

As used in sections 17b-262- 779 to 17b-262- 791, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Applied income" means the amount of income that each client receiving chronic disease hospital services is expected to pay each month toward the cost of his or her care, calculated according to the department's Uniform Policy Manual, section 5045.20;

(2) "Assessment" means a comprehensive written evaluation of an individual's functional performance in relation to a set of measurable medical or physical criteria;

(3) "Client" means a person eligible for goods or services under the department's Medicaid program;

(4) "Chronic disease" means a disease having one or more of the following characteristics:

(a) is permanent;

(b) leaves residual disability;

(c) is caused by non-reversible pathological alteration;

(d) requires special training of the client for rehabilitation; or

(e) is expected to require a long period of supervision, observation or care;

(5) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(6) "Commissioner" means the commissioner of social services or his or her designee;

(7) "Department" means the department of social services or its agent;

(8) "Durable medical equipment" means equipment that meets all of the following requirements:

(a) can withstand repeated use;

(b) is primarily and customarily used to serve a medical purpose;

(c) is generally not useful to a person in the absence of an illness or injury; and

(d) is non-disposable;

(9) "Institution for mental diseases" means "institution for mental diseases" as defined in 42 CFR 435.1009, as amended from time to time;

(10) "Licensed practitioner" means any person licensed by the state of Connecticut, any other state, the District of Columbia or the Commonwealth of Puerto Rico and authorized to prescribe treatments within the scope of his or her practice as defined and limited by federal and state law;

(11) "Medicaid" means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(12) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternate treatments or diagnostic modalities;

(13) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring;

(14) "Preadmission assessment" means a clinical assessment of ongoing needs and prognosis as necessary to determine the chronic disease hospital's ability to provide for a client's expected needs;

(15) "Provider" means a chronic disease hospital that is enrolled in Medicaid;

(16) "Provider agreement" means the signed, written, contractual agreement between the department and the provider;

(17) "Physician" means a physician licensed pursuant to section 20-10 of the Connecticut General Statutes;

(18) "Rehabilitation" means any medical or remedial services recommended by a physician or other licensed practitioner for maximum reduction of physical or mental disability and restoration of an individual to his or her best possible functional level;

(19) "Resident" means a client living in a chronic disease hospital;

(20) "Team" means a group of individuals employed by or under contract to the chronic disease hospital and may include physiatrists, specialized skilled nurses, physical therapists, occupational therapists or other rehabilitation specialists, such as speech therapists, respiratory specialists, prosthetists, orthotists, physiatrists or respiratory specialists. Other practitioners, including but not limited to, mental health practitioners, may be part of the team as appropriate;

(21) "Team conference" means a meeting of the team to develop a treatment plan of care;

(22) "Treatment plan of care" means the written description of services designed to meet a resident's medical, nursing and rehabilitation needs that are identified in the resident's assessment. The treatment plan of care shall include measurable objectives and a specific timetable; and

(23) "Usual and customary charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, "usual and customary" shall be defined as the median charge. Token charges for charity patients and other exceptional charges are to be excluded.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-781 Provider participation

(a) To enroll in Medicaid and receive payment from the department, a chronic disease hospital shall comply with the provider participation requirements of sections 17b-262-522 through 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.

(b) In order to enroll in Medicaid and to receive payment from the department, a chronic disease hospital shall meet the requirements for state licensure described in section 19-13-D5 of the Regulations of Connecticut State Agencies, the requirements for federal certification to participate in the Medicaid program that are described in 42 CFR Part 482, as amended from time to time, and the requirements stated in sections 17b-262-779 to 17b-262-791, inclusive, of these regulations.

(c) In addition to the requirements in subsections (a) and (b) of this section, in order to participate in the Medicaid program, a chronic disease hospital shall be federally certified as either:

(1) a long term care hospital that meets the criteria of 42 CFR 412.23(e);

(2) a rehabilitation hospital that meets the criteria of 42 CFR 412.23(b); or

(3) an acute care hospital with a psychiatric unit excluded from the prospective payment system that meets the criteria of 42 CFR 412.25.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-782 Eligibility

Payment for chronic disease hospital services is available on behalf of all clients subject to the conditions and limitations that apply to these services.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-783 Need for service

In order for a client to be approved for admission to a chronic disease hospital, the client shall meet the criteria for admission as either a chronic disease client or a rehabilitation client. All care shall be medically necessary and medically appropriate.

(a) The criteria for admission as a chronic disease client are as follows:

(1) Each chronic disease client shall require services that can be provided safely and effectively at a chronic disease hospital level, shall be ordered by a physician and documented in the client's medical record, and shall include at least a daily physician visit and assessment or the 24-hour availability of medical services and equipment available only in a hospital setting; and

(2) The client's medical condition and treatment needs are such that no effective, safe, less costly alternative placement is available to the client.

(b) The criteria for admission as a rehabilitation client are as follows:

(1) Each rehabilitation client shall require an intensive rehabilitation program at the level of a chronic disease hospital level of care that includes a multi-disciplinary approach to improve the client's ability to function to his or her maximum potential. Factors shall be present in the client's condition that indicate the potential for functional improvement or freedom from pain. A client who requires therapy solely to maintain function shall not be considered an appropriate rehabilitation candidate;

(2) Each client's medical condition and treatment needs are such that no effective, safe, less costly alternative placement is available to the client;

(3) A preadmission assessment shall be developed, prior to admission by specialized skilled nurses, physical therapists, occupational therapists or other rehabilitation specialists, such as speech therapists, prosthetists or orthotists;

(4) The treatment plan of care shall be directed by a physician who is board certified or eligible for board certification in an appropriate specialty; and

(5) The treatment plan of care shall be designed to achieve specific goals within a specified timeframe.

(c) Team conferences shall be conducted for each client. The first team conference shall occur not later than seven calendar days after the client's admission.

(d) For rehabilitation clients, subsequent conferences shall occur at least once every fourteen calendar days. All team members, or a designee within the same specialty, shall be in attendance. The purpose of the conference shall be to conduct an assessment of the client's progress, make adjustments to the established goals as indicated or terminate the program when the expected goal has been reached or determined to be no longer attainable.

(e) For chronic disease clients, subsequent conferences shall occur at least once every 90 days. The depth of the periodic review shall be appropriate to the client's clinical status and prognosis.

(f) The department may use nationally recognized guidelines applicable to chronic disease hospitals or inpatient rehabilitation hospitals in determining if the admission is medically necessary and medically appropriate.

(g) The department shall authorize payment for any individual who meets the criteria set forth in subsections (a) or (b) of this section when he or she:

(1) is a client seeking admission to a chronic disease hospital;

(2) is an individual who applies for Medicaid while in the chronic disease hospital; or

(3) is a client seeking an extension of treatment at a chronic disease hospital.

(h) The department shall pay a provider only when the department has authorized the client's admission to that chronic disease hospital and all other requirements for payment are met.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-784 Services covered

The department shall pay an all-inclusive per diem rate to the provider for each resident for whom payment has been authorized pursuant to section 17b-262-783 of the Regulations of Connecticut State Agencies. This per diem rate represents payment for the following goods and services:

(a) all services as required by section 19-13-D5 of the Regulations of Connecticut State Agencies and 42 CFR Part 482, as amended from time to time, including, but not limited to:

(1) medical direction in accordance with section 19-13- D5(c) of the Regulations of Connecticut State Agencies and 42 CFR 482.22;

(2) nursing services in accordance with section 19-13- D5(e) of the Regulations of Connecticut State Agencies and 42 CFR 482.23, as amended from time to time;

(3) therapeutic recreation in accordance with section 19-13- D5(k) of the Regulations of Connecticut State Agencies;

(4) rehabilitation services in accordance with section 19-13-D5(k) of the Regulations of Connecticut State Agencies and 42 CFR 482.56, as amended from time to time;

(5) room and board in accordance with sections 19-13-D5(h) and (i) of the Regulations of Connecticut State Agencies and 42 CFR 482.28 and 482.41 as amended from time to time;

(6) diagnostic and therapeutic services in accordance with section 19-13-D5(f) of the Regulations of Connecticut State Agencies and 42 CFR 482.26, as amended from time to time;

(7) pharmacy services in accordance with section 19-13-D5(g) and 42 CFR 482.25, as amended from time to time;

(8) laboratory services in accordance with 42 CFR 482.27, as amended from time to time;

(9) respiratory services in accordance with 42 CFR 482.57, as amended from time to time; and

(10) consultation and assistance to residents in obtaining other needed services including, but not limited to, dental services, vision services, hearing services and services to address mental and psychosocial functioning;

(b) all services required as conditions of participation for certification under 42 CFR 412, Subpart B, Subpart O or Subpart P as applicable;

(c) all physical therapy, occupational therapy, speech therapy and respiratory therapy included in the treatment plan of care;

(d) routine personal hygiene items required to meet the needs of the resident including, but not limited to, hair hygiene supplies, soaps and other cleansing agents to treat skin problems, shaving supplies, dental and denture supplies, lotions, incontinence supplies, bathroom supplies and over the counter drugs;

(e) prescription drugs;

(f) durable medical equipment including customized equipment;

(g) supplies used in the care of the resident including, but not limited to:

(1) antiseptics and solutions;

(2) bandages and dressing supplies;

(3) catheters and urinary incontinent supplies;

(4) diabetic supplies;

(5) diapers and underpads;

(6) compression, burn and specialized medical garments;

(7) ostomy supplies;

(8) respiratory and tracheotomy supplies;

(9) enteral and parenteral supplies; and

(10) miscellaneous supplies;

(h) all oxygen supplies including oxygen concentrators; and

(i) transportation services necessary to transport a resident to and from any service included in the per diem rate as described in this section.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-785 Service limitations

Payment shall be made for the date of admission but not for the date of discharge. Exceptions to this are:

(a) payment shall be made for the date of death when the resident dies in the chronic disease hospital.

(b) in the case of a resident admitted and discharged on the same day, payment shall be made for one day of care.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-786 Services not covered

(a) The department shall not pay a chronic disease hospital that is characterized as an institution for mental diseases except for services to clients aged 65 and older or under age 22 in accordance with section 17-134d-68 of the Regulations of Connecticut State Agencies and 42 CFR 435.1009.

(b) The department shall not reimburse any provider for any costs incurred before the authorized length-of-stay period or after the expiration of the specified length-of-stay period.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-787 Authorization process

(a) The department shall pay a provider only when the department has authorized payment for the client's admission to that chronic disease hospital.

(b) The provider shall comply with the authorization requirements described in section 17b-262-528 of the Regulations of Connecticut State Agencies and sections 17b-262-779 to 17b-262-791, inclusive, of the Regulations of Connecticut State Agencies. The department, in its sole discretion, shall determine what information is necessary to approve an authorization request. Authorization does not, however, guarantee payment unless all other requirements for payment are met.

(c) An authorization request, on forms and in a manner as specified by the department, shall include documentation of medical need and shall be signed by the licensed practitioner. For individuals who become clients while in the chronic disease hospital, this authorization request shall include, but not be limited to, a treatment plan of care under the direction of a physician that is designed to achieve specified goals within a specified timeframe and developed by a team.

(d) Initial authorizations for treatment shall be authorized by the department for up to 30 days. Subsequent requests for the extension of authorization for the same client may be made for up to three months or longer, on a case-by-case basis.

(e) If a safe discharge is not possible from the chronic disease hospital, the department shall authorize a continued stay and payment at the current Medicaid rate for up to three months or longer, on a case by case basis.

(f) The department shall act on prior authorization requests for readmissions to a chronic disease hospital from an acute care hospital within one business day so that clients do not remain at the acute care hospital level longer than necessary.

(g) No chronic disease hospital shall be required to admit a client if such hospital has not received an authorization for treatment from the department.

(h) The department will process a request for authorization for treatment, and deliver a decision on such request within two full business days from the date a chronic disease hospital notifies the department that a client who is a patient of such hospital has exhausted his or her other third party insurance or whose coverage by such insurance has been denied.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-788 Applied income

(a) A client who receives chronic disease hospital services is responsible for paying applied income to the chronic disease hospital.

(b) The department shall calculate the applied income. The department shall notify the chronic disease hospital of the amount of any applied income that the chronic disease hospital is responsible for collecting. Applied income shall be deducted from what otherwise would have been the department's monthly payment to the chronic disease hospital.

(c) The chronic disease hospital shall notify the department's caseworker of any errors in the amount of applied income processed against the claim using the form specified by the department. Payment adjustments resulting from retroactive applied income corrections shall be processed periodically.

(d) In any month that a resident returns to the community or dies, and the cost of care is less than the applied income, the department shall adjust the applied income as follows: the applied income shall equal the number of days that the resident was in the chronic disease hospital multiplied by the per diem rate.

(e) Applied income is not pro rated. It is used to cover the cost of care until it is expended.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-789 Billing and payment procedures

(a) Claims from providers shall be submitted on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) The chronic disease hospital is responsible for:

(1) completing the daily admission and discharge forms in accordance with the department's instructions;

(2) notifying the department's caseworker if the chronic disease hospital is aware that the resident's asset level exceeds the established resource limit. The report shall be made on the form specified by the department;

(3) notifying the department of any and all credits due the department on the form specified by the department; and

(4) exhausting other payment sources of which the chronic disease hospital is aware before billing the department.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-790 Rates

(a) The per diem rate for a chronic disease hospital is determined annually pursuant to section 17b-239 of the Connecticut General Statutes for freestanding chronic disease hospitals or section 17b-340 of the Connecticut general statutes for chronic disease hospitals associated with chronic and convalescent nursing homes.

(b) the department shall reimburse the chronic disease hospital at the lower of:

(1) the per diem rate minus the applied income; or

(2) the usual and customary charge minus the applied income.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-791 Documentation

(a) The chronic disease hospital shall maintain all documentation required for rate setting purposes in accordance with section 17-311-56 of the Regulations of Connecticut State Agencies. This documentation is subject to review and audit by the department.

(b) The chronic disease hospital shall maintain all other documentation required by this section for at least five (5) years or longer as required by statute or regulation, subject to review by authorized department personnel. In the event of a dispute concerning a service provided, the chronic disease hospital shall maintain all documentation until the end of the dispute, for five (5) years, or for the length of time required by statute or regulation, whichever is longest.

(c) Failure to maintain all required documentation may result in the disallowance and recovery by the department of any amounts paid to the chronic disease hospital for which the required documentation is not maintained and provided to the department upon request. Documentation requirements are described in detail in the provider agreement and sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.

(d) The department requires that each chronic disease hospital maintain fiscal and medical records to fully disclose services and goods rendered to residents. Records shall be maintained in accordance with the department's Provider Enrollment Agreement as signed by the chronic disease hospital.

(e) Required documentation includes:

(1) certification for chronic disease hospital admission as required by the department. The form shall be signed by a licensed practitioner;

(2) the department's written authorization of the client's need for chronic disease hospital care;

(3) all admission and discharge forms supporting the claim;

(4) medical records in accordance with section 19-13-D5(d) of the Regulations of Connecticut State Agencies and 42 CFR 482.24 that contains all pertinent diagnostic information and documentation of each service provided;

(5) the initial and all subsequent treatment plans of care signed and dated by a licensed practitioner; and

(6) For clients in the rehabilitation level of care, a record that includes:

(A) each team member's goals for the client and progress notes from each team conference;

(B) all decisions reached; and

(C) the reason for any lack of progress in reaching a specific goal.

History

• Adopted effective October 6, 2009

Regs., Conn. State Agencies § 17b-262-792 Scope

Sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment to providers of hearing aids and supplies that are medically necessary and that are provided to clients who are determined to be eligible to receive such goods and services under Medicaid pursuant to section 17b-262 of the Connecticut General Statutes.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-793 Definitions

As used in sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Actual acquisition cost" means the price paid to a manufacturer by a hearing aid provider for a hearing aid or accessory, as documented on the manufacturer's invoice, less any applicable discounts or rebates. The actual acquisition cost shall be verified by a copy of the manufacturer's invoice;

(2) "Advanced practice registered nurse" means a person who is licensed pursuant to section 20-94a of the Connecticut General Statutes;

(3) "Audiologist" means a person who is licensed under Chapter 399 of Connecticut General Statutes as an audiologist;

(4) "Audiometric report" means a written report that describes the results of measurement of overall performance in hearing, understanding and responding to speech for a general assessment of hearing and an estimate of the degree of practical handicap. The results are recorded on a graph or grid, also called an audiogram, to show the results and the impact of the hearing loss;

(5) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1(b)(2) of the Regulations of Connecticut State Agencies;

(6) "Client" means a person eligible for goods or services under the Medicaid program;

(7) "Commissioner" means the Commissioner of Social Services or his or her designee;

(8) "Department" means the Department of Social Services or its agent;

(9) "Dispensing fee" means a one-time fee pertaining to the selection, orientation, training in proper use, fittings and adjustments required within the first year of service;

(10) "Documented in writing" means handwritten, typed or computer printed;

(11) "Early Periodic Screening, Diagnosis and Treatment special services" or "EPSDT special services" means services that are not otherwise covered under Connecticut's Medicaid program but which are nevertheless covered as EPSDT services for Medicaid-eligible children pursuant to the requirements of 42 U.S.C. 1396d(r)(5) when the service is medically necessary, the need for the service is identified in an EPSDT screen, the service is provided by a participating provider, and the service is a type of service that may be covered by a state Medicaid agency and qualify for federal reimbursement under 42 U.S.C. 1396b and 42 U.S.C. 1396d;

(12) "Ear specialist" means any licensed physician who specializes in diseases of the ear and is medically trained to identify the symptoms of deafness in the context of the total health of the patient, and is qualified by special training to diagnose and treat hearing loss. Such physicians are also known as otolaryngologists, otologists and otorhinolaryngologists;

(13) "Hearing aid" means any wearable instrument designed or offered for the purpose of aiding or compensating for impaired human hearing and any parts, attachments or accessories, excluding batteries and ear molds;

(14) "Hearing aid dealer" means a "licensed hearing instrument specialist" as defined in section 20-396 of the Connecticut General Statutes or a "hearing aid dealer" as described in section 20-406-1 to 20-406-15, inclusive, of the Regulations of Connecticut State Agencies;

(15) "Hearing aid supplies" means those items purchased by the provider that are necessary for the proper operation of the hearing aid;

(16) "Hearing testing" means the measurement of an individual's level of hearing, as set forth in section 20-406-9(f) of the Regulations of Connecticut State Agencies, for the purpose of determining if a hearing aid is medically necessary;

(17) "Home" means the client's place of residence including, but not limited to, a boarding home, community living arrangement or residential care home. "Home" does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for the mentally retarded or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(18) "Hospital" means a "short-term hospital" as defined in section 19-13-D1(b)(1) of the Regulations of Connecticut State Agencies;

(19) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for the mentally retarded licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in the Medicaid program as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(20) "Licensed practitioner" means a physician, a physician assistant or an advanced practice registered nurse;

(21) "Medicaid" means the program operated by the department pursuant to section 17b-261 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(22) "Medical evaluation" means an examination to ensure that all medically treatable conditions that may affect hearing are identified and treated first and the client is an appropriate candidate for a hearing aid;

(23) "Medical necessity" or "medically necessary" has the same meaning as in section 17b-259b of the Connecticut General Statutes;

(24) "Nursing facility" means "nursing facility" as defined in 42 USC 1396r(a), as amended from time to time and licensed according to section 19-13-D8t(b) of the Regulations of Connecticut State Agencies as a chronic and convalescent home or rest home with nursing supervision;

(25) "Physician" means a person licensed pursuant to section 20-10 of the Connecticut General Statutes;

(26) "Physician assistant" means "physician assistant" as defined in section 20-12a(5) of the Connecticut General Statutes;

(27) "Practice of fitting hearing aids" means "practice of fitting hearing aids" as defined in section 20-396 of the Connecticut General Statutes;

(28) "Prescription" means an original, written order documenting medical necessity that is signed and dated by the licensed practitioner who issued the order;

(29) "Prior authorization" or "PA" means approval from the department for the provision of a service or the delivery of goods before the provider actually provides the service or delivers the goods;

(30) "Provider" means the vendor or supplier of a hearing aid and supplies who is enrolled with the department as a hearing aid dealer;

(31) "Replacement of a hearing aid" means any occasion in which a new hearing aid is to take the place of a prior hearing aid; and

(32) "Usual and customary charge" means the amount that the provider accepts for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is accepted in the majority of cases, usual and customary shall be defined as the median charge. Token charges for charity patients and other exceptional charges are to be excluded.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-794 Provider participation

To enroll in the Medicaid program and receive payment from the department, providers shall comply with sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies and sections 17b-262-522 to 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-795 Need for service

(a) The department shall pay for the purchase or repair of a medically necessary hearing aid or supply, subject to the conditions and limitations described in sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies.

(b) All clients who have been identified as having a hearing loss, such as through the performance of a hearing screening, shall receive a medical evaluation by a licensed practitioner, preferably an ear specialist, before a hearing aid is considered to ensure that all medically treatable conditions that affect hearing are identified and treated first. The medical evaluation shall have taken place within the six-month period prior to the date in which the client receives the first hearing aid and may, at the licensed practitioner's discretion, be accompanied by a prescription for a hearing aid.

(c) Medical necessity shall be documented by the provider and shall include:

(1) An estimate of the client's ability to benefit from the use of a hearing aid as demonstrated by improvement in speech discrimination or environmental awareness of sound;

(2) test results showing the client's current hearing level and an estimate of improvement in speech discrimination or environmental awareness of sound;

(3) evidence of a medical evaluation signed by a licensed practitioner; and

(4) a written prescription signed by a licensed practitioner or an order by an audiologist or hearing aid dealer.

(d) In addition the provider shall document:

(1) The commitment on the part of the appropriate caregiver to assist the client in the use and care of the hearing aid, if the client is incapable of caring for the hearing aid on his or her own; and

(2) the status of any previous hearing aid used by the client.

(e) The department shall pay for hearing aids and supplies for a client who lives at home or in a nursing facility, ICF/MR, hospital or chronic disease hospital, except as limited by sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies.

(f) All hearing aids dispensed to a child under eighteen years of age shall meet the requirements of section 20-406-10 of the Regulations of Connecticut State Agencies.

(g) Hearing testing shall meet the requirements of section 20-406-9(f) of the Regulations of Connecticut State Agencies.

(h) There shall be a thirty-day trial period for a hearing aid in accordance with section 20-402a of the Connecticut General Statutes; the cancellation fee applies to the total acquisition cost and dispensing fee.

(i) An audiometric report to support medical necessity is required for the purchase of all hearing aids.

(j) A hearing aid shall be replaced only when the prior hearing aid no longer meets the client's needs, has been lost, stolen or damaged beyond repair.

(k) For a hearing aid that has been lost, stolen or damaged beyond repair, the provider shall document:

(1) The disposition of the prior hearing aid and statement of circumstances of loss or damage;

(2) in the case of damage, a statement from the hearing aid dealer or audiologist that the hearing aid cannot be repaired;

(3) the measures to be taken by the client, family or other caregiver, to prevent future loss or damage.

(l) For a hearing aid that is no longer meets the client's needs, the provider shall document the significant change in the client's hearing loss to warrant the replacement.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-796 Eligibility

Payment to a provider for hearing aids and related supplies is available for clients who have a need for such products and services which meets the department's definition of a hearing aid when the items are medically necessary, subject to the conditions and limitations set forth in sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-797 Services covered and limitations

(a) The department shall maintain a fee schedule for hearing aids and supplies, subject to the conditions and limitations set forth in sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies. This fee schedule is designed to meet the needs of most Medicaid clients.

(b) The department shall pay for the servicing, repair or replacement of hearing aids and supplies, provided that any manufacturer's or dealer's warranty has been exhausted. The provider shall first utilize existing warranties that cover required servicing, repairs and replacement.

(c) The department shall pay for one hearing test provided by either:

(1) A hearing aid provider, who is not an audiologist; or

(2) an audiologist, ear specialist or any other physician under contract to, or employed by a hearing aid provider, who does not separately bill the department for any other hearing test or audiological examination.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-798 Goods and services not covered

The department shall not pay providers for:

(a) Any hearing aid that is of an unproven, experimental or research nature or for services in excess of those deemed medically necessary by the department to treat the client's condition or for services not directly related to the client's diagnosis, symptoms or medical history;

(b) any hearing aid prescribed and ordered for a client who:

(1) Dies prior to delivery of the item; or

(2) is not otherwise eligible on the date of delivery. It shall be the provider's responsibility to verify that the client is eligible on the date the item is delivered;

(c) the purchase or repair of a hearing aid necessitated by inappropriate, willful or malicious misuse on the part of the client, as determined by the department;

(d) any hearing aid or supply provided for cosmetic reasons;

(e) a hearing aid for a client in a nursing facility, ICF/MR, chronic disease hospital, hospital or other facility if the hearing aid is included in the facility's per diem Medicaid rate; or

(f) a hearing aid that can be billed to another payer.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-799 Payment and payment limitations

(a) Fees shall be the same for in-state, border-state and out-of-state providers.

(b) Payment shall be made at the lowest of:

(1) The provider's usual and customary charge;

(2) the lowest Medicare rate;

(3) the amount in the applicable fee schedule as published by the department pursuant to section 4-67c of the Connecticut General Statutes; or

(4) the amount billed by the provider.

(c) The department shall reimburse a provider when all the requirements of sections 17b-262-792 to 17b-262-803, inclusive, of the Regulations of Connecticut State Agencies have been met.

(d) The fee for a hearing aid includes an initial one-year manufacturer's warranty against loss, theft or damage.

(e) Hearing aids provided shall be new and guaranteed against all defects in workmanship and materials for at least one year from the date of delivery of the hearing aid to the client.

(f) The department shall pay providers for:

(1) The actual acquisition cost of a hearing aid to the provider up to the maximum amount allowed by the department's fee schedule;

(2) a dispensing fee up to the maximum allowed by the department's fee schedule; and

(3) hearing testing for the purpose of fitting a hearing aid.

(g) The department shall pay for custom ear molds for a client who dies or is not otherwise eligible on the date of delivery provided the client was eligible on the date the item was ordered.

(h) If the cost of repairs to any hearing aid exceeds its replacement cost, the hearing aid shall be replaced.

(i) The provider shall meet the exact specifications of a hearing aid selected by an audiologist, ear specialist or licensed practitioner.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-800 Prior authorization

(a) The department shall require PA for:

(1) Any hearing aid that is identified on the department's fee schedule as requiring PA;

(2) EPSDT special services; and

(3) any service or device that is not on the department's fee schedule.

(b) To receive reimbursement from the department, a provider shall comply with all prior authorization requirements. The department, in its sole discretion, shall determine what information is necessary to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements are met.

(c) A PA request, on a form and in the manner specified by the department, shall include documentation of medical necessity and shall be signed by the provider.

(d) A prescription is required from a licensed practitioner for all services and goods provided as EPSDT special services. A copy of the prescription from the licensed practitioner may be attached to the completed PA request in lieu of the actual signature of the licensed practitioner on the PA request form. The licensed practitioner's original prescription shall be on file with the provider and be subject to review by the department.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-801 Billing procedure

(a) Claims from providers shall be submitted on a hard copy invoice or electronically transmitted to the department in a form and in a manner specified by the department and shall include all information required by the department to process the claim for payment.

(b) A claim submitted for hearing aids and supplies that does not require prior authorization shall include the national provider identifier number of the licensed practitioner or audiologist prescribing the hearing aid, if applicable.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-802 Documentation

(a) Providers shall maintain all fiscal and medical records related to services and goods rendered or delivered to clients.

(b) All required documentation, including evidence of a medical evaluation for a hearing aid, results of audiometric evaluations, results of any testing to support the need for a hearing aid and expected hearing improvement and notes related to fittings and adjustments shall be maintained for at least five years in the provider's primary place of business and shall be subject to review by the department.

(c) The department shall accept, when feasible, faxed or electronic medical evaluations and other orders. If evidence indicates that the documentation being reviewed has been falsified or the provider is unable to provide adequate assurance of the medical necessity of the items or services, the department may request additional information, including an original signature, in order to obtain that assurance.

(d) Any documentation, including a medical evaluation, that is electronically submitted to a vendor shall identify the sender and display the sender's fax number and date. The department may request the original medical evaluation and results of the hearing test whenever medical necessity is in question.

(e) In the event of a dispute concerning a service or a hearing aid provided, documentation shall be maintained until the end of the dispute or five years, whichever is longer.

(f) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for the hearing aid or service for which the required documentation is not maintained or provided to the department upon request.

(g) The provider shall have on file the manufacturer's purchase invoice for any hearing aid dispensed to a client, for any repairs or servicing and for any processing charges associated with replacement of a hearing aid under warranty.

(h) Providers shall maintain signed receipts for all goods and services that are provided to a client regardless of whether the item is delivered or picked up by the client or client's representative. The receipt for hearing aids, services and supplies shall at a minimum, contain the following:

(1) The provider's name;

(2) the client's name;

(3) the client's address;

(4) the date of delivery; and

(5) itemization of the hearing aid, service or supplies delivered, including, but not limited to:

(A) Product description;

(B) brand name;

(C) model name and number, if applicable;

(D) serial number, if applicable;

(E) the quantity delivered;

(F) the amount billed per hearing aid; and

(G) any warranty in effect.

(i) A prescription or order for hearing aids and supplies, regardless of the format used, shall, at a minimum, contain the following:

(1) The client's name, address and date of birth; and

(2) the diagnosis for which the hearing aid is required.

(j) Evidence of the medical evaluation shall, at a minimum, include the following:

(1) The client's name, address and date of birth;

(2) the date of the physician's medical evaluation;

(3) the prescribing physician's signature and date of his or her signature; and

(4) a statement that the client's hearing loss has been medically evaluated and that the client may be considered a candidate for a hearing aid.

(k) All required documentation shall be subject to review by authorized department personnel upon the department's request.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-803 Other

(a) Where brand names or stock or model numbers are specified on the prescription or the PA, no substitution shall be permitted without the written approval of the department.

(b) The provider shall instruct the client, his or her family or a designated representative on the proper use and care of the hearing aid.

(c) The provider shall maintain a written usual and customary price list that details individual product and service charges. This list, including updates along with any required manufacturer's list pricing, shall be available for review by the department.

(d) A hearing aid purchased by the department shall become the property of the client on the date of delivery to the client.

History

• Adopted effective July 11, 2011

Regs., Conn. State Agencies § 17b-262-804 Scope

Sections 17b-262-804 to 17b-262-816, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment for Psychiatric Residential Treatment Facilities (PRTF) services provided to clients who are determined eligible for Connecticut's Medicaid Program pursuant to section 17b-261 of the Connecticut General Statutes.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-805 Definitions

As used in section 17b-262-804 to section 17b-262-816, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Active treatment" means "active treatment" as defined in 42 CFR, Part 441, section 44l.l54;

(2) "Acute" means having rapid onset, severe symptoms and a short course;

(3) "Allied Health Professional" or "AHP" means a licensed individual who is qualified by special training, education, skills and experience in behavioral health care and treatment and shall include, but shall not be limited to: psychologists, social workers, psychiatric nurses, professional counselors and other qualified therapists as defined in Title 20 of the Connecticut General Statutes;

(4) "Authorization" means the approval of payment for services or goods by the department based on a determination of medical necessity and appropriateness. For elective admissions, authorization also serves as the certification of need as defined in this section;

(5) "CMS" means the Centers for Medicare and Medicaid Services;

(6) "Certification of need" means an evaluation process for clients who are under consideration for admission to a PRTF;

(7) "Client" means a person eligible for goods or services under Medicaid who is under age twenty-one at the time services are received. If a client received services immediately before reaching age twenty-one, payment shall be available for services received before the earlier of the date that the client no longer requires the services or the date that the client reaches age twenty-two;

(8) "Department" means the Department of Social Services or its agent;

(9) "Elective admission" means any admission to a PRTF that is non-emergent, including, but not limited to, transfers from one PRTF to another;

(10) "Independent team" means a team that meets the requirements set forth in 42 CFR, Part 441, section 441.153(a). The independent team may not include anyone who is related, in any way, to the admitting facility, or who is directly responsible for the care of patients whose care is being reviewed or has a financial interest in the admitting facility. The department performs the functions of the independent team;

(11) "Individual plan of care" or "plan of care" means a written plan that meets the criteria set forth in 42 CFR, Part 441, Section 441.155;

(12) "Inpatient" means "inpatient" as defined in 42 CFR, Part 440, section 440.2;

(13) "Interdisciplinary team" means a team that meets the requirements set forth in section 42 CFR, Part 441, section 441.156;

(14) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(15) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities;

(16) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition or to prevent a medical condition from occurring;

(17) "Medical record" means "medical record" as described in 42 CFR, Part 482, section 482.6l and subsection (d) of section 19-13-D3 of the Regulations of Connecticut State Agencies;

(18) "Overnight pass" means a conditional release to the client's proposed residence on discharge of not more than two days duration, after admission and prior to the day of discharge, in which the client has been permitted by the attending physician to be absent from the facility premises and in accordance with the client's treatment needs and goals as specified in the plan of care;

(19) "Provider" means a PRTF that is enrolled in Medicaid;

(20) "Provider agreement" means the signed, written contractual agreement between the department and the provider;

(21) "Psychiatric emergency" means a sudden onset of a psychiatric condition, as determined by a physician, that manifests itself by acute symptoms of such severity that the absence of immediate medical care and treatment in an inpatient psychiatric facility could reasonably be expected to result in serious dysfunction, disability or death of the client or harm to self or another person by the client. Court commitments and clients admitted on a physician emergency certificate are not automatically deemed to qualify as a psychiatric emergency;

(22) "Psychiatric Residential Treatment Facility" or "PRTF" means a facility that meets all the requirements in 42 CFR Part 441, Subpart D and 42 CFR Part 483, Subpart G;

(23) "Quality of care" means the evaluation of medical care to determine if it meets the professionally recognized standard of acceptable medical care for the condition and the client under treatment;

(24) "Retrospective review" means the review conducted after services are provided to a client, to determine the medical necessity, medical appropriateness and quality of the services provided;

(25) "Transfer" means that a client is discharged from a PRTF and directly admitted to another;

(26) "Under the direction of a physician" means that health services may be provided by allied health professionals or paraprofessionals whether or not the physician is physically present at the time that the services are provided; and

(27) "Utilization management" means the prospective, retrospective or concurrent assessment of the medical necessity and appropriateness of the allocation of health care resources and services given, or proposed to be given, to a client.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-806 Provider participation

In order to enroll in Medicaid and receive payment from the department, a provider shall meet the following requirements:

(a) General:

(1) meet and maintain all applicable licensing, accreditation and certification requirements;

(2) meet and maintain all departmental enrollment requirements; and

(3) have a valid provider agreement on file which is signed by the provider and the department upon application for enrollment into Medicaid. This agreement, which shall be periodically updated, shall continue to be in effect for the duration of the agreement or for the stated period in the agreement. The provider agreement specifies conditions and terms which govern the program and to which the provider is mandated to adhere in order to participate in the program.

(b) Specific:

(1) be accredited in accordance with 42 CFR 441.151(a)(2);

(2) satisfy all federal and state requirements governing the use of restraint and seclusion including, but not limited to, a written attestation of facility compliance with CMS standards governing the use of restraint and seclusion and filed annually with the department no later than July 1st of each year; and

(3) if located outside of Connecticut, meet all of the provider requirements in subsections (a) and (b) of this section and be an enrolled Medicaid provider in the provider's state of residence, when that state participates in the optional Medicaid of inpatient psychiatric facility services provided for clients.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-807 Eligibility

Payment for PRTF services shall be available, subject to the conditions and limitations set forth in sections 17b-262-804 to17b-262-816, inclusive, of the Regulations of Connecticut State Agencies, for services rendered to clients.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-808 Services covered

(a) The department shall pay a per diem rate, which is an inclusive payment for all services that are required to be provided by the facility as a condition for participation as a PRTF, including, but not limited to:

(1) therapeutic services provided by PRTF staff;

(2) active treatment services including, but not limited to, individual, group and family therapy;

(3) diagnostic testing and assessment;

(4) room and board; and

(5) case management, discharge planning.

(b) The department shall pay for authorized PRTF services for clients provided by an enrolled provider.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-809 Services not covered

The department shall not pay for the following PRTF services that are not covered under Medicaid:

(a) procedures or services of an unproven, educational, social, research, experimental or cosmetic nature or for any diagnostic, therapeutic or treatment procedures in excess of those deemed medically necessary and appropriate by the department to treat the client's condition;

(b) services or items furnished for which the provider does not usually charge;

(c) services that do not directly relate to the client's diagnosis, symptoms or medical history;

(d) the day of discharge;

(e) a PRTF admission or a day of care that does not meet all the department's requirements for inpatient services;

(f) a day when the client is absent from the PRTF at the midnight census, unless the absence is a medically authorized overnight pass and part of the treatment plan; or

(g) costs associated with the education or vocational training of the client which shall be excluded from Medicaid payments.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-810 Certification of need requirements

(a) In order to receive payment for PRTF services for an individual, admissions shall have a certification of need as required in 42 CFR 441 Subpart D, as amended from time to time.

(b) The certification of need shall be based on a determination that:

(1) ambulatory care resources available in the community do not meet the treatment needs of the client;

(2) proper treatment of the client's psychiatric condition requires services on an inpatient basis under the direction of a physician; and

(3) the services shall reasonably be expected to improve the client's condition or prevent further regression so that inpatient services shall no longer be needed.

(c) When the admission of a client is elective, an independent team shall perform the certification of need. The facility shall maintain written documentation of the independent team's certification of need as evidenced by the signature of a member of the independent team on a certification of need form or letter(s) of authorization by the independent team.

(d) When the admission is of a person who is not Medicaid eligible and who applies for Medicaid while in the PRTF, the certification of need shall be conducted at the time of application for or by the first day of Medicaid eligibility. The interdisciplinary team responsible for the individual plan of care shall perform the certification of need, which shall cover any period prior to application for which Medicaid claims are made. The facility shall maintain written documentation of the certification of need.

(e) For psychiatric emergency admissions, the certification of need shall be performed by the interdisciplinary team responsible for the plan of care not later than fourteen days after the day of admission. The facility shall maintain written documentation of the certification of need as evidenced by the signature of a member of the independent team on a certification of need form.

(f) When the client is admitted from a PRTF to a hospital and, upon discharge, is readmitted to the PRTF, a new certification of need shall be performed.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-811 Individual plan of care requirements

(a) PRTF services for clients shall involve active treatment, as documented in the professionally developed and supervised individual plan of care.

(b) A physician shall:

(1) assume professional responsibility for the services provided under the plan of care;

(2) assure that the services are medically appropriate;

(3) certify in writing that the services provided are necessary in the setting in which they will be provided; and

(4) be readily available in person or by phone but not necessarily on the premises.

(c) Not later than seven days after admission, the interdisciplinary team shall establish a written plan of care for each client, designed to achieve the client's discharge from the PRTF at the earliest possible time. This plan shall:

(1) be based on a diagnostic evaluation that includes examinations of the medical, psychological, social, behavioral and developmental aspects of the client's situation and thereby reflect the need for PRTF services;

(2) be developed by the interdisciplinary team of professionals in consultation with the client and his or her parents, legal guardian, or others into whose care he or she will be released after discharge;

(3) state the treatment objectives;

(4) prescribe an integrated program of therapies, activities and experiences designed to meet the treatment objectives;

(5) include, at an appropriate time, post-discharge plans and coordination of PRTF services with partial discharge plans and related community services to ensure continuity of care with the client's family, school and community upon discharge; and

(6) be a recorded document which is maintained in the client's medical record.

(d) The individual plan of care shall be reviewed every thirty days by the interdisciplinary team, starting on the date of admission. The purpose of the review is to determine whether services being provided are currently required, or were required on an inpatient basis, and to recommend any changes to the plan that are indicated by the client's overall progress towards the treatment goals.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-812 Utilization review program

(a) The department conducts utilization review activities for services delivered by the PRTF for clients where Medicaid has been determined to be the appropriate payer.

(b) To determine whether admission to a PRTF is medically necessary and medically appropriate, the department or the Administrative Service Organization shall:

(1) authorize each PRTF admission, unless the department notifies the providers that a specific admission or diagnosis does not require such authorization; and

(2) perform retrospective reviews, at the department's discretion, which may be a random or targeted sample of the admissions and services delivered. The review may be focused on the appropriateness, necessity or quality of the health care services provided.

(c) All claims for payment for admission and all days of stay and services that are provided shall be documented. Lack of said documentation may be adequate grounds for the department, in its discretion, to deny or recoup payment for the admission for some or all of the days of stay or services provided.

(d) The department may conduct medical reviews and inspections of care in PRTFs.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-813 Billing procedures

Claims from providers shall be submitted on the department's uniform billing form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-814 Documentation and record retention

(a) A provider shall meet the medical record requirements for a PRTF and shall maintain records to support claims made for payment. All documentation shall be made available upon request by and to authorized department, state or federal personnel in accordance with state and federal laws. Documentation shall be retained by the provider for a period of at least five years, except if otherwise required by law or, if any dispute arises concerning a service, until such dispute has been finally resolved.

(b) Failure to maintain all required documentation or to provide it to the department upon request may result in the disallowance and recovery by the department of any amounts paid out for which the required documentation is not maintained or provided.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-815 Payment

The Department shall reimburse PRTFs at a negotiated per diem rate.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-816 Audit and compliance review

All supporting accounting and business records, statistical data and all other records relating to the provision of PRTF services paid for by the department shall be subject to audit or compliance review by authorized personnel. All documentation shall be made available, upon request, to authorized representatives of the department.

History

• Adopted effective September 4, 2009

Regs., Conn. State Agencies § 17b-262-817 Scope

Sections 17b-262-817 to 17b-262-828, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services’ requirements for payment of accepted methods of treatment performed by behavioral health clinics for clients who are determined eligible to receive such services under Connecticut's Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-818 Definitions

For the purposes of sections 17b-262-817 to 17b-262-828, inclusive, of the Regulations of Connecticut State Agencies, the following definitions shall apply:

(1) “Allied Health Professional” or “AHP” means:

(A) A licensed or certified practitioner performing within the practitioner’s scope of practice in any of the professional and occupational license or certification categories pertaining to behavioral health covered in title 20 of the Connecticut General Statutes; or

(B) a license-eligible individual as defined in subdivision (23) of this section;

(2) “Ambulatory chemical detoxification services” has the same meaning as provided in section 19a-495-570 of the Regulations of Connecticut State Agencies;

(3) “Authorization” means approval of payment for services by the department before payment is made. “Authorization” includes, prior authorization, registration and retroactive authorization;

(4) “Behavioral health clinic” or “clinic” means a facility that provides services to outpatients, is not part of a hospital and is licensed as one of the following:

(A) A day treatment facility;

(B) a psychiatric outpatient clinic for adults;

(C) an ambulatory chemical detoxification facility;

(D) a chemical maintenance treatment service;

(E) a day or evening treatment service;

(F) an outpatient treatment facility for substance abuse; or

(G) an outpatient psychiatric clinic for children;

(5) “Behavioral health clinic service” means preventive, diagnostic, therapeutic, rehabilitative or palliative items or services within the behavioral health clinic’s scope of practice provided by:

(A) A physician within the scope of practice as defined in chapter 370 of the Connecticut General Statutes;

(B) an AHP acting within the practitioner’s scope of practice, as defined in title 20 of the Connecticut General Statutes;

(C) an unlicensed or non-certified individual, working under the direct supervision of a licensed AHP, who is otherwise qualified to perform services under the applicable licensure category in sections 17b-262-819(c) to 17b-262-819(e), inclusive, of the Regulations of Connecticut State Agencies;

(6) “Chemical maintenance treatment” has the same meaning as provided in section 19a-495-570 of the Regulations of Connecticut State Agencies;

(7) “Client” means a person eligible for goods or services under Medicaid;

(8) “Commissioner” means the Commissioner of Social Services or his or her designee;

(9) “Community Mental Health Center” or “CMHC” has the same meaning as provided in section 1861(ff)(3)(B) of the Social Security Act;

(10) “Day treatment facility” has the same meaning as provided in section 19a-495-550 of the Regulations of Connecticut State Agencies;

(11) “Day or evening treatment service” has the same meaning as provided in section 19a-495-570 of the Regulations of Connecticut State Agencies;

(12) “Day treatment program” means a day treatment facility, or day or evening treatment service that provides services between four and twelve hours per day;

(13) “Department” means the Department of Social Services or its agent;

(14) “Drug abuse testing” means the taking of physical samples or specimens and the qualitative screening of these samples or specimens for substances of abuse;

(15) “Early and Periodic Screening, Diagnostic and Treatment Special Services” or “EPSDT Special Services” means services provided in accordance with section 1905(r)(5) of the Social Security Act, as amended from time to time;

(16) “Episode of care” means a period of care that ends when the client has been discharged by the provider or there has been an extended cessation in treatment defined as 120 days from the last time the client was treated at the clinic;

(17) “Escort” means a person 21 years of age or older who accompanies a client under the age of 16 during transport in a motor vehicle from one location to another for the purpose of the client’s protection and safety. “Escort” does not include the driver of a public transportation vehicle;

(18) “Fee” means the department’s payment for services established by the commissioner and contained in the department's fee schedules;

(19) “Formulation” means a clinical assessment of information obtained that is used to provide the framework for developing the appropriate treatment approach for a specific client;

(20) “Group psychotherapy” means a type of behavioral health care in which clients meet in groups facilitated for the purpose of discussing their psychiatric or substance use disorders, the impact of these disorders and the barriers that may be overcome in order to progress in their recovery;

(21) “Intensive Outpatient Program” or “IOP” means an integrated program provided at a psychiatric outpatient clinic for adults, an outpatient treatment service for substance abuse or an outpatient psychiatric clinic for children;

(22) “Intermediate care program” means a day or evening treatment service, IOP or Partial Hospitalization Program;

(23) “License-eligible” means an individual (A) whose education, training, skills and experience satisfy the criteria, including accumulation of all supervised service hours, for one of the behavioral health licensure categories of title 20 of the Connecticut General Statutes, and (B) who has applied for but not yet passed the licensure exam;

(24) “Medicaid” means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(25) “Medical necessity” or “medically necessary” has the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(26) “Off-site services” means services that are provided at a location other than the clinic or a satellite of the clinic;

(27) “Outpatient Psychiatric Clinic for Children” or “OPCC” has the same meaning as provided in section 17a-20-11 of the Regulations of Connecticut State Agencies;

(28) “Outpatient treatment service for substance abuse” has the same meaning as provided in section 19a-495-570 of the Regulations of Connecticut State Agencies;

(29) “Partial Hospitalization Program” or “PHP” has the same meaning as provided in sections 1861(ff)(1) to 1861(ff)(3), inclusive, of the Social Security Act;

(30) “Physician” means an individual licensed or board-certified pursuant to chapter 370 of the Connecticut General Statutes and who has experience in the diagnosis and treatment of behavioral health or substance related conditions;

(31) “Plan of care” means a written individualized plan that contains the client’s diagnosis; the type, amount, frequency and duration of services to be provided; and the specific goals and objectives developed subsequent to an evaluation and diagnosis in order to attain or maintain a client’s achievable level of independent functioning;

(32) “Prior authorization” means approval of payment for a service from the department before the provider actually provides the service;

(33) “Provider” means a behavioral health clinic enrolled in Medicaid;

(34) “Psychiatric outpatient clinic for adults” has the same meaning as provided in section 19a-495-550 of the Regulations of Connecticut State Agencies;

(35) “Psycho-educational group” means a type of behavioral health care that utilizes a pre-determined and time limited curriculum that focuses on educating clients with a common diagnosis about their disorders, specific ways of coping and progressing in their recovery;

(36) “Registration” means the process of notifying the department of the initiation of a behavioral health clinic service that includes information regarding the evaluation findings and plan of care. Registration may serve in lieu of authorization if a service is designated by the department as requiring registration only;

(37) “Satellite site” has the same meaning as provided in section 17a-20-11 of the Regulations of Connecticut State Agencies;

(38) “Under the direct supervision” means that a physician or licensed AHP provides weekly supervision of the work performed by unlicensed clinical staff or non-certified staff or individuals in training, and a minimum of monthly supervision for the work performed by certified staff; and accepts primary responsibility for the behavioral health services performed by the unlicensed, certified or non-certified staff or individuals in training; and

(39) “Usual and customary charge” means the fee that the provider accepts for the service or procedure in the majority of non-Medicaid cases. If the provider varies the fees so that no one amount is accepted in the majority of cases, “usual and customary” shall be defined as the median accepted fee. “Usual and customary charge” does not include token fees and other exceptional charges.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-819 Provider participation

(a) Providers shall meet and maintain all department enrollment requirements, as described in sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies, to receive payment from the department.

(b) Clinic services, as defined in 42 CFR §440.90, shall be furnished by or under the direction of a physician. The physician shall sign the initial plan of care and all periodic reviews to the plan of care assuring that the services are medically necessary.

(c) Programs serving clients under 18 years of age that are primarily for the treatment of psychiatric conditions shall be licensed by the Department of Children and Families as an Outpatient Psychiatric Clinic for Children as provided in section 17a-20 of the Connecticut General Statutes.

(d) Programs serving clients 18 years of age and older that are primarily for the treatment of psychiatric conditions shall be licensed by the Department of Public Health as a day treatment facility or psychiatric outpatient clinic for adults as provided in section 19a-495-550 of the Regulations of Connecticut State Agencies.

(e) Programs that are primarily for the treatment of substance related conditions, regardless of the age of the client served, shall be licensed by the Department of Public Health as an ambulatory chemical detoxification service; a chemical maintenance treatment service; a day or evening treatment program; or an outpatient treatment service for substance abuse as provided in section 19a-495-570 of the Regulations of Connecticut State Agencies.

(f) All providers, except those licensed solely as a chemical maintenance treatment provider, shall maintain the ability to respond to phone calls 24 hours a day, seven days a week and shall ensure that a client who is in crisis speaks with a physician or an AHP.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-820 Eligibility

Payment for behavioral health clinic services shall be available to all clients eligible for Medicaid subject to the conditions and limitations that apply to provision of the services.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-821 Services covered

(a) The department shall pay providers for those procedures listed in the department’s behavioral health clinic fee schedule, provided such services are:

(1) Within the clinic’s scope of practice as described in sections 19a-495-550, 19a-495-570, 17a-20-11 or 17a-147-1 of the Regulations of Connecticut State Agencies;

(2) Medically necessary to treat the client’s condition; and

(3) Furnished in the clinic or a satellite site of the clinic.

(b) When a procedure or service requested by a provider is not on the department’s behavioral health clinic fee schedule, prior authorization is required. In such instances the provider shall submit a prior authorization request to the department or its agent including, but not limited to documentation showing the medical necessity for the service or procedure.

(c) The department shall pay for behavioral health clinic services and for EPSDT special services.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-822 Service limitations

(a) General

(1) Payment for individual, group, family or multiple-family psychotherapy is limited to one visit of each type per day, per provider, per client.

(2) Family and group psychotherapy sessions shall be not less than 45 minutes in length, except in an intermediate care program where family and group psychotherapy sessions shall be not less than 30 minutes.

(3) More than one psychiatric diagnostic interview examination shall only be provided in a single episode of care under the following circumstances:

(A) When it is necessary to have a psychologist perform an interview to initiate or determine the need for psychological testing; or

(B) When a client’s presentation requires that a physician or a psychiatric advanced practice registered nurse evaluate the need for medication for a client who is in the care of a non-medical practitioner.

(4) Group psychotherapy sessions, are limited in size to a maximum of twelve participants per group session regardless of the payment source of each participant, except as provided in subdivision (8) of subsection (d) of this section.

(5) Group psychotherapy sessions shall be facilitated by an individual qualified as provided in the applicable licensure category in sections 17a-262-819(c) to (e), inclusive, of the Regulations of Connecticut State Agencies.

(6) Multiple-family group psychotherapy sessions are limited in size to a maximum of 24 participants regardless of the payment source of each participant. Such sessions may be conducted with or without the client present.

(7) Family therapy shall be reimbursable for one identified client per encounter, without regard to the number of family members in attendance or the presence of behavioral health conditions among other family members in attendance.

(b) Chemical maintenance treatment

(1) Services shall be billed as chemical maintenance treatment when the goal is to stabilize a client on methadone or other federally approved medication for as long as is needed to avoid return to previous patterns of substance abuse. The induction phase of treatment, the maintenance phase and any tapering of treatment dosage downward, even to abstinence, shall be billed as chemical maintenance treatment.

(2) Payment shall be available only for services provided at the clinic. Payment shall not be made for weeks when no face-to-face services are provided.

(3) A weekly rate payment for chemical maintenance treatment shall be paid when opiate agonist medication and medication management services are provided to a client. Intake evaluation, initial physical examination; on-site drug abuse testing and monitoring; and individual, group and family counseling are services that are also included in the weekly rate, if medically necessary.

(4) Intermediate care programs may be billed separately if medically necessary.

(c) Ambulatory chemical detoxification

(1) Services shall be billed as ambulatory chemical detoxification when the goal is to systematically reduce to abstinence a client’s dependence on a substance. The goal of abstinence shall be documented in the client’s initial plan of care.

(2) Ambulatory chemical detoxification treatment services shall be limited to one clinic visit per day, per client regardless of the number of times the client is seen in the clinic during any given day.

(3) Ambulatory chemical detoxification treatment services shall be limited to a maximum of 90 days from the date the client is admitted into the program.

(4) Payment for ambulatory chemical detoxification includes, but is not limited to: An intake evaluation; a physical examination; all medication; medication management; laboratory and monitoring; and individual, group and family counseling, with the exception of intermediate care programs that specifically address a substance abuse disorder and are provided by the clinic.

(5) Chemical maintenance and ambulatory chemical detoxification shall not be billed for the same time period.

(d) Intermediate care programs shall meet the following requirements:

(1) Care planning shall be individualized and coordinated to meet the client’s needs.

(2) Clinic programs shall provide time-limited, active psychiatric or substance abuse treatment that offers therapeutically intensive, coordinated and structured clinical services within a stable therapeutic milieu.

(3) Clinic programs shall be designed to serve clients with serious functional impairments resulting from a behavioral health condition, and further serve to avert hospitalization or increase a client’s level of independent functioning.

(4) Clinic programs shall provide an adult escort to support the transportation of clients under 16 years of age, transported by a Medicaid non-emergency medical transportation provider, unless the parent or guardian of the client between the ages of 12 to 15 years does not feel an escort is necessary for the client and has provided written consent for transportation of the client to the program without an escort.

(5) Clients may attend day treatment, IOP or PHP for a maximum of five days per week.

(6) A treatment day at a day treatment program or PHP shall include a minimum of four hours of scheduled programming, of which three and one half hours shall be documented behavioral health clinic services.

(7) A treatment day at an IOP shall include a minimum of three hours of scheduled programming, of which two and one half hours shall be documented behavioral health clinic services.

(8) Psychotherapy and psycho-educational group size in intermediate care programs shall be limited to 12 participants except that psycho-educational group size for substance abuse related conditions shall be limited to 24 participants and may comprise no more than one and one-half hours of an intermediate care program.

(9) The department shall pay for partial hospitalization services only when provided in a CMHC.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-823 Services not covered

The department shall not pay for the following:

(1) Information or services provided to a client over the telephone;

(2) Cancelled services and appointments not kept;

(3) Any services, treatment or items for which the provider does not usually charge;

(4) Any procedures or services whose purpose is solely educational, social, research, recreational, experimental or generally not accepted by medical practice;

(5) Any behavioral health clinic service in excess of those deemed medically necessary by the department to treat the client's condition; or for services not directly related to the client's diagnosis, symptoms or medical history;

(6) Any service not included in the plan of care when treatment is recommended;

(7) Any service requiring authorization or registration for which the provider did not obtain such authorization or registration; or

(8) Off-site and certain other services, including but not limited to: Emergency mobile psychiatric services; home and community based rehabilitation services; and extended day treatment provided only as children’s rehabilitation services, as described in sections 17b-262-849 to 17b-262-861, inclusive, of the Regulations of Connecticut State Agencies. Such services are reimbursed as part of the rehabilitation option services rather than as a behavioral health clinic service.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-824 Need for service

(a) Each client’s care shall be under the direction of a physician directly employed by or under contract with the clinic. The physician shall authorize the care provided and periodically review the need for continuing care.

(b) Psychiatric diagnostic evaluations shall be provided by an allied health professional who is permitted to conduct such evaluations under the applicable clinic licensure category.

(c) The psychiatric diagnostic evaluation shall be used in formulating the plan of care and shall be completed for each client. The evaluation shall contain the following components:

(1) The client’s mental status;

(2) Psychosocial history or updated psychosocial history for clients who have previously been in the provider’s care;

(3) Psychiatric or substance abuse history or updated psychiatric or substance abuse history for clients who have previously been in the provider’s care;

(4) Current medications, if indicated, medication history, or updated medication history for clients who have previously been in the provider’s care;

(5) Orders for and medical interpretation of laboratory or other medical diagnostic studies, if indicated;

(6) The initial diagnosis, functional status and formulation; and

(7) Treatment recommendations or further disposition of the client.

(d) If treatment is recommended, a plan of care shall be developed.

(e) The physician shall review the evaluation and plan of care and sign the plan of care and periodic reviews of the plan of care assuring that the services are medically necessary.

(f) If treatment is not recommended, the physician shall sign the evaluation.

(g) The plan of care shall, at a minimum, meet the requirements of the individualized care plan as described in: section 19a-495-550 (k)(2)(C) of the Regulations of Connecticut State Agencies; individualized program plan described in section 19a-495-570 (m)(6) of the Regulations of Connecticut State Agencies; or individualized treatment plan as described in section 17a-20-42 to 17a-20-43, inclusive of the Regulations of Connecticut State Agencies, as appropriate to the licensure of the service.

(h) A psychiatric office consultation shall be billed only by a physician or advanced practice registered nurse. When a psychiatric office consultation is the only service provided by the clinic, only a written note is required as documentation and a plan of care is not necessary. If an advanced practice registered nurse provides the service, the written note shall be cosigned by a physician.

(i) The evaluation and plan of care shall be made a part of the client's medical record.

(j) Care planning shall be individualized and coordinated to meet the client's needs.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-825 Authorization

(a) Behavioral health clinic services for clients with psychiatric and substance abuse disorders shall be subject to authorization requirements to the extent required by this section. Where a service is subject to authorization requirements, Medicaid payment for such service shall not be available unless the provider complies with such requirements.

(b) Services that require authorization shall be designated as such on the provider’s fee schedule published at www.ctdssmap.com.

(c) The following requirements shall apply to all services that require authorization under subsection (b) of this subsection:

(1) The initial authorization period shall be based on the needs of the client;

(2) In order to receive payment from the department, a provider shall comply with all authorization requirements. The department or its agent, in its sole discretion, determines what information is necessary in order to approve an authorization request. Authorization does not, however, guarantee payment unless all other requirements for payment are met;

(3) A provider shall present medical or social information adequate for evaluating medical necessity when requesting authorization. The provider shall maintain documentation adequate to support requests for authorization including, but not limited to, medical or social information adequate for evaluating medical necessity;

(4) Requests for authorization for the continuation of services shall include the progress made to date with respect to established treatment goals, the future gains expected from additional treatment and medical or social information adequate for evaluating medical necessity;

(5) The provider shall maintain documentation adequate to support requests for continued authorization including, but not limited to: Progress made to date with respect to established treatment goals; the future gains expected from additional treatment; and medical or social information adequate for evaluating medical necessity; and

(6) The department may require a review of the discharge plan and actions taken to support the successful implementation of the discharge plan as a condition of authorization.

(d) The following requirements shall apply to all services that require prior authorization:

(1) If prior authorization is needed beyond the initial or current authorization period, requests for prior authorization for continued treatment shall be submitted prior to the end of the current authorization period; and

(2) Except in emergency situations or for the purpose of initial assessment, prior authorization shall be received before services are rendered.

(e) The following requirements shall apply to all services provided to a client whose eligibility is granted retroactively:

(1) A provider may request retroactive authorization, for services provided during the period of retroactive eligibility, from the department for a client who is granted eligibility retroactively or in cases where it was not possible to determine eligibility at the time of service;

(2) For a client who is granted retroactive eligibility, the department may conduct retroactive medical necessity reviews. The provider shall be responsible for initiating this review to enable retroactive authorization and payment for services; and

(f) The department may deny prior authorization, registration or retroactive authorization based on non-compliance by the provider with the department’s utilization management policies and procedures.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-826 Billing requirements

(a) Claims shall be submitted by the providers on the department's designated form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment.

(b) The provider shall bill its usual and customary charge for the services delivered, except as set forth in section 17b-262-827(b) of the Regulations of Connecticut State Agencies.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-827 Payment

(a) The commissioner shall establish fees in accordance with section 4-67c of the Connecticut General Statutes. Fees shall be the same for in-state, border and out-of-state providers.

(b) If the client is present for up to half of the intermediate care program day and attends at least one individual, family or group session, the provider may bill half of the applicable Medicaid fee or rate. If the client is present for more than a half of the intermediate care program day but less than a full day and attends at least two individual, family or group sessions, the provider may bill the full day charge on file. If the client does not attend at least one individual, group or family session the provider is not entitled to any payment from the department.

(c) A single per diem fee shall be billed for intermediate care programs inclusive of all medication evaluation or management services, treatment and rehabilitative services, administrative services and coordination with or linkages to other health care services. A provider may bill separately for medically necessary individual or family psychotherapy services provided outside of the program hours of operation if such services are necessary for the purpose of client transition or continuity of care.

(d) If a session includes a combination of individual and family psychotherapy, the provider shall bill for the type of psychotherapy that comprises the greater part of the session. Individual and family psychotherapy shall not both be billed for the same date of service unless each type of session individually meets the minimum time requirement for the modality.

(e) Practitioners who are clinic-based either on a full-time or part-time basis are not entitled to individual payment from the department for services rendered to clients at the clinic. The clinic shall bill for the services, except as provided in section 17b-262-460 (c) of the Regulations of Connecticut State Agencies.

(f) Payment for services provided to a client is contingent upon the client’s eligibility on the date that services are rendered.

(g) The department shall pay the lower of:

(1) The amount in the applicable fee schedule;

(2) The amount on the provider’s rate letter; or

(3) The amount billed by the provider.

(h) The department may establish higher reimbursement for providers that meet special requirements.

(1) The special requirements shall be established by the department and may vary by provider type and specialty. The department, in its sole discretion, shall determine whether a provider meets the requirements for the higher reimbursement.

(2) The special requirements shall be related to improvements in access, quality, outcomes or other service characteristics that the department reasonably determines may result in better care and outcomes.

(3) The department may grant provisional qualifications for higher reimbursement by means of an application process in which providers submit a plan that demonstrates the feasibility of meeting the requirements.

(4) The department shall conduct periodic qualifications reviews. If a provider fails to continue to meet the requirements, the department may grant a probationary period of not less than 120 days during which the provider continues to qualify for higher reimbursement and is permitted an opportunity to submit a corrective action plan and to demonstrate compliance to the department.

(5) The department may conduct provider audits to determine whether a provider is performing in compliance with the special requirements.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-828 Documentation and audit requirements

(a) Providers shall maintain a specific record for all services rendered for each client eligible for Medicaid payment including, but not limited to:

(1) Client’s name, address, birth date and Medicaid identification number;

(2) Results of the initial evaluation and clinical tests, and a summary of current diagnosis, functional status, symptoms, prognosis and progress to date;

(3) The initial plan of care, signed by a physician not more than 30 days after the initial evaluation, that includes the types and frequencies of treatment ordered. The physician shall also sign the plan of care at the time of each periodic review and when the plan of care is updated to reflect any change in the types of service. When a physician signs off on the plan of care, the signature indicates that the plan of care is valid, conducted properly and based on the evaluation;

(4) Documentation of each service provided by the clinician, including types of service or modalities, date of service, location or site at which the service was rendered and the start and stop time of the service;

(5) The name and credentials of the individual performing the services on that date; and

(6) Medication prescription and monitoring.

(b) For treatment services, the provider shall document the treatment intervention and progress with respect to the client’s goals as identified in the plan of care.

(c) For providers licensed under section 19a-495-550 of the Regulations of Connecticut State Agencies, the medical record shall conform to the requirements of section 19a-495-550(k)(2) of the Regulations of Connecticut State Agencies.

(d) For providers licensed under section 19a-495-570 of the Regulations of Connecticut State Agencies, the medical record shall conform to the requirements of section 19a-495-570(m)(3) of the Regulations of Connecticut State Agencies.

(e) For intermediate care programs a note shall document the duration of each distinct therapeutic session or activity and progress toward treatment goals.

(f) For psychological testing, documentation shall include the tests performed, the time spent on the interview, the administration of testing and the completion of the clinical notes.

(g) For services performed by an unlicensed individual or a non-certified individual or an individual in training, progress notes entered pursuant to subsection (b) of this section shall be co-signed by the supervisor at least weekly for each client in care and shall contain the name, credentials and the date of such signature. For services provided by a certified individual, evidence of clinical supervision for each client in care shall be documented in the client’s chart and shall contain the name, credentials and the date of such signature. The supervisor’s signature means that the supervisor attests to having reviewed the documentation.

(h) The medication plan shall include instructions for administration for each medication prescribed by a clinic practitioner and a list of other medications that the patient is taking that may be prescribed by non-clinic practitioners.

(i) All required documentation shall be maintained in its original form for at least five years or longer by the provider in accordance with applicable statutes or regulations and subject to review by authorized department personnel. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute, five years or the length of time required by statute or regulation, whichever is longest.

(j) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained or not provided to the department upon request.

(k) The department retains the right to audit any and all relevant records and documentation and to take any other appropriate quality assurance measures it deems necessary to assure compliance with these and other regulatory and statutory requirements.

(l) All documentation shall be entered in ink or electronically and incorporated into the client’s permanent medical record in a complete, prompt and accurate manner.

(m) All documentation shall be made available to authorized department personnel upon request in accordance with 42 CFR §431.107.

History

• Effective October 9, 2013

Regs., Conn. State Agencies § 17b-262-829 Scope

Sections 17b-262-829 to 17b-262-848, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for the payment of hospice services on behalf of clients who are determined eligible to receive services under the Connecticut Medicaid program pursuant to section 17b-262 of the Connecticut General Statutes.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-830 Definitions

As used in section 17b-262-829 to section 17b-262-848, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Advanced practice registered nurse" or "APRN" means an advanced practice registered nurse as defined in section 20-87a of the Connecticut General Statutes;

(2) "Applied income" means the amount of income that each client receiving hospice care is expected to pay each month toward the cost of care, calculated according to the department's Uniform Policy Manual, section 5045.20;

(3) "Attending physician" means a physician who is identified by the client at the time he or she elected to receive hospice care as having the most significant role in the determination and delivery of the individual's medical care;

(4) "Bereavement counseling" means emotional, psychosocial, and spiritual support and services provided before and after the client's death to the client and the client's family to assist with issues related to grief, loss and adjustment;

(5) "Client" means a person eligible for goods or services under Medicaid;

(6) "Commissioner" means the Commissioner of Social Services or his or her designee;

(7) "Concurrent" means in the same time period covered by the care plan;

(8) "Counseling" means services, including dietary counseling, provided for the purpose of helping the client and caregivers to adjust to the client's approaching death;

(9) "Date of terminal diagnosis" means the date on which a physician first diagnoses the client as terminally ill;

(10) "Department" means the Department of Social Services or its agent;

(11) "Election period" means one of three or more periods of care a client may choose to receive the hospice benefit. The periods consist of an initial 90-day period, a subsequent 90 day period and an unlimited number of subsequent 60-day periods;

(12) "Home" means the client's place of residence, including, but not limited to, a boarding home, residential care home or community living arrangement. "Home" does not include facilities such as hospitals, nursing facilities, chronic disease hospitals, intermediate care facilities for the mentally retarded (ICF/MR) or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(13) "Home health aide" means an individual who has completed the homemaker-home health aide services training and competency evaluation program in accordance with Sec.19-13-D69 of the Regulations of Connecticut State Agencies;

(14) "Home health care agency" means "home health care agency" as defined in section 19a-490 of the Connecticut General Statutes and licensed pursuant to sections 19-13-D66 to 19-13-D79, inclusive, of the Regulations of Connecticut State Agencies;

(15) "Hospice" means an agency that is primarily engaged in providing care to terminally ill individuals and meets the requirements of section 19-13-D72(b)(2) of the Regulations of Connecticut State Agencies. The hospice model of care is based on a coordinated program of home and inpatient care, employing an interdisciplinary team to meet the special needs of terminally ill individuals;

(16) "Hospice aide and homemaker" means a "hospice aide and homemaker" as defined in 42 CFR 418.76;

(17) "Hospital" means "general hospital" as defined in section 19-13-D1(b)(1) of the Regulations of Connecticut State Agencies;

(18) "Interdisciplinary team" means a group of hospice personnel to include, but not be limited to, a physician, a registered nurse, a pharmacist, a social worker and a counselor that is responsible for providing services to meet the physical, psychosocial, spiritual and emotional needs of a terminally ill client or family members, as delineated in a specific plan of care. The interdisciplinary team is responsible for participating in the establishment of a plan of care for each client, supervising hospice services and reviewing and updating the plan of care as necessary;

(19) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for persons with mental retardation licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in Medicaid as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(20) "Legal representative" means an individual who has been authorized under Connecticut state law to direct medical care or to elect or revoke the election of hospice care on behalf of a terminally ill individual who is mentally or physically incapacitated;

(21) "Licensed practical nurse" or "LPN" means "licensed practical nurse" as defined in section 20-87a of the Connecticut General Statutes;

(22) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time;

(23) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate setting; and is the least costly of multiple, equally-effective alternative treatments or diagnostic modalities;

(24) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; to prevent a medical condition from occurring; or to alleviate suffering through the palliation of symptoms at the end of life;

(25) "Medical record" means "medical record" as defined in section 19a-14-40 of the Regulations of Connecticut State Agencies;

(26) "Nursing care" means the services provided by a registered nurse or a licensed practical nurse;

(27) "Nursing facility" means "nursing facility" as defined in 42 USC 1396r(a), as amended from time to time, and licensed pursuant to section 19-13-D8t of the Regulations of Connecticut State Agencies;

(28) "Occupational therapy" means the services provided by an occupational therapist or an occupational therapy assistant as set forth in section 20-74a of the Connecticut General Statutes;

(29) "Palliative care" means care that addresses physical, intellectual, emotional, social and spiritual needs and facilitating patient autonomy, access to information and choice;

(30) "Physical therapy" means the services provided by a physical therapist or a physical therapy assistant as set forth in section 20-66 of the Connecticut General Statutes;

(31) "Physician" means a physician or surgeon licensed pursuant to section 20-10 or 20-12, inclusive, of the Connecticut General Statutes;

(32) "Plan of care" means a comprehensive assessment of the client's needs that identifies the types and frequency of services necessary to manage the client's discomfort and relieve the symptoms of the terminal illness as well as to identify any services necessary to meet the needs of the family that meet the requirements of 42 CFR 418.54;

(33) "Prior authorization" or "PA" means the approval for the provision of a service or delivery of goods from the department before the provider actually provides the service or delivers the goods;

(34) "Provider" means a hospice that is certified by Medicare as a hospice, is licensed by the Connecticut Department of Public Health as a hospice and is enrolled with Medicaid;

(35) "Registered nurse" means "registered nurse" as defined in section 20-87a of the Connecticut General Statutes;

(36) "Social worker" means an individual licensed pursuant to section 20-195n of the Connecticut General Statutes;

(37) "Speech therapy" or "speech pathology" means the services provided by a speech pathologist as set forth in section 20-408 of the Connecticut General Statutes; and

(38) "Terminally ill" means a condition in which the patient has a medical prognosis of a life expectancy of six months or less if the illness runs its normal course.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-831 Provider participation

To enroll in Medicaid and receive payment from the department, providers shall comply with sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies, shall be certified as a provider of hospice services under the Medicare program as described in 42 CFR 418.50 through 418.100, inclusive, and shall be licensed as a hospice by the State Department of Public Health in accordance with section 19a-122b of the Connecticut General Statutes and section 19-13D72(b)(2) of Regulations of Connecticut State Agencies.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-832 Eligibility

Payment for hospice services is provided to persons who meet all of the following conditions:

(1) the individual is eligible for Medicaid; and

(2) the individual is certified by a physician as being terminally ill.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-833 Refusal to serve

No hospice enrolled as a Medicaid provider shall select a service area or refuse to serve any person, based on the geographical location of the service to be provided unless the hospice has a legitimate, non-discriminatory reason for its choice of service area or its refusal to serve as provided in section 17b-262-5 to 17b-262-8, inclusive, of the Regulations of Connecticut State Agencies. Providers shall designate service areas, document any refusals to serve and be subject to the sanctions in section 17b-262-9 of the Regulations of Connecticut State Agencies.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-834 Certification of terminal illness

(a) The provider shall obtain an initial certification of the client's terminal illness jointly from the medical director of the hospice or a physician member of the hospice interdisciplinary group and the client's attending physician, if an attending physician is identified, prior to the beginning of hospice services.

(b) The initial certification shall state that the client's life expectancy is six months or less and shall include clinical information to support this medical prognosis. The initial certification is valid for the first 90 days of hospice care.

(c) At the end of the first 90-day period, a second 90-day period may be certified by the medical director of the hospice or the physician member of the hospice interdisciplinary group. The certification shall include clinical information to support this medical prognosis;

(d) An unlimited number of 60-day periods may be certified following the first two 90-day periods by the medical director of the hospice or the physician member of the hospice interdisciplinary group. The certification shall include clinical information to support this medical prognosis

(e) An APRN may not certify or recertify a terminally ill diagnosis.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-835 Plan of care

(a) The interdisciplinary team in conjunction with the attending physician shall establish an initial written plan of care for each client within 48 hours of the client's election of hospice. Services may not be billed until the plan is established.

(b) The interdisciplinary team, in collaboration with the individual's attending physician, if any, must review, revise and document the individualized plan as frequently as the client's condition requires, but no less frequently than every 14 calendar days.

(c) The plan of care shall specify the care and services necessary to meet the client's and family's needs identified in the comprehensive assessment.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-836 Election of hospice

(a) A client who meets the eligibility requirement of 42 CFR 418.20 may file an election statement with a particular hospice. If the individual is physically or mentally incapacitated, his or her legal representative may file the election statement. The election statement must indicate;

(1) that the individual is electing a hospice benefit and identify which hospice he has chosen;

(2) the effective date of the election;

(3) that the individual understands that hospice services are palliative rather than curative and waives all rights to Medicaid payment for services to cure the terminal illness and related condition. Medicaid shall continue to pay for covered benefits that are not related to the terminal illness; and

(4) that the individual is eligible to receive hospice services only through the provider he has designated.

(b) The election statement shall include the following information:

(1) name of client;

(2) address and telephone number of client;

(3) client's Medicaid number and Medicare number, if applicable;

(4) primary terminal diagnosis;

(5) client's date of birth;

(6) name of parent, guardian or legal representative, if applicable;

(7) sex of client;

(8) name, telephone number and Medicaid number of provider;

(9) name and Medicaid number of attending physician;

(10) date of physician's certification of terminal illness;

(11) date the diagnosis is terminal; and

(12) name and Medicaid number of the nursing facility or ICF/MR, if applicable.

(c) A client may revoke election of hospice services at any time during the election period by signing and dating a statement to this effect. The revocation shall be in writing and shall not be retroactive. When a client revokes the hospice benefit, he resumes coverage for any services waived when he elected hospice. The client may re-elect hospice at any time for the next 60 or 90 day election period.

(d) A client may change hospice agencies once during any election period by signing and dating a statement to this effect.

(e) A client who is eligible for Medicare in addition to Medicaid shall elect the hospice benefit in both the Medicare and Medicaid programs simultaneously.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-837 Discharge from hospice

(a) The provider may discharge a client if:

(1) the client moves out of the provider's service area or transfers to another hospice;

(2) the client is no longer terminally ill;

(3) the client revokes the hospice benefit;

(4) the client dies; or

(5) the provider determines that there is just cause because the client or other person living with the client is disruptive, abusive or uncooperative to the extent that delivery of care to the client or the ability of the hospice to operate effectively is seriously impaired. A discharge for just cause shall meet the criteria and follow the process described in 42 CFR 418.26(a)(3).

(b) No client shall be discharged for just cause or if he or she is considered no longer terminally ill without a review by the department. When the hospice advises the client that discharge is being considered either for good cause or because the physician believes the client is no longer terminally ill, a copy of that written communication shall be sent to the department and the attending physician.

(c) The hospice shall obtain a written physician discharge order consistent with 42 CFR 418(b) before discharging a client for any reason other than death.

(d) Upon discharge the client is no longer covered for hospice care for that election period and resumes the Medicaid benefit that had been waived unless the client is immediately transferred to another hospice. As long as the client is still eligible, he or she may re-elect the hospice benefit immediately and by so doing shall enter the next election period.

(e) The provider shall have a discharge planning process in place that is consistent with 42 CFR 418.26(d).

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-838 Services covered

(a) The following documents shall be in place prior to the provision of hospice services:

(1) certification of terminal illness for the applicable election period. The certification may be in writing, electronically transmitted or verbal. A facsimile is acceptable provided the original is available on request. Verbal orders are acceptable provided a written order is received within 48 hours of the verbal order.

(2) a statement signed by the client or his or her legal representative electing the hospice benefit; and

(3) an initial plan of care within 48 hours following election of the hospice benefit.

(b) Subject to the limitations and exclusions identified in sections 17b-262-829 to 17b-262-848, inclusive, of the Regulations of Connecticut State Agencies, the department shall pay an all-inclusive per diem rate to the provider for each Medicaid client. This rate represents payment for the provision of the following goods and services:

(1) Physician services to include: the general supervisory duties of the medical director, participation in the establishment of plans of care, supervision of care and services, periodic review and updating of plans of care and establishment of governing policies by the interdisciplinary group;

(2) nursing service provided by or under the supervision of a registered nurse;

(3) home health aide and hospice aide and homemaker services under the supervision of a registered nurse, as ordered by the physician-led interdisciplinary group;

(4) physical therapy, occupational therapy and speech-language pathology to control symptoms or to enable the client to maintain activities of daily living and basic functional skills;

(5) medical equipment, supplies, biologicals and appliances that are a part of the written plan of care and not included in the payment to facilities for room & board;

(6) drugs which are used primarily for the relief of pain and symptom control related to the client's terminal illness and that are included in the provider's formulary, subject to review and approval by the department;

(7) social work services based on the client's psychosocial assessment and the client's and family's needs and acceptance of these services;

(8) dietary counseling, when identified in the plan of care and performed by a qualified individual, including dietitians as well as nutritionists and registered nurses, who are able to address and assure that the dietary needs of the client are met;

(9) spiritual counseling in accordance with the client's and family's acceptance of this service, and in a manner consistent with patient and family beliefs and desires;

(10) bereavement, grief and loss counseling, to reflect the needs of the bereaved;

(11) short term care inpatient care according to 42 CFR 418.108 for pain control and symptom management;

(12) respite care;

(13) supervision of volunteers; and

(14) any covered medically necessary and reasonable services related to the terminal illness as identified by the interdisciplinary team.

(c) The professional component of physician and APRN services reasonable and necessary for the treatment and management of the hospice client's terminal illness not described in subsection (b)(1) of this section shall be paid in addition to the per diem amount according to the department's fee schedule for physician services.

(d) Hospice services are provided at one of the following four levels of care:

(1) Routine home care is furnished to a client who is at home, in a nursing facility, or ICF/MR; is under the care of a hospice; and is not receiving continuous care.

(2) Continuous home care is furnished during brief periods of crisis as described in 42 CFR 418.204(a) in order to maintain a client at home. A minimum of eight hours of care, of which at least half is direct licensed nursing care, shall be provided in a 24-hour period to qualify for continuous home care to be billed on a hourly basis. The care does not need to be provided in successive blocks of time so long as a need for an aggregate of eight hours is required in a 24-hour period. All direct service hours shall be clearly documented. Services provided by other disciplines, such as social workers or counselors, are expected during periods of crisis but are not counted towards the total hours of continuous care. In addition, documentation of care, modification of the plan of care and supervision of home health aides by a nurse shall not qualify as direct client care.

(3) General inpatient care is furnished in an inpatient facility that meets the requirements in 42 CFR 418.108 when pain control or acute or chronic symptom management cannot be managed in other settings.

(4) Respite care is furnished for each day the client is in an approved inpatient facility in order to give the caregiver a rest. It is available for a maximum of five days in a 60-day period.

(e) The department shall pay a nursing facility or ICF/MR to hold the bed of a client who is hospitalized when the requirements of section 19a-537 of the Connecticut General Statutes are met.

(f) The provider shall routinely provide all nursing services, medical social work services and counseling. The provider may contract for physician services and the services of other personnel consistent with the requirements of 42 CFR 418.64.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-839 Coordination of hospice and waiver services

(a) For clients who receive waiver services prior to electing the hospice benefit under Medicaid, waiver services shall continue to be available.

(b) It is the responsibility of hospice to develop a plan of care that coordinates the hospice and waiver services. It is the responsibility of the hospice to initiate coordination with the waiver program case manager so that the client receives all of the care and services necessary. The waiver program's case manger is responsible for adjusting the waiver services so there is no duplication of services provider by the hospice or the waiver. These objectives should be accomplished according to the following principles:

(1) The best interest of the client is the key consideration. In circumstances when the hospice and waiver program case managers cannot agree on what is best for the client they shall ask the department for assistance in this determination.

(2) Each program shall provide services consistent with the goals of their respective programs. The goal of hospice care is to keep the client as comfortable as possible while maintaining his or her dignity and quality of life; the goal of the waiver program is to keep clients out of institutions.

(3) Services related to the terminal diagnosis are the responsibility of the hospice.

(4) Services provided prior to the date of terminal diagnosis are generally considered to be unrelated to the terminal diagnosis.

(5) Services unrelated to the terminal diagnosis may be billed in addition to the hospice reimbursement by the provider rendering the service.

(6) For the purpose of developing a plan of care, the presumption is that waiver services provided prior to the date of the terminal diagnosis should continue to be provided as waiver services. It is presumed that services initiated after the date of the terminal diagnosis are the responsibility of the hospice although this is subject to review and reconsideration by the hospice as approved by the department.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-840 Volunteers

The provider shall maintain a volunteer program consistent with 42 CFR 418.78.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-841 Service limitations

(a) The department shall pay only for services listed in its fee schedule.

(b) the department shall not pay separately for any services that are related to the treatment of the terminal condition for which hospice services were elected.

(c) Hospice services are covered in a nursing facility only if the nursing facility has a written agreement with the provider such that the provider takes full responsibility for the professional management of the client's hospice care and the nursing facility agrees to provide room and board to the client. The agreement shall meet the requirements of 42 CFR 418.112.

(d) For a client eligible for both Medicare and Medicaid, the only service payable by Medicaid is the room and board charge for a client in a nursing facility. Room and board means the facility's per diem rate that includes the services described in section 17b-262-705 of the Regulations of Connecticut State Agencies.

(e) The department shall pay for only one level of care on any day.

(f) Respite care is not available for a client who resides in a nursing facility, hospital or ICF/MR.

(g) Bereavement counseling shall be available for the family for up to 13 months following the client's death but is not separately reimbursable.

(h) Home health agency services are not covered unless they are unrelated to the terminal illness and prior authorized by the department.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-842 Services not covered

(a) When a client elects the hospice benefit, the client waives his or her right to receive the following services under Medicaid:

(1) treatment intended to cure the terminal illness;

(2) treatment related to the terminal illness except for the treatment provided by the designated hospice;

(3) hospice services provided by a provider other than the one designated by the client on the hospice form submitted to the department. However, the provider may subcontract with another hospice for services as described is section. 17b-262-838(f); and

(4) any services that are duplicative of any service provided by the hospice provider with the exception of services of the client's attending physician.

(b) In order for charges to be billed separately, the provider shall first demonstrate that the service is not related to the terminal illness.

(c) The department shall not pay for services that are not medically necessary and medically appropriate.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-843 Prior authorization

(a) Prior authorization, on forms and in the manner specified by the department shall be required for:

(1) general inpatient days beyond the fifth day; and

(2) any service which the department indicates on its fee schedule requires prior authorization.

(b) The department, in its sole discretion, shall determine what information is necessary to approve a prior authorization request. Prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-844 Billing procedures

(a) Claims from providers shall be submitted on the department's designated form or electronically transmitted to the department, in a form and manner as specified by the department and shall include all information required by the department to process the claim for payment.

(b) The provider is responsible for:

(1) completing any admission and discharge forms consistent with the department's instructions; and

(2) exhausting other payment sources of which the provider is aware before billing the department.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-845 Payment

(a) The Commissioner shall establish fees that are consistent with section 1902(a)(13)(B) of the Social Security Act.

(b) the Commissioner may increase any fee payable to a hospice upon the application of such an agency evidencing extraordinary costs related to providing escort services. In no case shall any rate or fee exceed the charge to the general public for similar services.

(c) The department shall reimburse the provider at the per diem rate for the appropriate level of care.

(d) The department shall reimburse a provider when all of the requirements of sections 17b-262-829 to 17b-262-848, inclusive, of the Regulations of Connecticut State Agencies have been met.

(e) The fee for routine, inpatient or respite services represents the per diem reimbursement for the client and is payment for all services provided by the provider on that day. Only one level of care may be billed on any day.

(f) The fee for continuous hospice care is paid on an hourly basis. A minimum of eight hours must be medically necessary in a 24-hour period to qualify for continuous hospice care.

(g) The department shall pay the fee for the routine, inpatient or respite level of care for each day the client is within an election period, regardless of the volume or intensity of services provided on that day.

(h) The department shall pay the same fee for border providers as for in-state providers.

(i) When a client who has elected hospice resides in a nursing facility or ICF/MR, the department shall make a payment equal to the department's rate for the nursing facility or ICF/MR. This payment represents payment for room and board services and is payable to the provider. It is the responsibility of the provider to reimburse the nursing facility or ICF/MR for room and board expenses. Applied income shall be deducted from the room and board payment.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-846 Payment limitations

(a) It is expected that the provider shall provide bereavement counseling to the client's family after the client's death; however the department shall not pay the provider for such bereavement counseling.

(b) For a twelve month period beginning November 1 of each year and ending October 31, the aggregate number of inpatient days, both general inpatient and respite, shall not exceed twenty percent of the aggregate number of days of hospice care provided to all hospice clients during that same period. At the department's discretion, the days of inpatient care provided to individuals with AIDS may be excluded from the days counted toward the twenty percent limitation.

(c) Payment for inpatient care is limited as follows:

(1) The total payment to the provider for inpatient care, general and respite, is subject to a limitation that total inpatient care days for Medicaid clients not exceed 20 percent of the total days for which these clients had elected hospice care.

(2) At the end of a twelve-month period specified in subsection (b) of this section, the department calculates a limitation on payment for inpatient care to ensure that Medicaid payment is not made for days of inpatient care in excess of 20 percent of the total number of days of hospice care furnished to Medicaid clients. Payments to nursing facilities and ICF/MRs where Medicaid is the secondary payer to Medicare shall be excluded from the calculation.

(3) If the number of days of inpatient care furnished to Medicaid clients is equal to or less than 20 percent of the total days of hospice care to Medicaid clients, no adjustment is necessary. Overall payments to a provider are subject to the cap amount specified in 42 CFR 418.309. Any provider that has received an exemption as specified in 42 CFR 418.108(e) shall be exempt from this provision.

(4) If the number of days of inpatient care furnished to Medicaid clients exceeds 20 percent of the total days of hospice care to Medicaid clients, the total payment for inpatient care is determined in accordance with subsection (c)(5) of this section. That amount is compared to actual payments for inpatient care and any excess reimbursement shall be refunded by the provider or recouped from subsequent claims. Overall payments to the provider are subject to the cap amount specified in 42 CFR 418.309.

(5) If a provider exceeds the number of inpatient care days described in subsection (c)(4) of this section, the total payment for inpatient care is determined as follows:

(A) calculate the ratio of the maximum number of allowable inpatient days to the actual number of inpatient care days furnished by the provider to Medicaid clients;

(B) multiply this ratio by the total reimbursement for inpatient care made by the department;

(C) multiply the number of actual inpatient days in excess of the limitation by the routine home care rate;

(D) add the amounts calculated in subsections (c)(5)(B) and (C) of this section.

(E) compare the amount in section 5(D) of this section with the total reimbursement to the hospice provider for inpatient care during that period. The amount that total reimbursement to the hospice exceeds the amount calculated in section 5(D) of this section is the amount due from the hospice provider.

(d) Applied income shall be calculated and deducted from the department's payment to the provider for a client living in a nursing facility or a hospice facility as follows:

(1) Clients who receive hospice services while residing in a hospice facility or in a nursing facility pursuant to a room and board arrangement with a hospice are responsible for paying applied income to the hospice provider.

(2) The department shall calculate the applied income liability and shall inform the client and the provider of the amount that the client is required to contribute towards the cost of care each month. The client's applied income liability shall be deducted from the amount that the department would otherwise pay to the hospice provider each month.

(3) The provider and the nursing facility may assign responsibility for collecting the client's applied income and may assign the risk of loss for nonpayment in their agreement, depending on the result of their negotiations. In no event shall the department be liable to a hospice or to a nursing facility in the event that a client fails to pay his or her applied income obligation.

(4) The provider shall notify the department's caseworker of any errors in the amount of applied income processed against the claim using the form specified by the department. Payment adjustments resulting from retroactive applied income corrections shall be processed periodically.

(5) In any month that a resident returns to the community or dies, and the cost of care is less than the applied income, the department shall adjust the applied income as follows: the applied income shall equal the number of days that the resident was in the hospice multiplied by the per diem rate.

(6) Applied income is not pro rated. It is used to cover the cost of care until it is expended.

(e) A nursing facility that enters into an agreement with a hospice to provide room and board services for clients shall accept the amount paid by the hospice, if any, pursuant to the contractual agreement between the hospice and the nursing facility as payment in full. In no event may a nursing facility assert a claim against a client, or against the department, in the event that the hospice fails to pay the nursing facility in accordance with their agreement, except that a nursing facility may assert a claim against a client for nonpayment of the client's applied income amount only when the agreement between the hospice and the nursing facility assigns responsibility for collecting the client's applied income liability to the nursing facility.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-847 Review process

(a) a client or client representative may request a review with the hospice whenever a requested good or service is denied.

(b) Review Process:

(1) The hospice shall have a timely and organized review process. The review process shall be available whenever:

(A) the hospice denies a requested good or service; or

(B) the hospice fails to respond to a client's request for goods and services within five working days of such request.

(2) The results of the review shall be in writing and shall include a brief statement of the reasons for the decision and shall state that the client may request review by the department and how to obtain such review.

(3) The hospice's review process shall allow for an expedited review within one business day when the standard time frames for determining a review could jeopardize the comfort of the client.

(c) Department review:

(1) A client who is denied a good or service by the hospice provider may request a review by the department in accordance with the following procedures:

(A) The client shall file a written or verbal request for a review within fifteen days from the date of the hospice denial of the good or service.

(B) The request shall state the reasons the client believes he or she should receive the goods or services and include any additional documentation in support of his or her case.

(C) Within five days of the request, the department shall make a finding based on an evaluation of the evidence submitted and shall notify the client in writing.

(2) If the standard timeframe for the department's review could jeopardize the comfort of the client, an expedited review shall be completed by the department within one business day of the request.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-848 Documentation

(a) All required documentation shall be maintained for at least five years, or longer, by the provider in accordance with statute or regulation, subject to review by the department. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute, five years or the length of time required by statute or regulation, whichever is longest.

(b) Failure to maintain and provide all required documentation to the department upon request shall result in the disallowance and recovery by the department of any future or past payments made to the provider for which the required documentation is not maintained and not provided to the department upon request.

(c) The following information shall be documented in writing or electronically, consistent with the requirements described in the Provider Enrollment Agreement and maintained on file with the provider for each Medicaid client:

(1) signed and dated physician orders;

(2) initial and subsequent plans of care signed and dated by the licensed practitioner or interdisciplinary team;

(3) Medicaid identification number;

(4) pertinent diagnostic information;

(5) documentation of each service provided and its duration;

(6) dates of services provided;

(7) all election forms signed by the client indicating that he has elected the hospice benefit and which hospice he has elected to provide services;

(8) the initial certification of terminal illness signed by the attending physician and the medical director of the hospice;

(9) subsequent certifications of terminal illness signed by the medical director of the hospice or the physician member of the interdisciplinary team;

(10) forms signed and dated by the client indicating any change in the designation of the hospice, if applicable; and

(11) revocation statements signed and dated by the client, if applicable.

(d) All clinical records shall be maintained in accordance with 42 CFR 418.104.

(e) Each provider shall maintain fiscal and medical records that fully disclose services and goods rendered or delivered to Medicaid clients.

(f) Providers shall maintain documentation supporting all prior authorization requests.

History

• Adopted effective July 7, 2009

Regs., Conn. State Agencies § 17b-262-849 Scope

Sections 17b-262-849 to 17b-262-861, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for Medicaid coverage of rehabilitation services for individuals with behavioral health conditions who are determined eligible for Connecticut's Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-850 Definitions

As used in sections 17b-262-849 to 17b-262-861, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Admission" means an individual's initial participation in a rehabilitation services program;

(2) "Allied health professional" or "AHP" means:

(A) a licensed or certified practitioner performing within his or her scope of practice in any of the professional and occupational license or certification categories pertaining to behavioral health covered in Title 20 of the Connecticut General Statutes; or

(B) a license or certification-eligible individual whose education, training, skills and experience satisfy the criteria for any of the professional and occupational licensure or certification categories pertaining to behavioral health covered in Title 20 of the Connecticut General Statutes;

(3) "Authorization" means the approval of payment for services or goods by the department;

(4) "Behavioral health condition" means one or more mental disorders as defined in the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, but excludes mental retardation, dementia and conditions designated with V codes;

(5) "Behavioral health services" means health care that is necessary to diagnose, correct or diminish the adverse effects of a behavioral health condition;

(6) "Commissioner" means the Commissioner of Social Services or the commissioner's agent;

(7) "Complex behavioral health service needs" means behavioral health needs that require specialized, coordinated behavioral health services across several service systems; for example, school, mental health and court;

(8) "DCF" means the Department of Children and Families or its agent;

(9) "Department" or "DSS" means the Department of Social Services or its agent;

(10) "Early and Periodic Screening, Diagnostic and Treatment services" or "EPSDT services" means the services provided in accordance with the requirements of 42 USC 1396a(a)(43), 42 USC 1396d (r) and 42 USC 1396d(a)(4)(B) and implementing federal regulations found in 42 CFR 441, Subpart B and section 17b-261(i) of the Connecticut General Statutes;

(11) "Emergency" means a psychiatric or substance abuse condition manifesting itself by acute symptoms of sufficient severity, including severe distress, such that a prudent lay person, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate psychiatric attention may result in placing the health of the individual in serious jeopardy due to harm to self, harm to others or grave disability;

(12) "Emergency Mobile Psychiatric Services" or "EMPS" means rehabilitation services provided by a DCF-certified provider of such services in the home or other community setting to an individual in response to a psychiatric or substance abuse related crisis in order to reduce disability, restore functioning and achieve full community integration and recovery;

(13) "Extended day treatment program" or "EDT" means "extended day treatment" as defined in section 17a-147-1 of the Regulations of Connecticut State Agencies;

(14) "Home and community-based rehabilitation services" means services provided by a DCF-certified provider of such services in the home or other community setting to an individual with psychiatric or substance abuse needs in order to reduce disability, restore functioning and achieve full community integration and recovery. Services may be provided in settings appropriate to the achievement of the rehabilitation goals and objectives, and as mutually agreed upon with the child and family. For example, service locations may include a local neighborhood community center, police substation, social service office or any other public or private community setting;

(15) "Individual" means a Medicaid-eligible person under age 21 who receives covered rehabilitation services in accordance with sections 17b-262-849 to 17b-262-861, inclusive, of the Regulations of Connecticut State Agencies;

(16) "Licensed clinician" means:

(A) a doctor of medicine or osteopathy who is licensed under chapter 370 of the Connecticut General Statutes;

(B) a psychologist who is licensed under chapter 383 of the Connecticut General Statues;

(C) a marital and family therapist who is licensed under chapter 383a of the Connecticut General Statutes;

(D) a clinical social worker who is licensed under chapter 383b of the Connecticut General Statutes;

(E) an advanced practice registered nurse who is licensed under chapter 378 of the Connecticut General Statutes;

(F) a registered nurse who is licensed under chapter 378 of the Connecticut General Statutes and who has a minimum of one year of experience in the mental health field;

(G) a professional counselor who is licensed under chapter 383c of the Connecticut General Statutes; or

(H) an alcohol and drug counselor who is licensed under chapter 376b of the Connecticut General Statutes;

(17) "Medicaid program" means the program operated by DSS pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(18) "Medical necessity" or "medically necessary" has the same meaning as defined in section 17b-259b of the Connecticut General Statutes;

(19) "Office-based, off-site rehabilitation services" means services provided by a DCF-licensed outpatient psychiatric clinic operating within its scope of practice to an individual in a primary care, school or office setting other than a primary or satellite office as provided for on the clinic's license;

(20) "Prior authorization" means approval for the provision of service from the department before the provider actually provides the service;

(21) "Provider" means a person, entity or organization that meets the requirements for participation specified in section 17b-262-851 of the Regulations of Connecticut State Agencies as a DCF-licensed or DCF-certified entity that provides office-based, off-site rehabilitation services, extended day treatment, emergency mobile psychiatric services or home and community-based rehabilitation services and participates in the Medicaid program as a qualified provider of rehabilitation services as evidenced by an executed provider agreement with the department;

(22) "Provider agreement" means the signed, written contractual agreement between the department and the provider;

(23) "Provider network" means the providers enrolled or contracted with the department;

(24) "Quality management" means the process of reviewing, measuring and continually improving the processes and outcomes of care delivered;

(25) "Registration" means the process of notifying the department of the initiation or continuation of a behavioral health service that includes information regarding the evaluation findings and plan of treatment. Registration may serve in lieu of authorization if a service is designated by the department as requiring registration only;

(26) "Rehabilitation plan" means a written individualized plan of care developed by the performing provider in accordance with the applicable licensing requirements and section 17b-262-851(7) of the Regulations of Connecticut State Agencies;

(27) "Rehabilitation services" means those services identified in section 17b-262-854 of the Regulations of Connecticut State Agencies when provided by a qualified provider to an individual with a behavioral health condition;

(28) "Trainee" means a person enrolled in an educational program or acquiring the supervisory experience necessary to obtain licensure or certification in any of the professional and occupational license or certification categories pertaining to behavioral health covered in Title 20 of the Connecticut General Statutes;

(29) "Under the direct supervision" means that a licensed clinician operating within his or her scope of practice provides periodic supervision of the work performed by unlicensed clinical staff and accepts primary responsibility for the rehabilitation services performed by the unlicensed staff; and

(30) "Utilization management" means the prospective, retrospective or concurrent assessment of the medical necessity of the allocation of health care resources and services given, or proposed to be given, to an individual.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-851 Provider participation

In order to participate in the Medicaid program and provide rehabilitation services that are eligible for Medicaid reimbursement from the department, the provider shall:

(1) Enroll with the department and have on file a valid provider agreement;

(2) be licensed by DCF as an Outpatient Psychiatric Clinic for Children, as defined in section 17a-20-11 of the Regulations of Connecticut State Agencies, if providing office-based off-site rehabilitation services;

(3) be licensed by DCF as an extended day treatment program under section 17a-147-1 to 17a-147-36, inclusive, of the Regulations of Connecticut State Agencies, if providing extended day treatment program services;

(4) comply with any applicable DCF certification requirements necessary to be qualified to provide home and community-based rehabilitation services or emergency mobile psychiatric services;

(5) comply with all Medicaid record keeping, documentation and other requirements including, but not limited to, those delineated in the department's administrative manuals, provider agreements and memoranda of understanding;

(6) comply with all laws, rules, regulations, policies and amendments that govern the Medicaid program as they relate to reimbursement for rehabilitation services;

(7) except as noted below in subdivision (G) of this subsection, develop a written rehabilitation plan for each individual in accordance with section 17a-20-42 of the Regulations of Connecticut State Agencies not later than thirty days after the individual's admission to the program. This rehabilitation plan requirement applies to all providers of Medicaid-funded rehabilitation services for individuals, not just DCF psychiatric clinics, which are the specific subject of section 17a-20-42 of the Regulations of Connecticut State Agencies. Such plan shall be developed by the provider, with input from the individual, the individual's family or the individual's legal representative and shall:

(A) Specify the behavioral health disorder to be addressed;

(B) specify reasonable, individualized behavioral health goals and objectives based on each individual's behavioral health diagnosis and diagnostic and functional evaluation and be targeted toward the reduction of an individual's behavioral health symptoms, restoration of functioning and recovery;

(C) identify the type, amount, frequency and duration of services to be provided;

(D) document that the services provided have been determined to be rehabilitation services consistent with section 17b-262-854 of the Regulations of Connecticut State Agencies;

(E) ensure the active participation of the individual and his or her family or the legal representative of the individual;

(F) contain a timeline, based upon the individual's assessed and anticipated needs, for reevaluation of the plan, which should occur not later than one year after the date of the prior plan; and

(G) providers of EMPS to individuals are not required to develop an individualized rehabilitation plan that meets the requirements of section 17a-20-42 of the Regulations of Connecticut State Agencies unless the services are provided for a period of more than 45 days. The Statewide Uniform Crisis Plan shall serve as the rehabilitation plan for the EMPS until an individual rehabilitation plan for EMPS is developed;

(8) ensure that a licensed clinician operating within his or her scope of practice and employed by or under contract with the provider reviews and signs the individual rehabilitation plan. The first review and signature shall occur not later than thirty days after admission;

(9) ensure that rehabilitation plans are reassessed by a licensed clinician at 90-day intervals, as well as when a significant change in condition or diagnosis occurs. Reassessed rehabilitation plans shall be reviewed and signed by the supervising licensed clinician;

(10) keep current service and progress notes in a permanent case record for each client in accordance with section 17a-20-54 of the Regulations of Connecticut State Agencies;

(11) cooperate with the department in the rate-setting process including, but not limited to, licensing or any quality assurance reviews or periodic audits to ensure compliance with rehabilitation service requirements defined in section 17b-262-849 to section 17b-262-861, inclusive, of the Regulations of Connecticut State Agencies;

(12) provide an initial orientation, training and periodic supervision to direct service staff responsible for the provision of rehabilitation services;

(13) conduct ongoing assessment and service planning;

(14) ensure that the program director is a licensed clinician operating within his or her scope of practice and has a minimum of three years of experience in a behavioral-health-services-related position;

(15) ensure that the program director, or the program director's designee who shall be a licensed clinician, is accessible after hours, by telephone or pager, to staff on duty;

(16) ensure that direct service staff of providers of office-based off-site rehabilitation services are physicians, allied health professionals or trainees;

(17) ensure that direct service staff of providers of extended day treatment meet the minimum requirements established in sections 17a-147-1 to 17a-147-36, inclusive, of the Regulations of Connecticut State Agencies;

(18) ensure that direct service staff of providers of home and community-based rehabilitation services and EMPS are physicians, allied health professionals or trainees or persons who hold either a bachelor's degree in a behavioral-health-related specialty or have two years of experience in the provision of behavioral health services, provided such individuals meet the minimum requirements of any applicable certification authority;

(19) ensure that all unlicensed staff work under the direct supervision of licensed clinical staff; and

(20) ensure that direct service staff of providers of home and community-based rehabilitation services and EMPS are accessible to clients after hours, whether face-to-face or by telephone.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-852 Eligibility

Medicaid coverage for the cost of rehabilitation services is available for individuals with behavioral health conditions when the service is medically necessary and is provided by a provider to an individual with a behavioral health condition, subject to all of the qualifications, conditions and limitations contained in sections 17b-262-849 to 17b-262-861, inclusive, of the Regulations of Connecticut State Agencies.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-853 Need for services

Payment for rehabilitation services shall be made by the department only if all of the following conditions are met:

(1) Medicaid payment for rehabilitation services may be made only to the extent that a covered rehabilitation service is provided by a qualified participating provider of such services and the service is medically necessary for the client. Where a service is subject to prior authorization requirements in accordance with section 17b-262-855 or 17b-262-857 of the Regulations of Connecticut State Agencies, eligibility for Medicaid payment is conditioned upon compliance with such requirements. Furthermore, all Medicaid payments, including payments for services that are prior authorized or for which registration is required, are subject to record keeping and post-payment review and audit requirements, and are subject to subsequent recoupment if it is subsequently determined that the service was not medically necessary or if record keeping or other requirements for payment are not satisfied;

(2) For no more than thirty days after an individual's admission, rehabilitation services shall be provided in accordance with an initial assessment of need that is signed by a licensed clinician operating within his or her scope of practice. This assessment shall, for no more than thirty days after an individual's admission, be utilized as the individual's rehabilitation plan;

(3) Not later than thirty days after an individual's admission, the rehabilitation services shall be provided in accordance with the rehabilitation plan developed in accordance with section 17a-20-42 of the Regulations of Connecticut State Agencies. The rehabilitation plan shall include a progress note that describes the services that the individual has received to date; the individual's overall response; the individual's specific progress toward the goals and objectives listed in the rehabilitation plan and justification of the need for continued treatment. The progress note shall include discussion of any variance between the services listed on the rehabilitation plan and the services actually delivered. The progress note shall also include discussion of suggested changes, if any, to the rehabilitation plan. The rehabilitation plan shall be reviewed and signed by the licensed clinician employed by or under contract with the provider at least every ninety days thereafter; and

(4) The individual is sufficiently stable to be able to function outside of a twenty-four hour medically managed setting and participate in community-based treatment services.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-854 Covered services

(a) Rehabilitation services shall be recommended by a physician or other licensed clinician operating within his or her scope of practice.

(b) Rehabilitation services are services designed to assist individuals in reaching an achievable level of independent functioning.

(c) Rehabilitation services include office-based off-site rehabilitation services, home and community-based rehabilitation services and EMPS when provided by a qualified and enrolled provider of such services.

(d) Depending upon the particular needs of each individual and the rehabilitation plan, office-based off-site services may include any of the routine outpatient services listed on the department's fee schedule for behavioral health clinics.

(e) Depending upon the particular needs of each individual and the rehabilitation plan, home and community-based rehabilitation services, extended day treatment program services and EMPS may include the following components:

(1) Intake and assessment, which means assessing and reassessing the individual's behavioral health needs in the context of medical, social, educational and other needs through face-to-face contact with the individual, the individual's family and through consultation with other professionals;

(2) development of an individual rehabilitation plan in accordance with sections 17b-262-851(7) and 17b-262-858 of the Regulations of Connecticut State Agencies;

(3) individual and group psychotherapy or counseling;

(4) family therapy or training;

(5) socialization skills development, which means individual-centered skill development activities that are provided to support the goals and objectives in the rehabilitation plan and that are directed at reducing individuals' psychiatric and substance abuse symptoms, restoring individuals to an achievable functioning level;

(6) behavior modification or management training and intervention;

(7) supportive counseling directed at solving daily problems related to community living and interpersonal relationships;

(8) psycho-educational services pertaining to the alleviation and management of psychiatric or substance abuse disorders;

(9) teaching, coaching and assisting with daily living and self-care skills such as the use of transportation, meal planning and preparation, personal grooming, management of financial resources, shopping, use of leisure time, interpersonal communication and problem solving;

(10) therapeutic recreation and other skill development activities directed at reducing disability; restoring individual functioning and achieving independent participation in social, interpersonal or community activities and full community reintegration and independence as identified in the rehabilitation plan;

(11) support with connecting individuals to natural community supports;

(12) orientation to, and assistance with, accessing self-help and advocacy resources;

(13) development of self-advocacy skills;

(14) health education;

(15) teaching of recovery skills in order to prevent relapse;

(16) crisis response services, either face-to-face or telephonic only, when provided as part of a home and community-based rehabilitation service; and

(17) consultation for persons responsible for the development of healthy social relationships and the promotion of successful interpersonal and community experiences.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-855 Coverage limitations

(a) Coverage of services shall be subject to the following limitations:

(1) Services that do not meet medical necessity requirements or any applicable authorization or certification requirements are not eligible for Medicaid payment.

(2) Services shall be based on the rehabilitation plan developed pursuant to section 17b-262-851(7) of the Regulations of Connecticut State Agencies and the requirements of sections 17b-262-849 to 17b-262-861, inclusive, of the Regulations of Connecticut State Agencies, and shall be performed by or under the supervision of a licensed clinician employed by or under contract with the provider.

(3) Home and community-based services and EMPS may be provided in a facility, home, hospital or other setting, except as follows:

(A) When an individual resides in a facility or institution, the services may not duplicate services included in the facility's or institution's rate; or

(B) if the provider operates a clinic or practice for the provision of outpatient services, no more than 10 visits may be provided at the site of the outpatient clinic or practice per individual per episode of care, other than the initial assessment, which may occur off-site. The services rendered under this exception are considered reimbursable services only if the services rendered are part of a rehabilitation plan.

(4) EDT programs shall meet the following requirements:

(A) Provide time-limited, active services within a clinic or off-site community setting;

(B) employ an integrated, comprehensive and complementary schedule of treatment approaches;

(C) serve individuals with significant functional impairments resulting from a behavioral health condition in order to avert hospitalization or increase the client's level of independent functioning;

(D) provide an adult escort to support the transportation of individuals under 16 years of age, transported by a Medicaid non-emergency medical transportation provider, unless the parent or guardian of the individual between the ages of 12 to 15 years consents, in writing, to transportation of the individual to the EDT program without an escort; and

(E) provide a minimum of three hours of scheduled, documented programming of which at least two and one half hours are services.

(5) Services may be provided indirectly through counseling of parents, other family members or other persons responsible for the care of the individual, regardless of the Medicaid eligibility of these persons, only to the extent that the provision of such indirect treatment service is necessary and is intended to primarily benefit the individual.

(6) The department shall not pay for the following:

(A) Programs, services or components of services that are of an unproven, experimental, cosmetic or research nature;

(B) programs, services or components of services that do not relate to the individual's diagnosis, symptoms, functional limitations or medical history;

(C) programs, services or components of services that are not included in the fee established by the department;

(D) programs, services or components of services that are intended solely to prepare individuals for paid or unpaid employment or for vocational equipment and uniforms;

(E) programs, services or components of services provided solely for social or recreational purposes not in compliance with section 17b-262-854(e)(5) or 17b-262-854(e)(10) of the Regulations of Connecticut State Agencies;

(F) time spent by the provider solely for the purpose of transporting clients;

(G) services that are solely educational or vocational;

(H) costs associated with room and board for individuals; and

(I) services that are provided out-of-state unless the services are not available within Connecticut.

(b) Notwithstanding subparagraph (a)(3)(B) of this section, services that are provided at the primary or satellite site of a DCF-licensed clinic, as indicated on the clinic's license, do not qualify as rehabilitation services and may be reimbursed by the Medicaid program only to the extent that such services otherwise qualify for Medicaid reimbursement, for example, as covered clinic services.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-856 Non-billable activities

The following activities are not billable:

(1) Telephone contact with the department for the purpose of requesting or reviewing authorization;

(2) documentation of progress notes or billing documentation;

(3) individual or group supervision, routine case reviews and rounds; ad hoc consultation with supervisors; and discussion or consultation among participants of the rehabilitation team, including those conducted for the purpose of treatment planning;

(4) travel to an appointment with an individual or family; travel to and from collateral appointments (e.g. school planning meeting, court appearance); or transportation of the individual to or from meetings or appointments, unless the provider is also engaged in an activity that otherwise qualifies as a service;

(5) time on-call that does not otherwise qualify as a rehabilitation service;

(6) time spent performing routine services, such as cleaning, cooking, shopping or child care designed to provide relief or respite for the family;

(7) time spent waiting for individuals at their homes when they have a scheduled appointment and the individual has not arrived;

(8) no shows, missed or cancelled appointments;

(9) services of less than eight minutes duration for rehabilitation procedures whose billing codes are defined in 15-minute increments; and

(10) time spent engaged in activities required by a credentialing or oversight entity such as gathering and submitting care plan or service data or other information.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-857 Authorization

(1) Services are subject to prior authorization or registration requirements to the extent required by this section. Where a service is subject to authorization or registration requirements, Medicaid payment for such service is not available unless the provider complies with such requirements.

(2) Services that require authorization or registration will be designated as such on the provider's fee schedule or authorization and registration schedule published at www.ctdssmap.com.

(3) The following requirements shall apply to all services that require authorization or registration under subdivision (1) or (2) of this subsection:

(A) The initial authorization or registration period shall be based on the needs of the individual.

(B) If authorization or registration is needed beyond the initial or current authorization period, such requests for continued treatment shall be submitted prior to the end of the current authorization period.

(C) Except in emergency situations or for the purpose of initial assessment, providers shall obtain authorization or shall register, as appropriate, before services are rendered.

(D) In order to receive payment from the department, a provider shall comply with all prior authorization and registration requirements. The department or its agent in its sole discretion determines what information is necessary in order for a provider to register or to approve a prior authorization request. Registration or prior authorization does not, however, guarantee payment unless all other requirements for payment are met.

(E) A provider shall present medical or social information adequate for evaluating medical necessity when registering or requesting authorization. The provider shall maintain documentation adequate to support requests for authorization and registration including, but not limited to, medical or social information adequate for evaluating medical necessity.

(F) Registration or requests for authorization for the continuation of services shall include the progress made to date with respect to established treatment goals, the future gains expected from additional treatment and medical or social information adequate for evaluating medical necessity.

(G) The provider shall maintain documentation adequate to support registration or requests for continued authorization including, but not limited to, progress made to date with respect to established treatment goals, the future gains expected from additional treatment, and medical or social information adequate for evaluating medical necessity.

(H) The department may require a review of the discharge plan and actions taken to support the successful implementation of the discharge plan as a condition of registration or authorization.

(I) A provider may register or request authorization from the department after a service has been provided for individuals who are granted eligibility retroactively or in cases where it was not possible to determine eligibility at the time of service.

(J) For individuals who are granted retroactive eligibility, the department may conduct retroactive medical necessity reviews. The provider shall be responsible for initiating this review to enable registration or authorization and payment for services.

(K) The department may deny authorization or registration based on non-compliance by the provider with utilization management policies and procedures.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-858 Documentation and record retention requirements

(a) Providers shall comply with the following documentation and record retention requirements:

(1) An initial rehabilitation plan and all updated versions, including the current plan, shall be maintained.

(2) All rehabilitation service providers are required to develop a rehabilitation plan that meets the requirements of section 17a-20-42 of the Regulations of Connecticut State Agencies, except as provided for under subsection 17b-262-851(7) of the Regulations of Connecticut State Agencies. The rehabilitation plan shall include a medication plan, if the rehabilitation service includes medication management. The medication plan shall include an order and instructions for administration for each medication prescribed by a provider staff member and a list of other medications that the individual is taking that may be prescribed by non-clinic practitioners.

(3) A case record that meets the requirements of section 17a-20-54 of the Regulations of Connecticut State Agencies, shall be maintained and shall include, at a minimum: identifying information; social and health history; the reason for admission to the rehabilitation program; copies of the initial and all subsequent orders for rehabilitation services; the rehabilitation plan; identification of the care and services provided; a current list of all medications; and the plan for discharge and disposition of the individual. This case record requirement applies to all providers of rehabilitation services for individuals, not just to DCF-licensed psychiatric clinics that are subject to section 17b-20-54 of the Regulations of Connecticut State Agencies.

(4) Encounter notes shall be maintained for each rehabilitative service provided. The notes shall include the service rendered; actual time the service was rendered; location of service; the goal and objective that is the focus of the intervention; a general description of the content of the intervention to provide evidence that it is a rehabilitative service, as described in section 17b-262-854 of the Regulations of Connecticut State Agencies; and the individual's response to the intervention. Encounter notes shall be signed and dated and shall indicate the credentials of the staff member who provided the service.

(5) For EDT programs the encounter notes shall document the duration of each distinct therapeutic session or activity and progress toward treatment goals.

(6) For the purpose of documenting the supervision of services provided by unlicensed direct care staff, licensed clinical staff shall document in the case record that they have reviewed the encounter notes corresponding to services provided by such unlicensed direct care staff at least once every 30 days. Documentation shall include the signature and credentials of the licensed clinical staff that reviewed the encounter notes.

(b) Other documentation and record retention requirements:

(1) The provider shall maintain a current record of the applicable licenses and certificates of practice of all licensed or certified persons furnishing rehabilitation services.

(2) The provider shall be substantially in compliance with all documentation requirements in its most recent licensure review and relevant state agency quality assurance reviews.

(3) The provider shall maintain all required records for at least five years or longer as required by statutes or regulation. All required records shall be subject to review by the department. In the event of a dispute concerning a service provided, documentation shall be maintained until the end of the dispute or five years, whichever is longer.

(4) All documentation shall be recorded in the eligible individual's case record in a complete, prompt and accurate manner. All documents shall be made available to authorized personnel of the department upon request.

(5) Failure to maintain all required documentation shall result in the disallowance and recovery by the department of any amounts paid to the provider for which the required documentation is not maintained and not provided to the department upon request.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-859 Billing requirements

(a) Claims for office-based off-site rehabilitation services shall be billed with routine outpatient procedure codes and an off-site modifier or appropriate place of service code as designated by the department.

(b) For home and community-based rehabilitation services that are delivered by more than one staff member, each staff member may bill for time spent engaged in rehabilitative services, whether the staff members are working together or independently. When more than one staff member is in the home at the same time co-facilitating a family therapy or crisis intervention, each staff member may bill for the time spent engaged in this activity. The staff members may co-sign a single note that documents the rehabilitation service that was conducted by the team. If the staff members worked with different family members, each staff member shall write an encounter note in accordance with section 17b-262-858(a)(4) of the Regulations of Connecticut State Agencies.

(c) A single per diem fee shall be billed for EDT inclusive of all medication evaluation or management services, treatment and rehabilitative services, administrative services and coordination with or linkages to other health care services. The provider may bill separately for medically necessary individual psychotherapy clinic services while the individual continues to receive extended day treatment services, if such services are rendered outside of the EDT program hours of operation, are provided by persons other than EDT program staff and are necessary for the individual's transition or continuity of care.

(d) For EDT if the individual is present for up to half of the program day and attends at least one therapy session, the provider may bill for half of their fee on file. If the individual is present for more than half of the program day but less than a full day and attends at least two therapy sessions, the provider may bill the full day charge on file. If the individual does not attend at least one therapy session the clinic is not entitled to any payment from the department.

(e) Claims for payment of rehabilitation services shall be on the department's uniform billing form or electronically transmitted to the department's fiscal agent and shall include all information required by the department to process the claim for payment. All claims submitted to the department for payment of services covered under section 17b-262-854 of the Regulations of Connecticut State Agencies shall be substantiated by documentation in the individual's permanent case record.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-860 Payment

(a) In order to receive payment from the department, the provider shall be enrolled in the Connecticut Medical Assistance Program and comply with the requirements of sections 17b-262-522 through 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies.

(b) The department shall establish rates for rehabilitation services. By enrolling in the program and providing covered rehabilitation services to individuals, the provider agrees to accept the department's rate as payment in full for rehabilitation services provided to individuals.

(c) Office-based off-site rehabilitation services provided by a provider that is not a Federally Qualified Health Center shall be reimbursed at the same rate applicable to such services when provided at a primary or satellite site as provided for on the clinic's DCF license.

(d) Office-based off-site rehabilitation services provided by Federally Qualified Health Centers shall be reimbursed at the Federally Qualified Health Center's psychiatric encounter rate.

(e) Home and community-based rehabilitation services and EMPS provided by Federally Qualified Health Centers shall be reimbursed at the same rates paid to non-Federally Qualified Health Center providers.

(f) Rates for rehabilitation services include any associated travel costs.

(g) Payment shall be made at the lowest of:

(1) The provider's usual and customary charge;

(2) the lowest Medicare rate; or

(3) the amount in the provider's rate letter or the amount on the applicable fee schedule as published by the department.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-861 Audit and compliance reviews

All supporting accounting and business records, statistical data and all other records relating to the provision of rehabilitation services paid for by the department shall be subject to audit or compliance review by authorized personnel. All documentation shall be made available, upon request, to authorized representatives of the department.

History

• Effective February 2, 2012

Regs., Conn. State Agencies § 17b-262-862 Scope (Repealed)

Repealed July 9, 2025.

History

• Effective April 3, 2013; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-863 Definitions (Repealed)

Repealed July 9, 2025.

History

• Effective April 3, 2013; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-864 Limitations on Coverage of Certain Non-emergency Dental Services (Repealed)

Repealed July 9, 2025.

History

• Effective April 3, 2013; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-865 Services Not Covered (Repealed)

Repealed July 9, 2025.

History

• Effective April 3, 2013; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-866 Prior Authorization Requirements (Repealed)

Repealed July 9, 2025.

History

• Effective April 3, 2013; Repealed July 9, 2025

Regs., Conn. State Agencies § 17b-262-912 Scope

Sections 17b-262-912 to 17b-262-925, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services' requirements for payment of services performed by licensed behavioral health clinicians in independent practice for HUSKY C and HUSKY D clients under age twenty-one and HUSKY A clients of any age who are determined eligible to receive services under Connecticut's Medicaid program pursuant to sections 17b-261, 17b-261n and 17b-277 of the Connecticut General Statutes.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-913 Definitions

As used in sections 17b-262-912 to 17b-262-925, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Advanced practice registered nurse" or "APRN" means an individual licensed pursuant to section 20-94a of the Connecticut General Statutes;

(2) "Behavioral health clinician services" means preventive, diagnostic, therapeutic, rehabilitative or palliative services provided by a licensed behavioral health clinician within the licensed behavioral health clinician's scope of practice under state law;

(3) "Client" means a person who is eligible for goods or services under Medicaid and is a HUSKY C or HUSKY D member under age twenty-one or a HUSKY A member of any age;

(4) "Commissioner" means the Commissioner of Social Services or the commissioner's agent;

(5) "Current treatment plan" means a treatment plan that has been reviewed and updated by the provider not more than six months before each treatment session;

(6) "Department" means the Department of Social Services or its agent;

(7) "Early and Periodic Screening, Diagnostic and Treatment Services" or "EPSDT Services" means the services described in 42 USC 1396d(r)(5);

(8) "Early and Periodic Screening, Diagnostic and Treatment Special Services" or "EPSDT Special Services" means services that are not covered under the Medicaid State Plan but are covered as EPSDT services for Medicaid-eligible children pursuant to 42 USC 1396d(r)(5) when the service is (A) medically necessary, (B) the need for the service is identified in an EPSDT screen, (C) the service is provided by a participating provider and (D) the service is a type of service that may be covered by a state Medicaid agency and qualifies for federal reimbursement under 42 USC 1396d;

(9) "Federally qualified health center" has the same meaning as provided in 42 USC 1396d(l);

(10) "Home" means a client's place of residence, including, but not limited to, a boarding house, community living arrangement, nursing facility or residential care home. "Home" does not include facilities such as hospitals, chronic disease hospitals, intermediate care facilities for the mentally retarded or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(11) "HUSKY A" means the Medicaid coverage groups for children, caretaker relatives and pregnant women authorized by Title XIX of the Social Security Act (Medicaid) and operated pursuant to sections 17b-261 and 17b-277 of the Connecticut General Statutes;

(12) "HUSKY C" means the Medicaid coverage groups for the aged, blind and disabled authorized by Title XIX of the Social Security Act (Medicaid) and operated pursuant to section 17b-261 of the Connecticut General Statutes;

(13) "HUSKY D" means the Medicaid coverage groups for low-income adults authorized by 42 USC 1396a(a)(10)(A)(i)(VIII) and operated pursuant to section 17b-261n of the Connecticut General Statues, formerly referred to as the State-Administered General Assistance program;

(14) "Licensed alcohol and drug counselor" means an individual licensed pursuant to section 20-74s of the Connecticut General Statutes;

(15) "Licensed behavioral health clinician" means a licensed alcohol and drug counselor, licensed marital and family therapist, licensed clinical social worker or licensed professional counselor;

(16) "Licensed clinical social worker" means a person licensed pursuant to section 20-195n of the Connecticut General Statutes;

(17) "Licensed marital and family therapist" means an individual licensed pursuant to section 20-195c of the Connecticut General Statutes;

(18) "Licensed professional counselor" means an individual licensed pursuant to sections 20-195cc and 20-195dd of the Connecticut General Statutes;

(19) "Licensed practitioner" means a physician, APRN or physician assistant;

(20) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(21) "Medical necessity" or "medically necessary" has the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(22) "Physician" means an individual licensed pursuant to section 20-13 of the Connecticut General Statutes;

(23) "Physician assistant" means a person licensed pursuant to section 20-12b of the Connecticut General Statutes;

(24) "Prior authorization" means the department's approval for the provision of a service before a provider actually provides such service, except where section 17b-262-920 of the Regulations of Connecticut State Agencies specifically authorizes the department to grant prior authorization before paying for a service but after the provider has provided such service;

(25) "Provider" means a licensed behavioral health clinician enrolled in Medicaid pursuant to a valid provider agreement with the department;

(26) "Provider agreement" means the signed, written agreement between the department and the provider for enrollment in Medicaid;

(27) "Registration" means the process of notifying the department of the initiation of a behavioral health clinician service, including evaluation findings and plan of care information;

(28) "State Plan" means the current Medicaid coverage and eligibility plan established, submitted and maintained by the department and approved by the Centers for Medicare and Medicaid Services in accordance with 42 CFR 430, Subpart B;

(29) "Treatment plan" means a written individualized plan developed and updated in accordance with section 17b-262-919 of the Regulations of Connecticut State Agencies that contains the type, amount, frequency and duration of services to be provided, and measurable goals and objectives developed in collaboration with the client after evaluation, in order to improve the client's condition to the point that treatment by the licensed behavioral health clinician no longer becomes necessary, aside from occasional follow-up or maintenance visits; and

(30) "Utilization management" means the prospective, retrospective or concurrent assessment of the medical necessity of services given, or proposed to be given, to a client.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-914 Provider participation

In order to enroll in Medicaid and receive payment from the department, a provider shall:

(1) Comply with all applicable licensing, accreditation and certification requirements;

(2) comply with all departmental enrollment requirements, including sections 17b-262-522 to 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies;

(3) comply with sections 17b-262-912 to 17b-262-925, inclusive, of the Regulations of Connecticut State Agencies; and

(4) have a valid provider agreement on file with the department.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-915 Eligibility

The department shall pay for medically necessary behavioral health clinician services provided to clients eligible for such services, subject to the conditions and limitations that apply to these services.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-916 Services covered

The department shall pay only for behavioral health clinician services that are:

(1) Within the licensed behavioral health clinician's scope of practice as defined by chapters 376b, 383a, 383b or 383c of the Connecticut General Statutes, as applicable to the behavioral health clinician; and

(2) medically necessary to treat the client's condition.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-917 Service limitations

The department shall pay for covered services only in accordance with the treatment plan and with the following additional limits:

(1) Only one diagnostic interview in any twelve-month period per licensed behavioral health clinician per client;

(2) only one unit of individual counseling or individual psychotherapy per client, per day;

(3) only one unit of family counseling or family psychotherapy per client, per day;

(4) only one unit of group counseling or group psychotherapy per client, per day;

(5) group psychotherapy sessions shall include a maximum of twelve participants per group session, to the extent clinically appropriate, regardless of each participant's payment source, and the provider shall document the number of participants in each session in the client's chart;

(6) family, group and multiple-family group psychotherapy sessions shall be at least forty-five minutes in length, and the provider shall document the length of time of each session in the client's chart;

(7) family and multiple-family group psychotherapy shall be reimbursable for one identified family member client per session, without regard to the number of family members in attendance or the presence of behavioral health conditions among other family members in attendance; and

(8) multiple-family group psychotherapy shall include a maximum of twenty-four participants per group regardless of each participant's payment source, shall include members of at least two unrelated families and the provider shall document the number of participants in each session in the client's chart.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-918 Services not covered

The department shall not pay for the following behavioral health clinician services:

(1) Information or services furnished by the licensed behavioral health clinician to the client electronically or over the telephone, except for case management services provided to clients age eighteen and under;

(2) case management services provided to clients age nineteen and older;

(3) evaluations, diagnostic interviews and therapy services performed in hospital inpatient or outpatient settings;

(4) concurrent services involving the same treatment modalities for the same client by different health professionals;

(5) cancelled office visits or appointments not kept;

(6) services, treatment or items for which the provider does not usually charge;

(7) behavioral health clinician services in excess of those medically necessary to treat the client's condition;

(8) services not directly related to the client's diagnosis, symptoms or medical history;

(9) services provided by anyone other than the provider; and

(10) services that are primarily for vocational or educational guidance.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-919 Need for service and treatment plan

The department shall pay for medically necessary behavioral health clinician services. The provider shall establish a treatment plan for each client based on the initial diagnostic evaluation before commencing treatment and shall regularly update the treatment plan in accordance with the client's progress as necessary and at least every six months. Notwithstanding section 17b-962-917 of the Regulations of Connecticut State Agencies, the department shall pay for an initial diagnostic evaluation in order to enable the licensed behavioral health clinician to develop the treatment plan. The treatment plan shall specify the treatment modalities and frequency of care necessary to meet the client's needs, identify measurable outcomes to be achieved and identify any medical providers with whom the licensed behavioral health clinician is coordinating care.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-920 Prior authorization and registration

(a) Where a service requires prior authorization or registration under this section, the department shall not pay for such service unless the provider complies with this section and all of the department's requirements for prior authorization or registration, as applicable.

(b) The department shall designate services that require prior authorization or registration in the department's fee schedule or on the department's website or by other means accessible to providers, with advance notice given to providers before changing the prior authorization or registration requirements. Registration may serve in lieu of prior authorization only if the department designates a service as requiring registration but not prior authorization. Prior authorization is also required for:

(1) Any service that is not in the department's fee schedule; and

(2) EPSDT Special Services.

(c) The following requirements shall apply to all services that require prior authorization or registration under subsections (a) and (b) of this section:

(1) The initial prior authorization or registration period shall be based on the client's needs;

(2) if prior authorization is needed beyond the initial or current prior authorization period, the provider shall submit a request to the department to extend the prior authorization before the end of the current prior authorization period;

(3) except as provided in subdivision (9) of this subsection or for the purpose of initial assessment, the provider shall receive prior authorization before rendering services or submit complete registration information to the department within the timeframes established by the department and posted on the department's website;

(4) in order to receive payment from the department, a provider shall comply with all prior authorization and registration requirements. The department, in its sole discretion, determines what information is necessary to approve a prior authorization request. Prior authorization does not guarantee payment unless all other requirements for payment are met;

(5) a provider shall present medical or social information adequate to evaluate medical necessity when requesting prior authorization. The provider shall maintain documentation adequate to support requests for prior authorization and registration including, but not limited to, medical or social information adequate to evaluate medical necessity;

(6) requests for prior authorization for continued services shall include: progress made to date with respect to established treatment goals; future gains expected from additional treatment; and medical or social information adequate to evaluate medical necessity;

(7) the provider shall maintain documentation adequate to support requests for continued prior authorization including, but not limited to: progress made to date with respect to established treatment goals; the future gains expected from additional treatment; and medical or social information adequate to evaluate medical necessity;

(8) the department may require a review of the discharge plan and actions taken to support successful implementation of the discharge plan as a condition of prior authorization;

(9) a provider may request retrospective prior authorization from the department before payment has been made but after a service has been provided for clients who are granted eligibility retroactively or in cases where it was not possible to determine eligibility at the time of service;

(10) for clients who are granted retroactive eligibility, the department may conduct retroactive medical necessity reviews. The provider shall initiate this review to enable authorization and payment for services;

(11) for all prior authorization requests for EPSDT Special Services, a provider shall attach a physical or electronic copy of a prescription signed by a licensed practitioner acting within the licensed practitioner's scope of practice under state law or an order signed by a licensed behavioral health clinician acting within the licensed behavioral health clinician's scope of practice under state law. The provider shall keep the original prescription or order on file and subject to the department's review; and

(12) the department may deny prior authorization or registration if the provider does not comply with utilization management policies and procedures.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-921 Billing procedures

(a) Providers shall submit claims on the department's designated form or by electronic transmission as established by the department and shall include all information required by the department to process the claim for payment.

(b) The amount billed to the department shall represent the licensed behavioral health clinician's usual and customary charge for the services provided.

(c) When a licensed behavioral health clinician is requested to attend a staff conference for a client, the name of the referring practitioner, clinic or agency shall be entered in the appropriate section of the claim form.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-922 Payment

(a) Licensed behavioral health clinicians who are fully or partially compensated by a Medicaid participating general hospital, public or private institution, freestanding clinic or federally qualified health center shall not receive payment from the department for services rendered at such entities unless the licensed behavioral health clinician maintains an office for private practice at a separate location from the entity referenced above where the licensed behavioral health clinician is employed. The licensed behavioral health clinician shall bill the department only for a service provided to a client whose overall treatment is provided through the provider's private practice, although each individual service may be provided either at the practice, the client's home or in the community.

(b) Payment for services directly performed by a licensed behavioral health clinician in private practice shall be made at the lowest of:

(1) The provider's usual and customary charge;

(2) the lowest Medicare rate; or

(3) the amount in the department's applicable fee schedule.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-923 Payment rate

The commissioner shall establish, update and publish the department's fee schedule pursuant to section 4-67c of the Connecticut General Statutes.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-924 Payment limitations

(a) The fees for a diagnostic interview examination, as stipulated in the department's applicable fee schedule, represent one unit of service. The provider shall bill for only one unit of service for a diagnostic interview examination regardless of the number of days it takes to complete.

(b) If a session includes a combination of individual and family psychotherapy, the provider shall bill for the modality that comprises the greater part of the session. The provider shall not bill for both individual and family psychotherapy for the same date of service unless each modality individually meets the minimum time requirement for the modality specified in the department's fee schedule or in section 17b-262-917 of the Regulations of Connecticut State Agencies.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-925 Documentation

(a) Providers shall maintain (1) a specific record for all services provided to each client including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, a current treatment plan signed by the licensed behavioral health clinician and (2) documentation of services provided, including, types of service or modalities, date of service, location of the service and the start and stop time of the service.

(b) For treatment services, the provider shall document the treatment intervention and progress with respect to the client's goals as identified in the treatment plan.

(c) Providers shall maintain all required documentation in its original form for a minimum of five years or longer if required by applicable statutes and regulations, subject to review by the department. In the event of a dispute concerning a service provided, the provider shall maintain documentation until the end of the dispute, five years or the time required by applicable statues and regulations, whichever is greater.

(d) The department may disallow and recover any amounts paid to the provider for which required documentation is not maintained and provided to the department upon request.

(e) The department may audit any relevant records and documentation and take any other appropriate quality assurance measures it deems necessary to assure compliance with these and other regulatory and statutory requirements.

(f) Providers shall make all entries in ink or electronically and shall incorporate all documentation into a client's permanent medical record in a complete, prompt and accurate manner.

(g) Providers shall make all documentation available to the department upon request in accordance with 42 CFR 431.107.

History

• Effective December 28, 2012

Regs., Conn. State Agencies § 17b-262-956 Scope

Sections 17b-262-956 to 17b-262-965, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for payment to birth centers that are medically necessary and are provided to clients who are determined to be eligible to receive such goods and services under Medicaid pursuant to section 17b-261 of the Connecticut General Statutes.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-957 Definitions

As used in sections 17b-262-956 to 17b-262-965, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Birth center" means a free-standing, separately licensed health care facility that is not a hospital, where a licensed practitioner performs low-risk deliveries;

(2) "Chronic disease hospital" has the same meaning as provided in section 19a-550 of the Connecticut General Statutes;

(3) "Client" means a person eligible for goods or services under Medicaid;

(4) "Commissioner" means the Commissioner of Social Services or the commissioner's designee;

(5) "Department" means the Department of Social Services or its agent;

(6) "Early Periodic Screening, Diagnosis and Treatment special services" or "EPSDT special services" means services that are not otherwise covered under Medicaid but which are nevertheless covered as EPSDT services for Medicaid-eligible children pursuant to 42 USC 1396d(r)(5) when the service is medically necessary, the need for the service is identified in an EPSDT screen, the service is provided by a participating provider, and the service is a type of service that may be covered by a state Medicaid agency and qualify for federal reimbursement under 42 USC 1396d;

(7) "Home" means the client's place of residence, including, but not limited to, a boarding house, community living arrangement or residential care home. "Home" does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for the mentally retarded or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(8) "Hospital" means a "short-term hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(9) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for individuals with intellectual disabilities licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in Medicaid as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(10) "Licensed practitioner" means a physician, physician assistant, nurse practitioner, nurse midwife or such other category of practitioner licensed by the Department of Public Health pursuant to Title 20 of the Connecticut General Statutes and whose scope of practice includes the ante-partum, intra-partum and post-partum care of pregnant women and the care of newborns;

(11) "Low-risk delivery" means a delivery following a low-risk pregnancy that is anticipated to be normal, as determined by the mother's licensed practitioner acting within the licensed practitioner's scope of practice under state law;

(12) "Low-risk pregnancy" means a pregnancy that is anticipated to be normal, as determined by the mother's licensed practitioner acting within the licensed practitioner's scope of practice under state law;

(13) "Medicaid" means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(14) "Medical necessity" or "medically necessary" has the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(15) "Nursing facility" has the same meaning as provided in 42 USC 1396r(a) and is licensed pursuant to section 19-13-D8t of the Regulations of Connecticut State Agencies as a chronic and convalescent home or rest home with nursing supervision;

(16) "Nurse midwife" means a person licensed pursuant to section 20-86c of the Connecticut General Statutes;

(17) "Nurse practitioner" or "advance practice registered nurse" or "APRN" means a person licensed pursuant to section 20-94a of the Connecticut General Statutes;

(18) "Physician" means a person licensed pursuant to section 20-13 of the Connecticut General Statutes;

(19) "Physician assistant" means a person licensed pursuant to section 20-12b of the Connecticut General Statutes;

(20) "Prescription" means an original written order documenting medical necessity issued, signed and dated by a licensed practitioner;

(21) "Prior authorization" means approval from the department for the provision of a service or the delivery of goods before the provider actually provides the service or delivers the goods;

(22) "Provider" means a birth center enrolled with Medicaid pursuant to a valid provider enrollment agreement with the department; and

(23) "Usual and customary charge" means the amount that the provider accepts for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is accepted in the majority of cases, usual and customary shall mean the median charge. Token charges for charity patients and other exceptional charges shall be excluded when calculating the usual and customary charge.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-958 Provider participation

(a) To enroll in Medicaid and receive payment from the department, a provider shall comply with sections 17b-262-956 to 17b-262-965, inclusive, of the Regulations of Connecticut State Agencies and sections 17b-262-522 to 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies.

(b) A birth center shall:

(1) Be accredited by the Commission for the Accreditation of Birth Centers;

(2) be licensed by the Department of Public Health as a maternity hospital in accordance with section 19-13-D14 of the Regulations of Connecticut State Agencies or be licensed by the Department of Public Health as a birth center in accordance with regulations adopted by the Department of Public Health that specifically regulate birth centers; and

(3) comply with (A) section 19a-505 of the Connecticut General Statutes and (B) section 19-13-D14 of the Regulations of Connecticut State Agencies or such other regulations adopted by the Department of Public Health that specifically regulate birth centers.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-959 Need for service

Service in a birth center shall be limited to maternal patients who have had a low-risk pregnancy and are likely to have a low-risk delivery, as determined by the maternal patient's licensed practitioner.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-960 Eligibility

Payment to a provider for birth center services is available for clients who have a need for such products and services when the items are medically necessary, subject to the conditions and limitations set forth in sections 17b-262-956 to 17b-262-965, inclusive, of the Regulations of Connecticut State Agencies.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-961 Services covered and limitations

(a) The department shall pay the provider a single all-inclusive fee for a normal, uncomplicated labor and delivery, which covers all services provided by the birth center, including, but not limited to:

(1) Care for, labor, delivery and recovery of the maternal patient;

(2) nursery care and other services provided to the infant patient; and

(3) other ambulatory services within the provider's scope of services established by the Department of Public Health that are offered by the provider and that are otherwise covered by Medicaid.

(b) Surgical procedures at a birth center shall be limited to those normally accomplished during an uncomplicated birth, including episiotomy and repair.

(c) No general or regional anesthesia shall be administered at a birth center. Local anesthesia may be administered at a birth center if the administration of the anesthetic is performed within the scope of practice of the licensed practitioner in attendance.

(d) No abortions shall be done at a birth center.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-962 Payment and payment limitations

(a) The department shall reimburse the provider when the provider has met all the requirements of sections 17b-262-956 to 17b-262-965, inclusive, of the Regulations of Connecticut State Agencies.

(b) The department's payment to the provider includes all birth center charges, including, but not limited to: charges for labor, delivery, anesthesia, laboratory, radiology, pharmacy, nursing and other clinical staff care. The department shall not pay any other charges to the provider.

(c) The department shall not pay the provider for a delivery at home or in any setting other than the birth center, except for services described in subsection (d) of this section.

(d) If the client is transferred to a hospital prior to the actual delivery, the department shall reimburse the provider for services provided in the birth center prior to such transfer at the lower of billed charges or the reduced fee specified for such services on the department's fee schedule.

(e) If the delivery occurs at the birth center, the department shall pay the provider at the lower of the fee on the department's fee schedule or the provider's usual and customary rate.

(f) Payment to the provider excludes all services provided by a licensed practitioner. Each licensed practitioner shall bill the department for services in accordance with the regulations applicable to the licensed practitioner's provider type.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-963 Prior authorization

(a) The department shall require prior authorization for:

(1) Any service identified on the department's fee schedule as requiring prior authorization;

(2) EPSDT special services; and

(3) any service that is not identified on the department's fee schedule.

(b) To receive reimbursement from the department, a provider shall comply with all prior authorization requirements. The department, in its sole discretion, shall determine what information is necessary to approve a prior authorization request. Prior authorization does not guarantee payment unless all other requirements are met.

(c) The provider shall submit and sign the prior authorization request, in a form and manner specified by the department, which shall include documentation of medical necessity.

(d) A prescription is required from a licensed practitioner for all services and goods provided as EPSDT special services. The provider may attach a copy of the prescription from the licensed practitioner to the completed prior authorization request in lieu of the actual signature of the licensed practitioner on the prior authorization request form. The provider shall keep the licensed practitioner's original prescription on file and available for review by the department.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-964 Billing procedure

Providers shall submit claims on a hard copy invoice or by electronic transmission to the department in a form and manner specified by the department, together with all information required by the department to process the claim for payment.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-965 Documentation

(a) Providers shall maintain a specific record for all services provided to each client, including, but not limited to: name, address, birth date, Medicaid identification number, pertinent diagnostic information, treatment notes signed by the licensed practitioner, documentation of services provided and the dates the services were provided.

(b) Providers shall maintain all required documentation in its original form for at least five years or longer in accordance with applicable federal and state statutes and regulations, subject to review by authorized department personnel. If there is a dispute concerning a service provided, documentation shall be maintained until the end of the dispute, five years or the length of time required by statute or regulation, whichever is longest.

(c) The department may disallow and recover any amounts paid to the provider for which required documentation is not maintained or not provided to the department upon request.

(d) The department may audit all relevant records and documentation and take any other appropriate quality assurance measures it deems necessary to assure compliance with regulatory and statutory requirements.

History

• Effective October 2, 2012

Regs., Conn. State Agencies § 17b-262-966 Reserved

Sec. 17b-262-966. Reserved

Regs., Conn. State Agencies § 17b-262-994 Scope

Sections 17b-262-994 to 17b-262-1004, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services’ requirements for payment to federally qualified health centers for services provided to clients who are eligible to receive such services under Medicaid pursuant to section 17b-261 of the Connecticut General Statutes. Federally qualified health centers shall be reimbursed in accordance with the Medicaid prospective payment system under 42 USC 1396a (bb).

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-995 Definitions

As used in section 17b-262-994 to section 17b-262-1004, inclusive, of the Regulations of Connecticut State Agencies:

(1) “Advanced practice registered nurse” or “APRN” means a person licensed under section 20-94a of the Connecticut General Statutes;

(2) “Allied health professional” or “AHP” means:

(A) A licensed or certified practitioner performing within his or her scope of practice in any of the professional and occupational license or certification categories in Chapters 376b, 378, 379a, 383a, 383c, and 384b of the Connecticut General Statutes and shall include alcohol and drug counselors, certified dietitians, certified nutritionists, dental hygienists, marital and family therapists, professional counselors, and registered nurses;

(B) A licensed master social worker working under the professional supervision of a physician, APRN, psychologist, licensed marital and family therapist, LCSW or a licensed professional counselor in accordance with section 20-195m of the Connecticut General Statutes; and

(C) A license-eligible individual as defined in subdivision (30) of this section;

(3) “Baseline encounter rate” means the encounter rate calculated for the initial or first year under the prospective payment system;

(4) “Behavioral health encounter” means an encounter between a client and a practitioner listed in subdivision (5) of this section for the provision of covered behavioral health services;

(5) "Behavioral health service" means a preventive, diagnostic, therapeutic, rehabilitative or palliative item or service provided by:

(A) A physician, psychiatric APRN, psychologist or LCSW acting within the practitioner’s scope of practice as defined in chapters 370, 378, 383 and 383b of the Connecticut General Statutes;

(B) An alcohol and drug counselor, licensed master social worker, marital and family therapist or professional counselor acting within the practitioner's scope of practice, as defined in title 20 of the Connecticut General Statutes; or

(C) An unlicensed or non-certified individual, who is otherwise qualified to perform services under the applicable licensure category sections of the Regulations of Connecticut State Agencies, working under the direct supervision of a licensed AHP. Supervision of unlicensed or non-certified individuals shall be provided in accordance with sections 20-74s, 20-195c, 20-195m, 20-195n and 20-195dd of the Connecticut General Statutes;

(6) “Certified dietitian” or “certified nutritionist” means a person certified as a dietitian or nutritionist pursuant to section 20-206n or 20-206o of the Connecticut General Statutes;

(7) “Change in the scope of service” means a change in the type, intensity, duration or amount of services provided by a FQHC. A change in the cost of the service alone is not considered a change in the scope of service;

(8) “Chiropractor” means a person licensed pursuant to section 20-27 of the Connecticut General Statutes;

(9) “Chiropractic services” means the services described in 42 CFR 440.60 and subdivision (1) of section 20-24 of the Connecticut General Statutes:

(10) “Client” means a person eligible for goods or services under Medicaid;

(11) “Clinical psychologist” means a person licensed pursuant to sections 20-188 and 20-190 of the Connecticut General Statutes;

(12) “CMS-1500” means the official standard Medicare and Medicaid health insurance claim form required by the Center for Medicare and Medicaid services of the United States Department of Health and Human Services;

(13) “Commissioner” means the commissioner of Social Services or the commissioner’s designee;

(14) “Dental encounter” means an encounter between a client and a dentist or dental hygienist for the provision of covered dental services;

(15) “Dental hygienist” means a person licensed pursuant to section 20-126j of the Connecticut General Statutes;

(16) “Dental service” means any diagnostic, preventive, or corrective procedures administered by or under the direct supervision of a dentist;

(17) “Dentist” means a person licensed pursuant to Chapter 379 of the Connecticut General Statutes;

(18) “Department” or “DSS” means the Department of Social Services or its agent;

(19) “Dietetic services” means services provided by a certified dietitian or certified nutritionist for the management of a person’s nutritional needs, including the evaluation and monitoring of nutritional status, nutrition counseling, dietetic therapy, dietetic education, and dietetic research necessary for the management of a recipient’s nutritional needs;

(20) "Early and Periodic Screening, Diagnostic and Treatment Services" or "EPSDT services" means the services provided in accordance with the requirements of 42 USC 1396a (a) (43), 42 USC 1396d (r) and 42 USC 1396d (a) (4) (B) and implementing federal regulations found in 42 CFR 441, Subpart B and subsection (j) of section 17b-261 of the Connecticut General Statutes;

(21) “Early and Periodic Screening, Diagnostic and Treatment Special Services” or “EPSDT Special Services” means services provided in accordance with 42 USC 1396d (r) (5), as amended from time to time;

(22) “Encounter” means a face-to-face visit between a client and health professional or an allied health professional for medically necessary services and includes the client’s visit to the FQHC and all services and supplies incidental to the health professional’s services. Visits with more than one health professional or allied health professional or multiple visits with the same health professional or allied health professional that take place on the same day shall be considered one encounter, except under either of the following circumstances:

(A) A client, subsequent to the first encounter, suffers an illness or injury requiring additional diagnosis or treatment; or

(B) A client has different types of encounters (medical, behavioral health and dental) for different diagnoses on the same day;

(23) “Encounter rate” means the all-inclusive PPS rate that the Department reimburses a FQHC for an encounter pursuant to 42 USC 1396a (bb);

(24) “Federally qualified health center” or “FQHC” has the same meaning as provided in 42 USC 1396d (l) (2) (B);

(25) “Healthcare common procedure coding system” or “HCPCS” means the set of health care procedure codes based on the American Medical Association’s current procedural terminology;

(26) “Health professional” means a physician, physician assistant, advanced practice registered nurse, nurse midwife, chiropractor, ophthalmologist, optometrist, podiatrist, dentist, clinical psychologist, licensed clinical social worker or psychiatrist;

(27) “Health Resources and Services Administration” or “HRSA” means the division of the U.S. Department of Health and Human Services that approves grant awards to and scope of projects for FQHCs;

(28) “Licensed clinical social worker” or “LCSW” means a person licensed pursuant to section 20-195n of the Connecticut General Statutes;

(29) “Licensed master social worker” or “LMSW” means a person licensed pursuant to 20-195n of the Connecticut General Statutes;

(30) “License-eligible” means a person whose education, training, skills and experience satisfy the criteria, including accumulation of all supervised service hours, for any of the professional and occupational license or certification categories in Chapters 370, 376b, 379a, 383, 383a, 383b and 383c of the Connecticut General Statutes, and has applied for but not yet passed the licensure exam;

(31) “Medicaid” means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(32) “Medical encounter” means an encounter between a client and a health professional or an allied health professional for the provision of covered medical services;

(33) “Medical service” means a preventive or diagnostic service provided by a physician, physician assistant, advanced practice registered nurse or nurse midwife for the treatment of an illness or injury;

(34) “Medically necessary” and “medical necessity” have the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(35) “Nurse midwife” means a person licensed under section 20-86c of the Connecticut General Statutes;

(36) "Ophthalmologist" means a physician licensed pursuant to chapter 370 of the Connecticut General Statutes, who within his or her scope of practice as defined by state law, specializes in the branch of medicine dealing with the structure, functions, pathology, and treatment of the eyes;

(37) "Optometrist" means a person licensed pursuant to Chapter 380 of the Connecticut General Statutes to practice optometry as delineated in subdivisions (1), (2) and (3) of subsection (a) of section 20-127 of the Connecticut General Statutes;

(38) “Physician” means a person licensed pursuant to section 20-13 of the Connecticut General Statutes;

(39) “Physician assistant” or “PA” means a person licensed pursuant to section 20-12b of the Connecticut General Statutes;

(40) “Podiatric services” means services provided by a podiatrist within the scope of practice under Chapter 375 of the Connecticut General Statutes;

(41) “Podiatrist” means a person licensed to practice podiatric medicine pursuant to section 20-54 of the Connecticut General Statutes;

(42) “Point-of-care testing” means medical testing at or near the site of patient care and includes, but is not limited to, blood glucose testing, blood gas and electrolyte analysis, rapid coagulation testing, rapid cardiac markers diagnostics, drugs-of-abuse screening, urine strips testing, pregnancy testing, fecal occult blood analysis, food pathogens screening, hemoglobin diagnostics, infectious disease testing and cholesterol screening;

(43) “Prior authorization” means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods;

(44) “PPS” means the prospective payment system under 42 U.S.C. 1396a (bb);

(45) “Registered Nurse” means a person licensed pursuant to section 20-93 of the Connecticut General Statutes;

(46) “Registration” means the process of notifying the department of the initiation of a service, which includes providing information regarding the evaluation findings and plan of care;

(47) "Routine foot care" means clipping or trimming of normal or mycotic toenails; debridement of the toenails that do not have onychogryposis or onychauxis; shaving, paring, cutting or removal of keratoma, tyloma or heloma; and nondefinitive shaving or paring of plantar warts except for the cauterization of plantar warts;

(48) “Scope of project” means the document that delineates the FQHC’s approved service sites, services, providers, service area and target population for which grant funds have been approved by HRSA under section 330 of the Public Health Service Act;

(49) "Simple foot hygiene” means self-care including, but not limited to: observation and cleansing of the feet; use of skin creams to maintain skin tone of both ambulatory and bedridden patients; nail care not involving professional attention; and prevention and reduction of corns, calluses and warts by means other than cutting, surgery or instrumentation;

(50) "Systemic condition" means the presence of a metabolic, neurologic, or peripheral vascular disease, including, but not limited to, diabetes mellitus, arteriosclerosis obliterans, Buerger's disease, chronic thrombophlebitis and peripheral neuropathies involving the feet, which would justify coverage of routine foot care;

(51) “Under the direct supervision” means that a health professional or a licensed AHP:

(A) Provides weekly supervision of the work performed by unlicensed clinical staff or non-certified staff or individuals in training;

(B) Provides a minimum of monthly supervision for the work performed by certified staff; and

(C) Accepts primary responsibility for the health services performed by the unlicensed, certified or non-certified staff or individuals in training.

(52) “Under the professional supervision” has the same meaning as provided in section 20-195m of the Connecticut General Statutes.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-996 Provider participation

In order to participate in the Connecticut Medicaid program and provide FQHC services eligible for reimbursement from the department, each FQHC shall:

(1) Comply with all applicable state licensing requirements;

(2) Comply with all departmental enrollment requirements, including sections 17b-262-522 to 17b-262-532, inclusive, of the Regulations of Connecticut State Agencies;

(3) Ensure that all health professionals and allied health professionals employed by or under contract arrangements with the FQHC to provide services meet all applicable federal and state licensing and certification requirements;

(4) Submit a copy of the FQHC’s scope of project and any amendments to the scope of project in accordance with subsection (c) of section 17b-245d of the Connecticut General Statutes; and

(5) Submit a copy of the HRSA Notification of Grant Award Authorization of Public Health Service Funds.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-997 Services covered

(a) Covered core services for FQHCs include the following:

(1) Medical services furnished by a physician, PA, APRN or nurse midwife. The services shall be within the scope of practice of his or her profession under state law. There shall be a written agreement between the FQHC and the physician, PA, APRN or nurse midwife, stating that he or she will be paid by the FQHC for such services; and

(2) Services and supplies furnished as incident to professional services furnished by a physician, physician assistant, or advanced practice registered nurse.

(b) Covered noncore services for FQHCs are those services, other than core services, that include the following:

(1) Behavioral health services;

(2) Chiropractic services;

(3) Dental services provided by a dentist or dental hygienist;

(4) Dietetic or nutrition services when prescribed by a physician, PA, or APRN. Dietetic services are limited to clients whose disease or medical condition is caused or complicated by diet or nutritional status;

(5) Podiatric services provided by a podiatrist, except for routine foot care, which is covered only when the client has a systemic condition and is limited to one treatment every 60 days;

(6) Tobacco cessation counseling services; and

(7) Vision care services provided by an ophthalmologist or optometrist.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-998 Services not covered

The following services are not covered:

(1) Services that are not covered in the Medicaid state plan;

(2) Services that are not medically necessary;

(3) Canceled services or appointments that are not kept;

(4) Inpatient services, except as provided in section 17b-262-999 (d) (1);

(5) Simple foot hygiene;

(6) Any service requiring authorization or registration for which the provider did not obtain such authorization or registration;

(7) Any procedures or services that are solely educational, social, research, recreational, experimental or generally not accepted by medical practice; or

(8) Visits for the sole purpose of obtaining or refilling a prescription, the need for which was previously determined.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-999 Billable services

(a) Billable services for FQHCs shall include core and noncore services identified in section 17b-262-997 of the Regulations of Connecticut State Agencies.

(b) Covered core and noncore services shall be billed on an encounter basis in accordance with section 17b-262-1002 and are subject to the following limitations:

(1) Billable encounters shall include encounters that:

(A) Take place at a service site approved by HRSA as part of a FQHC; or

(B) Take place in a patient's home for the purpose of providing services to FQHC patients; and

(C) Are documented in the patient health records.

(2) The services of a registered nurse may be billed as a medical encounter unless provided incident to a medical encounter as described in subsection (b)(3) of this section.

(3) Encounters with more than one health professional for the same type of service (e.g., a nurse and a physician provide a medical encounter) and multiple interactions with the same health professional that take place on the same day constitute a single encounter except when the patient, after the first interaction, suffers illness or injury requiring additional diagnosis and treatment.

(4) Tobacco cessation counseling shall be prescribed by a physician, physician’s assistant, dentist or APRN and may be billed as a medical encounter, behavioral health encounter or dental encounter depending upon the type of health professional or allied health professional providing the service. The following health professionals may provide tobacco cessation counseling:

(A) Physicians;

(B) Physician assistants;

(C) APRNs;

(D) Dentists;

(E) Clinical Psychologists;

(F) LCSWs; and

(G) Allied health professionals.

(5) Group sessions prescribed by a health professional shall be billed as an encounter subject to the following limitations:

(A) All group sessions shall be limited to a maximum of twelve participants, shall be facilitated by a health professional or allied health professional practicing within his or her scope of practice and shall last at least 45 minutes; and

(B) The services provided in the session shall be documented in each client’s health record if the FQHC bills the session as an individual encounter for each participant.

(6) Consultations with anyone other than the patient are not considered encounters, and are therefore not billable.

(c) The following services shall be included in the encounter rate and the FQHC shall not bill separately for these services:

(1) Services and supplies incidental to the services of a health professional or allied health professional when the services and supplies are:

(A) Of the type commonly furnished in a physician’s office;

(B) Of a type commonly rendered either without charge or included in the FQHC’s bill;

(C) Furnished as an incidental, although integral, part of the professional service; and

(D) Provided by FQHC employees under the direct supervision of a physician, clinical psychologist or licensed clinical social worker;

(2) Laboratory, point-of-care testing or radiology services provided in conjunction with a FQHC encounter and furnished by FQHC staff; and

(3) Transportation provided by the FQHC.

(d) The following services are not billable as a FQHC encounter. These services may be billed by the FQHC in accordance with the applicable Medicaid fee schedule:

(1) Inpatient hospital services;

(2) Delivery of a baby; and

(3) Outpatient surgery.

(e) The following services may be billed for by the provider of the services in accordance with the Medicaid fee schedule:

(1) Laboratory services beyond point of care testing that are referred to and performed by an independent laboratory; and

(2) The technical component of radiology tests that are referred to and performed by an independent radiologist.

(f) A FQHC shall not seek reimbursement for services provided under subsections (c) (d) and (e) of this section as a FQHC encounter. The non-FQHC services shall not be included in the overall costs of providing services at the FQHC.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-1000 Prior authorization requirements

(a) In order to receive payment from the department, each FQHC shall comply with all prior authorization requirements. The department in its sole discretion determines what information is necessary to approve a prior authorization request. Prior authorization does not guarantee payment unless all other requirements for payment are met.

(b) The department shall designate services that require prior authorization or registration on the department’s fee schedule, on the department’s website or by other means accessible to providers with advance written notice to providers before establishing or amending such requirements. Registration may serve in lieu of prior authorization only if the department designates a service as requiring registration but not prior authorization. Prior authorization is also required for the following:

(1) Dental procedures or services that require prior authorization as set forth on the dental fee schedule;

(2) Chiropractic services in excess of 5 encounters per month;

(3) EPSDT Special Services; and

(4) Any procedure or service that is not listed on the department’s medical clinic, behavioral health clinic or dental fee schedule as applicable.

(c) The provider shall attach a prescription from a physician, APRN or PA to all prior authorization requests for EPSDT Special Services. The provider may attach a physical or electronic copy of the prescription from the licensed practitioner to the prior authorization request in lieu of the actual signature of the licensed practitioner on the prior authorization request form. The provider shall keep the original prescription on file and subject to the department’s review.

(d) The length of the initial prior authorization or registration period shall be for no longer than three months except as follows:

(1) For longer periods as determined by the department on a case-by-case basis; and

(2) For up to one year for routine psychotherapy.

(e) If the client needs a service beyond the initial authorization period, the provider may request authorization to continue services for up to six additional months of continued treatment per request.

(f) If the department denies a request for prior authorization for continuation of services, the recipient may request an administrative hearing in accordance with section 17b-60 of the Connecticut General Statutes.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-1001 Change in scope of services

(a) Each FQHC shall notify the department of any increase or decrease in the scope of services provided by the FQHC in accordance with section 17b-245d of the Connecticut General Statutes. If the FQHC seeks an adjustment to its encounter rate based on the change in scope of services, the FQHC shall submit a written request to the department in accordance with subsection (c) of this section.

(b) Examples of changes in scope of services by a FQHC for which the department may adjust the encounter rate include, but are not limited to, the following:

(1) A change in the volume or amount of services as a result of a significant expansion or reduction of an existing clinic, or the addition or discontinuance of a satellite or new site;

(2) A change in operational costs that is attributable to capital expenditures, including new service facilities or regulatory compliance, provided that the additional costs result in a change in the volume, amount, or intensity of services. The cost of a new or expanded building alone would not necessarily qualify;

(3) The addition or deletion of any Medicaid covered service eligible under the FQHC reimbursement program;

(4) A change in the operational costs attributable to changes in technology or medical practices at the FQHC;

(5) A change of costs due to recurring taxes, malpractice insurance premiums, or workers’ compensation premiums that were not recognized and included in the PPS baseline calculation;

(6) A change in federal or state regulatory requirements that would impact FQHC costs; or

(7) A HRSA-approved change in the scope of project, provided that the change is consistent with federal and state Medicaid regulations.

(c) In the event of a change in scope of service for which a FQHC seeks a rate adjustment, a FQHC shall submit a written request to the Commissioner that includes the following:

(1) A description of the change in scope of services and the reason for the change;

(2) The impact on capital and operating costs;

(3) The requested change in rate; and

(4) All documentation submitted to HRSA regarding a change in scope of project, if applicable.

(d) A FQHC shall file a preliminary cost report to support its request for a rate adjustment not later than 90 days after the date on which the FQHC submitted its request for a rate adjustment.

(e) If a FQHC has received approval for a change in scope of project from HRSA for which it seeks a rate adjustment for a change in scope of services, the FQHC shall submit a written request for a change in scope of service in accordance with subsection (c) of this section not later than sixty days after the FQHC has received approval from HRSA for the change in scope of project. The FQHC shall submit all documentation submitted to HRSA regarding the change in scope of project.

(f) If a FQHC is not required to file a change in scope of project with HRSA but plans an increase or decrease in services or sites to be offered by the FQHC that result in a change to the FQHC’s scope of services, the FQHC shall submit a written request for a change in scope of service in accordance with subsection (c) of this section not later than sixty days after the end of the FQHC’s fiscal year. A FQHC shall submit all documentation required or requested by the department with respect to the change in scope of service.

(g) The department may initiate a change in scope of service and resulting encounter rates following a review of the FQHC’s scope of project, subsequent amendments to the scope of project, cost reports and audited financial statements by notifying the FQHC in writing and requesting documentation with respect to the proposed change in scope of service. A FQHC shall submit all requested documentation not later than ninety days after receipt of the notice of the proposed change in scope of services.

(h) In making its determination with respect to whether a FQHC’s encounter rate may be adjusted based upon a change in scope of services, the department shall review the following:

(1) The FQHC’s Medicaid cost report;

(2) The FQHC’s audited financial statements; and

(3) Any other documentation relevant to the change in scope of services.

(i) The department shall issue a decision on a request for an adjustment to the FQHC’s encounter rate not later than 120 days after the date on which the FQHC submits the request to the department.

(j) If the department approves the request, the new encounter rate shall take effect on the date specified in the department’s decision. The FQHC shall submit a final cost report by January 1 of the year following the request for an adjustment to its encounter rate.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-1002 Billing requirements

(a) Each FQHC shall bill for FQHC services per encounter. Claims are limited to one all-inclusive encounter per day to include all services received by a client on the same day unless the client suffers an illness or injury subsequent to the first encounter that requires additional diagnosis or treatment or if the client has different types of visits on the same day such as medical and dental or medical and behavioral health. Medicaid pays for one medical, one dental, and one behavioral health encounter per day.

(b) Each FQHC shall submit medical and behavioral health claims on the CMS-1500 utilizing both the encounter code and all applicable HCPCS code(s) on the FQHC fee schedule that identify the services provided.

(c) Each FQHC shall submit dental health claims on the original designated American Dental Association Dental Claim form.

(d) Each FQHC shall submit claims electronically or on the department’s designated form and shall include all information required by the department to process the claim for payment.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-1003 Reimbursement

(a) The department shall reimburse a FQHC an all-inclusive encounter rate per client encounter in accordance with a PPS as required by 42 USC 1396a (bb).

(b) The department shall establish the baseline encounter rate for each FQHC in existence during fiscal years 1999 and 2000 as follows:

(1) Total encounters and costs shall be obtained from the annual reports submitted by the FQHC for fiscal years 1999 and 2000;

(2) Each year’s total costs shall be divided by the total encounters. The FQHC shall include the costs of all Medicaid covered services provided by the FQHC;

(3) A two-year average of the calculated cost per encounter rates for fiscal years 1999 and 2000 will be used for each facility. The department shall determine the two-year average for each FQHC by calculating the average cost per encounter rate separately for each year, then adding the averages together and dividing by two.

(c) For a FQHC that did not file a 1999 annual report, the baseline encounter rate shall be based upon the annual report submitted for fiscal year 2000.

(d) For a center that first qualified as a FQHC after fiscal year 2000, the department shall determine the baseline encounter rate based upon the encounter rate established under this section for FQHCs located in the same area with similar services.

(e) The department shall adjust annual encounter rates by applying the percentage increase in the Medicare economic index (MEI) as defined in 42 USC 1395u (i)(3) to the previous fiscal year’s encounter rate in accordance with 42 USC 1396a (bb) (3) (A).

(f) The department may adjust the encounter rate for a change in the scope of services provided by a FQHC in accordance with section 17b-262-1001 of the Regulations of Connecticut State Agencies.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-1004 Documentation and audit requirements

(a) Each FQHC shall maintain a specific record for all services provided to each client including, but not limited to: name, address, birth date, Medicaid Identification Number, pertinent diagnostic information, treatment notes signed by the provider, documentation of services provided and the dates on which the services were provided.

(b) For services performed by an LMSW, an unlicensed individual, a non-certified individual or an individual in training, progress notes shall be co-signed by the supervisor at least weekly for each client in care and shall contain the name, credentials and the date of such signature. For services provided by a certified individual, evidence of clinical supervision for each client in care shall be documented in the client's chart and shall contain the name, credentials and the date of such signature. The supervisor's signature means that the supervisor attests to having reviewed the documentation.

(c) Each FQHC shall maintain all required documentation in its original form for at least five years or longer in accordance with statute or regulation, subject to review by authorized departmental personnel. In the event of a dispute concerning a service provided, the provider shall maintain the documentation until the dispute is resolved.

(d) The department may disallow and recover any amounts paid to the provider for which the required documentation is not maintained and not provided to the department upon request.

(e) The department may audit all relevant records and documentation and may take any other appropriate quality assurance measures it deems necessary to assure compliance with all regulatory and statutory requirements.

(f) Notwithstanding the provisions of subsections (a) through (d) of this section, FQHCs may maintain an electronic medical record system such that medical records for all patients treated within the FQHC shall be available to, and shared by, all health professionals.

History

• Effective May 13, 2015

Regs., Conn. State Agencies § 17b-262-1006 Scope

Sections 17b-262-1006 to 17b-262-1017, inclusive, of the Regulations of Connecticut State Agencies set forth the Department of Social Services requirements for the payment of dental services for clients who are determined eligible to receive services under Connecticut's Medicaid program pursuant to section 17b-261 of the Connecticut General Statutes.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1007 Definitions

As used in section 17b-262-1006 to section 17b-262-1017, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Adjunctive dental services" means services that are not primarily dental in nature but are used in conjunction with dental therapy to support or enhance the treatment of a patient's oral health;

(2) "Alveoloplasty" means the surgical procedure used to reconfigure alveolar bone in the lower or upper arch;

(3) "American Dental Association" or "ADA" means the national professional association of dentists that performs public education and professional services through education, research, advocacy and the development of standards;

(4) "Anterior teeth" means the incisor and canine teeth located in the lower and upper arches;

(5) "Apexification" means the process of inducing root formation by the placement of a calcified material to encourage the continued development and closure of the root in a tooth without a fully formed root of the growing permanent tooth;

(6) "Apicoectomy" is the removal of the root end of a tooth and placement of a definitive retrograde fill material in the root end in the permanent dentition;

(7) “Arthrocentesis” means the injection or the removal of fluid from the temporomandibular joint space and may include non-arthroscopic lysis and lavage;

(8) "Appliance" means a removable or fixed dental device that is worn on the upper or lower jaw or palate for therapeutic purposes;

(9) "Behavior management" means the professional techniques or therapies used to modify the actions of a patient who is receiving dental treatment to deliver treatment in a safe and comfortable manner;

(10) "Best practices" means the highest quality of service delivery that has been established by professional leaders that represents the current accepted evidence for the treatment of a specific clinical circumstance, as is found in the larger body of dental literature and a practice used among peers;

(11) “Bitewing” means the horizontal or vertical form of the dental radiograph that reveals the coronal halves of the upper and lower teeth showing the interproximal contacts and portions of the interdental alveolar septa on the same film;

(12) "Care coordination" means services delivered to an identified patient by a non-dental professional to assist the individual with access to oral healthcare services;

(13) "Case management" means the coordination and monitoring of treatment rendered to a patient with a complex treatment plan or multiple medical conditions by multiple dental and medical practitioners;

(14) “Children’s Health Insurance Program” or “CHIP” means the federally subsidized program of health care for uninsured, low-income children authorized by Title XXI of the Social Security Act and operated by the department pursuant to Chapter 319v, of the Connecticut General Statutes, known as HUSKY B;

(15) “Client” means a person eligible for services under the department’s Medicaid program;

(16) "CODA" means the Commission on Dental Accreditation;

(17) “Commissioner” means the Commissioner of Social Services or his or her agent;

(18) "Complete mouth series" or "full mouth series" means an image of the entire oral cavity produced by radiography and consists of at least ten periapical films plus bitewings or one panoramic film plus bitewings;

(19) "Comprehensive oral examination" means an evaluation by a general dentist consisting of a thorough examination and recording of the extraoral and intraoral hard and soft tissues, evaluation for oral cancer, the evaluation and recording of the patient's medical and dental history and a general health assessment, and includes the recording of dental caries, previously placed dental restorations, missing or unerupted teeth, existing prosthesis, periodontal conditions, hard and soft tissue anomalies, and occlusal relationships, and may require interpretation of information acquired through additional diagnostic procedures;

(20) "Comprehensive orthodontic therapy" means the treatment of permanent dentition or facial structures of the craniofacial complex;

(21) "Condylotomy" means the excision of the articulating surface of the mandible;

(22) "Connecticut Medical Assistance Program" or "CMAP" means all the medical assistance programs administered by the Department pursuant to state and federal law, including, but not limited to, Medicaid, Medicaid waiver programs and the Children's Health Insurance Program;

(23) "Core build up" means a restorative procedure where a missing portion of the tooth is restored with dental filling material to support a crown restoration;

(24) "Cosmetic dentistry" means employing several different dental procedures singularly or in concert with each other to enhance the appearance of the teeth or face, including, but not limited to, procedures performed for cosmetic reasons include, but are not limited to, crown replacement, veneer placement, bonding techniques for reasons other than the restoration of caries, mechanical reshaping of a tooth or teeth, orthodontic treatment, provision of removable dentures or implant placement and restoration;

(25) "Dental clinic" means a facility that has been issued a license by the Department of Public Health to operate a clinic to provide comprehensive dental services to members on an outpatient basis;

(26) "Dental home" means a dentist that:

(A) provides comprehensive care, including, but not limited to, preventive, restorative, periodontal, endodontic, prosthetic, oral and maxillofacial surgery and emergency services;

(B) has a plan to assist a member after hours in the event an emergency arises; and

(C) refers patients to appropriate dental specialists for advanced care needs;

(27) "Dental hygienist" means an individual who holds a license issued under Chapter 379a of the Connecticut General Statutes;

(28) "Dental services" means any service provided by a dentist or a dental hygienist or under the direct or indirect supervision of a licensed dentist as defined in section 20-126l(a)(3) of the Connecticut General Statutes;

(29) "Dentist" means an individual who holds a license issued by the Department of Public Health to practice dental medicine in the State of Connecticut pursuant to Chapter 379 of the Connecticut General Statutes;

(30) "Dentures" or "denture prosthesis" means artificial structures made by or under the direction of a dentist to replace some or all of the patient's teeth;

(31) "Department" means the Department of Social Services or its agents;

(32) "Durable medical equipment" or “DME” has the same meaning as provided in section 17b-290 of the Connecticut General Statutes.

(33) "Early and periodic screening, diagnostic, and treatment services" or "EPSDT" means the services provided in accordance with section 1905(r) of the Social Security Act, as amended from time to time;

(34) "Emergency" means a dental condition manifesting itself in acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect that the absence of immediate dental attention could result in placing the health of the individual, or with respect to a pregnant woman, her unborn child, in serious jeopardy, cause serious impairment to bodily functions or cause serious dysfunction of any body organ or part and could potentially result in death;

(35) "Endodontic services" means the procedures used to treat infections or repair trauma that has reached deep into the tooth structure, adversely affecting the pulp or periarticular structures of the tooth;

(36) “Examination” means inspecting and charting of the oral structures;

(37) "Excessive loss of tooth structure" means for:

(A) molar teeth, the loss of three or more tooth surfaces, including two cusps;

(B) premolar teeth, the loss of three or more tooth surfaces, including one cusp; and

(C) anterior teeth, the loss of four or more tooth surfaces, including the loss of one incisal angle;

(38) "Exodontia" means the process used to remove a tooth or tooth remnants;

(39) "Fixed location" has the same meaning as provided in section 17b-282f of the Connecticut General Statutes;

(40) "Fluoride treatment" means the application of any professionally prescribed product containing a professional dose of applied fluoride;

(41) "Genioplasty" means the surgical process employed to reshape gingival tissue;

(42) "Gingivectomy" means the excision or removal of gingival tissue;

(43) “Group home” means “community residential facility” as defined in section 17a-220 of the Connecticut General Statutes or a “community residence” as defined in section 19a-507a of the Connecticut General Statutes;

(44) "Guided enamel regeneration" means a material that contains a self-assembling peptide that regenerates weakened tooth structure that rebuilds enamel by replicating the molecular mechanism of natural enamel formation in teeth that have early tooth decay or molar incisal hypoplasia;

(45) “Healthy adult” has the same meaning as provided in section 17b-282d of the Connecticut General Statutes;

(46) "Home" means the member's residence which includes group home facilities, but does not include institutions, skilled nursing facilities, intermediate care facilities or short-term rehabilitation facilities;

(47) “Hospital” means a “general hospital” or “special hospital” as defined in section 19-13-D1(b)(1) of the Regulations of Connecticut State Agencies;

(48) “Implant” means the material inserted or grafted endosteally, eposteally or transosseally into the mandible or maxillae as a means of providing for a dental replacement;

(49) "Implant supported overdenture" means a complete or removable partial denture that has one or more implants to provide support to the prosthesis in the maxillae or mandible;

(50) “Intraoral” means within the oral cavity;

(51) “Intraoral sleep apnea treatment device” means an appliance that is placed within the oral cavity or embedded in the tissues of the oropharynx and may include, but is not limited to, a mandibular advancement device, a tongue retaining device, and a hypoglossal nerve stimulator;

(52) "Limited orthodontic therapy" means the treatment of teeth in the transitional or permanent dentition stage and the developing facial structures to alleviate or reduce severity of abnormalities of the craniofacial complex later in life;

(53) "Marketing" means any communication from a provider to a Medicaid or CHIP member that can reasonably be interpreted as intended to influence the member’s choice of provider;

(54) "Marketing materials" means materials produced in any medium designed or intended to be provided to Medicaid or CHIP members or the member's parent or legal representative to influence the choice of provider. Does not include materials relating to the prevention, diagnosis or treatment of a medical or dental condition;

(55) "Medicaid" means the Connecticut Medical Assistance Program operated by the department under Title XIX of the Social Security Act, and related state and federal rules and regulations;

(56) "Medical necessity" or "medically necessary" has the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(57) “Medical record” means a medical record as set forth in section 19a-14-40 of the Regulations of Connecticut State Agencies;

(58) "Member" has the same meaning as provided in section 17b-290 of the Connecticut General Statutes;

(59) "Mobile dental clinic" has the same meaning as provided in section 17b-282f of the Connecticut General Statutes;

(60) “Nutritional Counseling” means the evaluation of dietary habits and food consumption for the treatment of periodontal disease and for the control of dental caries by a dietitian or nutritionist;

(61) "Obstructive Sleep Apnea" means a disorder of breathing characterized by episodes of complete or partial upper airway obstruction during sleep, often resulting in gas exchange abnormalities and arousals that cause disrupted sleep patterns;

(62) "Occlusal guard" means a removable hard acrylic or soft dental laboratory processed appliance that is designed to minimize the effects of tooth grinding and clenching, or other occlusal factors including the treatment of temporomandibular joint disease in symptomatic patients;

(63) "Oral health" means the well-being of the:

(A) teeth and the gingivae and their supporting connective tissues, ligaments, and bone;

(B) hard and soft palate;

(C) mucosal tissue lining of the mouth and throat;

(D) tongue;

(E) lips;

(F) the salivary glands;

(G) muscles of mastication and facial expression;

(H) mandible;

(I) maxillae;

(J) temporomandibular joints; cranial nerves; and

(K) vascular systems that support the head and neck;

(64) "Orthognathic surgery" means the surgical correction of skeletal anomalies or malformations involving the maxilla or mandible, including malformations that may be present congenitally or become evident as the individual develops;

(65) “Orthodontia” means pertaining to orthodontic treatment, which is the specialty of dental medicine concerned with the growth and development or oro-facial structures, including irregularities of bone and alignment, the non-alignment of teeth within the dental arch, alignment discrepancies between the maxillary and mandibular arches and associated oro-facial anomalies;

(66) "Patient record" means the collection of written dental, medical and social documentation, diagnostic laboratory tests, diagnostic imaging, and diagnostic casts and any other information pertinent to the treatment of the patient;

(67) “Periapical image” means intraoral films used to reveal the apices of a specified tooth or teeth;

(68) “Periodic oral examination” means an evaluation performed on a patient of record to determine any changes in the patient’s dental and medical health status since the previous periodic oral evaluation or comprehensive examination and includes oral cancer evaluation, periodontic screening and may require interpretation of information required through additional diagnostic procedures;

(69) "Periodontal services" means the procedures used to treat diseases of the surrounding and supporting structures of the teeth;

(70) "Permanent dentition" means the second set of teeth in the lower and upper arches, which are conventionally described using the Universal or National Numbering System as 1 through 32;

(71) "Post-surgical sequela" means a pathological condition resulting from surgery to the orofacial boney structures;

(72) "Primary care dentist" means a licensed, enrolled dentist who:

(A) is primarily responsible for the delivery of comprehensive dental services to members and when necessary, coordinates the care of a patient between other dental and medical specialists; and

(B) functions as the dental home for patients of record. A pediatric dentist can be considered a primary care dentist for infants and children through adolescence;

(73) "Primary dentition" means the first set of teeth which are exfoliated and replaced by the secondary dentition of the lower and upper arches, and are the teeth of the primary dentition conventionally denoted using the Universal/National Numbering System as A through T;

(74) "Prior authorization" means approval from the department or its designee for the provision of a service or the delivery of goods before the provider provides the service or delivers the goods;

(75) “Post procedure review” means the post treatment assessment by radiographic and other accompanying documentation of specified services on a case-by-case basis after the services have been performed to verify proper coding has been submitted for the procedure, and that procedures performed comport with program coverage guidelines and the prevailing standards of care, and shall include, but not be limited to, those procedures which are performed on an emergency or urgent basis;

(76) "Prophylaxis" means the complete removal of calculus, soft debris, plaque, stains and smoothing of unattached tooth surfaces through scaling by rotary, ultrasonic or other mechanical means as described as standard procedure by the American Dental Association or the American Association of Pediatric Dentistry, and includes the review of dietary standards for foods and beverages containing sugar and oral-hygiene instruction;

(77) "Prosthodontic services" means the procedures used to repair or replace missing teeth when a great deal of tooth structure is lost due to disease or trauma or used to replace missing teeth;

(78) "Public health facility" has the same meaning as provided in section 20-126l of the Connecticut General Statutes;

(79) "Public health hygienist" means a hygienist who is licensed to practice dental hygiene as provided in section 20-126h, enrolled in the Connecticut Medical Assistance Program, and elects to practice independently from a dental practice in order to provide services in a public health facility;

(80) "Pulpotomy" is the removal of the diseased portion of the connective tissue of a primary or permanent tooth with the intent of maintaining tooth vitality;

(81) "Retrospective review" means the post treatment assessment by radiographic and other accompanying documentation of specified services on a case-by-case basis after the services have been performed to verify proper coding has been submitted for the procedure, and that procedures performed comport with program coverage guidelines and the prevailing standards of care;

(82) "School-based health center" or "SBHC" has the same meaning as provided in section 19a-6r of the Connecticut General Statutes;

(83) "Specialist" means a dentist who has taken and passed the required practicum for dental licensure and received and successfully completed a post graduate training program accredited by CODA leading to a certificate, master's degree in dental science, board eligibility or board certification in any of the following specialty areas of dental medicine:

(A) Anesthesiology 122300000X;

(B) Dental Hygienist 124Q00000X;

(C) Endodontology 1223E0200X;

(D) Oral Pathology 1223P0106X;

(E) Oral Radiology 1223D008X;

(F) Oral Surgery 223S0112X;

(G) Orthodontics 11223X0400X;

(H) Pediatric Dentistry 1223P0221X;

(I) Periodontist 1223P0300X;

(J) Prosthodontics 1223P0700X;

(K) Public Health Dentist 1223D001X; and

(L) General Dentist 1224G001X;

(84) “Specialty practice" means a practice that:

(A) holds itself out as a specialty practice;

(B) offers selective dental services concurrent with a dental specialty that is recognized by the ADA;

(C) employs a dentist who has obtained a degree or certificate in a specialty or interest area from a CODA accredited training program; and

(D) provides services deemed to require advanced knowledge and skills that are essential to maintain or restore oral health, including, but not limited to, anesthesiology, endodontics, oral surgery, orthodontics, pediatric dentistry, periodontics or prosthodontic services;

(85) "Teeth" are described using the Universal/National Numbering System:

(A) Anterior primary teeth are denoted as C through H, M through R;

(B) Anterior permanent teeth are denoted as 6 through 11 and 22 through 27;

(C) Premolar teeth are denoted as 4, 5, 12, 13, 20, 21, 28, 29;

(D) Molar primary teeth are denoted as A, B, I, J, K, L, S and T;

(E) Molar permanent teeth are denoted as 1 through 3, 14 through 19, 30 through 32;

(F) Posterior permanent teeth are denoted as 1 through 5, 12 through 21, 28 through 32;

(G) Posterior primary teeth are denoted as A, B, I through L, S, and T;

(H) Supernumerary permanent teeth are denoted as 51 through 83; and

(I) Supernumerary primary teeth are denoted as AS through TS;

(86) "Tomosynthesis" means an imaging modality that uses a fixed array of carbon nanotube enabled x-ray sources to produce a series of projections from which three-dimensional information can be reconstructed and displayed;

(87) "Tooth surfaces" are described using the following designations:

(A) Distal (D) - Surface furthest from the midline;

(B) Facial (F) - Facing the mucosa;

(C) Incisal (I) — Edge of anterior teeth;

(D) Lingual (L) - Facing the tongue;

(E) Mesial (M) — closest to the midline; and

(F) Occlusal (O) - of the posterior teeth;

(88) "Treatment plan" means a detailed list of dental procedures organized in descending order from urgent to less urgent treatment needs, which are necessary to maintain and restore the member's oral health;

(89) "Unilateral removable appliance" means a dental appliance or device that is prescribed, constructed and placed in or on a patient by a dentist as part of a treatment protocol for the sole purpose of addressing anomalies or deficiencies on one side of the oral cavity, dental quadrant or with the facial structures;

(90) “Usual and customary charge” means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in a majority of cases, “usual and customary” means the median charge. Token charges for charity patients and other exceptional charges are to be excluded;

(91) "Utilization review" means the post claim or post payment compilation and assessment of aggregated services delivered by providers after the services have been performed, and includes an objective, qualitative computer-based regression that is conducted to determine through statistically significant measures if the services delivered to members are appropriate;

(92) "Vestibulopathy" means any of a series of surgical procedures designed to restore alveolar ridge height by lowering the muscles attached to the buccal, labial, and lingual aspects of the jaws; and

(93) “Xerostomia” means abnormal dryness of the mouth.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1008 Provider Participation

(a) In order to participate in the Connecticut Medicaid program and provide dental services eligible for reimbursement from the department, each dental provider shall:

(1) Comply with all applicable licensing, accreditation, and certification requirements;

(2) Comply with all departmental enrollment requirements, including sections 17b-262-522 to 17b-262-533, inclusive, of the Regulations of Connecticut State Agencies;

(3) Have a valid provider enrollment agreement on file with the department and comply with the provider enrollment agreement; and

(4) Cooperate with investigations of quality concerns, including, but not limited to, review of the quality of care rendered by the provider, visits at the provider's site of service or business address, and quality improvement or corrective action plans for the provider.

(b) In addition to satisfying the requirements of subsection (a) of this section, a dental home shall:

(1) Provide comprehensive care, which includes, but is not limited to, restoration of cavities, root canal therapy, prosthetic services and extractions, in addition to primary dental care prevention and emergency services;

(2) Be accessible and have a fixed location within a twenty-mile radius of the patient’s residence, school or place of employment and have regularly scheduled appointment hours available weekly including the summer months;

(3) Have a plan for providing emergency care after regularly scheduled office hours twenty-four hours a day, seven days per week, other than simply providing a referral to the local hospital emergency room; and

(4) Have the capacity to make referrals to specialists if needed, within the patient's established dental plan's network.

(c) In addition to satisfying the requirements of subsection (a) of this section, dental specialty practices shall:

(1) Employ at least one dental specialist;

(2) Have a dental specialist on site at all times when the practice is open and providing services to Medicaid enrolled members, particularly if the practice employs a dentist who is not a specialist; and

(3) Comply with prior authorization and post procedure review requirements listed on the Medicaid fee schedule for any dentist who is not a specialist but provides specialty services.

(d) Mobile dental clinics shall:

(1) Have or contract with a fixed location pursuant to section 17b-282f of the Connecticut General Statutes. The key features of such contract are as follows:

(A) The fixed location shall be a Medicaid enrolled provider;

(B) The fixed location shall be subject to all Medicaid policies and regulations;

(C) The members may be referred to and receive comprehensive care from one primary care dentist, excluding treatment by dental specialists when the need arises;

(D) The mobile clinic shall provide all administrative support necessary to ensure that members receive the same services the patient would receive if the members were being served at the fixed location; and

(E) All patient records shall be placed in or available electronically to the fixed location not more than five business days following the provision of dental services in the mobile clinic.

(2) Provide or place referred patients into comprehensive dental care for services such as restorations, endodontic treatment or extractions. The dentist shall be able to handle emergencies on a twenty-four-hour, seven day a week basis;

(3) Be limited to submitting claims for services provided within a geographic area that is not more than thirty miles from the associated dentist’s fixed dental location, except that a mobile dental clinic in the counties of New London, Litchfield and Windham may submit claims for Medicaid reimbursement for dental treatment of Medicaid beneficiaries not more than fifty miles from the dentist’s fixed location;

(4) Review each member's service history before rendering treatment, if available. If the member has a dental home, the mobile clinic shall consult with the dentist of record at the dental home before providing any treatment to the member;

(5) Obtain consent from the member's legal guardian before rendering treatment to a member under the age of eighteen years and comply with the following requirements:

(A) All permission slips shall clearly state that the services being offered are in coordination of care with the member's dental home;

(B) The permission slip shall be valid for one year which shall all be specified on the permission slip; and

(C) The permission slip may include a list of procedures that may be provided at the mobile dental clinic and shall include the option for the parent or guardian to opt out of certain procedures;

(6) Have all written materials available in English and a proficient Spanish version written at no greater than a seventh-grade reading level.

(e) School-Based Health Centers shall:

(1) Obtain consent from the member's legal guardian before rendering treatment to a member under the age of eighteen years and comply with the following requirements:

(A) All permission slips shall clearly state that the services being offered are in coordination of care with the member's dental home;

(B) The permission slip shall be valid for one year, which shall be specified on the permission slip, and shall clearly state that the parent or guardian may revoke their consent at any time; and

(C) The permission slip may include a list of procedures that may be provided at the school-based health center and shall include the option for the parent or guardian to opt out of certain procedures;

(2) Review each member's service history before rendering treatment, if available. If the member has a dental home, the school-based health center shall consult with the dentist of record before providing any treatment to the members;

(3) Refer members into comprehensive dental care for services such as restorations, endodontic treatment, or extractions;

(4) Have all written materials available in English and a proficient Spanish version written at no greater than a seventh-grade reading level;

(5) Have all written materials available in oral and written form in languages other than English as required by 45 CFR 92.201; and

(6) Make all records and imaging available to any authorized requester not later than five days after the request. In the event of an emergency, the SBHC shall provide the requested records to the authorized requester not later than twenty-four hours after receipt of the request.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1009 Eligibility

Payments for dental services shall be made available to CMAP providers for members enrolled in the CMAP.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1010 Administrative Services Organization

(a) The department may contract with an administrative services organization, or ASO, to administer dental health services in accordance with a contract between the ASO and the department.

(b) The ASO shall assist the department in developing, managing, and maintaining a comprehensive network of dental providers that has the capacity to deliver all covered services to members. The ASO's responsibilities may include, but are not limited to:

(1) Network management and development;

(2) Development of a comprehensive provider database; and

(3) Evaluation of the adequacy of the provider network.

(c) The ASO shall identify individuals who may need case management or care coordination and offer such services to individuals who are not already receiving case management services from their primary care dental provider.

(d) The ASO shall be responsible for member services.

(e) The ASO shall be responsible for quality improvement and management programs.

(f) The ASO shall be responsible for utilization review and utilization management and shall develop a utilization review and utilization management program subject to the review and approval of the department.

(g) The ASO shall assist with programmatic and financial reporting.

(h) The ASO shall implement a prevention and intervention strategy for identified members to reduce poor oral health habits and prevent oral disease.

(i) The ASO may investigate and address concerns related to the quality of care or the office environment rendered by providers.

(j) The ASO may require a dentist or dental hygienist to evaluate the appropriateness, quality and type of care rendered.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1011 Services covered and limitations

Non-exhaustive coverage for dental services and limitations to such services are set forth in subsections (a) to (j), inclusive, of this section subject to the exception process through prior authorization set forth in subsections (k) and (1) and section 17b-262-1014 of the Regulations of Connecticut State Agencies.

(a) The department shall cover the following adjunctive dental services:

(1) General anesthesia and moderate sedation administered by a dentist, dental anesthesiologist or oral and maxillofacial surgeon, who holds a valid general anesthesia or moderate sedation permit issued pursuant to section 20-123b of the Connecticut General Statutes:

(A) To provide preventative treatment in conjunction with endodontic, restorative services or oral surgical procedures for any members under the age of twenty-one years or members who have a behavioral or cognitive condition which prevents them from receiving care safely;

(B) For use with members undergoing in-office oral surgical procedures where sedation is required to perform the procedure;

(C) For the extraction of five or more teeth, or removal of a tooth which fails to become adequately anesthetized using local anesthesia;

(D) For the extraction of third molars if removal of the third molars is medically necessary and all four third molars are being removed during one procedure; and

(E) With the following documented in the member's chart:

(i) The member's cognitive or behavioral health diagnosis, which may be fulfilled by a physician's letter or certificate from another state agency that services the member;

(ii) Documentation of the reasons for a medical necessity determination and the condition of the tooth or teeth;

(iii) The type of agent utilized, and any other drug administered including the dose or doses, time given and route of administration;

(iv) The induction time of the anesthetic agent administered and the stop time of the anesthetic agent;

(v) Staff members present and the party responsible for monitoring and recording the vital signs; and

(vi) The member's vital signs before, during and after the administration of anesthesia.

(2) Inhalation of nitrous oxide for members of any age who have a diagnosis of a documented anxiety, behavioral health, cognitive disorder or medical condition which supports the need for behavior management related to the dental procedures to be delivered, provided that:

(A) Techniques are employed in conjunction with the delivery of dental services to individuals to help to facilitate a safe environment and reduce dental anxiety; and

(B) The member's chart contains the following documentation:

(i) A brief description of the member's anxiety, illness or disability including the diagnostic code;

(ii) If the member does not have a cognitive disability, then a description of the anxiety and behaviors warranting behavior management; and

(iii) A letter from the member's attending physician certifying the medical or behavioral diagnosis, or if the member is a member of the Department of Developmental Services, such member's certificate.

(3) Care-related adjunctive dental services, including the following:

(A) Care coordination provided by care coordinators or other non-dental professionals to facilitate delivery of dental services to a member; and

(B) Case management when the coordination of dental care is delivered by a dentist or under the direct supervision of a dental professional for a member who has a complicated medical or dental condition.

(4) Home or facility visits, one time per home or facility per member per day.

(5) Inpatient hospital services approved by the department as medically necessary by either a preadmission or retrospective review and provided by licensed dental professionals acting within the dental professional's scope of the practice.

(6) Outpatient hospital services provided by licensed dental professionals acting within the dental professional's scope of the practice.

(7) Intraoral sleep apnea treatment device with prior authorization for members one time per two-year period for custom-fitted laboratory-processed devices designed to minimize the effects of sleep disturbances related to airway pathology as documented by examination and a sleep study. All follow-up care, not limited to appliance adjustments, shall be included in the payment for this service. The CMAP dental provider must enroll as a DME provider to deliver intraoral sleep apnea treatment devices.

(8) Palliative treatment of dental pain with documentation and post procedure review.

(b) The department shall cover the following diagnostic services:

(1) Oral Examinations:

(A) One initial comprehensive oral examination per member per provider and performed by a general or pediatric dentist or prosthodontist. The examination shall include the taking of the medical history, vital signs, the thorough evaluation and recording of the state of both intra-oral and extra-oral hard and soft tissue findings resulting in a new treatment plan for the member. The department may authorize a second comprehensive oral examination only when the member has experienced a lapse in treatment of one and a half years or more and such lapse is documented in the member's treatment record;

(B) One comprehensive periodontal examination per lifetime for patients who are showing signs and symptoms of periodontal disease and includes an evaluation of the periodontal conditions, probing depths and complete charting, evaluation for oral cancer, evaluation of the salivary system, the member's medical and dental history, and general health assessment. Caries and restorations shall be noted, and the condition of the restorations provided;

(C) One detailed and extensive examination per member per provider and performed by an anesthesiologist, endodontist, oral medicine specialist, orofacial pain specialist, oral and maxillofacial surgeon, orthodontist, pathologist, periodontist, or radiologist per provider per year;

(D) A periodic oral examination performed by a dentist six months after the initial oral comprehensive examination and every six months thereafter for members under the age of twenty-one;

(E) One periodic oral exam for members twenty-one years of age and over unless dental or medically necessary to obtain additional periodic examinations;

(F) Additional periodic examinations that have received prior authorization based on medical necessity;

(G) A problem focused oral examination performed by a dentist, four times per member in a twelve-month period. A problem-focused oral examination shall not be reimbursed in conjunction with other examination codes, routine or previously scheduled dental care or palliative treatment and is limited to four occurrences per member per year;

(H) A screening examination performed by a public health hygienist, two times per member per every twelve-month period, consistent with the following requirements:

(i) The screening examination results shall be documented on the department's "Screening for Oral Health" form and placed in the patient's electronic health record or chart; and

(ii) A screening examination shall not be covered as a separate billable procedure when performed in a dental office, at the member's dental home or in a federally qualified health center;

(I) A screening examination performed by a physician, physician assistant or nurse practitioner, one time per member during well-child visits with the following requirements:

(i) The findings shall be documented in the patient's medical record; and

(ii) The member shall be referred for care coordination or to a dental home if oral disease is found; and

(J) An orthodontic screening examination limited to two times per member per lifetime.

(2) Diagnostic imaging when taken in compliance with accepted criteria and practices specified by state and federal standards governing radiation hygiene, developed by the National Council on Radiation Protection and Measurements including the guidelines adopted by the U.S. Department of Health and Human Services and the ADA. Diagnostic imaging shall be taken according to the accepted standards of dental care and according to a specific member's needs. Diagnostic imaging shall be limited to the minimum number of images needed to diagnose a member's condition, shall be correctly mounted, accurately recorded with the date on which the images were taken and clearly identify the patient's right and left sides, and shall be of diagnostic quality for the department to reimburse the provider. All radiographic images shall have a reason documented in the chart as to why the radiograph was taken including any pathologies found on the image. The department shall cover the following:

(A) One set of horizontal or vertical, intraoral or extraoral bitewing images or tomosynthesis images per member in a twelve-month period as follows:

(i) Bitewing or tomosynthesis images are included in the complete mouth or tomosynthesis series and shall not be reimbursed separately from a complete mouth or tomosynthesis series or where a panoramic radiograph is substituted for a complete mouth or tomosynthesis series;

(ii) No more than four bitewing or tomosynthesis images may be taken per visit; and

(iii) Additional bitewing or tomosynthesis images may be prior authorized for members who have had a diagnosis of white spot lesions or interproximal decay within the previous twelve months that require monitoring;

(B) One pre-operative cephalometric image per member per orthodontic and oral surgical providers for orthodontic cases and for cases requiring orthognathic surgery as follows:

(i) Additional cephalometric images with prior authorization for members who have dento-facial anomalies; and

(ii) For members twenty-one years of age and over in the event of facial trauma or need for reconstruction;

(C) Either one complete mouth or tomosynthesis imaging series or a panoramic film plus bitewing or tomosynthesis diagnostic imaging one time per three-year period for members nine years of age and over;

(D) One cone beam image when medically necessary to determine the extent of disease states such as cysts, tumors or when major traumatic events have occurred within the upper or lower jaw or oro-facial structures. Additional cone beam imaging may be prior authorized for members who have dento-facial anomalies for any reason or have undergone repair and require monitoring;

(E) One cone beam maxillae or mandible image for multi-rooted premolar and molar teeth undergoing endodontic therapy limited to one time every three years with prior authorization if the tooth to be treated is eligible for endodontic therapy, including, but not limited to, root canal therapy, retreatment of previously endodontically treated teeth and apicoectomies, and can be restored with an exception being made if a root fracture is discovered;

(F) Occlusal imaging one time per arch every two years and shall not be reimbursed for routine screening purposes. Additional occlusal images may be approved with prior authorization for members who have experienced trauma or have dento-facial anomalies;

(G) A panoramic image one time per three-year period per member per dental home or oral and maxillofacial surgeon or oral radiologist or oral pathologist or orthodontist for members nine years of age and over. The panoramic radiograph may be taken with tomosynthesis bitewing diagnostic imaging in lieu of the complete series and shall have the right and left sides clearly identified;

(H) One initial periapical or tomosynthesis image and up to three additional tomosynthesis or images annually per member or four periapical or tomosynthesis images in total per member subject to the following limitations:

(i) Shall not be covered for routine screening services for children or adults;

(ii) Shall not be covered on an individual basis when ten or more periapical or tomosynthesis images are taken over multiple visits to constitute a complete series; and

(iii) If two or more periapical or tomosynthesis images are taken on the same day, the first periapical shall be coded as the first periapical image by each provider and subsequent periapical images shall be coded as additional periapical images regardless of the tooth number by each provider; and

(I) Temporomandibular imaging for each joint with prior authorization.

(3) Diagnostic testing to determine susceptibility to caries and other dental diseases. Caries susceptibility test includes the collection of saliva, plaque, or carious dentin for the evaluation and determination of the relative risk rate of future caries development for children.

(4) Diagnostic casts or digital models are covered at one set per member per provider. Oral surgeons and orthodontists are allowed two sets of diagnostic casts or digital models per member.

(c) The department shall cover the following endodontic services:

(1) Apexification one time per tooth for members up to the age of eighteen years including all visits needed to complete the treatment excluding final root canal therapy.

(2) Apicoectomy one time per tooth when the prognosis of the tooth is favorable. Apicoectomy therapy shall be available for members twenty-one years of age and over with the exception of third molars. There shall be no active periodontal disease, at least 75% of the alveolar bone remaining, and an adequate tooth structure shall remain to restore the tooth to form and function.

(3) Anterior endodontic therapy:

(A) For members under the age of twenty-one years when the prognosis for the treated tooth and dentition is favorable, there is at least 75% of the alveolar bone remaining and there is no active periodontal disease. An adequate tooth structure shall remain to restore the tooth to form and function; and

(B) For members twenty-one years of age and over when the prognosis is favorable, there is at least 75% of the alveolar bone remaining, no subgingival decay and there is no active periodontal disease. An adequate tooth structure shall remain to restore the tooth to form and function.

(4) Premolar endodontic therapy:

(A) For members under the age of twenty-one years when the prognosis for the treated tooth and dentition is favorable, there is at least 75% of the alveolar bone remaining and there is no active periodontal disease. An adequate tooth structure shall remain to restore the tooth to form and function; and

(B) For members twenty-one years of age and over when the prognosis is favorable, no sub-gingival decay is present, there is at least 75% of the alveolar bone remaining and there is no active periodontal disease. An adequate tooth structure shall remain to restore the tooth to form and function.

(5) Molar endodontic therapy:

(A) For members under the age of twenty-one years when the prognosis for the treated tooth and dentition is favorable, there is no active periodontal disease, there is at least 75% of the alveolar bone remaining and an adequate tooth structure shall remain to restore the tooth to form and function; and

(B) For members twenty-one years of age and over when there is no active periodontal disease, no sub-gingival decay, at least 75% of the alveolar bone remaining and an adequate tooth structure shall remain to restore the tooth to form and function.

(6) The department shall require that all endodontic therapy as described in this subsection is documented with pre- and post-treatment radiographs. The department shall require post-procedure review for endodontic therapy procedures on permanent dentition and described in the subsection for all providers except for endodontists. The department shall require the following depending on the age of the member and the type of endodontic treatment provided:

(A) For members under the age of twenty-one years who receive anterior endodontic therapy or premolar endodontic therapy:

(i) Immediate restoration for the tooth that is endodontically treated if there is no periapical pathology remaining; and

(ii) Postponement of the final or definitive restoration until the growth phase of development is completed; and

(B) For members twenty-one years of age and over who receive anterior endodontic therapy, premolar endodontic therapy or molar endodontic therapy, there shall be an immediate restoration of the tooth endodontically treated.

(7) Direct pulp cap for members under the age of twenty-one years including all bases and liners.

(8) Indirect pulp cap for members under the age of twenty-one years including all bases and liners.

(9) Obturation or canal preparation for the retreatment for each canal of a previously endodontically treated tooth for members.

(10) Pulpotomy for members under the age of twenty-one years where the vitality must be maintained, provided that the primary tooth that has been treated by a pulpotomy is restored with a crown restoration.

(11) Retreatment of previous root canal therapy for child and adult members one time per tooth per lifetime, provided that the need for retreatment will be documented radiographically with a periapical or tomosynthesis image that is of diagnostic quality.

(d) The department shall cover the following oral and maxillofacial surgery services:

(1) Alveoloplasty when two or more contiguous teeth are extracted.

(2) Arthrocentesis procedures.

(3) Biopsies of soft and hard tissues.

(4) Bonding device (ligation) to facilitate eruption of an impacted tooth.

(5) Bone grafting when performed in conjunction with a surgical procedure.

(6) Fracture reduction.

(7) Implants to replace multiple congenital missing teeth, excluding lateral incisors, or to retain denture prosthesis where not enough bone exists to provide a stable base for the denture prosthesis.

(8) Non-surgical exodontia.

(9) Orthognathic surgery when the member has one of the following:

(A) Acute traumatic injury and post-surgical sequelae that require reconstruction;

(B) Resection of cancerous or non-cancerous tumors and cysts, cancer and post-surgical sequela that require re-construction to restore form and function;

(C) Obstructive sleep apnea where other non-invasive modalities of treatment have failed;

(D) Cleft lip or palate; or

(E) Congenital abnormalities that meet the criteria for reconstruction depending upon a patient-specific clinical review and include, but are not limited, to the following:

(i) Midface hypoplasia;

(ii) Mandibular Prognathism;

(iii) Hemifacial microsomia;

(iv) Treachers Collins Syndrome; and

(v) Crouzon's Syndrome.

(10) Orthognathic surgery only when it has been approved by the department or its designee and the member is undergoing active orthodontic treatment and has any of the following facial skeletal abnormalities that cannot be corrected to function through orthodontic therapy associated with masticatory malocclusion after undergoing corrective orthodontics:

(A) Anteroposterior discrepancies:

(i) Maxillary/mandibular incisor relationship with overjet of 5mm or greater or a negative value of 3 mm or greater; or

(ii) Maxillary/mandibular anteroposterior molar relationship discrepancy of 4mm or greater;

(B) Transverse discrepancies:

(i) Total bilateral maxillary palatal cusp to mandibular fossa discrepancy causing pain of 4 mm or greater; or

(ii) A unilateral discrepancy of 3 mm or greater given normal axial inclination of the posterior teeth;

(C) Vertical discrepancies:

(i) The presence of a vertical facial skeletal deformity which is two or more standard deviations from the published norms for skeletal landmarks;

(ii) Open bite and no vertical overlap of the anterior teeth;

(iii) Unilateral or bilateral posterior open-bite greater than 4 mm;

(iv) Deep overbite with impingement or irritation of the buccal or lingual soft tissues of the opposing arch; or

(v) Super eruption of a dentoalveolar segment due to lack of occlusion;

(D) Anteroposterior, transverse, or lateral asymmetries greater than 3 mm with concomitant occlusal asymmetry and one of the following:

(i) Masticatory disfunction due to skeletal malocclusion; or

(ii) Speech abnormalities determined by a speech pathologist or therapist to be due to a malocclusion and not helped by orthodontia or at least six months of speech therapy;

(E) Obstructive sleep apnea that is moderate or severe as measured by polysomnography, objective documentation of hypopharyngeal obstruction, failure of nonsurgical treatment, including a good faith effort at continuous positive airway pressure or bilevel positive airway pressure, or custom laboratory constructed intraoral devices with an expectation that orthognathic surgery will decrease airway resistance and improve breathing; and

(F) Difficulty swallowing with significant weight loss or failure to thrive documented in the member's medical records for a period of six months or longer, a low body mass index and low serum albumin related to malnutrition.

(11) Reimplantation of an anterior tooth or teeth.

(12) Ridge augmentation.

(13) Surgical access or ligation of an unerupted tooth for members under the age of twenty-one years.

(14) Surgical exodontia, except for the prophylactic removal of third molars. Removal of impacted teeth requires supporting documentation for the need for the service.

(15) Surgical treatment of dentofacial abnormalities, trauma, or diseased states.

(16) Condylotomy or cricoidectomy.

(17) Reconstruction of the temporomandibular joint or associated anatomical components.

(18) Mass, hard or soft tissue removal.

(19) Closed reduction of a fracture or fractures.

(20) Open reduction, internal fixation of fractures.

(21) Oro-facial reconstruction.

(22) Temporomandibular joint surgery.

(23) Surgical placement or removal of temporary anchorage devices.

(24) Transplantation of a tooth or tooth bud for members under the age of eighteen years.

(25) Vestibulopathy to create a stable ridge for denture prostheses.

(e) The department shall cover the following limited orthodontic therapy:

(1) Orthodontic appliance therapy is covered with prior authorization for members under the age of twenty-one years.

(2) For interceptive orthodontic purposes with documentation, including a description of the condition, the type of interceptive orthodontics proposed, length of treatment, models, radiographs, and photographs, demonstrates the need to correct dentofacial conditions using:

(A) Fixed or removable space maintainers;

(B) Corrective spacing deficiency devices used to influence the development phase of upper or lower jaw growth;

(C) Habit-breaking appliances with documentation of the significant effects of the habit; and

(D) Retainers for each arch limited to replacement one time per lifetime per member regardless of the reason.

(f) The department shall cover comprehensive orthodontic therapy:

(1) With prior authorization for members under the age of twenty-one years by a licensed orthodontist, pediatric dentist or general dentist who is qualified to treat orthodontic cases. Records shall be submitted for prior authorization and includes, but is not limited to, color facial photographs on photographic paper, panoramic and cephalometric imaging, diagnostic casts and if necessary, a letter by a licensed professional attesting to an adverse psychological event or outcome due to the malocclusion. The orthodontic case fee includes the first set of maxillary and mandibular retainers. To qualify for orthodontic therapy:

(A) Members shall be free from active gingivitis or untreated decay and score a twenty-six or greater on a correctly scored Salzmann Assessment Record; or

(B) If the member does not achieve twenty-six points on the Salzmann Assessment Record but is undergoing continuous therapy for six months or greater by a physician, a licensed psychologist, licensed clinical social worker, independent licensed practitioner, family counselor or other recognized and licensed specialist who attests the treatment of the malocclusion will significantly ameliorate the psychological condition or conditions caused by the malocclusion.

(2) If the member has one of the following congenital conditions:

(A) Cleft palate or history of a treated bony cleft palate;

(B) Impacted anterior teeth;

(C) Congenitally missing teeth that will be prosthetically replaced, excluding premolar teeth;

(D) Deep impinging overbite with soft tissue impaction causing severe tissue damage which is demonstrated by laceration or attachment loss;

(E) Anterior or posterior crossbite, or both, of three or more teeth per arch;

(F) Overjet greater than 9 mm or a Reverse overjet of .3.5 mm;

(G) When the mandible or maxillae, or both, or when the dentition are significantly affected by a congenital or developmental disorder, such as a craniofacial anomaly, trauma or pathology; or

(H) Syndromic craniofacial conditions or conditions which effect the development of teeth.

(3) For members twenty-one years of age and over only when there are untreated congenital conditions, facial forms of cancer or trauma, or surgical facial reconstruction is required.

(g) The department shall cover the following periodontal services:

(1) Periodontal therapy for members under the age of twenty-one years as part of early and periodic, screening, diagnosis and treatment services.

(2) Periodontal scaling and root planing therapy for all members who have diabetes, end stage renal disease, will have or have had heart valve procedures, infection of the heart valves, undergone chemotherapy, radiation therapy to the head and neck or stem cell or organ transplantation and on medications for epilepsy.

(3) Periodontal scaling and root planing therapy for treatment of quadrants with three or more contiguous teeth when medically necessary.

(4) Periodontal scaling and root planing therapy may not be performed in conjunction with prophylaxis or extraction of teeth or other surgical procedures.

(5) Covered non-surgical procedures include:

(A) Full mouth debridement for all members to facilitate evaluation limited to one time per member per provider per year with the following prior authorization documentation:

(i) a comprehensive periodontal evaluation with a complete radiographic series, except panoramic radiographs are not acceptable; and

(ii) a comprehensive phased treatment plan specific to the member;

(B) Periodontal maintenance limited to two times per year when a member has previously undergone periodontal treatment;

(C) Scaling and root planing of the root surfaces and crowns of teeth limited to one time per quadrant during a one-year period for members under the age of twenty-one years when medically necessary; and

(D) Scaling and root planing of the root surfaces and crowns of teeth limited to one time per quadrant per three-year period for members twenty-one years of age and over with chronic disease conditions identified in section 17b-262-1011(g)(2). Full oral and periodontal charting and assessments and diagnostic imaging are required as part of the documentation, including pocket depths, and intraoral photographs and medical necessity documentation. The documentation shall state the quadrants to be treated and the procedure to be prior authorized.

(6) Covered surgical procedures:

(A) Gingivoplasty and gingivectomy limited to one time per quadrant during a one-year period; and

(B) Gingival flap procedure including root planing limited to one time per quadrant per lifetime for members under the age of twenty-one years with medical necessity and full oral and periodontal charting including pocket depths documented and prior authorization as part of EPSDT requirements.

(7) Any requested periodontal procedure shall clearly state the nature of the medical condition, provide a complete or tomosynthesis image series complete and thorough periodontal charting and description of the oral hygiene condition. Intra-oral color photographs shall be included and are adjunctive documentation requirements.

(8) Members who are eligible and require periodontal services shall review and sign the department's form, "Periodontal Therapy" and placed in the member's chart as part of the permanent record.

(h) The department shall cover the following preventive services:

(1) Custom laboratory made athletic guards for members under the age of twenty-one years who are engaged in a contact sport and who have no other means for the provision of the guard for the members.

(2) Occlusal guards for members one time per two-year period for custom-fitted laboratory-processed occlusal guards designed to minimize the effects of occlusal related pathologies and clearly documented in the member's chart. All follow-up care shall be included in the payment for this service.

(3) Topical application of fluoride or a professional anti-cariogenic agent for members, one time per every six-month period, or in conjunction with dental prophylaxis.

(4) Additional fluoride treatments with prior authorization when:

(A) The member resides in a long-term care facility;

(B) The member has a significant cognitive impairment;

(C) The member has a chronic medical condition placing him or her at higher risk for decay;

(D) The member has undergone or is currently on intravenous, parenteral or oral bisphosphonate or similar therapy;

(E) The member has undergone head and neck radiation treatment;

(F) The member has xerostomia secondary to autoimmune disease or medications;

(G) The member has a debilitating illness where the recipient cannot maintain proper oral hygiene; or

(H) The member is at higher risk for decay as determined by the Caries Risk Assessment.

(5) Silver diamine fluoride used as a caries arresting medicament, in a “sandwich technique” or as a topical fluoride treatment for children and adults as recommended by the American Academy of Pediatric Dentistry and American Dental Association respectively as the prevailing standard of care.

(6) Custom fluoride trays one time every two years for members under the age of twenty-one with a documented need and for members twenty-one years of age and over with prior authorization for reasons of medical necessity.

(7) Prophylaxis:

(A) For members under the age of twenty-one years, one time every six months or more if prior authorized; and

(B) For members who are twenty-one years of age and over, limited to one time per year for a healthy adult or where there are no dental or medical conditions that warrant additional prophylaxis procedures. Members with predetermined medical conditions may be pre-approved for a cleaning two times per year.

(8) Screening or risk assessment shall be accompanied by the submission of the risk assessment form used for members under the age of twenty-one years.

(9) Sealants one time per three-year period per member for non-carious teeth for pits and fissures in the permanent dentition. The department shall not reimburse for repair or replacement of a sealant until three years have lapsed from the initial placement of the sealant.

(A) Teeth 2, 3, 14, 15, 18, 19, 30 & 32 are candidates for sealant placement. Such teeth shall be free from decay or determined by the provider that the sealant will arrest decay and shall have erupted sufficiently so proper isolation can be achieved for sealant placement;

(B) Sealant placement shall be reimbursed on a per tooth basis and includes the following:

(i) All surfaces of the permanent molar tooth;

(ii) Proper preparation of the enamel surface;

(iii) Etching, placement and finishing of the sealant; and

(iv) Reapplication by the same provider if the sealant fails in less than three years;

(C) Sealant placement shall be subject to the following age limitations:

(i) On the first molar teeth for members from ages five to twenty-one, inclusive;

(ii) On second molar teeth from the ages eleven to twenty-one, inclusive;

(iii) Primary dentition only in the case of the presence of early childhood decay or high caries susceptibility test by prior authorization; and

(iv) For premolar teeth only in the case of the member having a high caries susceptibility test or by prior authorization.

(10) Space maintainers when there is a premature loss of primary teeth that may lead to the loss of the developmental integrity of the lower or upper arch, or when the premature loss of primary molars occurs, and placement is necessary to prevent the migration of adjacent teeth. The member's chart shall contain the initial radiograph of diagnostic quality, supporting the need for a space maintainer showing the unerupted permanent tooth or that migration of the adjacent tooth is in the initial stages. Only one space maintainer shall be covered per member per area, regardless of the reason.

(i) The department shall cover the following prosthodontic services:

(1) Complete and removable partial dentures provided for functional purposes that are constructed by any dentist require prior authorization and are subject to the following:

(A) For members twenty-one years of age and over, if the member or the member's caregiver can care for the dentures, the recipient has the ability to benefit from the dentures and the member uses the denture prosthesis on a daily basis; and

(B) All adjustment services are included in the six-month post denture delivery period and adjustment services are not billable separately.

(2) Replacement dentures one time in each seven-year period regardless of the reason and subject to the following:

(A) Replacement dentures shall not be approved if lost within the first year of placement regardless of the reason for the loss except for in the case of a catastrophic reason for the loss;

(B) After the receipt of replacement dentures within the seven-year time limit, the member shall not be eligible to receive another set of dentures for seven years from the date of delivery regardless of the reason;

(C) In cases where there are catastrophic reasons for the loss of the removable complete or partial denture prosthesis, the request for prior authorization must include a statement from the member or his or her representative explaining the nature of the loss or destruction. In cases where the denture is missing or destroyed due to theft, an accident or fire, the member shall provide a copy of the police or fire marshal incident report;

(D) In cases where the member resides in a long-term care facility, a copy of the member's dietary record log prior to and after the loss of the denture or dentures shall be required;

(E) Replacement denture prosthesis shall only be considered for purposes of mastication, excluding replacement for the reasons of cosmetics and phonation. The department shall require medical documentation from the member's dentist or physician that establishes the member's medical need for the requested treatment in accordance with the definition of medical necessity provided in subsection (a) of section 17b-259b of the Connecticut General Statutes; and

(F) Replacement dentures are subject to the same requirements for the placement of the initial denture prosthesis.

(3) Removable partial dentures shall be covered when the member is missing an anterior tooth or teeth or does not have an adequate number of posterior teeth in functional occlusion for mastication, subject to the following:

(A) Teeth with sixty percent or greater bone loss shall be extracted and included in the partial denture prosthesis;

(B) The member shall have at least two stable abutment teeth;

(C) In the absence of qualifying posterior missing teeth, the member may have one or more missing anterior teeth;

(D) When both maxillary and mandibular dentures are requested, there shall be teeth missing bilaterally in both arches;

(E) Unilateral removable partial dentures are covered if a member is missing posterior teeth in one quadrant and missing posterior teeth in the opposite quadrant or arch resulting in a lack of an adequate surface area for mastication;

(F) If a member requires a complete denture within the first two years of placement of a partial denture by the same provider, the money for the partial denture shall be recouped; and

(G) All preventive, restorative, endodontic and extraction procedures shall be completed prior to requesting prior authorization and before constructing the partial denture.

(4) Denture labeling shall be reimbursed for members who reside in long-term care facilities only.

(5) Delivery of dentures.

(A) The date of service for reimbursement purposes as defined in the provider contract reflects the date of delivery of the permanent prosthesis;

(B) The provider shall have the patient sign the department's form acknowledging the receipt and acceptance of the denture, provide an explanation of the department's replacement policy, maintain the documentation in the patient's chart and shall give the brochure "Caring for Your Dentures" to the patient; and

(C) If a member fails to receive and accept the final removable or complete denture or dentures and the provider has made at least three attempts to contact the member, the provider may submit for reimbursement of the laboratory bill which must include the laboratory's invoice.

(6) Repair of dentures shall be covered after twelve months from the date of initial delivery, unless an unusual undocumented circumstance applies, as follows:

(A) A direct or indirect reline or rebase of denture prosthesis six months after post-denture prosthesis delivery;

(B) Direct reline office procedures one time per prosthesis every twelve months; and

(C) Indirect processed procedures every twelve months.

(7) Fixed acid-etched partial dentures for members under the age of twenty-one years who have congenitally missing or traumatic loss of anterior teeth may be covered with prior authorization and subject to the following limitations:

(A) Acid etch or "Maryland" bridgework shall be the only type of fixed bridgework covered;

(B) The member shall have all decay treated and shall be free from gingivitis or periodontal disease;

(C) The member's abutment teeth shall be sound; and

(D) The member shall be able to maintain oral hygiene, which includes brushing and flossing daily.

(8) Implant supported overdentures.

(9) Implants if the member has had facial trauma or a severe infection that results in the removal of necrotic bone or resection due to tumors and there is missing bone, and the implants are used to restore occlusion or support the facial prosthesis. Implants may be covered:

(A) When there is not enough alveolar ridge to support a denture with medical necessity documentation, intraoral photographs, diagnostic imaging and diagnostic casts are submitted for prior authorization; and

(B) For members under the age of twenty-one years for missing anterior teeth based on medical necessity.

(10) Devices for obstructive apnea will be covered under durable medical equipment.

(j) The department shall cover the following restorative services:

(1) Amalgam, composite or glass ionomer fillings performed by the same provider shall be limited to one restoration per every two years to the same tooth regardless of the number of surfaces treated and are subject to the following:

(A) More than one amalgam, composite or glass ionomer filling placed on a single surface shall be considered a single restoration. The predominant material (amalgam, composite or glass ionomer) used for the restorations shall be the material used for determining the billing code;

(B) More than one amalgam, composite or glass ionomer filling placed in multiple separate surfaces on a tooth is considered a multi-surface restoration counting duplicative surfaces as one surface. If multiple restorative materials are used, the predominant material shall be the material used for determining billing codes;

(C) More than one amalgam, composite or glass ionomer fillings placed in two separate locations, the buccal pit or lingual groove, on the first permanent molars, tooth numbers 3, 14, 19 and 30, shall be considered separate restorations and:

(i) On the first permanent maxillary molars, tooth numbers 3 and 14, the distinction is limited to the occlusal-lingual surfaces; and

(ii) On the first permanent mandibular molars, tooth numbers 19 and 30 the distinction is limited to the occlusal-buccal surfaces;

(D) Glass ionomers may be used in lieu of composite resin when placed on root surfaces of teeth if the member has a high rate of decay or is unable to maintain oral hygiene;

(E) Placement of liners or bases and the final polishing shall be considered part of the final procedure; and

(F) Amalgam and composite resin restorations are expected to last a minimum of five years and may be recouped if determined to be at an unacceptable level and of poor quality or inappropriately placed.

(2) Composite resin infiltration of incipient lesions.

(3) Guided enamel restorative regeneration.

(4) Artificial permanent crowns:

(A) For members under the age of twenty-one years and at least sixteen years of age where root formation is complete;

(B) For members twenty-one years of age and over where the crown is used to restore a tooth where there is excessive loss of tooth structure due to caries or trauma, or root canal therapy has been performed and the prognosis is favorable. The tooth to be treated must be in occlusion with a natural tooth or the opposing tooth will be immediately restored or replaced with an artificial tooth;

(C) For members with bilaterally missing teeth in the same arch, except such members are not eligible for multiple, single crowns to restore deteriorated dentition unless the crowns will form the last remaining abutment tooth or teeth in an arch for partial denture placement; and

(D) Crown types covered include:

(i) Cast crowns on all permanent teeth;

(ii) Ceramic/zirconia crowns on all primary and permanent teeth;

(iii) Milled crowns which follow the provisions of this section for crowns on permanent teeth;

(iv) Porcelain fused to metal crowns on all permanent teeth;

(v) Stainless-steel crowns on primary teeth or permanent teeth when the root apices are open or if the tooth is nearing exfoliation, there is remaining root structure which warrants the placement of a stainless-steel crown; and

(vi) Aesthetic coated stainless steel crowns for primary and permanent teeth.

(5) Indirect placed onlays with prior authorization.

(6) Core build up when greater than fifty percent of the tooth structure is missing, subject to the following:

(A) Shall not be used in conjunction with or when a tooth has received an amalgam or composite restoration in the previous three months; and

(B) Shall not be used in conjunction with a stainless-steel crown on a primary tooth.

(7) Guided enamel regeneration.

(8) Pin retention.

(9) Sedative filling for vital teeth two times per tooth per year.

(10) Replacement of an existing artificial crown shall be covered only when the crown becomes defective in the permanent teeth after a ten-year period has lapsed.

(11) Replacement of a stainless-steel crown or zirconia crown in the primary dentition shall be covered if the crown is lost and only if the tooth is not nearing exfoliation and there is remaining root structure which warrants replacement of the crown.

(12) Replacement of a lost crown on a permanent tooth shall be reimbursed to the same provider only after a three-year period has lapsed.

(k) Notwithstanding the provisions of subsections (a) through (j), inclusive, of this section, a type of non-experimental dental service not described in or limited by said subsections to situations not including an individual member's particular situation may be authorized through the prior authorization process where the member's dentist or physician provides required medical documentation establishing the member's medical need for the requested treatment in accordance with the definition of medical necessity in subsection (a) of section 17b-259b of the Connecticut General Statutes.

(l) Notwithstanding the provisions of subsections (a) through (j), inclusive, of this section, a numerical or frequency limitation on a type of dental service shall not be applied in instances where the member's dentist or physician through the prior authorization process provides medical documentation establishing the member's medical need for the quantity or frequency in accordance with the definition of medical necessity provided in subsection (a) of section 17b-259b of the Connecticut General Statutes.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1012 Services not covered

The following services are not covered by the CMAP:

(a) Adjunctive dental services: General anesthesia and conscious sedation

(1) For members over the age of twelve who do not have a cognitive impairment for the extraction of less than five teeth except for the surgical extraction of four or more third molars.

(2) For members twenty-one years of age and over who do not have trauma, an oro-facial infection or a cognitive impairment for general dental treatment, including root canal therapy, retreatment of a root canal, restorative, prophylactic, non-surgical periodontic therapies, orthodontic or prosthodontic procedures.

(3) If any form of inhalation or intravenous sedation is employed.

(b) Diagnostic Services:

(1) Periapical or tomosynthesis diagnostic imaging performed on the same date of service as a complete mouth series or tomosynthesis or full mouth series.

(2) Periapical or tomosynthesis diagnostic imaging taken on the same tooth during active endodontic treatment or not later than fourteen days after endodontic therapy is completed;

(3) Periapical or tomosynthesis diagnostic imaging taken for general or screening purposes unless infection, trauma or a developmental abnormality is suspected and is documented in the patient's chart.

(4) Panoramic diagnostic imaging taken for the purposes of endodontics, periodontics, or for the purpose of diagnosing interproximal decay.

(5) Panoramic diagnostic imaging taken for the purposes of routine screening for children under the age of eight years.

(6) Any images that are not of diagnostic quality.

(c) Endodontic Services:

(1) Apexogenesis for members the age of eighteen years and over.

(2) Endodontic services shall not be covered for a tooth where the member expects to receive a removable partial denture replacing multiple teeth in the same arch unless the tooth is functioning as a rest.

(3) Third molars are not covered unless the tooth or teeth will function as a rest for a partial denture.

(4) Pulpotomy on a primary tooth nearing exfoliation when periradicular pathology extends into the underlying developing tooth bud, when the tooth is non-vital, and if excessive internal root resorption has occurred or the pulp floor naturally or iatrogenically opens into the bifurcation.

(5) Pulpotomy for a permanent tooth by the same provider that is expecting to perform complete root canal therapy during the one-year period after the pulpotomy has been performed.

(d) Oral Surgical Services:

(1) Alveoloplasty in conjunction with single or singular extractions.

(2) Brush biopsy.

(3) Cosmetic surgical services.

(4) Suture of wounds when the laceration is caused by a surgical procedure or occurs secondary to extraction or trauma resulting from a surgical procedure.

(5) Orthognathic surgery for members the age of thirty years and over who do not have a severely handicapping malocclusion score of greater than fifty on the Salzmann Handicapping Malocclusion Index.

(6) Orthognathic surgery that is cosmetic and not medically necessary because it is primarily to change physical appearance that would be within normal human anatomic variation.

(7) Genioplasty or anterior mandibular osteotomy that is considered cosmetic and not medically necessary because it is performed to reshape or enhance the size of the chin to restore facial harmony and chin projection and it is not associated with masticatory malocclusion.

(8) Post-operative follow up visits, including post-operative radiographs, for the first two postoperative visits shall not be reimbursed separately and shall be included in the global fee for surgical procedures.

(e) Periodontal Services:

(1) Any surgical periodontal procedure without obtaining prior authorization through a request for EPSDT special services.

(2) Any non-surgical chemotherapeutic or mechanical periodontal therapies without obtaining prior authorization through a request for EPSDT services.

(3) Scaling and root planing without obtaining prior authorization.

(4) Splinting of teeth without obtaining prior authorization through a request for EPSDT services.

(5) Periodontal therapy without obtaining prior authorization.

(f) Preventive Services:

(1) Counseling or education services.

(2) Nutritional counseling.

(3) Habit breaking devices unless orthodontic prior authorization is requested.

(4) Removable unilateral space maintainers.

(5) Space maintainers for anterior teeth.

(6) Space maintainers in conjunction with active orthodontic therapy.

(7) Toothbrush prophylaxis.

(8) Athletic guards for members twenty-one years of age and over.

(g) Prosthodontic Services:

(1) Cosmetic dentistry.

(2) Fixed conventional partial dentures, including bridges.

(3) Immediate dentures.

(4) Implant placement for the replacement of teeth that are lost due to dental disease.

(5) Routine implant placement for the replacement of single or multiple teeth lost unless significant congenital abnormalities, surgical reconstruction or traumatic situations exist.

(6) Implant placement for congenitally missing lateral incisors.

(7) Indirect labile veneers.

(8) Nesbit partial dentures.

(9) Office visits to obtain a prescription where the need for such prescription has already been ascertained.

(10) Complete or partial removable dentures for members who are in a semi-conscious or unconscious state.

(11) Sleep apnea devices for neurological reasons causing sleep apnea.

(h) Restorative Services:

(1) Procedures performed for purely cosmetic or aesthetic reasons.

(2) Coping restorations.

(3) Gold foil restorations.

(4) Direct or indirect inlays.

(5) Indirect labial veneers.

(6) Unilateral removable appliances for one arch.

(7) Placement of an indirect pulp cap.

(8) Procedures to teeth nearing exfoliation or to teeth that are non-restorable.

(9) Procedures to teeth with less than 75% bone support or significant periodontal involvement.

(10) Any procedure, service or goods not explicitly allowed pursuant to section 17b-262-866 of the Regulations of Connecticut State Agencies.

(i) Any service or good that is not covered or approved by Medicaid for a member may be paid by the member if she or he chooses to undergo as a private pay patient. The provider shall make a clear and concise written agreement at the initial treatment planning of the procedure with the member regarding financial responsibility due to the service not being covered by Medicaid and include a payment schedule if applicable for the non-covered procedure.

(j) Any non-experimental procedure or service which is not listed on the dental fee schedule shall not be covered unless the provider submits a request for prior authorization pursuant to section 17b-262-1014 of the Regulations of Connecticut State Agencies and provides required medical documentation establishing the member's medical need for the requested service in accordance with the definition of medical necessity set forth in subsection (a) of section 17b-259b of the Connecticut General Statutes.

(k) Any procedure that has been attempted but not completed.

(l) Any procedure that is an upgrade to the Medicaid covered procedure where the member is balanced billed for the difference.

(m) Any service divided into smaller components of treatment that is by common definition and standards of care included in a single Current Dental Terminology code.

(n) Unbundling of a group of procedures normally performed in a single visit as is the standard of care.

(o) Cancelled or missed appointments.

(p) Office visits to obtain a prescription when the need has already been determined.

(q) Procedures, treatments, or surgeries of an unproven, experimental or research nature or that are not proven as safe or effective as documented by peer review literature and best practices.

(r) Procedures, treatments, or surgeries more than those deemed medically necessary by the department to treat a member's condition, or for services not directly related to the member's diagnosis, symptoms, or medical history.

(s) Scheduling appointments.

(t) Admitting services or any inpatient dental services performed by the admitting dentist if the admission was not approved by the department or its designee as medically necessary in either a preadmission or post-procedure review.

(u) Services, procedures or dentures not provided.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1013 Documentation

(a) The member's chart and dental records shall contain the following information:

(1) The member's full name, including such member’s first, middle, and last name;

(2) The member's residential and mailing address;

(3) The member's date of birth;

(4) The member's phone number;

(5) The member's Medicaid identification number and social security number;

(6) Third party insurance coverage, if applicable;

(7) Medical history, including a listing of current pharmaceuticals;

(8) Charting of the member's present and missing teeth;

(9) Charting of the member's restorations, fixed dental appliances and removable prosthetic appliances for general dentists, pediatric dentists, prosthodontists, and public health dentists;

(10) Charting of the member's periodontium for general dentists, prosthodontists, periodontists, and public health dentists;

(11) The treatment plan for the member and a signed consent form;

(12) The date and written or electronic signature with each entry in the member's dental chart. Initials are not acceptable;

(13) Full description of the procedure or procedures performed, including the location, tooth number, soft tissue location, techniques or materials used in the procedure, if applicable, that justifies the Current Dental Terminology code used for the procedure billed;

(14) Notes regarding any diseased states, unusual circumstances or conditions;

(15) For periapical or other images that are not taken in conjunction with a complete mouth series, the provider shall document the reason for taking the periapical image or other images and include the tooth numbers with such image;

(16) All imaging shall be properly labeled and shall include the date the images were taken, the reason why the image was taken and the interpretation of the imaging by a licensed dentist;

(17) The member's diagnosis, vital signs and the reason for the procedure being performed on each date of service; and

(18) A copy of any required departmental dental forms.

(b) Records may be kept in electronic format or in paper chart format, but diagnostic imaging or images stored in an electronic format shall be maintained in a state that can reproduce the diagnostic quality. Storage of the patient record contents offsite shall be acceptable if the documentation can be accessed as needed.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1014 Need for Service and Authorization Process

(a) The need for a dental service includes any services that are deemed by the department to be medically necessary and that:

(1) Are within the scope of the dentist's practice; and

(2) Are made part of the recipient's medical record.

(b) In order to receive payment from the department, each dental provider shall comply with all prior authorization requirements. The department, in its sole discretion, shall determine what information is necessary to approve a prior authorization request, provided such determination includes a finding of medical necessity and is consistent with sections 17b-262-1006 to 17b-262-1017, inclusive, of the Regulations of Connecticut State Agencies. Prior authorization does not guarantee payment unless all other requirements for payment are met, including the member being eligible for services at the time of service.

(c) Prior authorization or post-procedure review of dental services shall be determined by patient age and the dental taxonomy of the rendering dentist in accordance with the following:

(1) Procedures that require prior authorization and post-procedure review by the department or its designee may be found adjacent to the dental code on the department's dental fee schedule;

(2) Providers shall submit requests for prior authorization to the department or its designee electronically through a secure portal or by submitting a completed request on an American Dental Association claim form;

(3) Supporting documentation shall include the following:

(A) Charted records of the dentition and soft tissue;

(B) Documentation of a condition or disease state from another healthcare provider or agency;

(C) Models of the dental arch with bite registration when appropriate;

(D) Photographs electronically or printed on photographic paper;

(E) Diagnostic imaging;

(F) Treatment notes;

(G) Post-procedure review requests containing the date of service; and

(H) Any teeth expected to be extracted that are documented on the prior authorization or post procedure review claim form.

(4) All requests for EPSDT related services shall be submitted using a prior authorization claim form. The following information shall be included:

(A) Diagnosis;

(B) Supporting medical or diagnostic documentation;

(C) Clinical description of the condition as it presents; and

(D) Proposed treatment plan.

(5) The initial prior or post procedure review authorization period is valid up to twelve months from the date the service is authorized, providing that the patient remains eligible for the CMAP.

(d) Requests submitted for services that are performed more often than frequency limitations may be allowed in instances of medical necessity and may be requested by prior authorization through the department or its designee.

(e) Fully developed individualized treatment plans that contain phase one, two and the third stage of treatment shall be presented for review and approval with any combination of endodontic or prosthodontic services that require prior authorization. The plan shall be clear and include all teeth to be restored or extracted, provided:

(1) The department or its designee reserves the right to amend any submitted treatment plan based on prognosis and the dental regulations; and

(2) Failure to provide a treatment plan shall result in the denial of services submitted for prior authorization.

(f) Any requests for modifications of any authorized treatment plan or service shall include the reason and supporting documentation for such requested modification. The department or its designee reserves the right to modify treatment plans or dental services to the least expensive but appropriate treatments that will restore form or function as directed by a qualified licensed dentist.

(g) Any member denied prior authorization, in whole or in part, for any reason shall be provided a written notice explaining the action and advising of the right to appeal such action through requesting an administrative hearing with the department in accordance with section 17b-60 of the Connecticut General Statutes.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1015 Payment

(a) The Commissioner shall establish the fees contained in the dental fee schedule annually. The fees shall be based on moderate and reasonable rates prevailing in the respective communities where the services are rendered.

(b) Payments shall be made at the lower of:

(1) The usual and customary charge to the public;

(2) The fee as contained in the dental fee schedule published by the department; or

(3) The amount billed by the provider.

(c) A dental provider who is fully or partially salaried by a hospital, public or private institution, physicians' group, dental group, or clinic may not receive payment from the department unless the dental provider maintains an office for private practice at a separate and distinct location from the hospital, institution, physicians’ group, dental group, or clinic in which the provider is employed.

(d) Dentists who are solely hospital, institution, physicians’ group, dental group or clinic-based, either on a full time or part time salary, shall not be entitled to direct payment from the department for services rendered to Title XIX recipients.

(e) The department shall reimburse dental providers enrolled in the CMAP for services provided to members by dental residents or dental students working under the supervision of a licensed dentist.

(f) The department or its designee may refer a member for an evaluation or radiographically or clinically evaluate any dental procedure or treatment provided to the member to ensure the appropriate treatment was performed in accordance with the prevailing standard of care. The department may recoup the fee rendered for any service that was not performed or if substandard care was rendered to a member.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1016 Billing

(a) All dental services performed on behalf of members that do not require prior authorization or post-procedure review shall be recorded in the member's permanent record and submitted to the department's claims processing agent either electronically or in hard copy.

(b) The provider shall submit to the department or its designee the amount billed to the department that represents the provider's usual and customary charge for the services delivered.

(c) If the provider does not charge usual and customary fees and retroactive mass adjustment is made, the department shall not compensate a provider for the difference between the adjustment and the fee billed.

(d) Timely filing for dental claims, including orthodontic services, shall be one hundred and twenty days from the date of service.

History

• Effective July 9, 2025

Regs., Conn. State Agencies § 17b-262-1017 Marketing Guidelines

(a) Prohibited marketing activities. Any dental provider, including a dentist, dental clinic, mobile dental clinic or SBHC, participating in the CMAP shall not engage in any marketing activity, including any dissemination of material or other attempt to communicate, that:

(1) Involves unsolicited personal contact, including door-to-door solicitation, solicitation at a childcare facility or other type of facility, direct mail, or telephone, with a Medicaid member or a parent whose child is enrolled in the CMAP;

(2) Is directed at the member or parent solely because the member or the parent's child is receiving benefits under the CMAP; and

(3) Is intended to influence the member's or parent's choice of provider.

(b) Permissible marketing activities by dental providers participating in the CMAP. Nothing in this section prohibits a dental provider participating in the CMAP from:

(1) Engaging in a marketing activity, including any dissemination of material or other attempt to communicate, that is intended to influence the choice of provider by a Medicaid client or a parent whose child is enrolled in the Medicaid program, if the marketing activity:

(A) Is conducted at a community-sponsored educational event, health fair, outreach activity, or other similar community or nonprofit event in which the provider participates and does not involve unsolicited personal contact or promotion of the provider's practice that is not used as part of health education; or

(B) Involves only the general dissemination of information, including by television, radio, newspaper, or billboard advertisement, and does not involve unsolicited personal contact.

(2) As permitted under the dental provider's contract, engaging in the dissemination of material or another attempt to communicate with a Medicaid member or a parent whose child is enrolled in the CMAP, including communication in person or by direct mail or telephone, for the purpose of:

(A) Providing an appointment reminder;

(B) Distributing promotional health materials;

(C) Providing information about the types of services offered by the provider; or

(D) Coordinating patient care.

(3) Engaging in a marketing activity that has been submitted for review and obtained a notice of prior authorization from the department under subsection (c) of this section.

(c) Review and prior authorization. A dental provider participating in the CMAP may submit proposed marketing materials to the department or its designee for review and prior authorization to ensure that the materials are in compliance with this section. The department may grant or deny a provider's request for prior authorization in accordance with the following:

(1) The department or its designee shall review materials submitted for approval and respond to review requests from the provider or provider's offices not later than sixty days after the receipt of the material;

(2) If the department or its designee does not respond to materials submitted for approval not later than sixty days after submission, the provider, provider group, facility or its representative may use the materials as presented; and

(3) The department may request revisions or recall any materials that advertise or represent CMAP in advertisements or specific materials at any time.

History

• Effective July 9, 2025

17b-342 Connecticut Home Care Program for Elders, Standards for Access Agencies and Assisted Living Service Agencies Program Requirements

Regs., Conn. State Agencies § 17b-342-1 Connecticut home care program for elders; standards for access agencies and requirements for assisted living service agencies

(a) Scope

The purpose of sections 17b-342-1 to 17b-342-5, inclusive, of the Regulations of Connecticut State Agencies is to describe non-financial program requirements, services available and limitations under the Connecticut Home Care Program for Elders. This program provides home health services, community based services and assisted living services funded under a waiver to the Medicaid program and under a program funded with an appropriation by the General Assembly. The financial eligibility requirements for these three parts of the program differ and are specified under sections 2540.92 and 8040 to 8040.50, inclusive, of the Uniform Policy Manual of the Department of Social Services. This program includes all clients transferred from the following programs as of July 1, 1992: Promotion of Independent Living for the Elderly, Department on Aging Home Care Demonstration Project and Long Term Care Preadmission Screening and Community Based Services Program. Sections 17b-342-1 to 17b-342-5, inclusive, of the Regulations of Connecticut State Agencies also establish standards and requirements for access agencies and assisted living service agencies which operate under the Connecticut Home Care Program for Elders and the Connecticut Partnership for Long Term-Care.

(b) Definitions

As used in sections 17b-342-1 to 17b-342-5, inclusive, of the Regulations of Connecticut State Agencies the following definitions apply:

(1) "Access Agency" means an organization which assists individuals in receiving home and community based services by conducting assessments and developing plans of care tailored to the needs of the individuals and making arrangements with service providers. If needed by the individuals the access agency shall also coordinate services and monitor the quality of the services over an extended period, but the access agency shall not be a provider of services, other than to provide care management to department clients that are approved for program participation. An access agency shall have a governing body which assumes all financial and programmatic responsibility for the agency's activities and shall meet the requirements pursuant to section 17b-342-1(h) of the Regulations of Connecticut State Agencies and the provisions set forth in a legal contractual provider agreement;

(2) "Applicant" means an elderly person who directly or through any representative, including but not limited to, a guardian, conservator, family member, physician, social worker or discharge planner completes a Home Care Request Form and submits it to the department or indicates to the department a desire to be considered for services under the Connecticut Home Care Program;

(3) "Assisted Living Services Agency" or "ALSA" means an agency authorized to provide and arrange for the delivery of assisted living services to clients. The participating ALSA shall be licensed with the Department of Public Health and shall enter into a contract with a managed residential care facility that has been approved for participation and be an enrolled service provider with the Department of Social Services. The ALSA shall comply with the standards and requirements in section 19-13-D105 of the Regulations of Connecticut State Agencies;

(4) "Assisted living services" means a special combination of housing, supportive services, personalized assistance and health care designed to respond to the individual needs of clients who need help with activities of daily living and instrumental activities of daily living in managed residential care facilities approved for participation. Services are delivered in a service package model within a specific service cost package level;

(5) "Assessment" means a comprehensive written evaluation of an individual's medical, psychosocial and economic status, degree of functional impairment and related service needs. For the purposes of the Connecticut Home Care Program, this assessment shall include a face-to-face interview and shall utilize a standard assessment tool approved by the department;

(6) "Average nursing facility cost" means a weighted average calculated by multiplying the nursing facility Medicaid rates in effect on July 1 of that calendar year for each facility by their respective number of days, adding the products and then dividing that total by the total patient days, and reducing the result by the average applied income for nursing facility patients. This figure shall be used when calculating the cost limits for fee-for-service;

(7) "Client" means a person who has met the requirements for eligibility and enrolled as an active participant in the program;

(8) "Commissioner" means the Commissioner of Social Services or his or her designee;

(9) "Community based services" includes but is not limited to care management, adult day services, assisted living services, chore services, companion services, elderly foster care, home delivered meals, homemaker services, laundry services, mental health counseling, minor home modification services, respite care, transportation and personal emergency response systems;

(10) "Connecticut Home Care Program" or "the Program" means the program operated for elders pursuant to section 17b-342 of the Connecticut General Statutes. This program was formerly known as the Long Term Care Facility Preadmission Screening and Community Based Services Program and includes all home care clients who were transferred from the former Department on Aging and the department's Fairfield pilot program clients;

(11) "Cost of home care services" means the total amount of direct costs in state administered public funds expended to provide the home health and community based services set forth in sections 17b-342-1 to 17b-342-5, inclusive, of the Regulations of Connecticut State Agencies;

(12) "Day" means calendar day;

(13) "Department" or "DSS" means the Department of Social Services, its employees and agents;

(14) "Elder" or "elderly person" means an individual 65 years of age or older and a resident in the State of Connecticut;

(15) "Emergency admission" means that an individual has been determined by the department to be in need of protective services and is referred to a nursing facility for admission by an appropriate state agency pursuant to the provisions of section 17b-450 to 17b-460,inclusive, of the Connecticut General Statutes. This does not include nursing home placements from the community in which the family desires to make the placement as soon as possible because of an applicant's deteriorating health condition;

(16) "Fee-for-service" means a service delivery system which a cost-and-payment methodology is used for services rendered to care-managed and self-directed clients who receive benefits under the Medicaid waiver or state- funded portions of the program, except those services rendered to clients participating in the assisted living services component of the program;

(17) "Health care professional" means a Connecticut licensed physician, Connect-icut licensed nurse, social worker or hospital discharge planning personnel;

(18) "Health screen form" means a department form used to determine whether an individual is at risk of institutionalization and if the individual meets the functional criteria for the program. This form includes information regarding the person's physical (functional and medical) and psycho-social status;

(19) "Home care request form" means a department form used to indicate if an applicant appears to be financially eligible and wishes to apply for the Connecticut Home Care Program;

(20) "Home care services" means any combination of community based services and home health services as defined in sections 17b-342-1(b)(9) and (21) of the Regulations of the State Agencies which enable elders to live in noninstitutional settings. Such services may be provided to elders living in private homes, congregate housing, assisted living demonstration project facilities, housing and urban development facilities, private facilities and homes for the aged and other community living situations as long as the services needed are not considered a regular component of the services of the community living situation;

(21) "Home health services" for the purposes of the Connecticut Home Care Program means those medical procedures included in the definition of home health services under the Medicaid program. Home health services provided under the Connecticut Home Care Program shall be defined in the same way and covered to the same extent as they are under the Medicaid program;

(22) "Hospital" means a general short term or chronic disease hospital licensed by the Department of Public Health pursuant to section 19a-490(b) of the Connecticut General Statutes;

(23) "Medicaid recipient" means an individual who has been determined eligible for Medicaid benefits;

(24) "Nursing facility" means a facility licensed by the Department of Public Health pursuant to section 19a-490(c) of the Connecticut General Statutes as a chronic and convalescent nursing home or rest home with nursing supervision and certified to participate in the Medicaid program as a nursing facility as evidenced by a Medicaid provider agreement between the department and the facility. For purposes of this section, the term "nursing facility" does not include an Intermediate Care Facility for the Mentally Retarded (ICF/MR) or any other residential or inpatient health care facility;

(25) "Person" means an individual applicant or elder client enrolled in the Connecticut Home Care Program and a representative authorized to act on the applicant or client's behalf including guardians, conservators or other legally authorized representatives;

(26) "Plan of care" means a written individualized plan of home care services which specifies the type and frequency of all services and funding sources required to maintain the individual in the community, the names of the service providers and the cost of services, regardless of whether or not there is an actual charge for the service. The plan of care shall include any in-kind services and any services paid for by the client or the client's representative;

(27) "Re-evaluation" means a review of the functional and financial status of an applicant or client for the purpose of establishing functional and financial eligibility and determination of needs for consideration for program participation;

(28) "Related party" means an entity which is associated with another by common ownership or control. Control of or by another entity exists where an individual or organization has the power, directly or indirectly, to significantly influence or direct the actions or policies of an organization or institution. Common ownership exists when an individual or individuals possess significant ownership or equity in the provider or organization serving the provider;

(29) "Relative" means spouse, natural parent, child, sibling, adoptive child, adoptive parent, stepparent, stepchild, stepbrother, stepsister, father-in-law, mother-in-law, son-in-law, daughter-in-law, sister-in-law, grandparent and grandchild;

(30) "Risk of institutionalization" means that the individual is in danger of hospitalization or nursing facility placement due to his or her medical, functional or cognitive status but would be able to remain at home, without the creation of an unacceptable risk to the safety of the individual or others, if home care services were provided. This definition includes individuals who are currently institutionalized and who are at risk of continued institutionalization unless home care services are provided;

(31) "Self-directed care" means the ability of the client to be responsible for the self-direction, coordination and arrangement of his or her plan of care under the fee-for-service delivery option of the program;

(32) "Standard assessment tool" means a department form used to conduct an initial assessment and re-evaluation of applicants and clients for the purpose of establishing functional eligibility and determination of needs for consideration for program participation;

(33) "Status review" means a review of the functional and cognitive status of a client enrolled in the program based on a face-to-face interview in order to reevaluate the plan of care and program participation when the individual is not receiving ongoing monitoring by an access agency or services through any program component;

(34) "State administered public funds" means direct payments of state or federal funds allocated by a state agency to an individual or to an agency to pay for medical or social services required to be provided under an individual's plan of care;

(35) "Unacceptable risk" means a situation which places an individual's life or health in immediate jeopardy. In determining whether an unacceptable risk exists, the department shall take into account the provider's professional standards, the client's needs and the client's informed viewpoint with regard to the potential risk;

(36) "Waiting list" means a record maintained by the department for the Connecticut Home Care Program that includes the names of the applicants seeking to be screened for program participation and specifies the date the contact was made. The department may maintain separate waiting lists, regional or statewide, depending on the program component and type of service.

(c) General

(1) The purposes of the Connecticut Home Care Program are to:

(A) Assess whether cost-effective home care services can be offered to elders who are at risk of institutionalization;

(B) determine, prior to admission to a nursing facility whether the elder does or does not need nursing facility services;

(C) authorize department payment for elders for nursing facility care or home care services if appropriate; and

(D) provide a full range of community based services, home care services and assisted living services to eligible individuals who choose to remain in the community, if such services are appropriate, available and cost effective.

(2) The program application process shall consist of:

(A) A financial eligibility determination in accordance with section 17b-10-1 of the Regulations of Connecticut State Agencies and the department's Uniform Policy Manual sections 8040 and 2540.

(B) an initial determination as to the elder's needs, which shall include the category of services needed, the elder's functional eligibility and potential service options under the program. The initial determination shall be conducted by department staff based on completion or review of the health screen form.

(i) As a result of a review of the health screen form, the department shall determine:

(aa) Whether the elderly person meets the functional level for admission to the program;

(bb) whether the elderly person needs care that would otherwise be provided in a nursing facility;

(cc) which program component and category of services may be appropriate and authorized for the person in the community;

(dd) whether an initial assessment is deemed appropriate. The assessment shall be conducted only after the elder or the elder's representative gives written consent. The assessment shall include, but not be limited to: Explaining Program participation to the elder or the elder's representative; explaining client's rights and responsibilities; explaining the state's recovery policy; confirming client's functional eligibility and financial information; determining if the elder can be offered a cost-effective plan of care to enable the elder to remain in the community without creating an unacceptable risk to the elder or others;

(ee) whether the elderly person should be admitted to a nursing facility without an assessment; and

(ff) whether the elderly person requires assistance in the completion of the financial application or other assistance to establish program eligibility and participation. This does not relinquish the elderly person's responsibility to comply with all program requirements necessary to determine eligibility and program participation.

(ii) Initial determination as to the elder's needs, the category of services and functional level based on the health screen form shall be valid for sixty (60) days unless the department receives information which indicates that a person's condition has changed significantly.

(iii) The health screen form shall also be used to verify recommendations for short term placement. For purposes of this section, a short term placement means a maximum stay of ninety (90) days for rehabilitative or recuperative care which is expected to result in the person's return to the community.

(C) a referral to other sources of assistance, including authorization for admission to a nursing facility without an assessment, if appropriate.

(D) The department shall send a screening outcome letter to the applicant to provide notice of the initial functional and financial screening determination issued and to advise the applicant of their rights.

(3) Determination of Need

(A) The determination as to whether the elder is at risk of institutionalization or needs services that would otherwise require institutionalization shall be made by the department based upon an evaluation of the completed health screen and an assessment, if deemed appropriate.

(B) The basis for determining the level, type, frequency and cost of services and funding source that an elder may receive under the program shall be determined by their financial and functional eligibility and need for services.

(C) Functional eligibility means the elder must be at risk of institutionalization and needs assistance with at least one critical need. For the purposes of eligibility, critical needs are defined as "activities of daily living" which are hands-on-activities or tasks that are essential for a client's health and safety. These include, but are not limited to; bathing, dressing, transferring, toileting (bowel or bladder), feeding, meal preparation, administration of medication or ambulation.

(4) Category types

The following three category types define the funding sources which pay for the client's community based services and home health services. The category types apply to care managed cases, self directed cases and the assisted living service program component.

(A) Category Type 1:

This category applies to elders who are at risk of institutionalization but who might not immediately enter a hospital or nursing facility in the absence of the program. This category type is available to elders who meet the financial and functional eligibility criteria for the state-funded portion of the program as defined in section 17b-10-1 of the Regulations of Connecticut State Agencies and the department's Uniform Policy Manual section 8040. Some clients under Category Type 1 may be Medicaid recipients because they do not meet the functional criteria for the Medicaid waiver portion of the program.

(B) Category Type 2:

This category applies to elders who would otherwise require admission to a nursing facility on a short or long term basis. This category type is available to elders who meet the financial and functional eligibility criteria for the state-funded portion of the program as defined in the department's Uniform Policy Manual section 8040.

(C) Category Type 3:

This category applies to elders who, but for the provision of home care services, would require nursing facility care funded by Medicaid. This category type is available to elders who meet the financial and functional eligibility criteria for Medicaid under the federal waiver as defined in the department's Uniform Policy Manual section 2540.92.

(D) The program category type identifies the maximum funding level available for all program clients. The access agencies, department staff and assisted living service agencies shall specify the category type on the client's plan of care in the funding source section.

(5) The determination of services for the program's fee-for-service and assisted living services option consists of:

(A) Completion of an initial assessment by the access agency or the department;

(B) a determination if program participation is feasible;

(C) a determination of what service options under the program are appropriate;

(D) development of a plan of care for care managed cases by the access agency or the department. For clients participating in the assisted living service option, the assisted living service agency shall develop the plan of care;

(E) a determination as to the feasibility and cost-effectiveness of home care services, if deemed appropriate; and

(F) authorization for community based services and home health services in the community.

(d) Initial Assessment and Plan of Care

(1) A person who is determined by the department to appear to meet the financial and functional eligibility criteria of the Connecticut Home Care Program shall be referred by the department to an access agency or the department's staff for an initial assessment as defined in section 17b-342-1 (b)(5) of the Regulations of Connecticut State Agencies. The results of the initial assessment shall be used to:

(A) Determine or verify the following:

(i) Whether program participation is feasible;

(ii) whether the elderly person's financial information;

(iii) whether the elderly person's functional eligibility;

(iv) whether the assisted living services option is appropriate; if appropriate the access agency, department staff or department designee will complete an initial assessment and forward the paperwork to the department for review and processing;

(v) whether the fee–for-service option is appropriate; if appropriate, verify the elderly person's category of services for fee-for-service;

(vi) the individualized plan of care based on the cost limits for care-managed or self-directed care cases under fee-for-service; and

(vii) if the elder resides in an assisted living facility, develop an individualized plan of care based on the service package levels under the program's assisted living services option; and

(B) develop an individual plan of care. The access agencies, department, assisted living service agencies or department designee, when developing a plan of care, shall verify the elderly person's category type, category of services, level of service and financial information according to the following provisions:

(i) Determine the feasibility and cost-effectiveness of meeting the elderly person's care needs with home care services, pursuant to section 17b-342-3(b) of the Regulations of Connecticut State Agencies;

(ii) include a thorough exploration of all available services and funding resources;

(iii) establish an appropriate service delivery mix and arrangement which is non-duplicative and not overlapping (i.e. two similar services being provided at the same time);

(iv) clients shall only receive home care services through one of the following program service options: Fee-for-service (care-managed or self-directed) or assisted living services, if appropriate; and

(v) applicants or clients shall receive home care services through only one department program or state agency.

(2) Such person shall be given the opportunity to participate, to the extent possible, in the development of his or her plan of care.

(3) When carrying out its responsibilities for the initial assessment and development of the plan of care under the Connecticut Home Care Program, the department, the access agency, department staff or department designee may collaborate with other health care professionals providing services to the person to avoid the duplication of services. The access agencies, assisted living service agencies, department staff or department designee may, to the extent permitted by section 17b-342 of the Connecticut General Statutes, involve other service providers in the completion of the assessment and care plan development.

(4) Written notice of the outcome of the assessment shall be provided to the applicant and to hospital discharge planning personnel in the case of hospitalized patients. The applicant shall also be notified of appeal rights and procedures, in accordance with the department's Uniform Policy Manual sections 8040 and 1570.

(5) If the person refuses to participate in the assessment, or does not agree to accept a plan of care approved by the department, services shall not be available under the Connecticut Home Care Program.

(6) If the department determines that a plan of care is feasible and cost-effective under the program, the elderly person may remain in the community with assistance provided under the Connecticut Home Care Program. If home care is desired, the plan of care shall be authorized by the department.

(7) For the Connecticut Home Care Program, all home care services shall be included as part of a written plan of care developed initially and updated regularly by the access agency, the assisted living service agency, department staff or department designee. The plan of care shall specify the start date of services, services to be provided, category type of services, frequency, cost, funding source and the providers of all home care services. The type and frequency of services contained in the plan of care shall be based upon the documented needs found in the assessment of the elderly person's needs and shall be reimbursed by the department only when it is determined that each service is needed in order to avoid institutional placement. For any services where the client would be at risk if the schedule of the service varied, a back-up plan shall be identified in the total plan of care. Services not included as part of the approved plan of care or not covered by sections 17b-342-1 to 17b-342-5, inclusive, of the Regulations of Connecticut State Agencies are not eligible for reimbursement from the Connecticut Home Care Program.

(8) The client's individualized plan of care must be signed by the client or the client's representative and the access agency staff, assisted living agency staff, department staff or department designee.

(9) Services that shall be covered by another payer, including but not limited to, any covered services through Medicare, private insurance or long-term care insurance, shall be included in the plan of care.

(10) In-kind services performed by family members, volunteer groups, community action agencies or any other person or entity shall be included as part of the client's plan of care.

(e) Status Reviews

(1) Status reviews shall be provided for clients enrolled in the program in order to re-evaluate the client's status and the plan of care. Status reviews may be conducted by the access agencies, assisted living service agencies (only when authorized by the department), department staff, department designee or agencies which provide home health services or adult day health services as described in sections 17b-342-2(b) and (h) of the Regulations of Connecticut State Agencies. The staff who conduct the status reviews shall be either registered nurses or social services workers who meet the requirements pursuant to subsections (h)(1)(A) and (B)of this section.

(2) For each client there shall be no more than one agency at any time, designated by the department, which shall be responsible for status reviews. When care management services by an access agency have been temporarily interrupted due to an institutional stay, a status review may be conducted by the access agency, department staff or department designee. When ongoing care management services have been suspended, the department shall determine in advance which agency may conduct any necessary status reviews taking into consideration the needs and preferences of the client, if deemed feasible and allowed under the program.

(3) Status reviews shall be provided only when care management services by the access agency are not authorized, when deemed appropriate by the department and are limited to the following situations:

(A) No more than one time during a hospital stay which is less than or equal to 45 days;

(B) No more than one time during a nursing facility stay which is less than or equal to 45 days;

(C) No more than one time every twelve months for annual reassessment of a person not receiving care management from an access agency; and

(D) In other circumstances, when there is prior authorization by the department, such as when an elder is being reevaluated to consider having the care management from the access agency, department staff, or department designee reinstated after a lapse of more than two months in this service or when an elder is being reevaluated by the access agency, department staff or department's designee for reinstatement of program services following a nursing facility or hospital stay of more than 45 days.

(f) Forms

(1) The department shall promulgate a uniform assessment tool and all required program-related forms, including a home care request form, financial application form, a health screen form and client notices.

(2) Program information and forms shall be distributed by the department to all nursing facilities and hospitals in the State and to other providers that have contact with the elderly. Other providers may receive program information and forms upon request.

(g) Information Submission

Persons seeking home care services may initiate a screening for program participation by submitting a Home Care Request Form or by calling the department. Individuals or client representatives are responsible for assuring that all information necessary for determining eligibility including,but not be limited to, completing and submitting a program financial application and providing any required verifications, is submitted on their behalf to the department. Authorization for home care services shall not be granted, nor a plan of care implemented, until complete information has been provided and a financial and functional eligibility determination has been issued by the department. Failure to provide required information and non-cooperation with any of the program requirements shall be grounds for denial or discontinuance from the Connecticut Home Care Program.

(h) Requirements of an access agency

(1) An access agency shall ensure the selection of qualified staff.

(A) The care manager who conducts the assessments, develops care plans and provides ongoing monitoring shall be either a registered nurse licensed in the state where care management services are provided or a social services worker who is a graduate of an accredited four-year college or university. The nurse or social services worker shall have a minimum of two years of experience in health care or human services. A bachelor's degree in nursing, health, social work, gerontology or a related field may be substituted for one year of experience.

(B) Care managers shall have the following additional qualifications:

(i) Demonstrated interviewing skills which include the professional judgment to probe as necessary uncover underlying concerns of the applicant;

(ii) demonstrated ability to establish and empathic relationships;

(iii) experience in conducting social and health assessments;

(iv) knowledge of human behavior, family/caregiver dynamics, human development and disabilities;

(v) awareness of community resources and services;

(vi) the ability to understand and apply complex service reimbursement issues; and

(vii) the ability to evaluate, negotiate and plan for the costs of care options.

(C) Care management supervisors shall meet all the qualifications of a care manager plus have demonstrated supervisory ability, and at least one year of specific experience in conducting assessments, developing care plans and monitoring home and community based services.

(2) An access agency shall ensure that care managers are appropriately trained and supervised.

(A) An access agency shall provide or arrange for orientation and initial and ongoing training for care managers and care management supervisors, including training in the use of the assessment tool, required program forms, program requirements and in all aspects of program operation.

(B) An access agency shall provide or arrange for appropriate supervision and clinical consultation for care managers. For care managers with a social service background, the access agency shall have nursing staff available for consultation during normal business hours; for care managers with a nursing background, the access agency shall have a social services staff available for consultation during normal business hours.

(3) An access agency shall have the following additional responsibilities:

(A) Establish working relationships with existing service providers and provide community education regarding the care management role;

(B) Establish a quality assurance process subject to approval by the department or the Office of Policy and Management, which includes at a minimum review of client records (without client identifiers) by professionals not employed by the agency and annual evaluation of client satisfaction;

(C) Maintain client records and administrative records to support agency activities and data collection activities;

(D) Under the Connecticut Home Care Program, subcontract with vendors to provide services needed in the plan of care;

(E) Under the Connecticut Home Care Program, submit claims through the department's claims processing agent; and

(F) Under the Connecticut Home Care Program, reimburse subcontractors when appropriate.

(4) An access agency shall establish a written client bill of rights and responsibilities to be provided to the client or the client's representative at the time of admission to the program. At a minimum, the bill of rights shall state that the clients have the following rights:

(A) To be treated as an adult with respect and dignity;

(B) to be fully informed about all services, charges and choices available through the access agency;

(C) to participate in and have control over the plan of care to the greatest extent possible;

(D) to be treated fairly by the department regardless of client's race, color, religious creed, sex, marital status, age, national origin, ancestry, criminal record, political beliefs, sexual orientation, mental retardation, mental disability, physical disability, learning disability or source of payment;

(E) to have any problems or questions addressed and resolved in a timely manner;

(F) to have all personal, financial and medical information treated in a confidential manner and released only as necessary to authorized persons;

(G) to choose among all qualified and available service providers;

(H) to file a grievance with the access agency or the department without fear of discrimination or reprisal; and

(I) to achieve maximum self-direction and choice in lifestyle as long as this does not create an unacceptable risk.

(5) All access agency offices serving participants in the Connecticut Home Care Program shall be located within the State of Connecticut and be accessible to the public.

(6) The access agency shall have a communication system adequate to receive requests and referrals for service, including the capacity to respond to clients and health professionals in emergencies on a 24-hour basis.

(7) The access agency shall establish a grievance procedure for home care clients who are aggrieved by adverse decisions of the access agency. The procedure shall specify that a decision shall be made by the access agency within 15 calendar days after a grievance is received from a client and sooner in the case of an emergency. The procedure shall also outline steps for requesting a fair hearing by the department or other funding source in the event that the issue is not resolved within the access agency.

(8) The access agency shall have the capacity to provide or arrange necessary services for individuals who are non-English speaking, hearing impaired or who have other special needs.

(i) Requirements of an Assisted Living Service Agency.

(1) The ALSA shall ensure the selection of qualified staff and comply with the requirements set forth in section 19-13-D105 of the Regulations of Connecticut State Agencies.

(A) The ALSA staff shall be employed by a licensed assisted living service agency. The staff shall be responsible for annual re-evaluation, development of plans of care, arrangement and delivery of core services, oversight of the delivery of core services and shall provide ongoing monitoring of clients.

(B) The ALSA staff that provide direct client services shall have additional qualifications as specified in section 17b-342-1(h)(1)(B)(i) to (vii) of the Regulations of Connecticut State Agencies.

(2) The ALSA shall ensure that all staff are appropriately trained and supervised.

(A) The ALSA shall provide or arrange for orientation and ongoing training for staff in all applicable department requirements, including training in the use of the assessment tool.

(B) The ALSA shall provide or arrange for appropriate supervision and clinical consultation for staff during normal business hours and after hours if needed to respond to client emergencies.

(3) The ALSA shall have additional responsibilities as specified in subsection 17b-342-1(h)(3)of the Regulations of Connecticut State Agencies.

(4) The ALSA shall provide required reports to the department, including but not limited to, reports on specific data collection. Reports shall be submitted to the department no later than the fifteenth day of every month. The reports shall include data from the preceding month.

(5) The ALSA shall establish a written bill of client rights and responsibilities, which shall be provided to each person at the time of admission to the program as specified in section 17b-342-1(h)(4)of the Regulations of Connecticut State Agencies.

(6) All ALSAs serving participants in the Connecticut Home Care Program shall be located within the State of Connecticut and be accessible to the public.

(7) The ALSA shall have a communication system adequate to receive requests and referrals for service, including the capacity to respond to clients and health professionals in emergencies on a 24 hour basis.

(8) The ALSA shall establish a grievance and appeal procedure for clients who are aggrieved by adverse decisions of the ALSA. The procedure shall specify that a decision shall be made by the ALSA within 15 calendar days after a grievance is received from a client and sooner in the case of an emergency. The procedure shall also outline steps for requesting a fair hearing by the department or other funding source in the event that the issue is not resolved within the ALSA.

(9) The ALSA shall have the capacity to provide or arrange necessary services for individuals who are non-English speaking, hearing impaired or who have other special needs.

History

• Effective July 8, 1998; Amended September 3, 2010

Regs., Conn. State Agencies § 17b-342-2 Services covered under the connecticut home care program for elders

The following services are available to elders who are determined eligible for the Connecticut Home Care Program either under the criteria for the Medicaid Waiver portion or the state-funded portion of the program. These services are also covered under fee-for-service and the assisted living services component of the program. The amount of services available or allowed shall be based on the category of service or service package level assessed in accordance with sections 17b-342-1 to section 17b-342-3, inclusive, of the Regulations of Connecticut State Agencies and shall be documented in the approved plan of care.

(a) Care Management Services

(1) Description

Care management services are only authorized through department-contracted access agencies or department designee. Care management services include those activities that involve implementation, coordination, monitoring and reassessment of care managed cases. Care management is a client-centered service that respects clients' rights, values and preferences. The care manager assists the client in coordinating all types of assistance to meet the individual's needs, monitoring the quality of services provided and using resources efficiently.

(2) Provider Participation

All providers reimbursed for care management services shall be access agencies as defined in section 17b-342-1(b)(1) of the Regulations of Connecticut State Agencies or ALSAs as defined in section 17b-342-1(b)(3) of the Regulations of Connecticut State Agencies and shall meet all provider enrollment requirements. This provision is not meant to restrict home health and other providers from providing such services to the extent required or authorized under their license. However, only department-contracted access agencies or ALSAs may receive reimbursement for this activity as a distinct service. The requirement for providers to be access agencies shall not prohibit the department from using its own staff to provide care management services in accordance with section 17b-342-2(b) of the Regulations of Connecticut State Agencies.

(3) Services Covered

(A) When authorized, the department shall reimburse the access agency or ALSA for care management services which include contacts with the clients, family, members of their informal support networks or service providers, as deemed necessary. The care manager shall monitor clients of the Connecticut Home Care Program who receive ongoing care management by an access agency or ALSA as follows:

(i) Making contact at least monthly with the client, family or provider by telephone or by a home visit, depending upon the client's needs;

(ii) making home visits to the client as needed and at least every six months to determine the appropriateness of the service plan and to assess changes in the client's condition;

(iii) conducting a formal reassessment of the client's health, functional and financial status and service needs every twelve months, utilizing a standardized assessment tool;

(iv) responding to changes in client needs as they occur by making appropriate changes in the type, frequency, cost or provider of services needed for the client to remain safely in the community within the limitations of service availability. This includes ongoing reassessment as needed to assure appropriateness of the plan of care, continued financial eligibility, category of service and quality of care; and

(v) providing information and service referral or access to appropriate resources on a 24 hour per day basis, including responding to emergencies.

(B) Care management services may be delivered in the person's home, in the community, in a community agency or other non-institutional settings as appropriate.

(4) Need for Service

(A) For the Connecticut Home Care Program, the need for ongoing care management services by an access agency is identified in conjunction with establishment of eligibility for the program. Upon completion of an assessment and development of a plan of care, the access agency shall confirm the risk of institutionalization and shall further establish that:

(i) The person can be appropriately served in the community without the creation of an unacceptable risk to the person or others;

(ii) the person chooses to remain in the community rather than be admitted to a nursing facility;

(iii) as specified in the person's plan of care, the total state administered funds of home care services specified in the client's plan of care do not exceed the limits set forth in section 17b-342-3(c) of the Regulations of Connecticut State Agencies;

(iv) the client has been informed of the assisted living services component and offered participation if feasible; and

(v) a review to determine if there is an ongoing need for care-management has been done and the client has been advised of the self-directed care option, if appropriate.

(B) For the Connecticut Home Care Program, ongoing care management services by an access agency may be suspended for a client who meets the following criteria:

(i) The client's functional and cognitive status have been determined to be stable (this can include the presence of chronic health problems if the conditions are under control and do not require involvement by an access agency);

(ii) the department determines that the person or the caregiver is able to assume responsibility for coordinating and monitoring services; or

(iii) the client is determined appropriate for the self-directed care or assisted living services component under the program.

(5) Authorization Process

(A) Care management services shall be included as part of the written plan of care and authorized by the department in order to be reimbursed under the Connecticut Home Care Program.

(B) When care management services by an access agency have been suspended, the client may continue to receive other home care services through the Connecticut Home Care Program. The department shall require renewals of orders for such home care services annually and complete annual redeterminations of eligibility for the program in order to continue services. If the client's condition becomes unstable and the client continues to reside in the community, the department may reinstate ongoing monitoring by an access agency including, but not limited to, transferring the client from the self-directed or the assisted living service component of the program to the access agency with services provided through fee-for-service, if feasible and allowed under the program.

(6) Limitations

In order to receive payment for care management services under the Connecticut Home Care Program, the access agency shall be in compliance with all terms of its contract with the department and in addition shall assure that home care service providers meet standards of quality as established in section 17b-342-2(b) to section 17b-342-2(o), inclusive, of the Regulations of Connecticut State Agencies and have documented such compliance to the access agency. The department shall not reimburse for care management services:

(A) Provided prior to completion of the assessment and development of an approved plan of care;

(B) provided while the elderly person is in a hospital, nursing facility or out of the state;

(C) provided to clients who are authorized for self-directed care;

(D) provided to clients who are program participants under the assisted living service component; or

(E) provided to clients who have been determined ineligible for program participation by the department and the access agency has been notified of such decision.

(b) Adult Day Health Services

(1) Description

Adult day health services are provided through a community-based program designed to meet the needs of cognitively and physically impaired adults through a structured, comprehensive program that provides a variety of health, social and related support services including, but not limited to, socialization, supervision and monitoring, personal care and nutrition in a protective setting during any part of a day. There are two different models of adult day health services: The social model and the medical model. Both models shall include the minimum requirements described in subsection (b)(2) of this section. In order to qualify as a medical model, adult day health services shall also meet the requirements described in subsection (b)(3)of this section.

(2) Provider Participation

In order to receive payment for adult day health services provided under the Connecticut Home Care Program, an adult day health provider shall:

(A) Meet all applicable federal, state and local requirements including zoning, licensing, sanitation, fire and safety requirements;

(B) provide, at a minimum, nursing consultation services, social work services, nutritionally balanced meals to meet specialized dietary needs as prescribed by health care personnel, personal care services, recreational therapy and transportation services for individuals to and from their homes;

(C) provide adequate personnel to operate the program, including:

(i) A full-time program administrator;

(ii) nursing consultation during the full operating day by a Registered Nurse (RN) licensed in the state of Connecticut; and

(iii) the direct care staff-to-participant ratio shall be a minimum of one to seven. Staffing shall be adequate to meet the needs of the client base. Volunteers shall be included in the ratio only when they conform to the same standards and requirements as paid staff.

(3) Adult Day Health Facility Requirements

(A) In order to be a provider of services to department clients, any facility located and operating within the State of Connecticut or located and operating outside the state of Connecticut, in a bordering state, shall be certified by the Connecticut Association of Adult Day Centers Incorporated, its successor agency or a department designee.

(B) A facility (center) located and operating outside the State of Connecticut in a bordering state shall be licensed or certified by its respective state and comply at all times with all pertinent licensure or certification requirements in addition to the approved standards for certification by the department.

(C) Certified facilities (centers) shall be in compliance with all applicable requirements in order to continue providing services to department clients. The failure to comply with any applicable requirements shall be grounds for the termination of its certification and participation as a department service provider.

(4) Services Covered and Limitations

(A) Payment for adult day services under the rate for a medical model is limited to providers which demonstrate to the department their ability to meet the following additional requirements:

(i) A program nurse shall be available on site for not less than fifty percent of each operating day;

(ii) the program nurse shall be a registered nurse, except that a program nurse may be a licensed practical nurse if the program is located in a hospital or long term care facility licensed by the Department of Public Health, with ready access to a registered nurse from such hospital or long term care facility or the program nurse is supervised by a registered nurse who can be reached by telephone at any time during the operating day and who can be called to the center if needed within one half hour of the request. The program nurse is responsible for administering medications as needed and assuring that the participant's nursing services are coordinated with other services provided in the adult day health center, health and social services currently received at home or provided by existing community health agencies and personal physicians;

(iii) additional personal care services shall be provided as specified in the individual plan of care, including but not limited to, bathing and transferring;

(iv) ongoing training shall be available to the staff on a regular basis including, but not limited to, orientation to key specialty areas such as physical therapy, occupational therapy, speech therapy and training in techniques for recognizing when to arrange or refer clients for such services; and

(v) individual therapeutic and rehabilitation services shall be coordinated by the center as specified in the individual plan of care including, but not limited to, physical therapy, occupational therapy and speech therapy. The center shall have the capacity to provide such services on site; this requirement shall not preclude the provider of adult day health services from also arranging to provide therapeutic and rehabilitation services at other locations in order to meet needs of individual clients.

(B) Payment for adult day services shall include the costs of transportation, meals and all other required services except for individual therapeutic and rehabilitation services.

(C) For participants in the assisted living service component, adult day services are included as part of the monthly rate. A separate reimbursement for this service is not authorized. The assisted living service agency may arrange for adult day health services and reimburse the adult day service provider from their all-inclusive rate.

(c) Assisted Living Services

(1) Description

Assisted living services are a special combination of housing, supportive services, core services, personalized assistance and health care designed to respond to the individual needs of those who require assistance with activities of daily living and instrumental activities of daily living. These services are necessary to enable the eligible clients to remain independent longer, thereby avoiding unnecessary or early transfer to a higher level-of-care facility.

(2) Provider participation

Assisted living services can be offered through an assisted living service package mechanism, provided by an ALSA licensed by the State of Connecticut Department of Public Health and enrolled as a performing provider with the department. Assisted living services shall be offered to eligible clients approved for participation in the following MRCs as defined in section 19-13-D105 of the Regulations of Connecticut State Agencies: State-funded congregates, housing and urban development facilities, private facilities and demonstration projects.

(3) Services covered and limitations

(A) Assisted living services are provided through a personal-assisted-living services package based on the needs of the eligible person. The negotiated per diem reimbursement represents the all-inclusive payment rate for the allowable personal care and core services.

(1) Personal care services include, but are not limited to, hands-on assistance with daily activities, including but not limited to, dressing, grooming, bathing, using the toilet, transferring, walking and eating. Personal care services may also include personal laundry and changing bed linens in conjunction with incontinence care or other needs which necessitate such assistance more than once per week. Some or all of the personal care services may be offered through an adult day center but, since the components of the adult day services are included in the payment to the ALSA, the adult day center shall be reimbursed by the ALSA through a sub-contract.

(2) "Core services" means the services described in section 19-13-D105 subsection (c)(3) of the Regulations of Connecticut State Agencies.

(3) The ALSA shall determine the assisted living services package appropriate for each client participating in the assisted living service component of the program from the following service levels:

(i) SP-1 Occasional personal care service-1 to 3.75 hours per week of personal services plus nursing visits as needed;

(ii) SP-2 Limited personal care service- 4 to 8.75 hours per week of personal care services plus nursing visits as needed;

(iii) SP-3 Moderate personal care service- 9 to 14.75 hours per week of personal care services plus nursing visits as needed; or

(iv) SP-4 Extensive personal care services- 15 to 25 hours per week of personal care services plus nursing visits as needed.

(B) Additional basic core services such as housekeeping, laundry and meal preparation beyond the level provided by the MRC under its core services package are allowed. The additional core services can be provided by the agency or the MRC facility. If the MRC is to perform the core services, the MRC must enter into a contract with the ALSA for the purposes of performing the core services. The ALSA shall reimburse the MRC facility for the additional core services rendered by the MRC. The additional core services shall be only to those clients that are determined to need the services regardless of whether or not they are determined eligible to receive personal assistance services.

(C) The licensed assisted living services are a substitute for Medicaid and state-funded nursing and home health aide services for individuals with chronic, stable conditions. Assisted living services shall not be offered in conjunction with services provided under traditional fee-for-service.

(D) Skilled home health services are covered by Medicare for acute needs, often post hospitalization, and may be covered by Medicare in limited circumstances for individuals in MRC facilities. Such services shall be covered under Medicaid only for persons who are not eligible for Medicare benefits. Home health services, which do not meet the Medicare criteria for skilled services, are included in the payment for assisted living services under the program. Clients determined to need skilled nursing services which are not covered by Medicare and cannot be provided through the assisted living services package shall be transferred by the access agency into the fee–for-service component of the program, if allowed and feasible under the program.

The department may allow the ALSA to provide assisted living services for these clients in combination with Medicare and any of the assisted living service packages. The department shall not pay for duplicative services already covered under Medicare or another source of payment.

(E) The only additional services and charges authorized are personal emergency response system services and mental health counseling services. The department will not reimburse the ALSA for services provided under the waiver program or for home health or skilled nursing services that are provided under Medicaid. The Medicaid waiver client will continue to be eligible to receive the other traditional Medicaid benefits permitted under the department's medical assistance program policy.

(F) The nursing visits shall be provided on an as-needed basis to the client. The ALSA shall provide the nursing visits as indicated on the client's plan of care and in the assigned assisted living service package level.

(G) The ALSA may change a client's service level package at any time, provided proper justification and documentation is recorded in the client's record.

(H) The ALSA shall have their reimbursement by the department adjusted if the department determines that the client has to pay a client's mandatory contribution of service. The ALSA is responsible for the collection of the client's contribution towards their care.

(I) The ALSA shall act in good faith regarding the determination of the service needs of the client and shall document justification of the needs accordingly to assure non-duplication of services and proper billing to the department.

(J) When Medicare coverage is determined appropriate for a client due to the need for skilled care, the ALSA shall not seek approval or payment for these additional services from the department. Medicare is to be the payer source for these services. If there is no Medicare coverage, then the ALSA shall determine what type of nursing needs the client requires. If the personal care needs involve maintenance, such as ambulatory needs, then these are services that are to be incorporated in the duties of the ALSA home health aide. The ALSA shall not seek additional approval or payment for these services since these types of services are included in the service level package rate.

(K) Physical therapy is not a covered service under the Medicaid waiver or state-funded components of the assisted living services program.

(L) If the client is no longer eligible for program participation, then the MRC facility determines if the individual can remain a resident at the facility.

(d) Chore Services

(1) Description

Chore services include the performance of heavy indoor work, outdoor work or household tasks for elders who are unable to do these tasks for themselves because of frailty or other conditions. These services are necessary to maintain and promote a healthy and safe environment for elders in their own homes.

(2) Provider Participation

Chore service providers are not licensed or regulated and shall be provided by a person who is not a relative of the service recipient. Chore service providers shall demonstrate the ability to meet the needs of the individual seeking services. The department or the access agency shall ensure that the services provided qualify as chore services and are not services which should be provided by a licensed provider of home health services.

(3) Services Covered and Limitations

When an individual requires one-time only unique or specialized services in order to maintain a healthy and safe home environment, the Connecticut Home Care Program shall pay for highly skilled chore services which include, but are not limited to:

(A) Extraordinarily heavy cleaning where the work required is beyond the heavy cleaning normally performed by chore services;

(B) electrical repairs or installation;

(C) plumbing repairs;

(D) minor home repairs; and

(E) extermination.

(e) Companion Services

(1) Description

Companion services are home-based supervision and monitoring activities which assist or instruct an individual in maintaining a safe environment, when the person is unable to maintain a safe environment or when the person primarily responsible for monitoring and supervising is absent or unable to perform such activities.

(2) Provider Participation

(A) In order to provide companion services and receive reimbursement from the Connecticut Home Care Program, a companion shall be at least eighteen (18) years of age, be of good health, have the ability to read, write and follow instructions, be able to report changes in a person's condition or needs to the department, the access agency, or the agency or organization that contracted the persons to perform such functions and shall maintain confidentiality and complete required record-keeping of the employer or contractor of services.

(B) Companion services are not licensed or regulated and shall be provided by a person hired by an agency or organization. Certain relatives, as defined in section 17b-342-1(b)(29) of the Regulations of Connecticut State Agencies, cannot be providers of services. Providers shall demonstrate the ability to meet the needs of the service recipient. The access agency or a department designee shall also ensure that the services provided are appropriate for companion services and are not services which should be provided by a licensed provider of home health services.

(C) Companion service agencies or organizations shall abide by the standards and requirements as described in the performing provider agreement and sub-contract with the department or any authorized entity.

(D) Any homemaker-companion agency must register with the Department of Consumer Protection pursuant to sections 20-671 to 20-680, inclusive, of the Connecticut General Statutes.

(3) Services Covered and Limitations

Companion services may include, but are not limited to, the following activities:

(A) Escorting an individual to recreational activities or the necessary medical, dental or business appointments;

(B) reading to or for an individual;

(C) supervising or monitoring an individual during the self-performance of activities of daily living such as meal preparation and consumption, dressing, personal hygiene, laundry and simple household chores;

(D) reminding an individual to take self-administered medications;

(E) providing monitoring to ensure the safety of an individual;

(F) assisting with telephone calls and written communications; and

(G) reporting changes in an individual's needs or condition to the supervisor or care manager.

(f) Adult Family Living

(1) Description

Adult family living services provide an individual with continuous monitoring, supervision, coordination of daily living and management of overall health and welfare. These services are provided on a 24-hour basis in a private non-related family residence, when necessary to prevent or delay institutionalization.

(2) Provider Participation

For purposes of obtaining reimbursement under the Connecticut Home Care Program, the adult family living provider shall meet the following conditions:

(A) There shall be an individual designated to meet the specific needs of an adult family living client and that individual shall:

(i) Be at least eighteen (18) years of age, be of good health, have the ability to read, write and follow instructions, be able to report changes in a person's condition or needs to the sponsor of the foster care program or access agency or department designee, maintain confidentiality and complete required record-keeping of the employer or contractor of services;

(ii) not be the service recipient's relative, as defined in section 17b-342-1(b)(29) of the Regulations of the Connecticut State Agencies; and

(iii) be able to provide the individual with necessary supervision and assistance with management of overall health and activities of daily living.

(B) The family shall document that its income is adequate to meet the needs of the family;

(C) An adult family living provider shall not provide services to more than three (3) elderly persons at the same time; and

(D) Adult family living shall be provided in a living arrangement which conforms to applicable local and state building, health and safety codes and ordinances and meets the individual's needs for privacy.

(3) Services Covered and Limitations

The services provided to the individual shall include, but not be limited to, the following activities:

(A) Escorting an individual to recreational activities and to medical, dental or business appointments;

(B) reading to or for an individual;

(C) supervising or performing household tasks such as meal preparation, laundry and simple chores;

(D) supervising or monitoring an individual during the performance of activities of daily living such as eating, dressing and personal hygiene;

(E) reminding an individual to take self-administered medications;

(F) providing evening monitoring to ensure the safety of an individual;

(G) assisting with telephone calls and written communications; and

(H) reporting changes in an individual's needs or condition to a sponsor of the adult family living program or the care manager.

(4) Non-Reimbursable Services

Separate room and board charges are non-reimbursable services through the program. The client may be required to make payments directly to the adult family provider for room and board and meals.

(5) Meals

(A) Meals in the adult family living setting shall:

(i) Be nutritionally balanced and at least three (3) times daily;

(ii) include snacks and fluids as appropriate to meet the participant's needs; and

(iii) be adapted to modified diets if prescribed by a physician.

(6) Meals on wheels, homemaker services, companion services and chores services are not allowed.

(7) Additional allowable services

Attendance at an adult day center, personal emergency response system, mental health counseling and other benefits, if such services are deemed appropriate and are allowed within the program policy.

(g) Home Delivered Meals

(1) Description

Home delivered meals, or "meals on wheels," include the preparation and delivery of one or two meals for persons who are unable to prepare or obtain nourishing meals on their own.

(2) Provider Participation

Reimbursement for home delivered meals shall be available under the Connecticut Home Care Program only to providers which provide meals that meet a minimum of one-third of the current daily recommended dietary allowance and requirements as established by the Food and Nutrition Board of the National Academy of Sciences National Research Council.

All "meals on wheels" providers shall provide their menus to the department, contracted agencies or department designee for review and approval. Quality assurance and quality control shall be performed by the department's contracted providers to ensure that the "meals on wheels" service providers are in compliance with the dietary requirements and the requirements for the preparation and storage and delivery of food based on the department policies for the elderly nutrition program and Title (III) of the Older American's Act.

(3) Service Covered and Limitations

Payment under the Connecticut Home Care Program is not available for more than two meals a day.

(4) Meals must be delivered at the client's place of residence and must be provided directly to the client or to an authorized person. If the client is attending an adult day center, the meal may be left at the center but the meal cannot be counted as part of the meals that the center is to provide to the client. The adult day center shall ensure that the client ordered meals are stored at an adequate temperature and the client takes the meal home.

(h) Home Health Services

(1) Description

Home health services include the same medical procedures that are included in the definition of home health services under the Medicaid program.

(2) Provider Participation

In order to receive payment from the Connecticut Home Care Program, providers of home health services shall be enrolled as home health providers under the Medicaid program and be licensed with the state Department of Public Health.

(3) Services Covered and Limitations

Home health services provided under the Connecticut Home Care Program shall be covered to the same extent as they are under the Medicaid program.

(i) Homemaker Services

(1) Description

Homemaker services are general household management activities provided in the home to assist or instruct an individual in managing a household when the elder is unable to manage the home or when the individual primarily responsible is absent or unable to perform such management activities. These services are provided on a part-time or intermittent basis.

(2) Provider Participation

(A) Homemaker services shall be provided by an individual that is at least eighteen (18) years of age, in good health, has the ability to read, write and follow instructions, is able to report changes in a persons' condition or needs to the department, access agency and the agency or organization that hired the service providers. Service providers shall demonstrate the ability to meet the needs of the individual service recipient and, when money management is involved, to protect the individual's financial interests. The homemaker service agency, the department or the access agency shall ensure that the services provided are appropriate for homemaker services and are not services which should be provided by a licensed provider of home health services or a professional financial advisor.

(B) Certain relatives, as defined in section 17b-342-1(b)(29)of the Regulations of the Connecticut State Agencies, are not allowed to provide homemaker services to program clients.

(C) Homemaker services shall only be provided through a homemaker service provider agency enrolled with the department and subcontracted with a department-contracted access agency or department designee.

(D) The homemaker service provider agency shall ensure that the individuals hired to perform the task of homemaker services meet all requirements set forth in subdivision (2)(A) of this subsection.

(E) The homemaker services shall be performed only for the benefit of the client and not for other members of the household.

(3) Services Covered and Limitations

Homemaker services include, but are not limited to:

(A) Changing linens;

(B) communication of health or other problems (neglect or abuse) to supervisor;

(C) correspondence, including written communications of a business or social nature;

(D) dishwashing;

(E) light housecleaning;

(F) laundry;

(G) meal planning and preparation;

(H) mending limited to repair of an individual's clothing;

(I) money management by bonded personnel, limited to check writing and balancing, bank deposits, paying bills and budgeting for the purpose of daily household expenses and personal needs, not including long term financial planning or investment advice;

(J) shopping; and

(K) transportation.

(j) Laundry Services

(1) Description

Laundry Service is designed to serve frail elders who have no other means of having laundry cleaned and shall be arranged by the contracted access agency or department designee.

(2) Provider Participation

Laundry Service is ordinarily to be provided by a commercial laundry company or by a provider of adult day health services.

(3) Services Covered and Limitations

The service is limited to one bag of laundry (up to 10 lbs.) every two weeks per client, except in cases where the case manager determines that a higher amount is necessary, such as when a client is incontinent. Two times in a 12-month period, an additional amount of laundry service may be provided per client. This additional service is limited to blankets, bedspreads and small rugs weighing no more than 20 pounds. Dry cleaning is not included in laundry services.

(4) Laundry services shall not be available to clients that are receiving homemaker services, to clients whose family caregivers are providing the service, to participants in the assisted living service component of the program or residing in any managed residential communities.

(k) Mental Health Counseling Services

(1) Description

Mental health counseling services are professional counseling services provided to help resolve or enable the eligible individual to cope with individual, family or environmentally related problems and conditions. Counseling focuses on issues such as problems in maintaining a home in the community, relocation within the community, dealing with long term disability, substance abuse and family relationships.

(2) Provider Participation

For purposes of receiving reimbursement under the Connecticut Home Care Program, a mental health counseling provider shall be a licensed clinical social worker as defined in section 20-195m of the Connecticut General Statutes, and shall have experience and training in providing mental health services to the elderly, or a social worker who holds a masters degree from an accredited school of social work, or an individual who has a masters degree in counseling, psychology or psychiatric nursing and has experience in providing mental health services to the elderly.

Service providers are not allowed to provide mental health counseling to relatives, as defined in section 17-342-1(b)(29)of the Regulations of Connecticut State Agencies.

(3) Services Covered and Limitations

The department shall pay for mental health services conforming to accepted methods of diagnosis and treatment, including:

(A) Mental health evaluation and assessment;

(B) individual counseling;

(C) group counseling; and

(D) family counseling.

(l) Minor Home Modification Services

(1) Description

Minor home modifications, also known as environmental accessible adaptations to the home or place of residence of the client, are services available, if required by the individual's plan of care, that are necessary to ensure the health, welfare and safety of the individual and to enhance independence in their home without which, the individual would require institutionalization.

(2) Provider participation

The vendor or contractor shall be registered with the state Department of Consumer Protection to do business in the state of Connecticut. The vendor or contractor shall show evidence of a valid home improvement registration and evidence of worker's compensation, if applicable, and liability insurance, at the time they provide an estimate for the job to the access agency.

The vendor or contractor shall meet any additional requirements as established by the department.

(3) Services covered and limitations

(A) Services may include, but are not limited to, the installation of handrails and grab bars in the tub area, widening of doorways and installation of ramps and stair-glides, if deemed feasible and appropriate.

(B) The vendor or contractor shall provide all services, materials and labor that are necessary to complete the project/minor home modifications as indicated in the agreement with the department-contracted access agency.

(C) All services shall be provided in accordance with applicable state and local building codes.

(D) Excluded services are those adaptations or improvements to the home which are of general utility and are not of direct medical or remedial benefit to the individual including, but not limited to, carpeting, roof repair and central air conditioning. Adaptations, which add to the total square footage of the home, are excluded from this service.

(E) Availability of services is contingent on appropriations of funds for services for both the Medicaid waiver and state-funded components under the program. No waiting list shall be maintained for services. Once the appropriated funds are exhausted, the access agency and department staff will be notified and no further requests for services will be taken. However, the access agencies and the department staff shall maintain a listing of those clients that can benefit from services if funds are made available.

(F) Review and approval of the service from the access agency shall include clients who are active and residing in a community setting that may include rental property, such as an apartment, or a private home. Clients must provide justification and documentation for the need and the cost related to the project. The department will provide a written decision to the request.

The access agency shall ensure that the client or client representative obtains written permission from the owner of the property, if the client is not the legal owner. This written permission must be obtained even if the property owner is a relative or friend of the client.

(G) The contractor or vendor and access agency shall ensure that the funding approved is used for the project approved. If the work is not completed, the contractor or vendor shall not be paid. Before payment is issued, the access agency shall verify that the work was completed as described in the work or project specifications.

If, after approval of a request for work on the property and prior to the commencement of the work, the client dies, enters a nursing facility, is hospitalized or institutionalized, moves out of state, moves in with a relative or friend or moves into another type of community setting, then the work shall not be done. In the event that the client is living with a family member or friend, is hospitalized or institutionalized, or in a nursing facility on a temporary basis, approval for the work shall be placed on hold until the client returns home.

(m) Personal Emergency Response System Services

(1) Description

A Personal Emergency Response System (PERS) service is an in-home, 24-hour electronic alarm system activated by a signal to a central switchboard.

(2) Provider Participation

For purposes of receiving reimbursement from the Connecticut Home Care Program, providers of a PERS shall adhere to the following requirements:

(A) Provide trained emergency response staff on a 24-hour basis;

(B) have quality control of equipment;

(C) provide service recipient instruction and training;

(D) assure emergency power failure backup and other safety features;

(E) conduct a monthly test of each system to assure proper operation;

(F) recruit and train community based responders in service provision; and

(G) provide an electronic means of activating a response system to emergency medical and psychiatric services, police or social support systems.

(3) Services Covered and Limitations

(A) PERS enables a high risk individual to secure immediate help in the event of a medical, physical, emotional or environmental emergency. These services are provided on a 24-hour basis when necessary to prevent or delay institutionalization of an individual.

(B) PERS services are provided through local hospitals or emergency response centers that provide 24-hour coverage.

(C) PERS is not allowed in those managed residential care facilities that offer PERS as part of the service package.

(D) PERS is not allowed for clients who enter a nursing facility as permanent placement, move out of state or are temporarily out of state.

(E) PERS providers shall be a legitimate vendor or contractor and be registered with the state Department of Consumer Protection.

(F) PERS providers shall meet all applicable requirements as described in subsections (m)(2) and (m)(3) of this section in order to be a provider of service to department clients.

(n) Respite Care Services

(1) Description

Respite care services provide short-term relief from the continuous care of an elderly individual for the individual's family or other primary caregiver.

(2) Provider Participation

Providers of respite care services shall meet one of the following qualifications to receive reimbursement from the Connecticut Home Care Program:

(A) In-Home Respite Care Provider

An in-home respite care provider is an individual who has received training as well as has experience in providing home care for elderly persons. In-home providers of respite care shall include, but not be limited to, companions, homemakers, home health aides and other home health care personnel; or

(B) Out-of-Home Respite Care Provider

An out-of-home respite care provider is an organized facility licensed, certified or otherwise operating under the guidelines of other State agencies to provide respite care appropriately as defined in sections 17b-342-1 to 17b-342-5, inclusive of the Regulations of Connecticut State Agencies. Out-of-home providers may include, but are not limited to, rest homes with nursing supervision, chronic and convalescent nursing facilities, adult day care centers, homes for the aged or elderly foster care providers. Respite services provided in a licensed facility are limited to thirty (30) days per year per recipient.

(3) Services Covered and Limitations

The primary purposes of respite care services are to reduce the stress on the family members or other primary caregivers in order to assure that the client can continue to receive such necessary support; to allow the caregiver to meet other family needs; or to provide care during temporary absence of the primary caregiver.

(o) Transportation Services

(1) Description

Transportation services provide access to medical services, social services, community services and appropriate social or recreational facilities that are essential to help some individuals avoid institutionalization by enabling these individuals to retain their role as community members.

(2) Provider Participation

(A) In order to receive payment from the Connecticut Home Care Program, all commercial transportation providers shall be regulated carriers and meet all applicable state and federal permit and licensure requirements and vehicle registration requirements. Commercial transportation providers shall also meet all applicable Medicaid program enrollment requirements.

(B) There are no enrollment requirements for private transportation. Private transportation is defined as transportation by a vehicle owned by a volunteer organization, or a private individual, provided the vehicle is not used for commercial carriage.

(3) Services Covered and Limitations

(A) These services are provided when transportation is required to promote and enhance independent living and self-support; and

(B) Transportation services may be provided by taxi, livery, bus, invalid coach, volunteer organization or individuals. They shall be reimbursed when they are necessary to provide access to needed community based services or community activities as specified in the approved plan of care.

(C) Transportation services are not allowed for the purpose of attending an adult day health center or for program clients that are participants in the assisted living component of the program and who reside in certain managed care residential facilities.

History

• Effective July 8, 1998; Amended September 3, 2010

Regs., Conn. State Agencies § 17b-342-3 Service limitations, payment limitations, cost limits, waiting list and fee setting

(a) Service Limitations

(1) All home care services provided to individuals under the Connecticut Home Care Program shall be authorized in accordance with procedures established by the department prior to the delivery of the service;

(2) Reimbursement is not available from the department for personnel or agencies providing a home care service when such person or agency is required to be licensed, certified or otherwise regulated and does not fulfill the relevant regulatory requirements including the requirements under sections 17b-342-1 to 17b-342-5 of the Regulations of Connecticut State Agencies;

(3) When two or more providers of community based or home health services offer essentially the same service, the least costly service provider shall be used, provided that the quality of the service is similar;

(4) Providers of services, including subcontractors of the access agency and assisted living service agencies, shall maintain records to support claims made for payment, which shall be subject to audit by the department or its designee for at least seven years;

(5) Reimbursement is not available from the department for services canceled in advance either by phone or in writing;

(6) Reimbursement is not available from the department when an individual does not utilize or refuses to utilize an arranged service;

(7) Reimbursement is not available from the department for any services provided prior to the assessment or the determination of program eligibility or not documented in an approved plan of care;

(8) Reimbursement is not available from the department including, but not limited to, when an individual dies, is hospitalized, enters a nursing facility, moves temporarily or permanently out of state, requests services to be terminated or is determined ineligible;

(9) Reimbursement is not available from the department if the access agency or assisted living service agency is determined not to have followed the requirements and process established by the department for uncollectible mandatory client contribution towards their care;

(10) Reimbursement is not available for home and community based services determined not to have been performed;

(11) Reimbursement is not available for services arranged by program clients or representatives, access agencies, assisted living service agencies or service providers without prior approval by the department or department designee;

(12) Reimbursement is not available for duplication of services or payment; and

(13) Reimbursement is not available from more than one department or state agency program.

(b) Payment Limitations

(1) All home care service providers shall bill the usual and customary charge and the department shall pay the lowest of:

(A) The usual and customary charge;

(B) the lowest Medicaid rate;

(C) the amount in the applicable fee schedule as published by the department;

(D) the fee or rate negotiated with the access agency and the assisted living service agency; or

(E) the amount billed by the provider of the community based service to the department.

(2) The access agency shall not use department funds to purchase home care services other than assessment, status reviews and care management from itself or any related parties.

(3) The assisted living service agencies shall not use department funds to purchase home care services other than assisted living services, which include all personal care assistance services and core services, or other allowable charges incurred buy the agency.

(c) Cost Limits on Individual Plans of Care

(1) In order to receive home care services under the Connecticut Home Care Program, the elderly person's plan of care shall be within the cost limits related to the person's category of service for both the fee-for-service and the assisted living service components. All state-administered costs of home care services shall be included.

The following are the cost limits which define the categories of services for fee-for-service (to be used only for care managed and self-directed clients):

(A) Category 1 Services:

Home care services may be authorized for up to 25% of the weighted average nursing facility cost for individuals who are at risk of institutional placement but who might not immediately enter a hospital or nursing facility in the absence of the program provided they also meet the financial eligibility criteria for the state-funded portion of the program.

Services for Medicaid recipients who are not functionally eligible for the Medicaid waiver portion of the program will be covered by the state-funded portion of the program.

(B) Category 2 Services:

Home care services may be authorized for up to 50% of the weighted average nursing facility cost for individuals who would otherwise require admission to a nursing facility and who meet the financial eligibility criteria for the state-funded portion of the program.

(C) Category 3 Services:

Home care services may be authorized for up to 100% of the average nursing facility cost for individuals who would otherwise require long term admission to a nursing facility and who also meet the financial eligibility criteria for Medicaid under the federal waiver. The cost of community-based services provided to individuals in category 3 shall not exceed 60% of the weighted average Medicaid rate in a nursing facility.

(2) Under the assisted living service component of the program there are four different levels of service that the assisted living service agency is to use when assigning the appropriate level of service to a client.

(A) The assisted living levels of service 1,2,3 and 4 are based on the client's nursing or personal care needs. Each level of service is reimbursed at a per diem rate established by the department. There may be different per diem rates for each of the assisted living services components depending on the negotiated rate by the assisted living service agency with the department. Refer to subsection (c)(1)(A) to (c)(1)(C), inclusive, of this section for specifics relating to the description of assisted living cost limits for categories of service.

(B) Additional cost for core services is allowed if the program client needs these supplemental services.

(C) The program client's cost for assisted living services cannot exceed the assigned service package and additional cost for core services which shall be specified on the client's plan of care and cost worksheet.

(3) Elders enrolled in the program have the ability to move from one service category to another within fee-for-service if care managed or self-directed, and from one level of service to another under the assisted living component. When the elderly person's functional or financial eligibility changes, the information shall be reviewed by department staff and a determination shall be made regarding the appropriateness of the change in service category and funding source for the services under the program.

(4) The agency that oversees an elder's plan of care shall be responsible for applying and monitoring the Connecticut Home Care Program cost limits in accordance with the following regulations:

(A) The agency shall first determine if the state-administered public funds to be expended for home care services in accordance with the elderly person's plan of care exceed the cost limits related to the individual's category of services or service package level cost. If the costs do not exceed the limit on a monthly basis, the person may receive services under the Connecticut Home Care Program, provided the program is accepting new applicants at the level for which the person is applying.

(B) If the monthly cost of state-administered public funds for home care services required to be provided under an individual's plan of care exceeds the cost limits related to the individual's category of services (fee-for-service only under the program), the agency shall project the cost of those services for the individual over a 12-month period. If the projected annualized cost of those services falls within the cost limits, the individual may receive services under this program provided that the program is accepting new applicants at the category of service for which the individual is applying.

(C) Clients participating in the assisted living services component whose needs cannot be met within the assisted living service package levels, may be referred to the access agency to determine if their needs can be met and the necessary services are available within the cost limits of the category of services provided under the fee-for-services delivery system. Once the client is care-managed, the client may be referred to the access agency as described under this subparagraph.

(D) If the agency does not have information on the actual cost of services being provided to the elder through other state administered programs, the agency shall estimate the cost based upon payments made for similar services. Information on all services provided under the requirements of an individual's approved plan of care shall be reported to the department.

(E) The agency shall be responsible for determining that the amount of state-administered public funds expended to provide services required under the person's plan of care continues to meet the cost limits set forth in this subsection and as described in subsection (c)(1)(A) to (C), inclusive, of this section.

(F) When the rates for home care services (including care management and assisted living services, such as personal care assistance and core services), covered by the Connecticut Home Care Program are increased, the access agency, assisted living service agency or department designee shall update the plans of care to reflect those increases upon receipt of the new rates. The access agency, assisted living service agency and other providers shall be liable for charges in excess of the cost limit following that transition period unless the case is under appeal or an exception to the cost limits is granted in accordance with subparagraph (G) or (H) of this subdivision or by the department Commissioner or his or her designee.

(G) Clients who were above the cost limits prior to July 1, 1992, shall continue to receive services to the extent that they qualify in accordance with section 17b-342(i) of the Connecticut General Statues.

(H) Any person who requires a care plan that shall place the client above the cost limits may request an exception to the cost limits from the Commissioner or his or her designee. Approvals shall be based on extreme hardship, shall be time-limited (not to exceed three months), shall in no case exceed 100% of the average nursing facility cost and shall be home health service related.

(I) Requests for exceptions to the cost limits are not allowed when a client is pending Medicaid, when the client loses his or her Medicaid eligibility because of changes to their income or assets, loses Medicare coverage or is an assisted living service participant.

(d) Waiting List

(1) The state funded portion of the program is subject to availability of funds.

The portion of the program funded under the federal waiver is subject to continued approval of the Medicaid waiver and to any limits on expenditures or the number of persons who can be served under the federal waiver application.

(2) In the event that the state appropriation or the upper limits under the federal waiver are insufficient to provide services to all eligible persons, the number of persons admitted to the program may be limited. When these limits are reached, the department may establish a waiting list. If a waiting list is established, the department shall serve applicants from the waiting list who meet all program requirements in order of their application except as otherwise provided in subdivision (d)(4) of this section.

(i) If there is a waiting list for either portion of the program and the applicant's name is reached, but the applicant is not eligible for benefits at the time the opening becomes available, the applicant's name may be placed in a "hold" position, unless the applicant is removed from the waiting list. The "hold" status enables the applicant to retain the position on the waiting list until such time as the applicant meets the requirements of the program. The applicant shall inform the department when the applicant meets the program requirements.

(ii) If the department learns that an applicant is deceased, or becomes enrolled in the Medicaid waiver portion of the program, the applicant shall be removed from the waiting list.

(iii) If the department learns that an applicant has entered a nursing facility or has moved out of state, or if the applicant requests removal from the waiting list, the department may remove the applicant's name from the waiting list.

(aa) The department shall notify the applicant that it intends to remove the applicant's name from the waiting list and the reason it intends to remove the applicant's name.

(bb) The applicant shall be provided with the opportunity to request that the name not be removed from the waiting list. It is the responsibility of the applicant to inform the department of the applicant's current address. If the applicant does not respond to the department, the applicant's name shall be removed from the waiting list.

(iv) If an applicant is removed from the waiting list in error, the applicant may be restored to the waiting list in the original place.

(3) Available openings within the program shall be allocated based on the proportion of the region's elder population adjusted to take into consideration the ratio of elders who are poor, minority, impaired or living in rural areas.

(4) If funds are available under the state-funded portion of the program, the department may from time to time establish priorities which ensure that persons with the greatest medical, social and economic need receive timely assistance. The department will only establish priorities under extreme circumstances.

(e) Rate Setting

(1) General Provisions

(A) The department shall, in accordance with section 17b-343 of the Connecticut General Statutes, establish a fee schedule for assessment, care management and other home and community based services as they are defined in section 17b-342-1(b)(7) of the Regulations of Connecticut State Agencies. The Commissioner may annually increase any rate in the rate schedule based on an increase in the cost of services. The department shall specify the rates for these services in the Request for Proposals (RFP).

(B) All financial and clinical records of providers shall be accessible at the request of the department and are fully subject to fiscal and programmatic audit by the department or its designees.

(2) Rates for Assessment and Care Management

(A) All access agencies wishing to provide assessment and care management services, and receive reimbursement for the same under contract with the department, shall submit bids to the department in response to the RFP. These bids shall be filed with the department on a date set by the department for the initial year of the contract.

(B) The rates for assessment and care management services shall be established by the department based on the responses to the RFP. In no event may a payment exceed the usual and customary charges of the access agency. In addition, the department shall not contract for any fees determined unreasonable or in excess of the fees set by the department.

(3) Rates for Status Reviews

The department shall establish a rate for status reviews.

(4) Rates for Other Community Based Services

(A) For the Connecticut Home Care Program, rates for other home and community based services (excluding assessment and care management) shall be set by the department in accordance with section 17b-343 of the Connecticut General Statutes. The rates to be charged for other home and community based services shall be set by a contract between the access agency and the service provider even when the services are provided without care management by the access agency. In no event may a contracted rate exceed the usual and customary charge of the provider or the rate set by the department.

(B) For the Connecticut Home Care Program, under no circumstances shall an access agency or assisted living service agency select a provider whose services do not meet the standards of quality established in section 17b-342-2(h) of the Regulations of Connecticut State Agencies.

(C) For the Connecticut Home Care Program, under no circumstances shall an assisted living service agency charge the department at a rate not approved by the department. The approved and enrolled assisted living service agency shall charge the approved rate established by the department and only for those allowable services.

(5) Rates for State-Funded Home Health Services

The rates for home health services provided to eligible persons, as defined in section 17b-342-2(h) of the Regulations of Connecticut State Agencies shall be the same as those paid under the Medicaid program. Home health services shall be paid only under fee-for-service for care managed or self-directed care program clients. For ALSA clients, these services are included in the rate.

History

• Effective July 8, 1998; Amended September 3, 2010

Regs., Conn. State Agencies § 17b-342-4 Nursing facility and hospital requirements

(a) Nursing Facility Admission Requirements

Nursing Facilities shall comply with the following Connecticut Home Care Program requirements:

(1) Information and Forms Distributions

When a nursing facility identifies an elderly applicant for admission to the facility, the nursing facility shall inform the person about the program by providing a copy of the Home Care Request Form and program information.

(A) Medicaid Recipients and Applicants

Prior to admission to a nursing facility, recipients and individuals who have applied for Medicaid who are aged 65 years or older shall:

(i) Complete and submit to the department a Home Care Request form to confirm that they are Medicaid recipients or applicants;

(ii) be screened by the department through its health screen form to determine the need for nursing home care and the feasibility of home care pursuant to section 17b-342-1(b)(15) of the Regulations of Connecticut State Agencies; and

(iii) receive department authorization for admission and Medicaid payment for nursing facility care or home care. The effective date for Medicaid reimbursement on behalf of such person shall be no earlier than the date admission is authorized by the department.

(B) Other Requirements

(i) At the time of the admission of all other elderly persons, the nursing facility shall obtain a statement signed by the person verifying that he or she received the Connecticut Home Care Program materials and understands his or her rights and responsibilities under the Connecticut Home Care Program. The statement shall be maintained in the individual's file. If the person indicates that the program materials were not received or requests Connecticut Home Care Program materials, the facility shall provide the person with a set of materials. The nursing facility shall complete a compliance form for this purpose.

(2) Emergency Admissions for Medicaid Recipients and Applicants

(A) In the case of emergency admissions as defined in section 17b-342-1(b)(15) of the Regulations of Connecticut State Agencies, elderly persons may be admitted to a nursing facility prior to completion of the health screen form. However, the facility shall notify the department within one (1) working day of the admission. Such an emergency shall be documented in writing on the department emergency admission documentation form prior to admission by a health care professional in the facility. The health care professional's name, business address and phone number shall be noted in the patient's record. A copy of the emergency admission form that specifies compliance with these regulations shall be provided to the department and maintained in the individual's records.

(3) Exemptions

The following are elderly persons who are exempt from the Connecticut Home Care Program screening process although they may request to be screened for participation in the program:

(A) Patients transferring from one nursing facility to another and intra-facility transfers;

(B) nursing facility patients who are admitted to a hospital and discharged back to a nursing facility;

(C) individuals who are out-of-state residents at the time they are seeking admission to a nursing facility;

(D) individuals seeking short term respite care in a nursing facility as defined in section 17b-342-2(n) of the Regulations of Connecticut State Agencies; and

(E) terminally ill individuals seeking nursing facility admission. For purposes of this subsection "terminally ill" means that a physician has signed a statement in a form specified by the department for this purpose only, identifying the patient's medical diagnosis and verifying that the individual's life expectancy is six (6) months or less. A copy of the physician's statement shall be submitted to the department and also be filed in the patient's nursing facility record.

(4) Coordination with screening process for Mental Illness and Mental Retardation under OBRA 1987.

(A) The preadmission screening procedures administered under the Connecticut Home Care Program shall be coordinated with the federally mandated screening for nursing home applicants with mental illness or mental retardation. Exemptions C, D and E above do not apply to the mandatory nursing home preadmission screening for mental illness and mental retardation related to the federal Omnibus Budget Reconciliation Act of 1987 (OBRA).

(B) Except when exemptions apply or the emergency admission procedures have been followed, the department shall not reimburse a nursing facility for any days that an elderly person spends in the facility prior to completion of the preadmission screening process for the Connecticut Home Care Program and the federally mandated screening for nursing home applicants with mental illness or mental retardation.

(b) Hospital Responsibilities

Hospitals shall comply with the following Connecticut Home Care Program requirements:

(1) Information and Forms Distribution

(A) If it can be determined by the hospital within three (3) days of admission that an elderly person, as defined in section 17b-342-1(b)(14) of the Regulations of Connecticut State Agencies, would be expected, based upon the professional judgement of hospital personnel, to be an applicant for admission to a nursing facility without the services available through the Connecticut Home Care Program, the hospital shall distribute the Connecticut Home Care Program forms packet to such elderly person and provide information about the program. Hospital staff are encouraged to provide program information to all elders or their representatives.

(B) If the patient's condition is too unstable to make the above determination by day three, the Connecticut Home Care Program forms and information shall be provided when the determination can be made. The hospital staff shall document in the patient's record the reason for the postponement (e.g. "patient's condition too unstable to make determination"). The hospital staff shall also document the date the materials are distributed.

(2) Completion and Submission of Forms

Personnel responsible for discharge planning shall complete and submit to the department any required forms for determining nursing facility level of care eligibility.

History

• Effective July 8, 1998; Amended September 3, 2010

Regs., Conn. State Agencies § 17b-342-5 Reporting

All nursing facilities, hospitals, access agencies, assisted living service agencies, lead service providers and home care service providers shall comply with any reporting, quality assurance review and audit requirements established by the department for purposes of administering, monitoring and evaluating the Connecticut Home Care Program.

History

• Effective July 8, 1998; Amended September 3, 2010

17b-349e Connecticut Statewide Respite Care Program

Regs., Conn. State Agencies § 17b-349e-1 Scope

(a) Sections 17b-349e-1 to 17b-349e-9, inclusive, of the Regulations of Connecticut State Agencies, describe administration, eligibility criteria, provider qualifications, service parameters and funding guidelines for the Connecticut Statewide Respite Care Program. Sections 17b-349e-1 to 17b-349e-9, inclusive, of the Regulations of Connecticut State Agencies apply to all activities and persons participating in the Connecticut Statewide Respite Care Program, including, but not limited to, applicants, eligible individuals, caregivers, sponsor agencies and providers.

(b) Pursuant to section 17b-349e of the Connecticut General Statutes, the Connecticut Statewide Respite Care Program is limited to the provision of and payment for respite care for individuals with Alzheimer's disease or related disorders as described in sections 17b-349e-1 to 17b-349e-9, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective March 11, 1999; Amended July 2, 2012

Regs., Conn. State Agencies § 17b-349e-2 Purposes

The purpose of the Connecticut Statewide Respite Care Program is to provide, within available appropriations, the following:

(1) Respite care services for individuals with Alzheimer's disease residing in the community in order to relieve some of the stress experienced by caregivers caused by the responsibility of daily caregiving;

(2) Supportive services to relieve caregivers in order to prevent premature institutionalization of an individual with Alzheimer's disease; and

(3) New services, or expand available services, for eligible individuals with Alzheimer's disease residing in the community.

History

• Adopted effective March 11, 1999; Amended July 2, 2012

Regs., Conn. State Agencies § 17b-349e-3 Definitions

For the purposes of sections 17b-349e-1 to 17b-349e-9, inclusive, of the Regulations of Connecticut State Agencies, the following definitions shall apply:

(1) "Adult day health services" means a program, of either a medical or social model, designed to meet the needs of cognitively or physically impaired adults through a structured, comprehensive program that provides a variety of health, social and related support services, in a protective setting, during any part of a day;

(2) "Campership" means a day or overnight accredited camp program for functionally impaired adults;

(3) "Caregiver" has the same meaning as "caretaker" as provided in section 17b-349e of the Connecticut General Statutes;

(4) "Commissioner" means the Commissioner of Social Services;

(5) "Companion service" or "sitter service" means a non-medical, basic protection and supervision service provided to an eligible individual in the eligible individual's home on a short-term basis;

(6) "Copayment" means "copayment" as defined in section 17b-349e of the Connecticut General Statutes;

(7) "Department" means the Department of Social Services;

(8) "Division" means the department's division of aging services;

(9) "Eligible individual" means an applicant who meets the eligibility criteria as set forth in section 17b-349e-6 of the Regulations of Connecticut State Agencies;

(10) "Homemaker services" means household tasks and activities provided to an eligible individual in the eligible individual's home by a homemaker, including, but not limited to, cooking, cleaning, laundry, mending and other light household chores;

(11) "Home health aide services" means services that include personal hands-on care, household tasks and similar activities provided to an eligible individual in the eligible individual's home by a home health agency;

(12) "Income" means any payment from any source and of any kind including, but not limited to, Social Security (minus Medicare Part B premiums), Supplemental Security, Railroad Retirement income, pensions, wages, interest, dividends, net rental income, veteran's benefits or any other payments received on a one-time or recurring basis;

(13) "Individual with Alzheimer's disease" has the same meaning as provided in section 17b-349e of the Connecticut General Statutes;

(14) "Liquid assets" means any checking accounts, savings accounts, individual retirement accounts, certificates of deposits, stocks or bonds, that can be converted into cash within twenty working days;

(15) "Personal emergency response system" means a twenty-four hour electronic alarm system which enables a high risk individual to secure help in a medical, physical, emotional or environmental emergency;

(16) "Personal care assistant services" means physical assistance to enable the eligible individual to carry out activities of daily living and instrumental activities of daily living. These services are provided by a person who is employed by the eligible individual or the eligible individual's representative to assist the eligible individual in carrying out the tasks required in the service plan;

(17) "Private duty nursing" means hourly services delivered by licensed nursing personnel in the eligible individual's home;

(18) "Program" means the Connecticut Statewide Respite Care Program;

(19) "Provider" means a person, public agency, private non-profit agency or proprietary agency that is licensed, certified or otherwise approved by the commissioner to supply any service, or combination of services, described under "respite care services" as defined in this section;

(20) "Representative" means a person designated by an eligible individual or the probate court to act on the eligible individual's behalf. A representative may include a family member, an attorney, a guardian, a conservator or a person designated by the eligible individual to act as the eligible individual's representative;

(21) "Residential health care facility" means a facility that, on a short-term basis, provides food, shelter, supervised health care and related services to four or more persons, eighteen years of age or older, who are unrelated to the owner or administrator;

(22) "Respite care services" means support services that provide short-term relief from the demands of ongoing care for an individual with Alzheimer's disease provided hourly, daily, overnight or on weekends including, but not limited to, companion or sitter services, home health aide services, homemaker services, personal care assistant services, adult day health services, short-term inpatient care in a licensed nursing facility, residential health care facility, overnight campership program, private duty nursing, transportation and the personal emergency response system;

(23) "Service plan" means a written document agreed upon by the eligible individual, the caregiver and the sponsor agency that specifies the type, frequency and duration of services to be provided. The service plan shall take into account other services available to the eligible individual and the eligible individual's caregiver;

(24) "Sponsor agency" means the organization that contracts with the department to administer the regional program, determine eligibility and arrange for services for eligible individuals; and

(25) "Relative" means spouse, natural parent, child, sibling, adoptive child, adoptive parent, stepparent, stepchild, stepbrother, stepsister, father-in-law, mother-in-law, son-in-law, daughter-in-law, sister-in-law, brother-in-law, grandparent, grandchild, aunt, uncle, niece or nephew.

History

• Adopted effective March 11, 1999; Amended July 10, 2000; Amended July 2, 2012

Regs., Conn. State Agencies § 17b-349e-4 Organization and administration of program

(a) The division shall oversee and regularly monitor the administration of the program as follows:

(1) The division shall ensure that the first five hundred thousand dollars ($500,000) of funds appropriated is distributed in equal shares among Connecticut's five regional Area Agencies on Aging as sponsor agencies administering the program. The division may allocate appropriations exceeding five hundred thousand dollars ($500,000) to sponsor agencies based upon the demonstrated level of need for services in a particular region, and may transfer funds between regions based upon the demonstrated level of need in a particular region. A percentage of each allocation to the sponsor agencies shall be designated to cover the cost of administering the program.

(2) The division shall regularly monitor the administration of the program to ensure, verify and determine the effectiveness and quality of the program.

(b) Sponsor agencies statewide shall administer the program at a regional level as follows:

(1) Sponsor agencies shall process program applications for eligibility, establish service plans and contract for services when applicable, for eligible individuals within their designated regions.

(2) Sponsor agencies shall monitor client satisfaction and compile and submit reports to the division as required.

History

• Adopted effective March 11, 1999; Amended July 10, 2000; Amended July 2, 2012

Regs., Conn. State Agencies § 17b-349e-5 Application process

(a) The application process includes all activity related to a request for a determination of eligibility under the program. The process begins with the receipt of an application by a sponsor agency and continues in effect until there is an official disposition of the eligibility request from that sponsor agency.

(b) The sponsor agency servicing the city or town in which the applicant resides shall perform appropriate assessments and make a written determination of eligibility within thirty days after the receipt of an application.

(c) When the applicant is incompetent or incapable of filing an application on the applicant's own behalf, the sponsor agency shall recognize any representative as defined in section 17b-349e-3 of the Regulations of Connecticut State Agencies for the purpose of initiating such application.

(d) Each sponsor agency has the responsibility to explain to the applicant or the applicant's representative the purposes and eligibility requirements of the program and the applicant's rights and responsibilities. Each sponsor agency shall accept and process applications and maintain files that shall include applications and documents supporting each application.

(e) The applicant or the applicant's representative is responsible for completing the application forms truthfully, legibly and accurately. The applicant or the applicant's representative shall provide the sponsor agency with documentation required to support statements made on the application.

(f) Each applicant or eligible individual shall notify the sponsor agency whenever a change in his or her circumstances relating to income, assets or address occurs.

History

• Adopted effective March 11, 1999; Amended July 2, 2012

Regs., Conn. State Agencies § 17b-349e-6 Eligibility

(a) An eligible individual shall be any person diagnosed with Alzheimer's or related diseases. An eligible individual who has been given a generic diagnosis of dementia shall have had a sufficient medical evaluation to rule out unrelated conditions such as depression, traumatic brain injury, alcoholism or drug interactions. An eligible individual shall have a physician with whom the sponsor agency may contact regarding the eligible individual. The physician shall certify that the eligible individual has completed an appropriate medical examination showing a diagnosis of irreversible and deteriorating dementia of the Alzheimer's type.

(b) An eligible individual shall be a resident of the state of Connecticut, be residing in a home in the community and be at risk of long-term institutional placement if the eligible individual's regular caregiver cannot continue in that role.

(c) An eligible individual shall not have an annual income or liquid assets that exceed the amounts designated in section 17b-349e of the Connecticut General Statutes. On July 1, 2009, and annually thereafter, the department shall recalculate the income and asset limitations over that of the previous year to account for the annual cost of living adjustment in Social Security income, if any.

(d) An individual receiving services through the Connecticut Homecare Program for Elders shall not be eligible for services under the Connecticut Statewide Respite Care Program.

History

• Adopted effective March 11, 1999; Amended July 2, 2012

Regs., Conn. State Agencies § 17b-349e-7 Sponsor agency requirements

(a) Each sponsor agency shall contract annually with the department to administer the regional program. Each sponsor agency shall determine the maximum number of eligible individuals to be served in its respective region based on the financial allocation made by the department. The sponsor agency shall not admit or serve more eligible individuals than can be afforded within available appropriations.

(b) Each sponsor agency shall determine the eligibility of all applicants for services under the program, additional sources of payment for such services and assess and collect all co-payments through retrospective billing.

(c) Each sponsor agency shall develop, as necessary, a service plan for each eligible individual to be served under the program, pay providers as required, provide statistical and financial reports as required by the department, and comply with sections 17b-349e-1 to 17b-349e-9, inclusive, of the Regulations of Connecticut State Agencies.

History

• Adopted effective March 11, 1999; Amended July 2, 2012

Regs., Conn. State Agencies § 17b-349e-8 Provider qualifications and requirements

(a) Providers shall enter into contracts with sponsor agencies for the delivery of respite care services to individual clients under the program, and shall be accountable to each contracting sponsor agency as well as to individual clients or each individual's representative for the provision of those services.

(b) Providers shall have demonstrated prior experience and training in delivering services to individuals with Alzheimer's disease and agree to provide services at the rates set by the department.

(c) Providers who have received accreditation by the Joint Commission on the Accreditation of Healthcare Organizations, when available, shall receive preference in contracting for services.

(d) Providers shall meet the requirements of provider participation of the specified services as established for the Connecticut Home Care Program for Elders, pursuant to section 17b-342-2 of the Regulations of Connecticut State Agencies to the extent that such requirements do not conflict with sections 17b-349e-1 to 17b-349e-9, inclusive, of the Regulations of Connecticut State Agencies.

(e) A provider under the Connecticut Statewide Respite Care Program shall not be a spouse or conservator of the person receiving the services. A relative of the conservator of the eligible individual receiving the services may be a provider with prior approval of the department.

History

• Adopted effective March 11, 1999; Amended July 10, 2000; Amended July 2, 2012

Regs., Conn. State Agencies § 17b-349e-9 Service, payment and cost limitations; fees

(a) The department shall determine provider reimbursement and payment levels for the respite care services to be provided under the program. Reimbursement levels for services provided under the program shall not exceed the levels established under the Connecticut Home Care Program for Elders for similar services.

(b) An eligible individual may not receive more than three thousand five hundred dollars ($3,500) for respite care services or receive more than thirty days of out-of-home respite care services, other than adult day care, under the program in any fiscal year. An eligible individual may receive additional respite services not to exceed seven thousand five hundred dollars ($7,500) if the eligible individual has demonstrated to the sponsor agency a need for additional respite care services. A sponsor agency may consider various factors to determine if an eligible individual needs additional respite care services including, but not limited to, whether:

(1) The primary caregiver is experiencing a physical or mental impairment;

(2) the caregiver is not receiving any other respite services;

(3) the client is physically or emotionally abusive to the primary caregiver;

(4) the client is at risk for neglect or abuse; or

(5) the burden of care is significant.

(c) Service levels are subject to the limits of the funding allocations to an eligible individual's sponsor agency. In the event that it appears that all requests for services cannot be accommodated within funding allocations, then approval for services under the program may be limited. Priority for the receipt of services shall be determined by the sponsor agency on a case by case basis, giving primary consideration to the following factors:

(1) The eligible individual is not currently receiving any other respite care;

(2) the caregiver is experiencing physical or mental impairments and has primary responsibility for caring for the eligible individual;

(3) the eligible individual has been combative, non-compliant or physically or mentally abusive to the caregiver;

(4) respite care services are being requested for a specific event or commitment rather than for ongoing, periodic services; or

(5) the eligible individual lives alone.

(d) If an eligible individual's respite care service costs are covered in whole or in part by another state or federal government program or insurance contract, the government program or insurance carrier shall be the primary payer and the Connecticut Statewide Respite Care Program shall be the secondary payer.

(e) An eligible individual shall pay a copayment of twenty per cent of the cost of all respite care services to the sponsor agency as required, unless granted a reduction or a waiver of the copayment in accordance with subsection (f) of this section. The copayment shall be applied to the cost of program services.

(f) The sponsor agency may grant a reduction or waiver of the copayment to an eligible individual based upon demonstration of financial hardship by the applicant as determined by the sponsor agency.

History

• Adopted effective March 11, 1999; Amended July 10, 2000; Amended July 2, 2012

Department of Consumer Protection Department of Consumer Protection

17b-363a Return of Drug Products to Pharmacies

Regs., Conn. State Agencies § 17b-363a-1 Return of drug products to pharmacies

(a) Any vendor pharmacy that accepts for return drug products dispensed to long-term care facilities, pursuant to section 17b-363a of the Connecticut General Statutes, shall comply with the requirements of this section.

(b) A vendor pharmacy shall not accept for return any drug products that do not meet the criteria for return under section 17b-363a of the Connecticut General Statutes.

(c) A vendor pharmacy shall immediately physically inspect all drug products that are returned by long-term care facilities. Any drug products in original manufacturer's dispensing packages that have been opened, have had doses removed, or show any signs of tampering shall not be returned to stock. Any drug products packaged in unit dose or blister type packaging that appear to have been removed from and returned to the dispensing package, or drug products in such packaging that appears to have been tampered with or the integrity of which appears to be compromised in any way, shall not be returned to stock, except as permitted in subsection (d)(2) of this section.

(d) Except as provided in subsections (b) and (c) of this section, a vendor pharmacy may return to stock for re-dispensing drug products:

(1) packaged in original manufacturer's dispensing packages;

(2) packaged in unit dose or blister type packaging whose individual labeling and integrity remains intact even though doses may have been removed from the outer package; or

(3) originally packaged by the vendor pharmacy into multiple dose blister packaging. Except as otherwise permitted by this subdivision, such drug products shall be removed from the original dispensing package before being placed into pharmacy stock for re-dispensing. This process shall be done in a manner that insures that the lot number and expiration date for the drug product are maintained and that the individual doses of the drug product are not exposed to possible adulteration or cross-contamination. Generically equivalent drug products from more than one drug manufacturer shall not be co-mingled. Removal of the drug product from the original dispensing package prior to re-dispensing shall not be required for packaging from which no doses have been removed and for packaging that allows disassembly without handling the drug product, while maintaining product identification, lot number, and expiration date.

(e)

(1) All drug products re-dispensed on prescription from the vendor pharmacy shall be labeled with all required information, including lot number and expiration date.

(2) The expiration date assigned to the drug product for re-dispensing shall be no later than the expiration date assigned to the product when originally dispensed, or no later than the earliest expiration date originally assigned to any dose contained in the repackaged multiple dose blister card dispensed.

(3) The lot number assigned shall be the manufacturer's original lot number for products dispensed in manufacturers' original packaging, or a lot number assigned by the vendor pharmacy for a repackaged product, from which the original lot numbers of the doses contained may be referenced.

History

• Adopted effective June 6, 2001

Department of Social Services Department of Social Services

17b-411 Office of the State Long-Term Care Ombudsman

Regs., Conn. State Agencies § 17b-411-1 Definitions

As used in sections 17b-411-1 to 17b-411-14, inclusive, of the Regulations of Connecticut State Agencies:

(1) “Applicant” has the same meaning as provided in section 17b-400 of the Connecticut General Statutes;

(2) “Commissioner” means the Commissioner of the Department on Aging or of any other state agency responsible for hosting the Long-Term Care Ombudsman’s Office;

(3) “Complaint” means an oral or written statement made to or initiated by the program, by or on behalf of a resident or applicant alleging or tending to allege circumstances, conduct, action, lack of action, instances or decisions by or relating to providers, public agencies, health and social service agencies or others that adversely affect the health, safety, welfare or rights of a long-term care facility resident;

(4) “Conflict of interest” means circumstances in which other interests intrude upon, interfere with or threaten to negate the ability of the Long-Term Care Ombudsman Program to advocate without compromise on behalf of long-term care facility residents;

(5) “Department” means the state Department on Aging;

(6) “Executive Board” means the Executive Board of the Statewide Coalition of Presidents of Resident Councils established pursuant to section 17b-411-7 of the Regulations of Connecticut State Agencies;

(7) “Host agency” means the Department on Aging or any other state agency that statutorily houses the Office of the Long-Term Care Ombudsman;

(8) “Long-term care facility” has the same meaning as provided in section 17b-400 of the Connecticut General Statutes;

(9) “Office” has the same meaning as provided in section 17b-400 of the Connecticut General Statutes;

(10) “Program” has the same meaning as provided in section 17b-400 of the Connecticut General Statutes, unless the context otherwise requires;

(11) “Provider” means an entity or person who provides goods or services to residents, and includes those who own, operate or work for long-term care facilities and their agents, employees, representatives and contractors;

(12) “Resident” has the same meaning as provided in section 17b-400 of the Connecticut General Statutes, and includes a person who seeks admission to a long-term care facility;

(13) “Regional Ombudsman” means a person duly designated by the State Long-Term Care Ombudsman to represent and act on behalf of the program in regions established throughout Connecticut;

(14) “State Long-Term Care Ombudsman” or “State Ombudsman” means the individual appointed by the commissioner; and

(15) “Volunteer Resident Advocate” or “VRA” means any person duly designated by the State Ombudsman and trained by the program to serve as an advocate for residents through the VRA’s association with, and on behalf of, the Long-Term Care Ombudsman program.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-2 Duties of Host Agency

The commissioner of the host agency, or the commissioner’s designee, shall perform the following duties:

(1) Appoint the State Ombudsman, based on the requirements of section 17b-400 of the Connecticut General Statutes and section 17b-411-3(c) of the Regulations of Connecticut State Agencies, to serve on a full-time basis;

(2) ensure that policies and procedures governing the program are established by the office;

(3) ensure that representatives of the office have access, in accordance with section 17b-411-9 of the Regulations of Connecticut State Agencies to the following:

(A) Long-term care facilities and residents;

(B) administrative records, policies and documents of long-term care facilities available to the general public;

(C) appropriate access to medical and social records of residents; and

(D) licensing and certification records of long-term care facilities maintained by the state;

(4) ensure that adequate legal counsel is available to the office in accordance with section 17b-411-14 of the Regulations of Connecticut State Agencies;

(5) ensure non-interference in the operation of the program in accordance with the Older Americans Act, 42 USC 3058g(j);

(6) ensure that conflict of interest provisions set forth in section 17b-411-13 of the Regulations of Connecticut State Agencies are followed;

(7) ensure that a state-wide reporting system is developed and maintained as required by section 17b-413 of the Connecticut General Statutes;

(8) ensure that representatives of the office advocate on behalf of residents in administrative and legislative hearings and other forums by presenting information and testimony;

(9) ensure that the office prepares an annual report that includes policy, regulatory and legislative recommendations for improving the health, welfare, safety and rights of long-term care facility residents in compliance with the Older American Act, 42 USC 3058g(h)(1); and

(10) ensure that no representative of the office shall be liable for the good faith performance of official duties.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-3 Long-Term Care Ombudsman Program. State Ombudsman Qualifications. Regional Ombudsman Qualifications. Volunteer Resident Advocates, Qualifications and Duties

(a) The long-term care ombudsman program, established pursuant to section 17b-400 of the Connecticut General Statutes, shall be known as the “Office of the Long-Term Care Ombudsman.” The Office of the Long-Term Care Ombudsman shall be an independent office free from conflict of interest as set forth in section 17b-411-13 of the Regulations of Connecticut State Agencies. The position taken by the State Ombudsman on issues affecting residents shall not be dictated or compromised by policies and positions held by the state administration, the host agency of the Office of the Long-Term Care Ombudsman or any other agency of the state. The Office of the Long-Term Care Ombudsman shall consist of the State Ombudsman, nine Regional Ombudsmen and Volunteer Resident Advocates.

(b) In the event the State Ombudsman is unable to fulfill the duties of the office, the commissioner shall appoint an Acting State Ombudsman. The Acting State Ombudsman shall meet the requirements of subsection (c) of this section.

(c) State Ombudsman. Qualifications. The State Ombudsman appointed by the commissioner shall:

(1) Be free of conflicts of interest as defined in section 17b-411-13 of the Regulations of Connecticut State Agencies;

(2) possess a minimum of a bachelor’s degree;

(3) possess a minimum of 8 years of experience and expertise involving long-term care and advocacy concerning social, human services or community service programs for the elderly and disabled; and

(4) possess knowledge and experience in the following areas:

(A) Management principles and techniques;

(B) relevant state and federal laws;

(C) relevant department policies and procedures;

(D) resident care and long-term care facility operations;

(E) the problems of the elderly and disabled in long-term care facilities;

(F) community resources available to the elderly;

(G) interpersonal skills;

(H) oral and written communication skills;

(I) ability to perform program planning, development, administration and evaluation;

(J) experience working with volunteers; and

(K) experience with dispute resolution, investigation, mediation, negotiation, problem solving or training in dispute resolution.

(d) Regional Ombudsmen. Qualifications.

(1) There shall be nine Regional Ombudsmen, with one Regional Ombudsman to serve in each service area of the state.

(2) In order to be appointed as a Regional Ombudsman by the State Long-term Care Ombudsman, an individual shall:

(A) Be free of conflicts of interest as defined in section 17b-411-13 of the Regulations of Connecticut State Agencies;

(B) possess a minimum of a bachelor’s degree;

(C) possess a minimum of 6 years experience, 1 year of which shall have been in the provision of advocacy services, and expertise involving long-term care and advocacy concerning social, human services or community service programs for the elderly and disabled;

(D) possess knowledge of the following:

(i) Problems of the elderly and disabled in long-term care facilities;

(ii) relevant state and federal laws; and

(iii) relevant department policies and procedures; and

(E) experience working with volunteers.

(e) Volunteer Resident Advocates. Certification. Qualifications.

(1) The State Ombudsman may certify the Volunteer Resident Advocates upon:

(A) The successful completion of the Volunteer Resident Advocate certification training program described in section 17b-411-8 of the Regulations of Connecticut State Agencies; and

(B) the submission of at least 2 recommendations from former employers, colleagues or non-family members.

(2) The initial certification shall be for a 90-day probationary period.

If the individual is requested to continue as a VRA after the 90-day probationary period, the designation shall be considered permanent and shall continue until the VRA provides a written notice of resignation or the VRA’s certification is revoked by the State Ombudsman.

(3) VRAs shall demonstrate or meet the following qualifications:

(A) If possible, be a resident of the region in which they shall serve;

(B) be at least 18 years of age;

(C) possess good communication and interpersonal skills, including knowledge of interviewing techniques, observation, ability to provide the resident with a sense of participation and self-determination;

(D) have the ability to identify and focus on relevant issues;

(E) be impartial and non-judgmental in approach to problems. For example, the individual shall not be biased toward or against facilities or specific aging and disability issues, such as end of life issues;

(F) have the ability to identify the parameters of their role and defer to a Regional Ombudsman or State Ombudsman when appropriate;

(G) be available to visit the long-term care facility at least once a week, during regular business hours, to receive concerns from residents, families, staff and administration concerning quality of care and welfare of residents;

(H) be able to get to the long-term care facility either by car or public transportation;

(I) be physically and mentally capable of fulfilling the responsibilities of the job;

(J) possess problem solving skills;

(K) possess the ability to clearly and effectively articulate the issues and facts either orally or in writing;

(L) be able to effectively interact with individuals who are physically or mentally incapacitated;

(M) be able to understand the medical, financial and psychosocial problems of aging and disabled individuals;

(N) be able to understand federal and state law and policies as they relate to long-term care facilities; and

(O) be free of any conflict of interest with the long-term care facility to which they are assigned in compliance with section 17b-411-13(c) of the Regulations of Connecticut State Agencies;

(4) VRAs shall serve without compensation but may be reimbursed, within available appropriations, for reasonable expenses incurred in the performance of their duties. A schedule of allowable expenses, reimbursement rates and procedures shall be issued by the State Ombudsman.

(5) The State Ombudsman may revoke a VRA’s certification and remove the VRA from duty by written notice whenever the State Ombudsman finds such VRA has committed misconduct, material neglect of duty or incompetence in the conduct of the office. The State Ombudsman shall provide the VRA with at least one verbal notice of the revocation of the VRA’s certification. The verbal notice shall be followed by one written notice, provided to the VRA at least two weeks prior to the date on which the VRA’s certification will be revoked. The written notice shall include a statement that provides the basis for the removal of the VRA’s certification. Written notice may be waived if the VRA's performance is so seriously delinquent that it merits immediate removal.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-4 State Ombudsman Responsibilities and Duties

(a) In fulfilling the responsibilities and duties of the Office of the State Long-Term Care Ombudsman, the State Ombudsman shall have full independence and authority to advocate without seeking the host agency’s approval. The position taken by the State Ombudsman on issues affecting residents shall not be dictated or compromised by policies and positions held by the state administration or the host agency.

(b) The State Ombudsman shall be independent in all actions, but shall consult with the commissioner of the host agency, or the commissioner’s designee, to ensure coordination of efforts when appropriate.

(c) The State Ombudsman shall direct the Office of the Long-Term Care Ombudsman Program and shall independently manage the administrative, advocacy, budget and program decisions of the office.

(d) The State Ombudsman, personally or through representatives of the office, shall perform the following duties:

(1) Identify, investigate, resolve or attempt to resolve complaints made by or on behalf of residents;

(2) provide services to protect the health, safety, welfare and rights of residents, including, but not limited to:

(A) Information and referral services; and

(B) education and training for residents, their family members, staff of the long-term care facility and the public;

(3) inform residents, family members, long-term care facility staff and the public about the Ombudsman program’s services, how residents can access those services or how those services can be accessed on behalf of residents;

(4) inform residents or the resident’s representative about means of obtaining services from long-term care service providers, public agencies and health and social service agencies;

(5) ensure that residents state-wide have regular and timely access to representatives of the office of the Ombudsman through on-site visits by a representative of the office to the facility. The required frequency of such visits shall be set forth in the office’s policies and procedures manual;

(6) ensure that complainants and residents receive timely responses to complaints and requests for assistance;

(7) advocate on behalf of residents in the following ways:

(A) Identify problems affecting residents at the facility, local, state or national levels and attempt to resolve those problems;

(B) identify problems in the long-term care system and advocate for changes to that system;

(C) represent the interests of residents before government agencies, legislative committees, individual legislators and other individuals, groups or entities at locations where issues that affect residents are addressed including, but not limited to, public hearings;

(D) communicate directly with legislators, policy makers and the media about issues affecting residents and other consumers of long-term care;

(E) analyze, comment on, provide public testimony about and monitor the development and implementation of proposed or existing federal, state or local laws, regulations, government policies and actions that affect residents;

(F) work in coalitions with residents, citizens and advocates on issues affecting residents and other consumers of long-term care;

(G) educate residents, their family members and the public about the need for changes to the long-term care system and empowering them to voice their concerns to legislators, policy makers and the media;

(H) facilitate public comment;

(I) provide information regarding problems and concerns to public agencies, private entities, state and federal legislators, the public and the media; and

(J) take any other action determined to be appropriate by the State Ombudsman;

(8) pursue administrative, legal and other remedies on behalf of residents, including, but not limited to:

(A) Presenting testimony to legislative and policy making bodies;

(B) identifying issues that may require legal action and providing information and direction to residents on how to seek legal redress;

(C) assisting in the coordination of efforts with legal service organizations, bar associations or other organizations to improve residents access to courts, administrative hearings and residents ability to seek legal remedies;

(D) explaining the appeals process to residents or their family members, assisting residents or their family members with requesting administrative hearings or assisting in such hearings;

(E) holding public hearings to provide a forum for discussion of the issues affecting residents; and

(F) assisting residents in petitioning local, state and federal government agencies for redress of grievances;

(9) prepare the office’s policies and procedures manual setting forth state-wide operational policies and procedures. The State Ombudsman shall have final authority in developing, interpreting and enforcing such policies and procedures;

(10) designate a Regional Ombudsmen and certify Volunteer Resident Advocates in accordance with section 17b-411-3 of the Regulations of Connecticut State Agencies and the office’s policies and procedures manual. The State Ombudsman may seek input in the designation process, but has sole and final authority to designate individuals to represent the office;

(11) identify, oversee, supervise and direct the activities of Regional Ombudsmen;

(12) provide or assure the provision of initial and ongoing training for Regional Ombudsmen and Volunteer Resident Advocates;

(13) provide administrative and technical assistance to Regional Ombudsmen and Volunteer Resident Advocates;

(14) monitor and evaluate the activities and performance of Regional Ombudsmen in accordance with section 17b-411-5 of the Regulations of Connecticut State Agencies;

(15) monitor and evaluate, in conjunction with Regional Ombudsmen, the activities and performance of the Volunteer Resident Advocates in accordance with section 17b-411-6 of the Regulations of Connecticut State Agencies;

(16) request needed program funding directly from the state legislature;

(17) seek and administer grant funds for the office;

(18) promote the development of citizen organizations to participate in the program;

(19) coordinate efforts with other private organizations, advocacy groups and public entities who share the mission and goals of the program to improve the well-being of long-term care facility residents;

(20) consult with state agencies and programs whose duties and services affect residents including, but not limited to, the Department on Aging; the Department of Social Services, the Department of Public Health, the Office of the Attorney General, the state’s Protective Services for the Elderly program and the state’s Unit on Aging;

(21) initiate and support the development and maintenance of resident and family councils;

(22) prepare an annual report in accordance with the Older Americans Act, 42 USC 3058g(h);

(23) ensure that the confidentiality of program records is maintained in accordance with 17b-411-10 of the Regulations of Connecticut State Agencies and other applicable state and federal laws;

(24) identify duties to be performed by Volunteer Resident Advocates in accordance with section 17-406 of the Connecticut General Statutes and section 17b-411-6 of the Regulations of Connecticut State Agencies;

(25) perform other duties specified in the office’s policies and procedures manual; and

(26) ensure that a state-wide registry of complaints is maintained as required by the Older American’s Act, 42 USC 3058g(c).

(e) The State Ombudsman shall have discretion to consult with the Executive Board regarding policy, legislative or advocacy issues. The State Ombudsman may also seek the advice of the Executive Board regarding any other issue the State Ombudsman determines necessary.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-5 Regional Ombudsmen. Duties and Responsibilities

Regional Ombudsmen shall perform the following duties:

(1) Identify, investigate, resolve or attempt to resolve complaints made by or on behalf of residents that relate to actions, inactions or decisions that may adversely affect the health, safety, welfare or rights of residents. Regional Ombudsmen shall inform the complainant, the resident or the resident’s legal representatives of the findings of an investigation or the reasons why a complaint cannot be investigated;

(2) provide services to protect the health, safety, welfare and rights of long-term care facility residents, including, but not limited to:

(A) Information and referral services;

(B) assistance to residents to locate and retain legal representation in those cases in which the problem appears, in the judgment of a Regional Ombudsman or State Ombudsman, to require legal action or when the resident explicitly requests assistance in retaining legal counsel or representation. Such legal counsel shall be at the resident's expense; and

(C) education and training for residents, their family members, staff of long-term care facilities and the public;

(3) ensure that residents have regular and timely access to representatives of the Ombudsman through frequent on-site visits by a representative of the office to the facility;

(4) respond to complaints and requests for assistance;

(5) support the development and maintenance of resident and family councils and assist in addressing council concerns;

(6) inform residents, their family members, citizen organizations, the public and long-term care facility staff about the Long-Term Care Ombudsman program;

(7) advocate on behalf of residents, at the direction of the State Ombudsman, in the following nonexclusive ways:

(A) Identify problems affecting residents at the facility, local, state or national levels and attempt to resolve those problems;

(B) identify problems in the long-term care system and advocate for changes to that system;

(C) represent the interests of residents before government agencies, legislative committees, individual legislators and other individuals, groups or entities where issues that affect residents are addressed;

(D) communicate with legislators, policy makers and the media about issues affecting residents and other consumers of long-term care;

(E) assist the State Ombudsman to analyze, comment on, provide public testimony about and monitor the development and implementation of proposed or existing federal, state and local laws, regulations, government policies and actions that affect residents; and

(F) provide information regarding the problems and concerns of residents and recommendations for resolving those problems and concerns to:

(i) Public agencies;

(ii) private entities; and

(iii) state and federal legislators;

(8) pursue administrative, legal and other remedies on behalf of individual residents;

(9) in accordance with federal and state laws and regulations, share information related to long-term care facilities with the State of Connecticut Department of Public Health;

(10) participate in surveys of long-term care facilities conducted by the State of Connecticut Department of Public Health and communicate with Department of Public Health surveyors regarding issues affecting a particular facility;

(11) document and report activities as required by the office;

(12) accept the direction, instruction, guidance and assistance of the State Ombudsman in all program activities;

(13) remain knowledgeable regarding current federal and state laws and regulations relating to issues affecting long-term care facility residents; and

(14) carry out other program-related activities that the State Ombudsman determines to be appropriate.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-6 Volunteer Resident Advocate Duties and Responsibilities

The Volunteer Resident Advocates shall be responsible for the following:

(1) Informing residents of their rights and advocating on their behalf;

(2) aiding to ensure the residents are satisfied with the care and services provided by the long-term care facility;

(3) assisting Regional Ombudsmen in carrying out the policies and procedures of the Long-Term Care Ombudsman program in the region or long-term care facility in which the VRA is assigned to serve;

(4) assisting Regional Ombudsmen, and possibly the State Ombudsman, with the evaluation, investigation and resolution of certain complaints which are determined to require such joint action;

(5) reporting, in writing, to the Regional Ombudsman any complaints received and actions taken by the VRA;

(6) when a complaint can be acted on by the VRA in the long-term care facility, the VRA may take action at the direction of Regional Ombudsmen or the State Ombudsman;

(7) at the resident’s request, acting as a liaison between the long-term care facility administrator, other staff, friends or family;

(8) aiding and assisting residents in ensuring that residents are satisfied with the management of their financial affairs including, but not limited to, informing them of their rights regarding knowledge of and control of their assets; and

(9) completing a minimum of 12 hours of in-service training each calendar year in accordance with section 17b-411-8 of the Regulations of Connecticut State Agencies.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-7 Executive Board

(a) There shall be an Executive Board of the Statewide Coalition of Presidents of Resident Councils. The Executive Board shall advocate for quality of care and services for Connecticut long-term care facility residents.

(b) The Executive Board shall consist of a maximum of nine members, comprised of three members from each of the three Long-Term Care Ombudsman Program regions. The Executive Board members shall be appointed as provided in the Executive Board’s bylaws.

(c) The Executive Board shall have the authority to establish and amend bylaws.

(d) The Executive Board shall make recommendations to the State Ombudsman regarding legislative issues, policy issues and quality of care concerns affecting individuals, or groups of individuals, residing in long-term care facilities.

(e) The State Ombudsman may request that the Executive Board make recommendations or advise the State Ombudsman on issues brought to the attention of the Executive Board. The Executive Board’s recommendations shall be taken into consideration by the State Ombudsman, but the Executive Board’s recommendations shall not be binding. Any final decision shall be that of the State Ombudsman.

(f) The State Ombudsman or the State Ombudsman’s designee shall assist to facilitate meetings of the Executive Board, to be held at least quarterly, and provide administrative support to the Executive Board.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-8 Volunteer Resident Advocate Certification and Training Program

(a) Every person who acts as a VRA is required to complete 28 hours of initial training, consisting of a curriculum developed and coordinated by the State Ombudsman, followed by a minimum of 12 hours per calendar year of in-service training, in addition to an annual training required for all VRAs. The annual training shall be developed and coordinated by the Long-Term Care Ombudsman Program.

(b) In-service training topics shall be related to issues affecting long-term care residents.

(c) VRAs may meet the in-service training requirement by attending trainings sponsored by the Office of the Long-Term Care Ombudsman or sponsored by other organizations so long as the training topic is related to issues affecting long-term care residents and the VRA obtains prior approval from the State Ombudsman. Trainings may be led by an instructor or web-based.

(d) The specific content of the initial certification training course shall include, but is not limited to, the following topics:

(1) Resident’s rights;

(2) Resident Councils and Family Councils;

(3) resident care plans;

(4) federal, state and local laws, regulations and policy affecting long-term care facility residents, their rights, and the Long-Term Care Ombudsman Program;

(5) oversight agencies, licensure and certification;

(6) legal issues, including but not limited to, conservatorship, power of attorney, and advanced directives;

(7) aging process: physical and mental health;

(8) types of facilities and levels of care;

(9) resident complaints, investigative techniques, complaint resolution techniques and conflict issues;

(10) admission issues, contracts and payer issues;

(11) facility grievance policies and procedures;

(12) systems advocacy, legislation and policy making;

(13) state and federal deficiency ratings and consumer reports; and

(14) the Long-Term Care Ombudsman program’s policies and procedures.

(e) The State Ombudsman shall provide a training manual to each trainee. The training manual shall contain information including, but not limited to, the topics covered in the initial certification training course as set forth in subsection (d) of this section.

(f) If, in the opinion of the State Ombudsman, a candidate for VRA exhibits an adequate understanding of the role and the responsibilities of a VRA, after the candidate has completed the initial certification training course, the State Ombudsman may certify that person as a VRA.

(g) At the expiration of each two-year certification period, the Regional Ombudsmen shall reassess a VRA’s ability to perform the duties associated with the role and responsibilities of a VRA and make a recommendation to the State Ombudsman regarding the recertification of the individual as a VRA.

(h) Regional Ombudsmen shall annually, in accordance with section 17b-411-13 of the Regulations of Connecticut State Agencies, ensure that the VRA is free of any conflict of interest.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-9 Access to Facilities, Residents and Resident Records

(a) Access to the Facility and Residents. The State Ombudsman or the State Ombudsman’s designee shall have access to long-term care facilities and residents at any time deemed reasonable and necessary to effectively carry out the duties of the Long-Term Care Ombudsman program as set forth in federal law and sections 17b-411-1 through 17b-411-14, inclusive, of the Regulations of Connecticut State Agencies.

(1) Access to long-term care facilities and residents shall be deemed reasonable and necessary at the following times:

(A) Anytime during a facility’s regular business hours; or

(B) any other time access may be required by a particular condition to be investigated or monitored and the visit is approved by the State Ombudsman or the State Ombudsman’s designee.

(2) The State Ombudsman or the State Ombudsman’s designee shall make announced and unannounced visits to residents of a facility.

(3) Upon entering the facility, or as soon as practicable thereafter, all representatives of the Ombudsman Program shall report their presence to the facility administration or staff in charge and, upon request, present identification as a representative of the Ombudsman Program.

(4) The State Ombudsman or the State Ombudsman’s designee shall have private access to residents without willful interference from the facility or the resident’s representative, including a guardian, family member, person holding power of attorney or conservator.

(b) Access to Resident Records. The State Ombudsman or the State Ombudsman’s designee shall have prompt access to a resident’s records if the Ombudsman or the Ombudsman’s designee has permission of the resident or the legal representative of the resident. The State Ombudsman or the State Ombudsman’s designee shall have access to a resident’s records if the person is unable to consent and has no legal representative, or the legal representative refuses to provide consent, and the State Ombudsman or the State Ombudsman’s designee has reasonable cause to believe that the legal representative is not acting in the resident’s best interest and the State Ombudsman designee, if acting on behalf of the State Ombudsman, obtains approval from the State Ombudsman. The State Ombudsman or the State Ombudsman’s designee shall have access to the following resident records including, but not limited to:

(1) Medical and social records of the resident;

(2) other records of a resident necessary to investigate a complaint;

(3) administrative records, policies and documents of the long-term care facility which residents and the general public also have access to; and

(4) all licensing and certification records maintained with the state.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-10 Confidentiality and Disclosure

(a) For purposes of this section, the terms “records” or “files” mean all documentation including, but not limited to, complaints, reports, findings, medical and social records of residents or information accessed or collected to conduct an investigation of a complaint.

(b) Maintenance of Records. The Long-Term Care Ombudsman Program records shall be maintained in a secure location to ensure confidentiality. Measures shall be implemented by the host agency and the local ombudsman entity to ensure the privacy of Regional Ombudsmen and the State Ombudsman with respect to the receipt of complaints by mail, fax or telephone.

(c) Confidentiality. All records and files maintained by the Long-Term Care Ombudsman Program shall remain confidential, unless otherwise provided under state or federal law.

(d) Disclosure. Subject to subsection (e) of this section, records maintained by the Long-term care ombudsman program may not be disclosed to any individual or entity unless the State Ombudsman authorizes the disclosure. The State Ombudsman or the person designated by the State Ombudsman may, at their discretion, disclose information to other persons or agencies when the Ombudsman determines that such release is in the best interest of the resident or resident population.

(e) The State Ombudsman, or any representative of the Long-Term Care Ombudsman Program, shall not release the identity of a complainant or a resident, either by name or by release of sufficient facts to allow the identity of the complainant or resident to be inferred, unless:

(1) The complainant or resident, or the legal representative of the complainant or resident, consents to the disclosure in writing; or

(2) a court orders the disclosure in the course of a legal proceeding.

(f) Requests for Disclosure. Requests by the parties involved in a complaint to review the report of findings shall be made in writing to the State Ombudsman.

(1) No records, required by state or federal law to be kept confidential, shall be released to any party except with the written consent of the resident or the resident’s legal representative.

(2) Upon receipt of authorization the Long-Term Care Ombudsman’s Office shall have ten days to provide the requested documentation.

(3) Materials, reports, records or other information utilized by the Volunteer Resident Advocate, Regional Ombudsmen or State Ombudsman in the investigation of the complaint or report and used to prepare a report of findings shall not be considered public information and shall, therefore, not be available for review.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-11 Complaints

(a) The Long-Term Care Ombudsman’s Office shall identify, investigate and resolve complaints made by, or on behalf of, residents that relate to an action, inaction or a decision of a provider, long-term care facility, a public agency or a health and social service agency, that may adversely affect the health, safety, welfare or rights of residents.

(b) Content of Complaint. Any complaint filed with the Long-Term Care Ombudsman’s Office pursuant to sections 17b-411-1 to 17b-411-14, inclusive, of the Regulations of Connecticut State Agencies, shall contain the name and address of the long-term care facility, the name of the involved resident or residents or the statement that all the residents are affected, information regarding the nature and extent of the complaint and any other information which the reporter believes might be helpful in the investigation of the complaint.

(c) Method of Filing Complaints.

(1) A complaint may be filed with the Long-Term Care Ombudsman’s Office or the VRA assigned to the resident’s facility in person, by mail, facsimile, electronic mail or by telephone.

(2) For information or for filing of complaints with the State Ombudsman, persons may contact the Long-Term Care Ombudsman’s Office. A toll free number shall be available and the number shall be conspicuously posted in each facility.

(d) A complaint filed by an individual who chooses not to disclose his or her identity shall be considered an anonymous complaint. Anonymous complaints shall be reviewed by the State Ombudsman or the State Ombudsman’s designee. An investigation shall be done only if the State Ombudsman or the State Ombudsman’s designee considers the nature of the complaint to be of such seriousness as to warrant follow-up.

(e) The State Ombudsman shall maintain a registry of all complaints.

(f) A complaint filed by a resident with the Long-Term Care Ombudsman’s Office may be withdrawn by the resident at any time. Any request for withdrawal of a complaint, where the complainant is an individual other than the resident, may be granted only after consultation with the resident. If the resident wishes to proceed with an investigation, the Long-Term Care Ombudsman’s Office shall proceed with the investigation on behalf of the resident. Requests for withdrawals shall be documented in the resident’s case record. The complainant shall be advised, at the time the withdrawal, of the consequences of the withdrawal and that a complaint may be reopened if requested.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-12 Investigation of Complaints

(a) Initial Evaluation of Complaints.

(1) Upon receipt of a complaint by a representative of the Long-Term Care Ombudsman’s Office, the complaint shall be evaluated within two working days by either the VRA or a Regional Ombudsman to determine whether there are reasonable grounds for an investigation. If there is reason to believe, based on the information contained in the complaint received, that the resident is potentially at risk for immediate physical or emotional harm the evaluation shall be done immediately. Examples of immediate risk of physical or emotional harm include, but are not limited to, allegations of physical endangerment or withholding of medication, nutrition or hydration. In cases where the complaint is received directly by the State Ombudsman or there is a question regarding whether the resident is potentially at risk for immediate physical or emotional harm, the evaluation may be done by the State Ombudsman.

(2) If such reasonable grounds are found, a representative of the Long-Term Care Ombudsman’s Office shall initiate a full investigation of the complaint within ten business days after the determination is made that an investigation is warranted. A copy of the investigation report shall be sent to the State Ombudsman who shall maintain a registry of investigation reports. A copy of the investigation report may be sent to the resident or the resident’s legal representative upon request. The State Ombudsman shall not disclose the identity or identifying information regarding another resident or the complainant if the complainant is someone other than the resident.

(3) If it is determined that reasonable grounds do not exist for an investigation, the complainant shall be notified of this determination within five business days after receipt of the complaint. The notification shall include a brief explanation of the reasons upon which the Long-Term Care Ombudsman’s representative concluded that an investigation was not warranted.

(4) If it is determined that reasonable grounds do exist, and an investigation is completed and the Long-Term Care Ombudsman’s Office has taken actions to attempt to resolve the complaint, but the complaint is not resolved to the satisfaction of the resident, the State Ombudsman may, with the authorization of the resident, request the advice or recommendations of the Executive Board. The State Ombudsman may, considering the advice or recommendations of the Executive Board, take any recommended actions or close the case. The State Ombudsman shall provide, upon request, a written explanation to the individual regarding the decision to close a case.

(b) Investigation of Complaint. Access to Facility and Records.

(1) The appropriate representative of the Long-Term Care Ombudsman’s Office shall conduct an impartial investigation of the complaint. The representative may, with the permission of the resident or the resident’s legal representative, speak with the administrator of the facility and any other persons who may be a source of information. Other persons may include, but are not limited to, the friends and family of the resident involved, and if there is a specific resident involved, the staff of the facility, representatives from involved or relevant public and private agencies or the legal representative of the resident. The representatives of the Long-Term Care Ombudsman’s Office shall make written recordings of all statements by all persons being interviewed.

(2) In the course of an investigation any representative of the Long-Term Care Ombudsman’s Office may observe the functioning of the entire facility and may interview residents at random. Except when the facts warrant immediate action, investigations shall be carried out at reasonable times and without interference with resident care.

(3) Nothing in these regulations shall be construed as permitting a long-term care facility, a representative of the Long-Term Care Ombudsman’s Office or any other person to interfere with the proper medical treatment of any resident.

(c) Confidentiality of Complaints

(1) Complaints filed pursuant to section 17b-407 of the Connecticut General Statutes are not deemed public record and are not subject to the provisions of section 1-210 of the Connecticut General Statutes. Information derived from complaints may be disclosed by the State Ombudsman, however, in no case shall the name of the resident or the complainant be disclosed except as provided in section 17b-411-10(e) of the Regulations of Connecticut State Agencies.

(2) A report of the findings of the investigation may be available for review by the parties involved in the complaint with the written authorization of the resident or the resident’s legal representative. However, the actual complaint filed by the complainant shall not be available for review.

(3) The name of the complainant or any person or any identifying information mentioned in the complaint or in the investigation report shall not be disclosed except in accordance with section 17b-411-10(e) of the Regulations of Connecticut State Agencies.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-13 Conflict of Interest

(a) Matters of Discipline, Suspension or Termination. Pursuant to section 17b-400(c) of the Connecticut General Statutes, the State Ombudsman and Regional Ombudsmen are classified service positions. Matters of discipline, suspension or termination of the State Ombudsman or Regional Ombudsmen by the host agency shall be governed by state laws that apply to such classified service positions.

(b) State Ombudsman. Any individual who has the following conflicts of interest, or any individual who has an immediate family member with the following conflicts of interest, shall not be appointed as the State Ombudsman:

(1) Direct involvement in the licensing or certification of long-term care facilities or a provider of long-term care services;

(2) ownership or investment interest in a long-term care facility or a long-term care service;

(3) employed by, or participating in the management of, a long-term care facility;

(4) receives, or has the right to receive, directly or indirectly, remuneration under a compensation arrangement with an owner or operator of a long-term care facility; or

(5) membership in a trade association for long-term care facilities.

(c) Regional Ombudsmen and Volunteer Resident Advocates. To be designated as a Regional Ombudsman or a VRA, an individual shall be free from the following conflicts of interest:

(1) Ownership or investment interest in a long-term care facility or long-term care service;

(2) service as a Regional Ombudsman or VRA in a long-term care facility in which the individual was employed at least one year prior to the date of designation;

(3) service as a Regional Ombudsman or VRA in a long-term care facility in which the individual or a member of the individual’s family resides or is employed;

(4) direct involvement in the licensing or certification of a long-term care facility or a provider of long-term care services;

(5) current employment in, contractual arrangement with, or participation in the management of, a long-term care facility;

(6) membership in a trade association for long-term care facilities;

(7) supervision of any state of Connecticut agency program that may come in conflict with the philosophy, goals and the objectives of the ombudsman program as determined by the State Ombudsman;

(8) service in a leadership role in a community or professional organization that may come in conflict with the philosophy, goals and the objectives of the Ombudsman program as determined by the State Ombudsman;

(9) performance of duties or provision of services, other than those required of the individual’s designation, that are in conflict with, or that may create conflict with, the representative’s duties as determined by the State Ombudsman. This may include, but is not limited to,

(A) case management services,

(B) pre-admission screening, or

(C) guardianship services or duties; or

(10) service as one of the following:

(A) a resident’s legal representative; or

(B) a member of the long-term care facility’s ethics committee which makes medical decisions for residents.

(d) Conflict of Interest Screening Tool. The host agency, in consultation with the State Ombudsman, shall develop a screening tool for conflicts of interest. The screening tool shall be used when an individual is initially designated a Regional Ombudsman or VRA and at least annually thereafter. The screening tool shall be used by:

(1) The host agency to screen the acting State Ombudsman or any applicant for appointment to State Ombudsman for potential conflicts of interest.

(2) The State Ombudsman to screen for potential conflicts of interest for any Regional Ombudsman or applicant for designation as a Regional Ombudsman.

(3) The State Ombudsman to, in consultation with Regional Ombudsmen, screen new applicants for VRA designation for potential conflicts of interest. Subsequent annual screenings of VRAs shall be done by Regional Ombudsmen.

(e) Resolving Conflicts of Interest

(1) Whenever a conflict of interest involves the State Ombudsman the following rules apply:

(A) A State Ombudsman who has knowledge of a conflict of interest shall immediately disclose the conflict of interest to the commissioner.

(B) The commissioner and the State Ombudsman shall determine and agree, in writing, on the method and deadline for removing or otherwise resolving the conflict of interest.

(C) Failure of the State Ombudsman and the commissioner to arrive at a written agreement shall be a reason to terminate the State Ombudsman.

(D) Failure of the State Ombudsman to comply with the terms of the written agreement shall result in termination of the appointment of the State Ombudsman.

(E) An applicant for appointment as State Ombudsman who fails to comply with the terms of the written agreement shall not be appointed.

(2) Whenever a conflict of interest, involving a Regional Ombudsman or a VRA, is identified by or reported to the State Ombudsman, the following rules shall apply:

(A) A Regional Ombudsman or a VRA, who has knowledge of a conflict of interest, shall immediately disclose the conflict of interest to the State Ombudsman.

(B) The State Ombudsman, a Regional Ombudsman or VRA shall agree, in writing, within a reasonable amount of time after the conflict is identified, on the method and deadline for resolving the conflict of interest.

(C) Failure to arrive at a written agreement shall be grounds for the State Ombudsman to deny designation or redesignation as a Regional Ombudsman or VRA.

(D) An acting Regional Ombudsman or VRA shall lose the designation if the individual fails to comply with the terms of the agreement within the timeframe specified in the agreement. An applicant for designation as a Regional Ombudsman or VRA that fails to comply with the agreed upon terms before the anticipated date of designation shall not be designated.

(E) Any individual applying for designation has the duty to disclose any known conflicts of interest at the time of application for designation.

History

• Effective April 3, 2013

Regs., Conn. State Agencies § 17b-411-14 Legal Representation

The host agency shall ensure that adequate legal counsel is available, and is able, without conflict of interest, to:

(1) Provide advice and consultation needed to protect the health, safety, welfare and rights of residents;

(2) pursue administrative, legal and other remedies on behalf of residents;

(3) assist representatives of the Office of the Long-term Care Ombudsman in the performance of their duties; and

(4) provide legal representation to any representative of the Office of the Long-term Care Ombudsman, including the ombudsmen, against whom legal action is threatened or brought in connection with performance of their duties.

History

• Effective April 3, 2013

Department of Aging and Disability Services Department of Aging and Disability Services

17b-423 Title III of the Older Americans Act

Regs., Conn. State Agencies § 17b-423-Acknowledgement1 from §§ 17a-306-1—17a-306-19)

History

• Transferred from §§ 17a-306-1—17a-306-19

Regs., Conn. State Agencies § 17b-423-1 Community services policy manual - introduction

(a) Definitions - as used in this manual:

For purposes of Section 17b-423-1 through 17b-423-7, the following definitions apply:

"Area Agency on Aging (AAA)" means an Agency designated by the Department to develop and administer an area plan in a planning and service area.

"Administration on Aging (AoA)" means the agency established in the Office of the Secretary, Department of Health and Human Services charged with the responsibility for administering the provisions of the Older Americans Act, except for Title V.

"Area Plan" means the official planning document submitted by all Area Agencies on Aging to the Department for approval, which identifies measurable objectives and action steps to achieve those objectives, as well as describing all other functions of the Area Agency.

"Assistant Secretary" means the assistant secretary on Aging of the Administration on Aging.

"Comprehensive and Coordinated System" means a program of interrelated social and nutrition services designed to meet the needs of older persons in a planning and service area.

"Department" or DSS means the Department of Social Services of the State of Connecticut.

"Donated Foods or Cash" means food or cash made available by the United States Department of Agriculture (USDA).

"Eligible Individuals for Title III Programs" means persons 60 years of age and older and their spouses, and people with disabilities residing in primarily elderly housing where congregate nutrition services are located may be provided meals.

"Elderly Nutrition Project (ENP)" means an entity that is awarded a subgrant from an area agency to provide nutrition services under the area plan.

"Focal Point" means a place or mobile unit in a community or neighborhood designated by the Area Agency to encourage the maximum collocation and coordination of services for older persons.

"Greatest Economic Need" means the need resulting from an income level at or below the poverty threshold established by the Bureau of the Census.

"Greatest Social Need" means the need caused by noneconomic factors which include physical and mental disabilities, language barriers, cultural or social isolation, including that caused by racial or ethnic status which restrict an individual's ability to perform normal daily tasks or which threaten his or her capacity to live independently.

"Indian Tribal Organization" means the recognized governing body of any Indian tribe or any legally established organization of Indians which is controlled, sanctioned, or chartered by the governing body.

"Indian Tribe" means any tribe, band, nation, or other organized group of community of Indians (Native Americans) which is recognized as eligible for the special programs and services provided by the United States to Indians because of their status as Indians; or, is located on, or in proximity to a federal or state reservation or rancheria.

"Manual" means the Community Services Policy Manual.

"Multipurpose Senior Center" means a community facility for the organization and provision of a broad spectrum of services including, but not limited to, health, social, nutritional, and educational services; and the provision of facilities for recreational and group activities for older persons.

"Nonprofit" means an agency, institution or organization which is with no part of the net earnings benefiting any private share holder or individual.

"Older Americans Act (OAA)" means the Older Americans Act of 1965, as amended.

"Older Person" means a person age 60 or older.

"Planning and Service Area (PSA)" means a geographic area that is designated by the department for purposes of planning, development, delivery and administration of services under an area plan.

"Reservation" means any Federal or state recognized Indian tribe's reservation.

"Service Provider" means an entity that is awarded a subgrant or contract from an Area Agency to provide services under the area plan.

"State Plan" means the plan developed by the Department detailing the utilization of federal funds in providing services to the elderly. The plan is based on Area Agency plans, and a statewide assessment of needs and priorities.

"Target Groups" means those individuals identified as being in the greatest economic or social need of services.

"Unit of general purpose local government" means (1) a political subdivision of the state whose authority is general and not limited to only one function or combination of related functions or (2) an Indian tribal organization.

(b) Purpose of Manual

(1) These regulations set forth the requirements for the conduct of the Title III of the Older Americans Act of 1965, as amended. They include requirements and procedures for designation of area agencies on aging, submission and approval of area plans, service requirements and hearing procedures.

(2) The purpose of the Manual is to outline the overall program and grants administration responsibilities of the Department and it's grantee/contractor agencies. The Manual should assist and guide Connecticut's Area Agencies on Aging grantees in the operation of their programs.

(3) The Manual constitutes all current policies which have been developed by the Department, unless otherwise noted, through the time of issuance. Additional policies may be incorporated by the Department pursuant to notice thereof published in the Connecticut Law Journal.

(c) Scope and Organization

The general organization of the Manual of Policies and Procedures is as follows:

Section 17b-423-1: Introduction-provides an overview of the scope and organization of the Manual and a description of the Title III Program.

Section 17b-423-2: Area Agency on Aging Designation-describes the procedures for designation of planning and service areas, Area Agencies on Aging and appeal procedures.

Section 17b-423-3: Application Procedures and General Policies-sets forth the basic procedures governing the preparation of area plans and other applications under the Older Americans Act, as well as the general policies which affect grantee/contractor operations.

Section 17b-423-4: General Area Agency on Aging Responsibilities/Title III-B Operations-sets forth the policies and procedures for the use of Title III-B funds, including the conduct of Area Agency on Aging operations and grantee/contractor activities.

Section 17b-423-5: Title III-C Operations-sets forth the policies and procedures governing the administration and operation of Title III nutrition services.

Section 17b-423-6: Title III-D Operations-sets forth the policies and procedures for the use of Title III-D in-home funds.

Section 17b-423-7 Title III-F: Operations-sets forth the policies and procedures for the use of title III- F disease prevention and health promotion funds.

Section 17b-423-8 through 17b-423-18: reserved

Section 17b-423-19: Index

(d) The Title III Program

(1) Purpose

Title III of the Older Americans Act of 1965, as amended establishes authority for the development of programs to assist older persons, especially those with greatest economic and social needs, in the area of social services (III-B and III-D), congregate nutrition services (III-C1), home delivered nutrition services (III-C2), and disease prevention and health promotion services (III-F).

(2) Process

Title III provides formula grants to state agencies, who in turn may award funds to Area Agencies on Aging for such activities as community planning, coordination, advocacy, and for the provision of services to older persons, through sub-grantees, in the areas of supportive services and nutrition.

History

• Adopted effective February 26, 1992; Transferred and AmendedOctober 7, 1997

Regs., Conn. State Agencies § 17b-423-2 Community services policy manual-area agency designation

(a) Designation of Planning and Service Areas

(1) General

The Department is responsible for dividing the State into five planning and service areas (PSAs), in accordance with guidelines issued by the assistant secretary.

The area agency on aging shall provide assurances of compliance with the Older Americans Act as required.

(2) Application for Designation

The Department provides an opportunity to apply for designation as a planning and service area to any unit of general purpose local government, region, metropolitan area, or Indian reservation(s). The application on behalf of an Indian reservation(s) shall be made by the governing tribal organization(s).

(3) Periodic Review

The Department shall periodically examine planning and service areas and make modifications as needed.

(4) Decision

The Department documents the basis for it designation of each planning and service area.

(b) Designation & Functions of Area Agencies on Aging (AAAs)

(1) General Rule

The Department has designated an Area Agency on Aging in each planning and service area in which it allocates funds under Title III, and shall designate successor Area Agencies on Aging as may be necessary.

(2) Intrastate Funding Formula & Procedures

Title III funds shall be distributed to the approved Area Agencies on Aging according to the intrastate funding formula conforming to the requirements of the Older Americans Act which has been approved in the most recently accepted State Plan On Aging.

(3) Area Agency on Aging Functions

The functions of Area Agencies on Aging shall include at a minimum:

(A) Development and administration of an area plan for a coordinated and comprehensive system of services; and

(B) Serving as the advocate and focal point for older persons in the PSA.

(4) Timetable for Designation

(A) The Department has made initial designations of Area Agencies on Aging which shall remain in effect unless a redesignation is required.

(B) If an organization not currently designated as an Area Agency on Aging wishes to be considered for designation as an Area Agency on Aging, it shall submit a request to that effect to the Department at least 12 months prior to the date on which it proposes to assume the functions of an Area Agency on Aging. This provision is required to provide adequate time for preparation of an area plan and development of new interagency relationships, should the designation be granted.

(5) Types of Agencies that May Be an Area Agency on Aging

(A) The Department may designate as an Area Agency on Aging any one of the following types of agencies that has the authority and the capacity to carry out the functions of an Area Agency on Aging:

(i) An established office on aging which operates within the planning and service area;

(ii) Any office or agency of a unit of general purpose local government that is proposed by the chief elected official of the unit;

(iii) Any office of agency proposed by the chief elected officials of a combination of units of general purpose local government; or

(iv) Any other public or private non-profit agency, except any regional or local agency of the State.

(B) In designating an Area Agency on Aging, the Department shall give preference to:

(i) An established office on aging: or

(ii) An Indian tribal organization (or consortia) in any planning and service area whose jurisdiction is essentially the same as that of an Indian reservation.

(C) In designating a new Area Agency on Aging after the date of enactment of the Older Americans Act Amendments of 1984, the Department shall give the right of first refusal to a unit of general purpose local government if

(i) such unit can meet the requirements of Section 17b-423-2(b) (5) (A), and

(ii) the boundaries of such unit and the boundaries of the area are reasonably contiguous.

(6) Removal of Area Agency on Aging Designation

For adequate reason(s), as specified in Section 17b-423-4(b) (6) of this Manual, the Department may remove the designation as Area Agency on Aging from an organization serving in that capacity. In such a case, the Department shall follow the procedures described in Section 17b-423-4(b) (6).

(c) Appeal Hearing Procedures to State Agency

(1) Applicants/Organizations Eligible for Appeal Hearings

(A) The Department shall provide an opportunity for a hearing to:

(i) Disapprove the area plan or plan amendment submitted by the Area Agency on Aging; or

(ii) Withdraw the Area Agency on Aging's designation.

(B) Any eligible applicant for designation as a planning and service area whose application is denied;

(C) Any nutrition or supportive service provider when the Area Agency on Aging has denied funds or terminated the project.

The Department shall hear an appeal only on the issue of the process utilized by the Area Agency on Aging in denying or terminating funding to a service provider. Content issues can not be appealed to the Department.

(2) Written Request for Hearing

(A) If an agency or organization wants a hearing, it shall file a written request for a hearing with the Department within 30 days following its receipt of the notice of the adverse action.

(B) Any service provider who wishes to appeal to the Department pursuant to Section 17b-423-2(c) (1) (C) shall first follow the area appeal procedures required by its Area Agency on Aging before the Department will grant a request for State Agency hearing.

(3) Hearing Components

(A) State hearings are held to provide Area Agencies on Aging and service providers with:

(i) An opportunity to review any pertinent evidence on which the contested action was based;

(ii) An opportunity to appear in person before an impartial decision maker to refute the basis for the decision;

(iii) An opportunity to be represented by counsel or other representative;

(iv) An opportunity to present witnesses and documentary evidence;

(v) An opportunity to cross-examine witnesses; and

(vi) A written decision by an impartial decision maker which sets forth the reasons for the decision and the evidence on which the decision is based.

(B) The Department may terminate formal hearing procedures at any point if the Department and the agency or organization that requested the hearing negotiate a written agreement that resolves the issue(s) which led to the hearing.

(4) Hearings for Service Denial Due to Discrimination

(A) The Department encourages any older persons who believe that they have been unfairly denied services under any older Americans Act assistance program due to discrimination to contact the Department about such complaints. The Department shall conduct a preliminary review of such complaints, and, as appropriate, refer them to the Commission of Human Rights and Opportunities.

(B) Every grantee shall post notices within its program and service locations which indicate procedures available to older persons who want to notify the Department of their complaint. Grantees shall post notices in a conspicuous location within view of all older persons who participate.

(d) Monitoring and Assessment

The Department conducts ongoing monitoring and assessment of Area Agencies on Aging, and of other activities and programs under the State Plan on Aging. The Department may monitor and assess grantees of the Area Agencies on Aging as appropriate.

History

• Adopted effective February 26, 1992; Transferred and AmendedOctober 7, 1997

Regs., Conn. State Agencies § 17b-423-3 Community services policy manual-general application and procedures and policies

(a) Purpose of Section

This Section sets forth the general policies and procedures governing the application process for obtaining Title III-B and C funds and the general policies which affect program grantees.

(b) Award of Older American Act Funds Administered by the Department

(1) Eligible Organizations

The Department may award Older Americans Act funds to an eligible public or private nonprofit agency, organization, institution, political subdivision of the State or an official Indian tribal organization.

(2) Conditions of Awarding Title III Fund

The Department shall award Title III funds in a designated planning and service area only to an Area Agency on Aging to develop and administer an area plan on aging. No Title III funds shall be awarded directly by the Department to any other agency within a PSA when a designated Area Agency on Aging exists, unless the Area Agency on Aging has been temporarily suspended from administering Older Americans Act programs. The designated Area Agency on Aging shall carry out, directly or through contractual or other arrangements, a program pursuant to an approved area plan within the PSA.

(c) Responsibilities of recipients of Award Under Title III of the Older Americans Act

The Department requires recipients of award under Title III of the Older Americans Act to carry out the policies and procedures set forth in this manual, in the Older Americans Act and in the appropriate Federal regulations. Recipients of award are responsible for familiarizing themselves with the contents of this Manual and referenced documents.

(d) Procedures for Application for Support

(1) General

All proposals for support through Older Americans Act or other Department administered funds shall be submitted to the Department on a format prescribed by the Department. The specific procedures applicable to each type of funding are located in the following sections of this Manual.

(A) Title III-B funds-Section 17b-423-4.

(B) Title III-C funds-Section 17b-423-5.

(C) Title III-D funds-Section 17b-423-6.

(D) Title III-F funds-section 17b-423-7

(2) Part of Area Plan Process

(e) Department Review of Applications

(1) General

Applications for funding shall be reviewed according to the procedures established in this manual. As necessary, additional information may be provided through General Letters, Series Memorandums or in other written formats.

(2) Notification of Award Process

The Department has established procedures to assure that all recipients of award are notified of the approval of projects in writing on a standard notification of grant award form (NOA) or other suitable award document.

(3) Award Conditions

All applications shall be approved as submitted unless the Department modifies and/or places additional conditions on the award. All approved projects shall receive a written notice of award which explains the specifics of the approved award.

(4) Operation of the Project Awarded

The recipient of the award shall operate the project in accordance with the approved application and the NOA documentation.

(f) General Policies

This subsection provides information on policies and procedures which uniformly impact on all Title III grantees.

(1) Applicable Laws and Regulations for Title III Older Americans Act Funds

Grantees receiving funds under the Title III Older Americans Act are subject to the following laws and regulations:

(A) All provisions of the Older Americans Act, as amended to date;

(B) Federal Regulations issued pursuant to the Older Americans Act;

(C) The policies and procedures specified in the Manual:

(D) Title 45 of the Code of Federal Regulation: Parts 74 (except subpart 80, 81, 84, and 90);

(E) Other applicable state and/or Federal regulations.

(2) Administration

The Department has been vested with the authority to carry out all functions and responsibilities prescribed for State Agencies on Aging under the Older Americans Act, Federal Regulations and Connecticut State Statutes and regulation of Connecticut State Agencies. Whenever the Department executes grants or contracts with local or Area Agencies on Aging to provide an aging service or program, it has the responsibility for assuring that such agencies or organizations are adhering to this Manual and other policies and procedures which might be developed. The Department requires all grantees to establish acceptable methods for administering Older Americans Act programs. The Department periodically monitors, assesses and evaluates the administrative systems being utilized by grantees in order to assure that they meet minimal standards of operations.

(3) Title VI of the Civil Rights Act

(A) General

All funds under the Older Americans Act shall be administered in compliance with Title VI of the Civil Rights Act of 1964, the Regulations (45 CFR Part 80) issued pursuant thereto, a Statement of Compliance Form 441 signed by each grantee and the contractors and subcontractors providing services directly to participants, and the methods of administration established by the Department in accordance with the requirements of the State Plan.

(B) Non Discrimination Policy

The Department requires that each recipient of award make no distinction because of race, color, sex, physical or mental disability, sexual orientation, marital status, age, ancestry, religion or national origin in providing to individuals any services of other benefits under projects financed in whole or in part with Older Americans Act funds.

(4) Affirmative Action

(A) Requirement as Condition of Award

The Department requires that all Older Americans Act grantees have acceptable affirmative action plans as a condition for approval of grant awards.

(B) Compliance with Title V Regulations

Any Area Agency on Aging which is a public agency shall have an affirmative action program which complies with the requirements of section 900.607 of Title V of the Code of Federal Regulations, Part 900, Subpart F, "Standards for a Merit System of Personnel Administration."

(C) Contractor/Subcontractor Compliance Statement

Older Americans Act project grantees shall, as a minimum, obtain a statement of assurance from contractors and subcontractors that they will comply with equal employment opportunity principles. Such assurance shall commit contractors and subcontractors to providing equal opportunities in carrying out activities funded under the Older Americans Act.

(i) The statement of assurance shall be on file with the award document.

(ii) Project grantees shall monitor contractors' and subcontractors' compliance with the equal employment opportunity requirements.

(5) Confidentiality and Disclosure

(A) Confidentiality

(i) Area Agencies on Aging and service providers shall develop and maintain procedures to ensure that no information about an older person, or obtained from an older person by a service provider or an Area Agency on Aging, is disclosed by the provider or the Area Agency on Aging, in a form that identifies the person without the informed consent of the person or his or her legal representative, unless disclosure is required by court order, 45 CFR 74.24, or for program monitoring by authorized Federal, State, or local monitoring agencies.

(ii) The Department requires that lists of older persons compiled under information and referral services be used solely for the purpose of providing services, and only with the informed consent of each individual on the list.

(iii) Area Agencies on Aging shall not require any provider of legal assistance under Title III to reveal any information protected by the attorney-client privilege.

(B) Department Non-Denial of Services Policy

The Department and its grantees shall ensure that no older person is denied services because such person refuses to provide informed consent to release personal information.

(C) Maintenance of Grantee Reports and Records

Any grantee or contractor which provides information and referral services shall maintain its records and reports in a manner consistent with the standards of confidentiality of the Department, as noted in this Manual and as modified from time to time.

(D) Disclosure

(i) Subject to the confidentiality requirement in subparagraph (A) of subdivision (5) of this subsection, the Department shall make available at reasonable times and places to all interested parties the written policies under which it administers Older American Act programs and other information and documents developed or received by the Department in carrying out its responsibilities under the Act.

(ii) The Department requires Area Agencies on Aging and their contractors and subcontractors to apply the standards in 1. above to their operations.

(iii) The Department and its grantee/contractors are not required to disclose those types of information or documents that are exempt from disclosure under applicable Freedom of Information laws.

(6) Program Access Requirements

(A) Policy for Facilities Acquired with Older Americans Act and Department Funds

When Older Americans Act or other Department administered funds are used to acquire the use of a facility which involves access by older persons, the facility shall meet the provisions of Section 504 of The Rehabilitation Act of 1973 if the acquisition of the facility occurs after October 1, 1980.

(B) Policy for Facilities Acquired Prior to October 1, 1980

Facilities acquired for use before October 1, 1980 should meet the requirement in (A) where feasible.

(7) General Program Reporting Requirements

All recipients of grants from the Department shall submit such reports to the Department as are required or set forth in the Grant.

(8) Management Information System (MIS) Requirements

Area Agencies on Aging and all grantees and contractors under Title III are required to participate in the Statewide automated Management Information System (MIS), in accordance with the Department's requirements, unless a written waiver is received and approved from the Department.

When Performance-Based Contracting is used, Area Agencies on Aging shall reimburse contractors based on current MIS statistics, unless it is determined by the Department that the service cannot be accurately measured by the MIS.

History

• Adopted effective February 26, 1992; Transferred and AmendedOctober 7, 1997

Regs., Conn. State Agencies § 17b-423-4 Community services policy manual-general area agency responsibilities

(a) Responsibilities of the Area Agency on Aging

(1) Staffing

An Area Agency on Aging shall be responsible for recruiting and employing adequate numbers of staff members to develop and administer its area plan, and to carry out the functions and responsibilities prescribed by the Older Americans Act, Title III regulations and this Manual. The Area Agency on Aging shall develop and implement a staffing plan consistent with Federal and State requirements and the standards listed herein:

(A) The Area Agency on Aging shall be headed by a director qualified by education and experience to administer the areawide program, who shall be hired in conformance with the job description promulgated in the approved area plan. The director shall devote full-time solely to activities which benefit the aging population.

(B) No Area Agency on Aging shall be allowed to operate without a director for an extended period of time.

(i) In the absence of an Area Agency on Aging director, an acting director shall be designated within one week.

(ii) An Area Agency on Aging may not operate under the leadership of an acting director for more than 90 days, or it shall be subject to suspension or termination. In the case of maternity or extended medical leave, the Area Agency on Aging has the option of extending the 90 day limit with the Department's approval.

(iii) The Area Agency on Aging shall employ:

Adequate numbers of staff (including members of minority groups), qualified by experience and training, assigned full or part-time to Title III activities; and

Persons knowledgeable-through education and/or experience-in the program area for which they will be responsible (planning, administration, coordination, program activities, etc.).

(iv) All other factors being equal, the Area Agency on Aging shall give preference to persons aged sixty or over for any full-time or part-time positions for which such persons qualify-subject to any merit system requirements.

(v) The Area Agency on Aging may contract for the performance of certain functions and responsibilities, but such contractual arrangements shall not be utilized as a substitute for adequate staffing. Prior written approval of the Department is required for such contractual arrangements.

(vi) The Area Agency on Aging may not discriminate against any qualified person with a disability as defined by the ADA who is seeking employment.

(vii) An Affirmative Action Statement shall be submitted to the Department by each Area Agency in a manner prescribed by the Department.

(2) Direct Provision of Services by an Area Agency on Aging

(A) General Rule

Area Agency on Aging shall use grants or contracts with service providers to provide all services under this part unless the Department decides that direct provision of a service by the Area Agency on Aging is necessary to assure an adequate supply of the service, or where the service is directly related to the Area Agency on Aging's administrative functions, or where such service of comparable quality can be provided more economically by the Area Agency on Aging.

(B) Services Not Funded Under Older Americans Act

The Area Agency on Aging may plan, coordinate, and provide services funded under other programs, if it does not use funds under this part for those services, and if it continues to meet all its Area Agency on Aging responsibilities.

(C) Notification of Intent to Deliver Services

At the time when an Area Agency on Aging submits its area plan, it shall include waiver proposal(s) detailing any intent to utilize Title III B monies to directly deliver services. The proposal(s) shall include a description of the service to be provided directly by the Area Agency on Aging, an estimated budget, and an explanation as to how this service will impact Title III B services in general.

For fiscal years, when the Area Agency on Aging is not required to submit an area plan and the Area Agency on Aging intends to utilize Title III B service monies to directly deliver services for any reason, public notice and the opportunity for public comment shall be given prior to submission of the Area Agency on Aging's annual budget to the Department. Acceptable forms of public notice include a public hearing, a public service announcement, a newsletter, an article or public notice announcement in the Area Agency on Aging's newsletter, or any other method of mass public distribution approved by the Department. The notice is to include, at a minimum, a description of the service to be delivered, an estimated budget, and an explanation as to how this service will impact Title III B service in general.

(3) Written Procedures

An Area Agency on Aging shall have written procedures for complying with all of its functions as prescribed in the regulations and this Manual. Such written procedures shall either be incorporated in its area plan, or in an Area Agency on Aging Manual on file at the Area Agency on Aging. The manual shall be available to the Department on request.

(4) Corporate Eldercare

(A) Scope and Definition

(i) Area Agencies on Aging may enter into contracts with corporations to provide corporate eldercare services, as hereinafter defined.

Such contracts shall require payment by the corporation to the Area Agency on Aging for the provision of such eldercare services, and may be entered into only in strict conformance with the requirements and limitations herein set forth.

These regulations shall be attached to all eldercare contracts as a condition thereof.

(ii) "Corporate Eldercare Services" means services funded by a private sector corporation, to benefit its employees who have caregiver responsibilities for elderly relatives. Such services most often consist of information and referral, but may extend to other services or programs as determined by the corporation.

(iii) Types of corporate eldercare services which Area Agencies on Aging may provide include activities such as, but not limited to, consulting, development and publication of written materials, development and production of videotapes, and presentation of or participation in workshops, seminars and conferences.

(B) Criteria

(i) Before engaging in any corporate eldercare service, the Area Agency on Aging shall first obtain the approval of the Area Agency on Aging board of directors.

(ii) Contracts with corporations for eldercare services shall be submitted to the Department for review at least two (2) weeks prior to their effective date. The Area Agency on Aging shall, upon request of the Department, submit such additional information as may be necessary to adequately assess the proposed service.

(iii) Simultaneous with its submission of any proposed corporate eldercare services contract to the Department for review, the Area Agency on Aging shall also provide the Department with written assurances as to the following considerations:

(I) The proposed activity is compatible with the statutory mission of the Area Agency on Aging as prescribed in the Older Americans Act and related state law;

(II) The proposed activity precludes any inference or requirement of exclusivity, i.e., the area agency must be free to negotiate other similar contracts;

(III) The proposed activity, when undertaken, shall not diminish the ability of the Area Agency on Aging to carry out its principal mission, not to target its efforts to older persons with the greatest economic or social needs, with particular attention to low income minority persons;

(IV) All personal, identifying information obtained regarding program participants shall remain confidential to the extent allowed under federal and state law;

(V) The proposed activity shall not directly or indirectly, involve the use of any governmental funds for any purposes, including administration and overhead.

(C) Fiscal controls

(i) Each Area Agency on Aging providing corporate eldercare services shall establish separate accounts for all funds devoted to eldercare activities, to which the Department shall have access for the purpose of reviewing the activity.

(ii) The percentage of staff time allocated to corporate eldercare services shall be identified.

(iii) Funds received by any Area Agency on Aging in connection with corporate eldercare services shall be accounted for by the Area Agency on Aging in accordance with generally accepted accounting and auditing practices and all other applicable requirements of federal and state law, and relevant provisions of the Area Agency on Aging's contract with the Department.

(D) Public interest & department oversight

(i) The Area Agency on Aging shall describe its approach to, plan for and involvement in corporate eldercare services in the area plan or amendments; and

(ii) The Department shall monitor each Area Agency on Aging's involvement in corporate eldercare services as contemplated by these regulations through annual on-site assessment, review of eldercare contracts, continued monitoring of area agency targets, and area plan review.

(b) The Area Plan Process

(1) General Provisions

(A) Purpose of the Area Plan

An area plan is the document submitted by an Area Agency on Aging to the Department which outlines the work plan of the Area Agency on Aging for the plan period. The Area Plan also functions as the application for Title III funding from the Department.

(B) Duration and Format of the Area Plan

(i) Area plan periods shall be determined by the Department in accordance with Title III regulations.

(ii) The Department shall periodically set forth the format, criteria for approval, and instructions for the development and submission of the area plan. The instructions and format shall be in conformity with the Title III regulations, this Manual and other AoA and Department directives which may be developed periodically.

(iii) The Area Agency on Aging shall submit an area plan, amendments, and annual budgets to the Department in accordance with the uniform area plan format, information provided by the Department, and other instructions contained in the Manual.

(2) Content of Area Plan

(A) General

The area plan shall contain provisions required by the Act and this Manual and commitments that the Area Agency on Aging shall administer activities funded under Title III in accordance with all Federal and State requirements. The area plan also shall contain a detailed statement of the manner in which the Area Agency on Aging is developing a comprehensive and coordinated system throughout the planning and service area for all services authorized under Title III. An Area Agency on Aging may use its Title III funds only for activities in its approved plan. Any deviation from activities or resource allocation in the approved plan requires prior written approval from the Department.

(B) Area Agency on Aging Function Requirements

An area plan shall provide that the Area Agency on Aging functional requirements, as specified in appropriate sections of this Manual, are met for:

(i) Monitoring, evaluation and commenting on policies and programs affecting older persons;

(ii) Arrangements with children's or adult day care organizations;

(iii) Assessment of need for services in the planning and service area, and evaluation of effectiveness of services being provided;

(iv) Entering into subgrants or contracts for the provision of services under the area plan;

(v) Technical assistance and evaluation of all service providers;

(vi) Considering the views of older persons;

(vii) Outreach efforts;

(viii) Designation of community focal points;

(ix) Coordination with other federal programs serving older persons;

(x) Conducting efforts to facilitate the coordination of community-based, long-term care services designed to retain individuals in their home;

(xi) Identifying entities involved in the prevention, identification and treatment of the abuse, neglect and exploitation of older individuals and determining the extent of unmet needs for appropriate services in this area;

(xii) Working to ensure community awareness of and involvement in addressing the needs of residents of long-term care facilities;

(xiii) Establishing a grievance procedure for individuals denied services;

(xiv) Cooperating with non-profit providers of housing for the elderly;

(xv) coordinating transportation services.

(C) Provision of Comprehensive and Coordinated Service Delivery System

An area plan shall provide for the development of a comprehensive and coordinated service delivery system for all supportive and nutrition services needed by older persons in the planning and service area. The Area Agency on Aging may accomplish this purpose by entering into new cooperative arrangements with other service planners and providers to:

(i) Facilitate access to and utilization of all existing services; and

(ii) Develop supportive and nutrition services effectively and efficiently to meet the needs of older persons.

(D) Service Delivery Requirements

An area plan shall provide that the service delivery requirements, as specified in appropriate sections of this Manual, are met for:

(i) Giving preference to older persons with greatest economic or social need, with particular attention to low-income minority individuals;

(ii) Restricting direct provision of services;

(iii) Service providers concerning licensure, training, outreach, coordination, giving preference to those with greatest economic or social need, contribution, maintenance of non-Federal support for services, and advisory role for older persons;

(iv) Multipurpose senior center activities;

(v) Nutrition services;

(vi) Legal assistance;

(vii) Information and referral services;

(viii) Transportation services.

In providing such services, special attention should be given to utilizing quality staff, meeting basic standards and use of voluntary relationships.

(E) Priority Service Requirements

(i) An area plan shall provide an adequate proportion of its supportive services allotment, excluding amounts used for administration, for the following categories of services, with at least some funds spent in each category:

Services associated with access to other services. These services are transportation, outreach, and information and referral;

In-home services. These services include homemaker and home-health aid, visiting and telephone reassurance, chore maintenance, and supportive services to families of elderly victims of Alzheimers's disease and related disorders with neurological and organic brain dysfunction;

Legal Assistance.

(ii) An area plan, as submitted or as amended, shall specify in detail the amount of funds expended for each of the above listed categories during the fiscal year most recently concluded.

(iii) The Department may waive the requirement for expending an adequate proportion of an Area Agency's Part B allotment for access, in-home, or legal service, if the area agency demonstrates to the department that the services being provided in the PSA for any specific category of service are sufficient to meet the need of such service.

(F) Informational Requirements

An area plan shall specify:

(i) Program goals and objectives, to implement the service delivery requirements of the Older Americans Act and goals, objectives, and measures established by the Department;

(ii) A resource allocation plan indicating the proposed use of all funds to be used in programs for older persons directly administered by the Area Agency on Aging;

(iii) An identification of designated community focal points;

(iv) Methods the Area Agency on Aging uses to set service priorities under the plan; and

(v) Proposed methods for giving preference in the provision of services under the plan to those with greatest economic or social need, with particular attention to low-income minority individuals. These methods:

Shall include, but are not limited to, consideration of older persons with greatest economic or social need in the designation of community focal points;

Shall include targeting of low income clients at a prescribed rate as determined by the Department of all clients served for each service category, and targeting of minority clients at a reasonable level, as determined by the Department, not to be less than the level of the prior planning year; at a minimum, minority targets should reflect the proportion of minority elderly persons to the total elderly population in the towns served by the specific program;

May not include use of a means test. A means test is the use of an older person's income or resources to deny or limit that person's receipt of services under the Act.

(3) Amendments to an Area Plan

An Area Agency on Aging shall amend its area plan if:

(A) A new or amended State or Federal statute or regulation requires a new provision, or conflicts with any existing plan provisions;

(B) A U.S. Supreme Court decision changes the interpretation of a statute or regulation;

(C) The Area Agency on Aging proposes to change the designation of the single organizational unit or component unit;

(D) The Area Agency on Aging proposes to add, substantially modify, or delete any area plan objective(s); or:

(E) The Department requires further annual amendments.

(4) Review of an Area Plan and Amendments

(A) Public Hearing

An Area Agency on Aging shall:

(i) Include participation of the Advisory Council in the development and implementation of the area plan. The Advisory Council shall review the area plan before the public hearing(s), and again after the public hearing(s), but before submission to the Department;

(ii) Hold at least one public hearing on its area plan;

(iii) Hold a public hearing on any proposed amendment to the area plan if instructed by the Department to do so;

(iv) Submit its area plan and any amendment for review and comment to the area Advisory Council and Board of Directors, prior to submission to the Department.

(B) Public Hearing Standards

The Area Agency on Aging shall apply the following standards in the conduct of its public hearing(s);

(i) Public notice shall be given at least two weeks before the public hearing(s);

(ii) The public hearing(s) shall be scheduled to allow sufficient time for review of the area plan by the Advisory Council and Board of Directors prior to the date of the public hearing(s);

(iii) Notice of the public hearing(s) shall be publicized through widely circulated newspapers or other forms of public media;

(iv) Notice of the public hearing(s) shall be published in a language other than English, when deemed appropriate by the Area Agency on Aging and/or the Department;

(v) Notice of the public hearing shall include the availability of a sign language interpreter and Hispanic interpreter upon request;

(vi) Notice of the public hearing(s) shall be provided to appropriate service providers, nutrition providers, organizations of older persons, and other public and private agencies in the planning and service area;

(vii) The public hearing(s) shall be scheduled at a convenient time(s) and location(s) to ensure:

maximum attendance by interested parties, including representatives of the Advisory Council, other local advisory councils to nutrition and other service providers, and older persons; and accessibility to the handicapped;

(viii) A complete copy of the area plan shall be available for review by the general public at the office of the Area Agency on Aging prior to, and after, the public hearing(s);

(ix) Summaries of major components of the area plan including a program description, objective, action plans, and resource allocation plans, shall be available prior to and during the public hearing(s);

(x) The formula or other methods used to distribute aging funds among service providers shall be available at the public hearing(s);

(xi) Procedures for review and analysis of comments received at the public hearing(s) shall be established and described in writing;

(xii) Summaries of the comments made at the public hearing(s) shall be available at the office of the Area Agency on Aging after the public hearing(s); and

(xiii) All records of the public hearing(s) shall be on file at the Area Agency on Aging as a part of the area plan.

(C) Other Methods For Public Participation

The Area Agency on Aging may utilize additional mechanisms to obtain the view of older persons in developing and administering its area plan.

(5) Area Plan Submission, Review and Approval

(A) General

An area plan shall be submitted to the Department in accordance with the schedules and procedures established by the Department.

(B) Schedule of Area Plan and/or Annual Update Reviews

The following schedule outlines the process for review and approval of area plans or annual updates:

(i) The Department shall notify all Area Agencies on Aging at least 90 days before the area plan is due at the Department office. This notice shall include the transmittal of the required area plan format, the Department criteria for area plan approval, and instructions for developing the area plan.

(ii) Area plans, whether for initial or continuation funding, are due at the Department office 75 days prior to the beginning date of the planned funding period.

(iii) Department staff requests for revisions in area plans, shall be made 45 days before the beginning date of the planned funding period.

(iv) Final area plan revisions shall be submitted by Area Agency on Aging to the Department at least 30 days prior to the beginning date of the planned funding period.

(v) An approval letter shall be issued by The Department prior to the start of the funding period. The letter shall include any contingencies to be placed on the award.

(C) Department Actions on Area Plans

The Department shall provide notification in writing to the Area Agency on Aging of the final actions taken in either approving, approving with conditions, or disapproving its area plan.

(i) Approval

The Department shall provide the Area Agency on Aging with a formal notice of approval of the area plan and the amount of approved funds on an appropriate award document.

(ii) Approval with Conditions

The Department may approve an area plan with conditions when necessary.

The conditions shall be stated in writing on the award letter to the Area Agency on Aging.

All conditions placed on an approved area plan shall be consistent with the authority delegated to the Department.

When an area plan is approved with conditions, it shall be the responsibility of the grantee to meet these conditions within the specified time frame. As the conditions are met by the grantee, the Department shall officially notify the grantee that all conditions have been met.

(iii) Disapproval

Any area plan which is not in conformity with the Older Americans Act, the Federal regulations or the Department's policies shall be disapproved.

When the Department proposes to disapprove an area plan, it shall notify the Area Agency on Aging in writing of its intention and set forth the reasons for the proposed disapproval. The Department shall:

Issue a letter of intent to disapprove the area plan to the Area Agency on Aging indicating the reasons for the proposed disapproval within sixty day of receipt of the area plan; and

Inform the area Agency on Aging of the opportunity for a hearing on the area plan under the provisions of Section 17b-423-2-(c) of this Manual and shall carry out those procedures.

(iv) Final Disapproval

If, after providing the Area Agency on Aging with a proper opportunity for a hearing, the Department still finds the area plan unacceptable, the Department shall disapprove the plan, using the following procedures:

The Department shall withhold further payments to the Area Agency on Aging.

If the Department terminates funds under the above provision, it shall notify the assistant secretary in writing of its action; provide a plan for the continuity of services in the affected planning and service area; and designate a new Area Agency on Aging in the planning and service area in a timely manner.

(6) Withdrawal of Area Agency on Aging Designation

(A) Conditions for Withdrawing Area Agency on Aging Designation

The Department may withdraw the Area Agency on Aging designation whenever the Department, after reasonable notice and opportunity for a hearing, finds that:

(i) The Area Agency on Aging does not meet the requirements under the Older Americans Act and Federal Regulations;

(ii) The plan or plan amendment is not approved; or

(iii) There is substantial failure in the provisions or administration of an approved area plan to comply with any provision of the federal regulations or this manual.

(B) Department Procedures to Withdraw Area Agency on Aging Designation

If the Department withdraws an Area Agency on Aging's designation under subparagraph A of this subdivision, it shall:

(i) Notify the Area Agency on Aging immediately;

(ii) Notify the assistant secretary in writing of its action at the time the Area Agency on Aging is notified;

(iii) Provide for the continuity of services in the affected planning and service area; and

(iv) Designate a new Area Agency on Aging in the planning and service area in a timely manner.

(7) Redesignation of an Area Agency on Aging

An agency that has had its designation as an Area Agency on Aging withdrawn in accordance with the policies in this Manual shall not be considered for redesignation until such time as it can demonstrate to the satisfaction of the Department that changes have occurred to remove the causes that led to the withdrawal of designation. The criteria for designation as an Area Agency on Aging set forth in Section 17b-423-2(b) of this Manual shall apply in all instances of redesignation.

(8) Prior Approval of Contracts

(A) The Department shall require prior written approval of a contract proposed for funding under an area plan when the contract will be executed with a profit-making organization and when the Area Agency on Aging is contracting for an administrative function. This includes, but is not limited to contracts for training, audit, personal services, and any Performance-Based Contracts which fall under this criteria. Such approval shall be obtained on an annual basis, except in the case of multiyear contracts.

(B) Record of the Department's approval of such contracts shall be maintained on file by the Area Agency on Aging or grantee.

(c) Area Agency on Aging Functions and Responsibilities Under an Area Plan

(1) Advocacy Responsibilities of the Area Agency on Aging

An Area Agency on Aging shall:

(A) Monitor, evaluate, and where appropriate, comment on all policies, programs, hearings, levies and community actions which affect older persons;

(B) Conduct public hearings on the needs of older persons;

(C) Represent the interests of older persons to local level and executive branch offices public and private agencies or organizations;

(D) Carry out activities in support of the State administered long-term Ombudsman program;

(E) Coordinate planning with other agencies and organizations to promote new or expanded benefits and opportunities for older persons; and

(F) Comment on other services provided for the elderly through the intergovernment review process.

No requirement in this section shall be deemed to supersede statutory or other regulatory restrictions regarding lobbying or political advocacy with Federal funds.

(2) Area Agency on Aging General Planning and Management Responsibilities An Area Agency on Aging shall:

(A) Develop and administer an area plan for a comprehensive and coordinated service delivery system in its planning and service area in compliance with all applicable laws and regulations, including all requirements of this Manual;

(B) Assess the kinds and levels of services needed by older persons in the planning and service area, and assess the effectiveness of the use of various resources in meeting these needs;

(C) Except as provided in Section 17b-423-4(b) (2) of this Manual, enter into grants or contracts to provide all services under the plan, utilizing a request for proposal (RFP) process which assures equal opportunity for all potential applicants for funding to apply, including publication of notice in the area's public media and the use of a wide mailing list which includes, but is not limited to, current grantees or contractors;

(D) Provide technical assistance, monitoring, and periodic evaluation of the performance of all service providers under the plan, utilizing a schedule that provides for conducting both fiscal and programmatic field monitoring of each grantee at least once biennially.

(E) Coordinate the administration of its plan with other Federal, State and local resources, in order to develop a comprehensive and coordinated service system;

(F) Establish an Advisory Council consisting of more than 50% older individuals and of minority individuals at least in proportion to the representation of minority elderly in the PSA.

(G) Give preference in the delivery of services under the plan to older persons with the greatest economic or social need; with particular attention to low income minority individuals.

(H) Assure that older persons in the planning and service area have reasonably convenient access to information and referral services;

(I) Provide adequate and effective opportunities for older persons to express their views to the Area Agency on Aging on policy development and program implementation under the plan;

(J) Have outreach efforts to identify older persons, including older Indians, and inform them of the availability of services under the area plan, and conduct an annual evaluation of the effectiveness of such outreach. These outreach efforts should have special emphasis on the rural elderly, and on those with greatest economic and social needs, especially low-income minority individuals, and older individuals with severe disabilities. With respect to nutrition services, the Area Agency on Aging shall have outreach efforts that ensure that the maximum number of eligible persons have an opportunity to receive services;

(K) If possible, have arrangements with organizations providing day care services for children or adults, and respite for families, so that older persons can volunteer to help provide such services;

(L) Develop and publish the methods that the Area Agency on Aging uses to establish priorities for services, particularly the consideration given to the Title III priority services;

(M) Establish procedures governing outreach, training, and coordination activities of service providers;

(N) Attempt to involve the private bar in legal assistance activities, including groups within the private bar that furnish legal services on a pro bono and reduced fee basis;

(O) Designate community focal points, where feasible.

(3) Designation of Community Focal Points for Service Delivery

In order to facilitate ready access to services provided under the area plan, an Area Agency on Aging shall designate, if feasible, a focal point for comprehensive service delivery in each community.

(4) Area Agency on Aging Board of Directors

(A) Functions of the Board

Each Area Agency on Aging shall establish a Board of Directors. The Board shall be responsible for:

(i) Achieving the stated objectives and purpose of the organization;

(ii) Making policies and plans;

(iii) Supervising the executive director;

(iv) Appointing committees.

(B) Composition of the Board

Board members and officers of private agencies or other community agencies or governmental body may serve on the board of directors, but may not vote, participate in discussions, or in any way influence matters related to the financial or contractual affairs of their agency or body. Area Agency on Aging board members shall sign an annual declaratory statement which discloses all other boards and commissions on which they currently serve, and declare their intent to avoid participation in, discussion of, or in any other way influencing, the vote on any issue affecting one of those boards or commissions.

Those ineligible for Board membership are:

(i) Paid staff of any Title III funded agency

(C) Frequency of meetings

The Area Agency Board of Directors shall hold at least ten (10) monthly meetings annually.

(D) Support

The Area Agency on Aging shall provide staff and assistance to the Board of Directors.

(E) Bylaws

The Area Agency on Aging shall develop and make public bylaws which specify the role and function of the Board of Directors, number of members, procedures for selection of member, terms of membership, and frequency of meetings.

(5) Area Agency on Aging Advisory Council

(A) Functions of the Council

Each Area Agency on Aging shall establish an advisory council in accordance with the requirements of this section. The council shall advise the agency on:

(i) Developing and administering the area plan;

(ii) Conducting public hearings;

(iii) The interests of older persons; and

(iv) Its review of and comments on all community policies, programs and actions which affect older persons.

(B) Composition of the Council

The advisory council shall be made up of:

(i) More than 50 percent older persons, including:

Older persons with greatest economic or social need; and Participants of Older Americans Act programs;

(ii) Minority individuals in proportion to their representation among older persons in the PSA.

(iii) Representatives of older persons;

(iv) Local elected officials, or their representatives;

(v) The general public.

(C) Frequency of Meetings

The Area Agency on Aging Advisory Council shall meet at least quarterly.

(D) Support

The Area Agency on Aging shall provide staff and assistance to the Advisory Council.

(E) ByLaws

The Area Agency on Aging shall develop and make public bylaws which specify the role and function of the Advisory Council, number of members, procedures for selection of members, terms of membership, and frequency of meetings.

(6) Preference for Older Persons with Greatest Economic or Social Need

All service providers under the Older Americans Act shall follow priorities set by the Area Agency on Aging for serving older persons with greatest economic or social need, with particular attention to low-income minority individuals. Service providers may use methods such as selecting certain locations for providing services and specializing in the types of services most needed by these groups to meet this requirement. Service providers may not use a means test.

(7) Contributions for Services Under the Area Plan

(A) Opportunity to Contribute

Each service provider shall:

(i) Provide each older person with a free and voluntary opportunity to contribute to the cost of the service he/she receives;

(ii) Protect the privacy of each older person with respect to his or her contribution;

(iii) Establish appropriate procedures to safeguard and account for all contributions; and

(iv) Use all contributions to expand the services of the provider under Title III. Nutrition service providers shall use all contributions to increase the number of meals served by the project involved, to facilitate access to such meals, and to provide other supportive services directly related to nutrition services.

(B) Failure to Contribute

A service provider that receives funds under the Act may not deny any older person a service because the older person will not or cannot contribute to the cost of the service.

(C) Contributions as Program Income

Contributions made by older persons who are recipients of services are considered program income.

(8) Maintenance of Non-Federal Support for Services

(A) All service providers shall assure their Area Agency on Aging that Federal funds shall not be used to replace funds from non-federal sources.

(B) Service providers shall agree to continue to initiate efforts to obtain support from private sources and other public organizations for services funded.

(9) Opportunity for Input by Consumers

Each service provider under the area plan shall have procedures for obtaining the views of participants about the services they receive.

History

• Adopted February 26, 1992; Amended June 2, 1992; Transferred and AmendedOctober 7, 1997

Regs., Conn. State Agencies § 17b-423-5 Community services policy manual - Title III-C nutrition services

(a) Purpose

An Area Agency on Aging shall award nutrition service funds received under Title III of the Older Americans Act to provide meals, nutrition screening and nutrition education, to older persons. In addition, these funds may be used to provide outreach, nutrition assessment, nutrition counseling, and other related services to older persons. In making these awards, the Area Agency on Aging shall assure that based on an assessment of need by the Area Agency on Aging and nutrition service providers, congregate meals, home delivered meals, nutrition screening and nutrition education are all provided in the PSA. The Area Agency on Aging shall develop a formula providing for equitable distribution of nutrition funds throughout the PSA.

(b) Selection of Nutrition providers

(1) General Rule

An Area Agency on Aging may make awards for congregate meals, home delivered meals, nutrition education, nutrition screening, nutrition assessment and counseling, and related nutritional services to a provider or providers that furnish any or all types of services. Such a provider shall meet the requirements of this section.

(2) Process for Selecting Nutrition providers

(A) Area Agency on Aging Award Process

An Area Agency on Aging shall award nutrition funds through a competitive grant or contract process.

Whenever there is no evidence of improved quality of services or cost effectiveness on the part of another bidder, an existing provider of services who receives funds under Title III of the Older Americans Act of 1965 as amended shall be given preference.

An Area Agency on Aging shall award Title III, Part C funds to organizations which are able to provide nutritional services efficiently and reasonably.

(B) Assurances of Maintenance of Effort and Non-Supplanting of Funds

The Area Agency on Aging shall have furnished assurances to maintain efforts to solicit voluntary support and not to use funds received under this part to supplant funds from non-Federal sources.

(c) Bid Procedures For Contracts With Caterers

(1) Procedure for Solicitation of Bids

The procedure for solicitation of bids shall be as follows:

(A) Bids shall be solicited on an annual basis, unless caterer is operating on a multi-year contract. In the case of a multi-year contract, additional bids should be solicited for maximum increases for the year(s) after the first year.

(B) The Area Agency on Aging shall assure that nutrition projects coordinate their bids or develop a combined bid to seek most favorable price and quality.

(2) Bid Specifications

(A) Bid Specifications shall include the requirement that the caterer either (i) obtains a Performance Bond in an amount and in form satisfactory to the Elderly Nutrition Project (ENP), the Area Agency on Aging and the Department or (ii) enters into an agreement for damages. The following is an example of a contractual default clause:

Default/Damages

"In the event of breach or default by bidder in performance of the contract, ENP may act immediately to provide replacement services and if so shall notify bidder. In the event replacement services are provided, bidder shall be liable to ENP for damages in an amount measured by the difference between the cost of services under the bidder's contract and the higher cost, if any, of providing similar requirement replacement services."

One of the following methods, as appropriate, should be utilized to define the period for which damages would be sought by ENP:

(i) If the contract contains a provision authorizing the caterer to give notice of its intention to terminate the contract, then the above damage clause shall contain the following additional sentence: "Damages shall be collected for the period from the time of default by caterer for the ensuing days" (The blank being the length of notice).

(ii) If the contract contains no such notice provision, or if the remaining term of the contract is less than any such notice term, then the damages shall be for the remainder of the contract term.

Bid specifications and Contracts may, at the option of ENP, contain the following paragraphs:

"The parties further agree that ENP may withhold any funds due to the bidder in the hands of ENP at the time of default or breach, which funds may be used by ENP to offset damages. The parties further agree that ENP may retain not to exceed $ (as determined by ENP otherwise due to bidder for services hereunder, for this purpose.

"The parties further agree that, in the event that ENP is unable to provide replacement services, damages shall be as determined by a court of law, or as otherwise agreed to by the parties, and that the amount retained by ENP as herein above set forth, may be retained by ENP until that time."

(B) Bid specifications shall include but are not limited to menu policies, delivery time, and food temperature maintenance requirements.

(C) The bid specification may request a working plan from the caterer on how they would set up their program to include anticipated staffing, employee requirement, and sanitation policies, use of standardized recipes, transport equipment and other relevant factors.

(D) If the contract contains a provision authorizing the caterer to give notice of their intention to terminate the contract, the notice term shall not be less than sixty (60) days.

(3) Options Available to Soliciting Party

After bids have been opened and reviewed, three options are open to the soliciting party:

(A) A bid can be accepted. After the bids have been received, the parties cannot negotiate price or specifications, or in any way alter the bids. The bids shall be accepted as they are submitted.

Any otherwise conforming bid may be amended by the bidder or soliciting party to correct computational errors which do not affect the cost or quality of services; such amendment shall be prior to acceptance.

(B) Any of the bids can be rejected with justification. Bids can be rejected if they are too high, if they do not meet specifications, or if they are incomplete.

(C) All bids can be rejected. If all bids received are unacceptable for any of the reasons cited above, the project can resolicit bids.

(4) Review of Approved Bids by the Department

AAA approved bid packages shall be submitted to the Department for review.

Proposed contracts with profit-making organizations shall require final approval from the Department. All bid packages shall include:

(A) A copy of the letter of solicitation for bids.

(B) A copy of advertisements of bids showing names of newspapers and dates published.

(C) A list of names and addresses of caterers the project contacted directly.

(D) A copy of the total bid packet sent to caterers, including the sample menu and bid specifications.

(E) A list of organizations who declined to bid and their reason if known.

(F) A copy of each detailed bid quotation.

(G) A description of the bid opening - date, location, persons in attendance, and organizations they represent.

(H) A description of criteria used for evaluation of bids and bidders and the rank given to each criterion.

(I) A description of involvement of the Project Council and grantee agency's governing body in evaluation of bids and selection decision.

(J) The name and address of selected bidder.

Note: If the lowest bid had not been chosen, specific, strong justification for choosing a higher bid shall be provided.

(K) A completed copy of the "Caterer's Assurance for USDA Cash Reimbursement". The level of USDA Cash Reimbursement is left blank until reimbursement level is known.

(L) A copy of the contract to be signed with caterer.

(d) Operating Requirement for nutrition service providers

(1) Staffing

(A) Adequate Number to Operate Program

Nutrition service providers shall employ adequate numbers of qualified staff to assure satisfactory conduct of the service in keeping with the provisions of this Manual.

(B) Employment Preference give to 60+

Preference should be given to employing persons age 60 and over.

(C) Consideration given to Employing Minorities

Consideration should be given to employing minority individuals at least in proportion to the numbers of minority older persons represented among the service area's populations.

(D) Nutritionist Staff Requirement

Each service provider that receives Title III-C funds shall be established and administered with advice of a nutritionist. In addition the nutritionist shall be responsible for menu development, nutrition screening and education, monitoring of food preparation and in-service training of food service personnel and volunteers. The nutritionist shall meet the following minimum qualifications:

Shall have two years of recent relevant full time work experience preferably in geriatric nutrition food service management or community nutrition, in addition to one of the following criteria:

(i) Registered Dietitian, or

(ii) State certified dietitian/nutritionist, or

(iii) Bachelor's Degree from an accredited four year institution with a major in foods and nutrition, institutional food management, community nutrition dietetics or related field.

One year of the work experience requirement may be waived with possession of Registered Dietitian status, and/or Master's degree from an accredited institution in nutrition, dietetics, institutional food management, public health, business administration or relate field.

(E) Nutrition Assistant

A Nutrition Assistant, under the supervision of the Nutritionist on staff or Nutrition Consultant on contract, may also provide nutrition education and conduct eligibility and nutritional screening interviews. The Nutrition Assistant shall meet the following minimum qualifications:

(i) Diet Technician, Registered; or,

(ii) Associate degree or equivalent from an accredited program with a major in foods and nutrition, community nutrition, dietetics or related field.

(2) Congregate Meals

(A) Requirement that the Area Agency on Aging approve all New, Reopened, or Relocated Meal Sites Prior to Opening.

The Area Agency on Aging shall approve all new, reopened or relocated sites prior to opening. This applies to temporary as well as permanent locations. The following shall be considered when granting approval:

(i) In the case of closing the site: the reason and procedures used to notify the participants and public;

(ii) In site relocation: the reasons and procedures to assure continued participation at the new location;

(iii) In a new or reopened site: location and assurances that it meets local and state fire, safety, sanitation and building requirements.

(B) Congregate Nutrition Provider Requirements

Each congregate nutrition service provider shall:

(i) Provide at least one hot or other appropriate meal in a congregate setting at least once a day, five or more days per week;

(ii) Locate congregate nutrition services as close as possible to, and where feasible and appropriate, within walking distance of the majority of eligible older persons, especially those in the greatest social and economic need;

(iii) When necessary (in case of illness, injury, etc.) make home delivered meals available to congregate mealsite participants;

(iv) Serve a minimum of 98% of all meals to eligible participants and their spouses;

(v) Develop procedures for responding to emergency situations for all congregate sites and provide ongoing training on emergency procedures to all site managers and other site staff;

(vi) Where feasible, seek out and be involved in local group purchasing efforts.

(vii) Make nutrition education available to mealsite participants at a minimum of once each quarter. Each Area Agency on Aging shall submit nutrition education plans for approval to, the Department or Area Agency on Aging nutritionist one month prior to the start of each program year.

Nutrition education sessions shall be conducted by the nutritionist, other health professionals with adequate background and training in nutrition, or nutrition assistant.

Nutrition education subjects shall be based on the needs of the participants. Nutrition information and visual educational materials shall be available to the participants on a continuing basis.

(C) Congregate Nutrition Site Requirements

Each congregate nutrition site shall:

(i) Have a designated site manager who is responsible for activities at the site.

Where Title III-C funds are utilized, they can pay for a maximum of 5 hours per mealtime if an average of 25 or more participants are served; and, for a maximum of 3 hours per mealtime if fewer than an average of 25 participants are served. If home delivered meals are prepared at a site serving fewer than 25 participants, Title III-C funds can pay for a maximum of 5 hours if a waiver is received from the Area Agency on Aging.

(ii) Where possible, local support should be sought for mealsite operations.

(iii) Serve an average of at least 25 participants per mealtime unless a waiver is received from the Area Agency on Aging. If fewer than 25 participants are served, consideration shall be given to providing meals in single serving units;

(iv) Be located in a facility which meets the accessibility requirements of the Americans With Disabilities Act of 1990 or, if not accessible, be located in an ENP catchment area. (An ENP catchment area is an area within the Project Service area containing at least one accessible site. Transportation shall be available to and from the site designated as accessible from all points in the catchment area);

(v) Be located in a facility where all eligible individuals will feel comfortable visiting. Site selection shall take into consideration the type and location of the facility so as not to offend the cultural and ethnic preference of the eligible individuals in the service area;

(vi) Meet all Local and State fire, health, safety and building codes;

(vii) Be open for at least three hours per mealtime unless a waiver is received from the Area Agency on Aging;

(viii) Be neat, clean and have adequate lighting, ventilation, and temperature control.

(ix) Establish written food handling procedures and provide site staff and volunteers with ongoing training and monitoring;

(x) Serve meals at a pre-established time each day.

(xi) Serve all hot food within 2 hours from the time food preparations ends unless a waiver is received from the Area Agency on Aging. Maintain hot foods at a temperature above 140°F. and cold foods at below 45°F (41°F after October 1, 1997) from the time preparation ends until the food is served to a participant. Reheat to 165°F hot foods received at 130°F to 140°F. Refuse or discard hot foods received at less than 130°F and potentially hazardous cold foods received at more than 50°F, and have available shelf stable or other suitable substitute foods as replacement.

(xii) Be equipped with the proper utensils to ensure portion control;

(xiii) Have an established procedure for closing the mealsite in inclement weather, and for informing the participants about the closing.

(3) Home Delivered Meals

Each home delivered meals provider shall:

(A) Assess the needs of, and complete the elderly nutrition assessment form (W689) for intakes on all eligible home delivered meals applicants annually or more often as necessary. (See 17b-423-5(g) (2) for definition of eligibility.) Individuals whose names have been on a waiting list for longer than six months shall be re-screened.

(B) Establish target groups for receipt of home delivered meals;

(C) Provide a nutritious home delivered meal at least once a day, 5 days a week.

Meals may be hot, cold, frozen, dried, or canned foods with a satisfactory storage life;

(D) With the consent of the older person, or his/her representative, bring to the attention of appropriate officials for follow up conditions or circumstances which place the older person or the household in imminent danger;

(E) Make arrangements for the availability of meals to older persons in weather related emergencies;

(F) Assist participants in taking advantage of benefits under other programs;

(G) Deliver meals to participants' homes within 2 hours after completion of preparation, unless a waiver is received from the Area Agency on Aging. The temperature shall be maintained above 140°F for hot foods, below 45°F (41°F after October 1, 1997) for cold foods and at 10°F for frozen meals from the time food preparation ends until the food is delivered to the participant's home.

(H) Offer nutrition education to home bound clients or their caretakers at least twice per year. One session should be a discussion with client or caretaker, unless refused by client or caretaker or deemed unproductive by the provider on a case by case basis.

(I) Appropriately instruct clients or their caretakers on the following safe practices for handling delivered food, as they may apply:

(i) To eat hot food within 1 hour of delivery.

(ii) To eat cold foods immediately or place them in the refrigerator.

(iii) To eat fast chilled meals within 3 days of delivery and to store them at 41°F or less.

(iv) To eat frozen meals within 1 month of delivery and to store them at 10°F or less.

(v) To have an accurate thermometer in their refrigerator if they store fast chilled meals, and one in their freezer if they store frozen meals.

(e) Food Procurement, Food and Nutrition requirements for Nutrition Service Providers

(1) Food Procurement

(A) USDA Food Assistance

(i) The Department has an agreement with the USDA State Distributing Agency to assure the availability of food, cash, or a combination of food and cash to nutrition service providers.

(ii) Those nutrition service providers receiving cash instead of food from USDA shall spend the USDA cash only for U.S. agricultural commodities and other food.

(iii) In the case of the caterer using commodity foods: The caterer shall allow to the elderly nutrition project a credit equal to the value of the USDA Commodities that are furnished to the caterer for use in the program.

(iv) In the use of USDA Commodities, sufficient precautions should be taken to transport and store commodities to preserve their quality and prevent theft.

(B) Food Stamp Program

Nutrition service providers shall assist participants in taking advantage of benefits available to them under the food stamp program.

(2) Food Requirements

(A) For Purchasing, Preparing and Delivering Meals

In purchasing food, and in preparing and delivering meals, the nutrition service providers shall follow appropriate procedures to preserve nutritional value and food safety.

(B) Provision of Special Menus

Nutrition service providers shall provide special menus, where feasible and appropriate, to meet the particular dietary needs arising from the health requirements, religious requirements, or ethnic backgrounds of eligible individuals. In determining feasibility and appropriateness, a provider shall use at least the following criteria:

(i) Whether there are sufficient numbers of persons who need the special menus to make their provision practical; and

(ii) Whether the food and skills necessary to prepare the special menus are available in the planning and service area;

(C) Availability of Appropriate Food Containers and Utensils

Nutrition service providers shall use, upon request, appropriate food containers and utensils for blind and handicapped participants.

(3) Food Quality and Safety

(A) Standards of Quality, Sanitation and Safety

(i) All personnel and facilities involved in producing or dispensing foods or beverages for the elderly, including caterers, shall comply with State of Connecticut Public Health Regulations 19-13-B42 and B48, as amended.

(ii) Meals shall be delivered to a congregate site or home delivered meal recipient within two hours after completion of preparation unless a waiver is received from the Area Agency on Aging. The temperature shall be maintained above 140°F for hot foods, below 45°F (41°F after October 1, 1997) for cold foods and at 10°F or below for frozen meals from the time preparation ends until the food is delivered (whether to the participant's home or to the congregate site). The Area Agency on Aging may grant a waiver for the 2 hours and extend the delivery time if proper equipment is used and if the ENP will agree to conduct regularly scheduled monitoring to assure that proper food temperatures and food quality are maintained throughout the delivery process (from the time food preparation ends until the food is delivered, whether to the congregate site or to the participant's home). The total time of rethermalization, delivery and holding of potentially hazardous hot food, shall not exceed 4 hours. In issuing the waiver, consideration shall be given to progress made toward reducing the total time to two hours or less.

(III) Meal sites storing quick-chilled food shall protect it from contamination (and oxygen where practical) and store it at 35°F or less. The total time between initial cooking and eating of quick-chilled food shall be no longer than 5 days unless extended by written authorization from the Department.

(B) Requirement to Use Only Commercially Processed Foods

No food prepared, frozen or canned in the home may be used in meals provided by projects financed through Title III. Only commercially processed canned and frozen food may be used.

(C) Items Prohibited from Purchase with Title III, Part C.

Nutrition service providers may not purchase vitamins and/or mineral supplements, nor alcoholic beverages, with funds under Title III, Part C.

(D) ENP Reporting Procedures Regarding Food Borne Illness

The ENP shall report immediately the occurrence, or suspicion of, any incidence of food borne illness to the proper public health authorities, to the Area Agency on Aging, and to the Department.

(E) Cooling Rate and Storage Requirements for Kitchens

Potentially hazardous food shall be served within 4 hours of cooking or meet cooling rate and length of storage requirements specified in writing by the department and use a batch coding system specifying an "eat by" date.

(F) Record of Recent Health Inspection

A recent (within 180 days) health inspection report having a score of 90 or above with no unresolved 4 point items shall be kept on file.

(4) Nutrition Standards

(A) Nutritional Value of Menus

The nutritional value of menus shall be confirmed either by

(i) nutritional analysis,

(ii) conformance to a department approved meal pattern,

(iii) selection from a list of department approved menus with accompanying recipes, or

(iv) an individually prescribed menu.

If the value of menus is confirmed by nutritional analysis, each regular meal shall provide all essential food components in amounts specified in writing by the department. If two meals are served per day, food components may be averaged over two meals; if three meals are served, over three meals. Fat and fat soluble vitamins may be averaged over one week.

More rigorous dietary standards may be used at the discretion of the nutritionist to improve nutrition, flavor, appearance, texture or smell.

(B) Fruit Requirement

Fruit (including fruit juices) shall be served at least three times every six meals with fresh fruit served at least once subject to seasonal quality.

(5) Menu and Recipe Requirements

(A) Menus

Menus shall specify amount of each item to be prepared and served, and shall reference all recipes used in the preparation of mixed dishes.

(B) Recipes

Tested quality recipes, adjusted to yield the numbers of servings needed, shall be used. Each recipe should specify cooking, cooling and storage procedures as well as exact ingredient amounts and preparation instructions, to assure the production of a uniform, high quality and safe food or dish.

(C) Certification Required

Menus shall be certified in writing by the nutritionist as providing at least one-third of the current recommended dietary allowances (RDA's) of The National Academy of Sciences for energy, protein, vitamins and essential minerals, and as conforming to theDietary Guidelines for Americans. Menus shall be submitted to the Department or Area Agency on Aging nutritionist at least two weeks prior to use for review of nutritional adequacy.

(D) Certification of Individually Prescribed and Therapeutic Menus

Individually prescribed menus, including menus for each type of therapeutic diet, shall be certified by a registered dietitian of the American Dietetic Association.

(E) Record Keeping

Recipes and certified menus shall be kept on file at the nutrition provider's office for a minimum of two years following the year during which they were in use.

(6) Funding restricted for foods not conforming to menu

No funds authorized under this section shall be used to pay for foods served that fail to conform to the menu, without approval by the nutritionist.

(7) Leftover Food

Only the following may be taken from the meal site and at the discretion of the manager: fruit, baked goods and other foods in individually sealed units that have been protected from contamination and held at 45°F (41°F beginning October 1, 1997) or less. All other food shall be offered as a second serving or discarded. Potentially hazardous food offered as a second serving shall be protected from contamination and held at 140°F or more if hot, and at 45°F (41°F beginning October 1, 1997) or less if cold.

(f) Coordination with other providers/educators in the PSA

Title III nutrition services may be coordinated with other preventive medicine, health maintenance and in-home service providers; with the University of Connecticut Cooperative Extension and other nutrition and physical fitness educators; and, with providers of elderly services in the PSA. Coordination may involve joint planning and resource sharing.

(g) Eligibility

(1) Congregate Nutrition Services

(A) Program Participants

Persons eligible to participate in this program include: a participating person age 60 or older, and the spouse of the person regardless of age; and handicapped or disabled individuals who have not attained 60 years of age, but who reside in housing facilities occupied primarily by the elderly at which congregate nutrition services are provided.

(B) Volunteers/Individuals with Disabilities

Each Area Agency on Aging shall establish procedures that will allow nutrition projects the option to offer a meal, on the same basis as meals are provided to elderly participants, to individuals providing volunteer services during meal hours, and to individuals with disabilities who reside at home with and accompany older eligible individuals.

(2) Home Delivered Meals

Persons eligible to participate in this program include: a person age 60 or older who is homebound because of illness, or incapacitating disability, or who is otherwise isolated; and the spouse of the older person, regardless of age, if, according to the criteria established by the Area Agency on Aging, receipt of the meal is in the best interest of the older person; and a non-elderly disabled person who is a member of the household of an elderly home-delivered meals recipient.

(3) Assessment of Need

The Area Agency on Aging shall assess the level of need for congregate and home delivered meals within the planning and service area.

(h) Contributions for Nutrition Services

(1) Mandated Uses of Contributions

Nutrition services contributions shall be used to increase the number of meals served by a project, to facilitate access to such meals, and to provide other supportive services directly relate to nutrition services.

(2) Area Agency on Aging Policy on Contributions

Each Area Agency on Aging shall develop clear written policies for use by its service providers regarding contributions for services received through the program. These policies shall include:

(A) A statement stressing that no older person shall be denied service for failure or refusal to contribute to the cost of the meal.

(B) Meal fee policies for non-participants.

(C) A procedure which ensures the confidentiality of individuals' contributions.

This may include highly specific steps such as placement of a contribution box or collection of envelopes. The procedure determined by the Area Agency on Aging should avoid giving participants the impression that there is a fee for nutrition services.

(D) Procedures to safeguard and account for all contributions; which should include the counting of donations by at least two people, and the regular deposit of contributions.

(3) Cost of meals for Non-Participants

The cost of meals to non-participants shall, at a minimum, include the following costs: raw food, labor, transportation of food, utilities, cost of disposables.

History

• Adopted February 26, 1992; Amended June 2, 1992; Transferred and AmendedOctober 7, 1997

Regs., Conn. State Agencies § 17b-423-6 Community services policy manual-title III-D/In-home services

(a) Purpose

An Area Agency on Aging shall award funds received under Title III-D of the older Americans Act to provide in-home services to frail older individuals, including in-home supportive services for older individuals who are victims of Alzheimer's disease and related disorders with neurological and organic brain dysfunction, and to families of such victims.

(b) Coordination

In carrying out the provisions of Title III-D, the Area Agency on Aging shall coordinate with other community agencies and voluntary organizations providing counseling and training for family caregivers and support services personnel in management of care, functional and needs assessment services, assistance with locating, arranging for, and coordinating services, case management, and counseling prior to admission to nursing home to prevent premature institutionalization.

(c) Eligibility Criteria

An Area Agency on Aging shall award Title III-D funds to provide in-home services to clients who meet at least two of the four following eligibility criteria, or to the families of such clients:

(1) Are age 75 or older.

(2) Are in greatest economic need.

(3) Have non-economic factors contributing to their frail condition. This is defined as having one or more functional limitations in their activities of daily living (ADLs), or being diagnosed as having an Alzheimer's related dementia.

(4) Have non-economic and nonhealth factors contributing to the need of such services.

(d) Maintenance of Effort

Title III-D funds shall be in addition to, and may not be used to supplant any funds that are or would otherwise be expended under Federal, State, or local law by a State or unit of general purpose local government.

History

• Adopted February 26, 1992; Amended June 2, 1992; Transferred and AmendedOctober 7, 1997

Regs., Conn. State Agencies § 17b-423-7 Disease Prevention and Health Promotion Services

(a) Purpose

An Area Agency on Aging shall award funds received under Title IIIF of the Older Americans Act to provide disease prevention and health promotion services, and information at multipurpose senior centers, at congregate meal sites, through home delivered meals programs, or at other appropriate sites.

(b) Distribution

The state agency shall give priority, in carrying out the provisions of Title IIIF to areas of the state which are (1) medically underserved; and (2) in which there are a large number of older individuals who have the greatest economic need for such services.

(c) Definition

In carrying out the provisions of Title IIIF, the term "disease prevention and health promotion services" means -

(1) Health risk assessments;

(2) Routine health screening, which may include hypertension, glaucoma, cholesterol, cancer, vision, hearing, diabetes, and nutrition screening;

(3) Nutritional counseling and educational services for individuals and their primary caregivers;

(4) Health promotion programs, including programs relating to chronic disabling conditions (including osteoporosis and cardiovascular disease) prevention and reduction of effects, alcohol and substance abuse reduction, smoking cessation, weight loss and control, and stress management;

(5) Programs regarding physical fitness, group exercise, and music, art, and dance-movement therapy, including programs for multigenerational participation that are provided by an institution of higher education; a local educational agency, as defined in section 1471 of the elementary and secondary education act of 1965 (20 U.S.C. 2891); or a community-based organization;

(6) Home injury control services, including screening of high-risk home environments and provision of educational programs on injury prevention (including fall and fracture prevention) in the home environment;

(7) Screening for the prevention of depression, coordination of community mental health services, provision of education activities, and referral to psychiatric and psychological services;

(8) Educational programs on the availability, benefits, and appropriate use of preventive health services covered under Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.);

(9) Medication Management screening and education to prevent incorrect medication and adverse drug reactions;

(10) Information concerning diagnosis, prevention, treatment, and rehabilitation of age-related diseases and chronic disabling conditions, including osteoporosis, cardiovascular diseases, and alzheimer's disease and related disorders with neurological and organic brain dysfunction;

(11) Gerontological counseling; and

(12) Counseling regarding social services and follow up health services based on any of the services described above.

History

• Adopted February 26, 1992; Amended June 2, 1992; Transferred and AmendedOctober 7, 1997

Regs., Conn. State Agencies § 17b-423-8 National Family Caregiver Support Program – Title III-E of the Older Americans Act. (Repealed)

Repealed May 4, 2023.

History

• Adopted effective November 17, 2003; Amended June 5, 2012; Amended June 28, 2013; Repealed May 4, 2023

Regs., Conn. State Agencies § 17b-423-9—17b-423-18 Reserved

Sec. 17b-423-9—17b-423-18. Reserved

Regs., Conn. State Agencies § 17b-423-19 Community services policy manual - index

Sec. 17b-423-1. Introduction

(a) Definitions

(b) Purpose of Manual

(c) Scope and Organization

Section 17b-423-1: Introduction

Section 17b-423-2: Area Agency Designation

Section 17b-423-3: Application Procedures and General Policies

Section 17b-423-4: General Area Agency Responsibilities/Title III-B Operations

Section 17b-423-5: Title III-C Operations

Section 17b-423-6: Title III-D Operations

Section 17b-423-7: Title III-F Operations

Section 17b-423-19: Index

(d) The Title III Program

Sec. 17b-423-2. Area agency designation

(a) Designation of Planning and Service Areas

(1) General

(2) Application for Designation

(3) Periodic Review

(4) Decision

(b) Designation and Functions of Area Agencies on Aging

(1) General Rule

(2) Intrastate Funding Formula & Procedures

(3) Area Agency on Aging Functions

(4) Timetable for Designation

(5) Types of Agencies that May be an Area Agency on Aging

(6) Removal of Area Agency on Aging Designation

(c) Appeal Hearing Procedures to State Agency

(1) Applicants/Organizations Eligible for Appeal Hearings

(2) Written Request for Hearing

(3) Hearing Components

(4) Hearings for Service Denial Due to Discrimination

(d) Monitoring and Assessment

Sec. 17b-423-3. General application procedures and policies

(a) Purpose of Section

(b) Award of Older Americans Act Funds Administered by the Department

(1) Eligible Organizations

(2) Conditions of Awarding Title III Funds

(c) Responsibilities of Recipients of Award Under Title III of the Older Americans Act

(d) Procedures for Application for Support

(1) General

(2) Part of Area Plan Process

(e) Department Review of Applications

(1) General

(2) Notification of Award Process

(3) Award Conditions

(4) Operation of the Project Awarded

(f) General Policies

(1) Application Laws and Regulations for Title III Older Americans Act

(2) Administration

(3) Title VI of the Civil Rights Act

(A) General

(B) Non-Discrimination Policy

(4) Affirmative Action

(A) Requirement as Condition of Award

(B) Compliance with Title V Regulations

(C) Contractor/Subcontractor Compliance Statement

(5) Confidentiality and Disclosure

(A) Confidentiality

(B) Department Non Denial of Services Policy

(C) Maintenance of Grantees Reports and Records

(D) Disclosure

(6) Program Access Requirement

(A) Policy for Facilities Acquired with Older Americans Act and Department Funds

(B) Policy for Facilities Acquired Prior to October 1, 1980

(7) General Program Reporting Requirements

(8) Management Information System (MIS) Requirements

Sec. 17b-423-4. General area agency responsibilities

(a) Responsibilities of the Area Agency on Aging

(1) Staffing

(2) Direct provision of Services by an Area Agency on Aging

(A) General Rule

(B) Services Not Funded Under Older Americans Act

(C) Notification of Intent to Deliver Services

(3) Written Procedures

(4) Corporate Eldercare

(A) Scope and Organization

(B) Criteria

(C) Fiscal Controls

(D) Public Interest & Department Oversight

(b) The Area Plan Process

(1) General Provisions

(A) Purpose of Area Plan

(B) Duration and Format of the Area Plan

(2) Content of Area Plan

(A) General

(B) Area Agency on Aging Function Requirements

(C) Provision of Comprehensive and Coordinated Service Delivery System

(D) Service Delivery Requirements

(E) Priority Service Requirements

(F) Informational Requirements

(3) Amendments to an Area Plan

(4) Review of Area Plan and Amendments

(A) Public Hearings

(B) Public Hearing Standards

(C) Other Methods For Public Participation

(5) Area Plan Submission, Review and Approval

(A) General

(B) Schedule of Area Plan and/or Annual Update Reviews

(C) Department Actions on Area Plans

(6) Withdrawal of Area Agency on Aging Designation

(A) Conditions for Withdrawing Area Agency on Aging Designation

(B) Departmental Procedures to Withdraw Area Agency on Aging Designation

(7) Redesignation of an Area Agency on Aging

(8) Prior Approval of Contracts

(c) Area Agency on Aging Functions and Responsibilities Under an Area Plan

(1) Advocacy Responsibilities of the Area Agency on Aging

(2) Area Agency on Aging General Planning and Management Responsibilities

(3) Designation of Community Focal Points for Service Delivery

(4) Area Agency on Aging Board of Directors

(A) Functions of the Board

(B) Composition of the Board

(C) Frequency of Meetings

(D) Support

(E) Bylaws

(5) Area Agency on Aging Advisory Council

(A) Functions of the Council

(B) Composition of the Council

(C) Frequency of Meetings

(D) Support

(E) Bylaws

(6) Preference for Older Persons with Greatest Economic or Social Need

(7) Contribution for Services Under the Area Plan

(A) Opportunity to Contribute

(B) Failure to Contribute

(C) Contributions as Program Income

(8) Maintenance of non-Federal Support for Services

(9) Opportunity for Input by Consumers.

Sec. 17b-423-5. Community services policy manual title III-C/nutrition services

(a) Purpose

(b) Selection of Nutrition Providers

(1) General Rule

(2) Process for Selecting Nutrition Providers

(A) Area Agency on Aging Award Process

(B) Assurances of Maintenance of Effort and Non-Supplanting of Funds

(c) Bid Procedures for Contracts with Caterersit

(1) Procedures for Solicitation of Bids

(2) Bid Specifications

(3) Options Available to Soliciting Party

(4) Review of Approved Bids by the Department

(d) Operating Requirements for Nutrition Service Providers

(1) Staffing

(A) Adequate Number to Operate Program

(B) Employment Preference Given to 60+

(C) Consideration Given to Employing Minorities

(D) Nutritionist Staff Requirement

(E) Nutrition Assistant

(2) Congregate Meals

(A) Requirement that the Area Agency on Aging Staff Approve All New, Reopened or Relocated Meal Sites Prior to Opening

(B) Congregate Nutrition Provider Requirements

(C) Congregate Nutrition Site Requirements

(3) Home Delivered Meals

(e) Food Procurement/Food and Nutrition Requirements for Nutrition Service Providers

(1) Food Procurement

(A) USDA Food Assistance

(B) Food Stamp Program

(2) Food Requirements

(A) For Purchasing, Preparing and Delivering Meals

(B) Provision of Special Menus

(C) Availability of Appropriate Food Containers and Utensils

(3) Food Quality and Safety

(A) Standards of Quality, Sanitation and Safety

(B) Requirement to Use Only Commercially Processed Foods

(C) Items Prohibited From Purchase With Title III-C Funds

(4) Nutrition Standards

(A) Nutritional Values of Menus

(B) Fruit Requirement

(5) Menu and Recipe Requirements

(A) Menus

(B) Recipes

(C) Certification Required

(D) Certification of Individually Prescribed and Therapeutic Menus

(E) Record keeping

(6) Funding Restricted for Foods Not Conforming to Menu

(7) Leftover Food

(f) Coordination With Other Providers/Educators in the PSA

(g) Eligibility

(1) Congregate Nutrition Services

(A) Program Participants

(B) Volunteers/Individuals With Disabilities

(2) Home Delivered Meals

(3) Assessment of Need

(h) Contributions for Nutrition Services

(1) Mandated Uses of Contributions

(2) Area Agency on Aging Policy on Contributions

(3) Cost of Meals for Non-Participants

Sec. 17b-423-6. Title III-D/In-home services

(a) Purpose

(b) Coordination

(c) Eligibility Criteria

(d) Maintenance of Effort

Sec. 17b-423-7. Title III-F/disease prevention and health promotion services

(a) Purpose

(b) Distribution

(c) Definition

Secs. 17b-423-8—17b-423-18. Reserved

Sec. 17b-423-19. Index

History

• Adopted February 26, 1992; Amended June 2, 1992; Transferred and AmendedOctober 7, 1997

Department of Social Services Department of Social Services

17b-461 Protective Services for the Elderly

Regs., Conn. State Agencies § 17b-461-1 Definitions

For purposes of sections 17b-461-1 through 17b-461-9

(a) "Abandonment" means the desertion or wilful forsaking of an elderly person by a caretaker, or the foregoing of duties, the withdrawal or neglect of duties and obligations owed an elderly person by a caretaker or other person.

(b) "Abuse" includes, but is not limited to, the wilful infliction of physical pain, injury or mental anguish, or the wilful deprivation by a caretaker of services which are necessary to maintain physical and mental health.

(c) "Capacity to consent" means the ability to understand, make and communicate responsible decisions concerning one's own person.

(d) "Caretaker" means"caretaker" as defined in Section 17b-450 of the Connecticut General Statutes.

(e) "Commissioner" means the Commissioner of Social Services.

(f) "Department" means the Department of Social Services.

(g) "Elderly person" means any resident of Connecticut who is sixty years of age or older.

(h) "Exploitation" means advantage taken of an elderly person by another person or caretaker whether for monetary, personal, or other benefit, gain or profit.

(i) "Neglect" means "neglect" as defined in section 17b-450 of the Connecticut General Statutes.

(j) "Protective Services" means the provision, by the state or other governmental or private organizations or individuals, of services necessary to prevent abuse, neglect, exploitation or abandonment.

(k) "Report" means a complaint received by the Commissioner or his designee which presents reasonable cause to believe that an elderly person is being or has been abused, neglected exploited or abandoned.

(l) "Reasonable cause" means sufficiently substantiated allegations of an elderly person's physical, mental, emotional or financial condition, and of the action or inaction of any other person(s) with regard thereto establishing a basis for suspicion or belief that the elderly person is being or has been abused, neglected, exploited or abandoned.

(m) The term "services which are necessary to maintain physical and mental health" includes, but is not limited to, the provision of medical care for physical and mental health needs, the relocation of any elderly person to a facility or institution able to offer such care, assistance in personal hygiene, food, clothing, adequately heated and ventilated shelter, protection from health and safety hazards, protection from maltreatment the result of which includes, but is not limited to, malnutrition, deprivation of necessities or physical punishment, and transportation necessary to secure any of the above stated needs, except that this term shall not include taking such person into custody without consent except as provided in Sections 17b-450 to 17b-461, inclusive, of the Connecticut General Statutes.

History

• Effective October 2, 1991; Transferred and AmendedJune 10, 1998

Regs., Conn. State Agencies § 17b-461-2 Reporting suspected cases of abuse, neglect, exploitation or abandonment of elderly persons

(a) Persons required by law to report instances of abuse, neglect, exploitation or abandonment of an elderly person shall report such information within five calendar days to the Commissioner or to the Commissioner's designee.

(1) Persons required to make such reports are any physician or surgeon licensed under the provisions of Chapter 370 or 371 of the Connecticut General Statutes, any resident physician or intern in any hospital in this state, whether or not so licensed, any registered nurse, any nursing home administrator, nurse's aide or orderly in a nursing home facility, any person paid for caring for a patient in a nursing home facility, any staff person employed by a nursing home facility, any patient's advocate and any licensed practical nurse, medical examiner, dentist, osteopath, optometrist, chiropractor, podiatrist, social worker, clergyperson, police officer, pharmacist or physical therapist, who has reasonable cause to suspect or believe that any elderly person has been abused, neglected, exploited or abandoned or is in a condition which is the result of such abuse, neglect, exploitation or abandonment, or who is in need of protective services, shall within five calendar days report such information or cause a report to be made in any reasonable manner to the Commissioner or to the person or persons designated by him to receive such reports. Any person required to report under the provisions of this section who fails to make such report shall be fined not more than five hundred dollars.

(2) This report shall include the name and address of the elderly persons, description of the abuse, neglect, exploitation or abandonment being reported, as well as any other information which the person making the report believes may be helpful in the investigation of the case or the protection of the victim.

(b) Any other person who has reasonable cause to believe that an elderly person is being, or has been, abused, neglected, exploited or abandoned or is in need of protective services, may report the matter to the Commissioner or the Commissioner's designee.

(c) Treatment of an elderly person by a Christian Science practitioner, rather than by a licensed physician or medical practitioner, shall not of itself constitute grounds for the implementation of protective services.

History

• Effective October 2, 1991; Transferred and AmendedJune 10, 1998

Regs., Conn. State Agencies § 17b-461-3 Reporting requirements

(a) Reports of suspected abuse, neglect, exploitation or abandonment shall be received:

(1) At the regional offices of the department during the usual and customary business hours of the Department or

(2) During nonbusiness hours, at such telephone numbers as the department may designate and appropriately publicize.

History

• Effective October 2, 1991; Transferred and AmendedJune 10, 1998

Regs., Conn. State Agencies § 17b-461-4 Evaluation of report

(a) Each report received shall be promptly and thoroughly evaluated, as follows:

(1) The department, or such other appropriate person(s) or agency as may be requested and available to assist in the evaluation, shall visit the elderly person, unless the elderly person or his caretaker denies access for such a visit;

(2) The department, or such other person(s) or agency as may be requested and available to assist in the evaluation, shall consult with such others as may have additional knowledge of the particular circumstances or needed expertise in regard thereto.

(b) Any person(s) requested and available to assist the department in evaluating a report must promptly transmit any findings to the department.

(c) Based on information gathered through personal visit(s) and/or consultations, or otherwise determined in the course of the evaluation, the department shall make written findings as to the report of abuse, neglect, exploitation or abandonment including verification of the elderly person's age.

History

• Effective October 2, 1991; Transferred and AmendedJune 10, 1998

Regs., Conn. State Agencies § 17b-461-5 Findings, referrals, registry and confidentiality

(a) If upon completion of the evaluation of a report the department determines that protective services are needed and, if the elderly person consents, the department shall arrange for protective services.

(b) If upon completion of the evaluation of a report the department determines that protective services are needed but the elderly person fails to consent thereto, and the department has reason to believe that such person is incapable of managing his personal or financial affairs, the department shall determine the appropriateness of establishing a conservatorship for such person.

(c) If the department determines that no protective services are needed, the department may:

(1) Take such steps, including contacting any other agencies, organizations or individuals as may be appropriate, to assure the resolution of the reported situation; and/or

(2) Close the case.

(d) The department shall maintain a statewide registry of reports received and case narrations which shall include actions recommended and taken in the form of a case plan.

(e) The client's file, the original report and the evaluation report shall not be deemed public records or be subject to the provisions of Section 1-19 of the Connecticut General Statutes. The name of the person making the original report or the name of any person mentioned in such report shall not be disclosed unless: the person making the original report specifically requests such disclosure; or unless a judicial proceeding results therefrom; or unless disclosure of the name of the elderly person about whom the report was made is required to fully evaluate a report.

History

• Effective October 2, 1991; Transferred and AmendedJune 10, 1998

Regs., Conn. State Agencies § 17b-461-6 Procedures on referrals

(a) Upon receipt of a report, the Department shall initiate activities for the provision of appropriate services.

(b) If the elderly person refuses services offered by the Department the case shall be closed unless the department has reason to believe that such elderly person is incapable of managing his personal or financial affairs. In such case, the department shall provide protective services to the extent possible and may apply to probate court for the appointment of a conservator of person or estate, as appropriate.

History

• Effective October 2, 1991; Transferred and AmendedJune 10, 1998

Regs., Conn. State Agencies § 17b-461-7 Access to records, authority of the department and assistance by public or private agencies

(a) Any person, department, agency or commission authorized to carry out the duties enumerated in Chapter 319dd inclusive of the Connecticut General Statutes shall have access to all relevant records, except that records which are confidential to an elderly person shall only be divulged with the written consent of the elderly person or his/her representative. The authority of the Department under Section 17b-454 of the Connecticut General Statutes, shall include, but not be limited to, the right to initiate or otherwise take those actions necessary to assure the health, safety and welfare of any elderly person, subject to any specific requirement for individual consent.

(b) In performing the duties set forth in Chapter 319dd of the Connecticut General Statutes, the department may request the assistance of the staffs and resources of all appropriate state departments, agencies and commissions and local health directors, and may utilize any other public or private agencies, groups or individuals who are appropriate and who may be available.

History

• Effective October 2, 1991; Transferred and AmendedJune 10, 1998

Regs., Conn. State Agencies § 17b-461-8 Court procedures

(a) If it appears to the social worker responsible for providing necessary protective services to a consenting elderly person that the caretaker of such person, as defined in Section 17b-461-1 of the Regulations of Connecticut State Agencies, is interfering with or threatens to interfere with the provision of protective services to the extent that the delivery of such services will become impaired, that information shall be reported to the Commissioner or his designee. If the facts of the case indicate that court action is required, a petition may be filed with the probate court in the district in which the elderly person resides for an order enjoining the caretaker as provided by Section 17b-453(b) of the Connecticut General Statutes. The Commissioner shall be represented by the Attorney General in any such proceedings. If it appears to the Attorney General that the application for a restraining order hereunder is of such serious nature that it may result in appeal or other legal problems, then upon the advice of the Attorney General, the commissioner may, as an alternative, file such application in the superior court of proper jurisdiction. At any hearing held on such application, those persons from the Department who have knowledge of the facts involved shall appear as witnesses. Other witnesses may be subpoenaed by the Attorney General as necessary.

(b) In the event that a restraining order is obtained under subsection (a) of this section and the caretaker of the elderly person refuses to allow the delivery of services as provided in Section 17b-453(b) of the Connecticut General Statutes, then the Commissioner shall apply to the superior court which has jurisdiction as set forth in the Connecticut General Statutes and the Connecticut Practice Book for a contempt of court order against such caretaker.

(c) If the Commissioner finds that an elderly person is being abused, neglected, exploited or abandoned and lacks capacity to consent to reasonable and necessary protective services, he may petition the probate court for appointment of a conservator of the elderly person pursuant to the provisions of Chapter 802h of the Connecticut General Statutes in order to obtain such consent. Such petition shall be brought in the probate court for the district in which such elderly person resides or has his or her domicile. At any hearing scheduled by the probate court on said petition, the commissioner or his designee shall be represented by the Office of the Attorney General.

(d) In any proceeding in probate court pursuant to provisions of the Connecticut General Statutes the probate court shall appoint an attorney to represent the elderly person if he or she is without other legal representation.

(e) If the probate court concludes that a conservator is required and appoints the commissioner to be conservator of the person, then the necessary protective services shall be delivered. Whenever the Commissioner is designated herein to act as conservator, he may delegate the performance of such duties in accordance with the Connecticut General Statutes.

(f) If the court appoints an individual, agency or organization other than the commissioner to be conservator of such elderly person then the commissioner or his designee shall make suitable arrangement with such conservator for the delivery of services. In the event the conservator refuses to allow the delivery of such services, the commissioner or his designee may petition the court of probate which appointed such conservator for his removal for cause shown.

(g) In the event that it appears to any person involved in the delivery of protective services that an elderly person is being abused, neglected, exploited or abandoned and lacks capacity to consent to reasonable and necessary protective services, and that to have an application for the appointment of a conservator of his person processed in the ordinary manner would result in a delay which would cause imminent danger to the health and welfare of such elderly person, then the commissioner shall apply for the appointment of a temporary conservator under the provisions of Section 45a-654 of the Connecticut General Statutes. The provisions of Section 17b-461-8(c) above with respect to the representation of the commissioner by the Office of the Attorney General shall apply.

(h) In the event that the commissioner or his designee concludes that there is no need for continuation of a conservatorship of an elderly person then the commissioner or his designee shall apply to the probate court which appointed such conservator for the termination of the conservatorship. The commissioner or his designee shall provide such investigative, medical reports and other evidence as may be requested by the court of probate for use in determining whether or not to grant such application. In the event the court of probate denies such application, but the commissioner determines that further involvement of the Department is either unnecessary or unwarranted, then the commissioner or his designee may resign as conservator of the elderly person. If the court of probate concludes that it is in the best interest of such elderly person, then it shall appoint some other suitable person to be conservator of his or her person under the provision of section 45a-660 of the Connecticut General Statutes.

History

• Effective October 2, 1991; Transferred and AmendedJune 10, 1998

Regs., Conn. State Agencies § 17b-461-9 Payment for protective services; procedures when elderly person unable to pay

(a) Protective services shall be provided for any elderly person prior to an evaluation of his or her ability to pay, if needed. The Department shall conduct an investigation to determine the client's ability to pay for such services as soon as possible.

(b) It shall be determined that an elderly person has the ability to pay for services if: (1) his or her income exceeds 200% of the federal poverty income guidelines as published from time to time in the Federal Register and/or; (2) his or her assets exceed those established for the state funded portion of the Connecticut Home Care Program for Elders.

(c) The commissioner or his designee may petition the probate court for reimbursement of provided services, from a client's income and/or estate, when a client has the ability to pay but refuses to do so.

(d) The commissioner or his designee shall follow the procedures and policies established under the department's uniform policy manual section 7500 when it becomes necessary to recover payment for protective services made for a financially ineligible client. This shall include referral to the regional resource staff and collection by the Bureau of Collections.

History

• Effective October 2, 1991; Transferred and AmendedJune 10, 1998

17b-533 Management of Continuing Care Facilities

Regs., Conn. State Agencies § 17b-533-1 Definitions

As used in Section 17b-533-1 to Section 17b-533-11, inclusive:

(a) Continuing-care contract means:

(1) An agreement pursuant to which a provider undertakes to furnish to a person not related by consanguinity or affinity to the provider, shelter and medical or nursing services or other health-related benefits for the life of a person or for a period in excess of one year, and which requires a present or future transfer of assets, or an entrance fee in addition to or instead of periodic charges, and the amount of the assets required to be transferred or the entrance fee is equal to or in excess of twenty thousand dollars.

(2) Notwithstanding the amount of assets or entrance fee, all contracts through which continuing-care is offered at a facility offering any "continuing-care contract" as hereinabove defined, shall be included in that definition.

(3) Contracts involving usual and customary leaseholds, and for conveyances of ownership interests, including condominiums, which are freely transferable and which constitute security for the purchaser's payment, shall not be deemed to constitute continuing-care contracts.

(b) Act means P.A. 86-252, an Act concerning management of continuing-care facilities (C.G.S. Sec. 17a-360 et seq.)

(c) Commissioner means the commissioner on aging.

(d) Committee means the advisory committee established by the C.G.S. 17b-535.

(e) Continuing care retirement community means the actual or proposed site or sites at which services or care are to be provided in accordance with a continuing care contract.

(f) Disclosure statement means the documents required to be filed with the department by either by the Act, or these regulations, or provided to a prospective purchaser or resident.

(g) Escrow Agent means a financial institution authorized to conduct business in this State, which has a fiduciary relationship with a provider, for the purpose of meeting the requirements of the Act and of these regulations.

(h) Legal representative means an attorney, guardian, conservator, or any other person including a family member, designated by a resident or potential future resident as his or her representative.

(i) Medical or nursing services or other health-related benefits means services or benefits to which a resident becomes contractually entitled as a result of a transfer of assets, payment of the entrance fee or of the periodic charges, or purchased for a fee in addition to a transfer of assets, an entrance fee, or periodic charges. These services or benefits include the following when a facility or service is licensed pursuant to C.G.S. Sec. 19a-490, et seq.:

Hospital care;

Home health care by a Home Health Care Agency, or Homemaker-Home Health Aide Agency; and

Care in a Nursing Home, or priority access to a nursing home.

(j) Offer means an offer through either personal, telephone or mail contact or other communication directed to or received by a person at a location within this state as an inducement, solicitation, or attempt to encourage a person to enter into a continuing-care contract and shall include any paid advertisement published or broadcast within this state, except for advertisements in periodicals where more than two-thirds of the circulation is outside this state.

The term "offer" shall not include marketing or feasibility studies, or any communication with an individual at the request of, or initiated by, that individual in regard to a continuing-care contract not intended to be performed within this state.

In regard to proposed facilities, the term "offer" shall not include options, or rights of first refusal involving consideration of one thousand dollars or less, provided that any such funds are (1) Either maintained in a passbook or equivalent account in the name of the prospective resident, or in an escrow account established with a financial institution solely for the purpose of holding such funds, (2) returnable to the individual upon demand, together with accrued interest thereon, by transfer of the passbook or otherwise, and the prospective resident is made fully aware of the foregoing provisions, by means which shall include contrasting, prominent type, setting forth the essence of these provisions in every option document.

(k) Reasonable charge means either the amount specified in a continuing-care contract or disclosure statement or, in the absence of being specified, a fee based upon actual costs in time, expense, overhead, etc. of selling or re-selling a continuing-care contract in regard to a specific dwelling unit at a facility.

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-2 Registration; filing and acknowledgment

(a)

(1) The commissioner, or the designee of the commissioner, shall acknowledge in writing the filing of a disclosure statement within ten business days of the date such statement is received if the disclosure statement, on its face, either meets the requirements of the Act, and these regulations, or contains only technical discrepancies. Such acknowledgment shall specify the fee which is due under Section 17b-533-10 (c) (2) of these regulations.

(2) If the commissioner determines that the disclosure statement, on its face, does not meet the requirements of the Act or these regulations, and will not be accepted for filing, written notification of that determination, stating the reasons therefor, will be given to the provider within ten business days of the date such statement is received. Such notification will not be accompanied by a return of the documents tendered.

(3) If neither an acknowledgment of filing nor notification of non-acceptance for filing is made within ten business days a provider may, until notification to the contrary, utilize the disclosure statement for the purposes of the Act.

(b) Upon notification that the disclosure statement has been accepted for filing, and that the required fee has been received pursuant to Section 17b-533-10 (c) of these regulations, the provider may use the disclosure statement for the purposes of the Act.

(c)

(1) Upon notification that the disclosure statement submitted is not accepted for filing, the provider may not, until resolution of the discrepancies by acceptable amendment, appeal, litigation, agreement, or otherwise, use the disclosure statement for the purposes of the Act and, until such resolution, shall refrain from offering or entering into a continuing-care contract in this state, or with any resident of this state, or regarding any facility in this state, based upon the rejected disclosure statement.

(2) Use of a rejected disclosure statement for the purposes of the Act shall be grounds for an immediate request to the Attorney General by the commissioner for the initiation of appropriate legal action, including action to enjoin use of such a rejected disclosure statement.

(d)

(1) Notwithstanding an acknowledgement of acceptance for filing, the commissioner may at any time thereafter review or investigate the information contained in any disclosure statements accepted for filing to determine accuracy and completeness thereof.

(2)

(A) In the event that a subsequent review or investigation determines that any disclosure statement does not in fact meet the requirements of the Act and of these regulations, the commissioner shall forthwith notify the provider thereof, and the reasons therefor, but no penalties shall be assessed or sought for use of the defective disclosure statement for the period between an initial favorable acknowledgement and subsequent review and notice of discrepancies.

(B) In the event of such a subsequent determination, the commissioner may, in the case of technical or minor discrepancies, authorize continued use of the defective disclosure statement until the discrepancies can be conveniently corrected either by way of amendment or in a subsequent disclosure statement.

(C)

(i) In the event discrepancies in the disclosure statement arise by reason of an untrue statement of material fact or failure to state a material fact then, on notification by the commissioner, the provider shall take such action as may be satisfactory to the commissioner to correct the disclosure statement and to notify prospective residents of changes therein.

(ii) In the event that a provider shall fail to take such action, or if it appears to the commissioner that the discrepancies were intentional, then the commissioner shall request the Attorney General to initiate appropriate legal action, including action to enjoin any use of the disclosure statement.

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-3 Disclosure statements: form and content

(a) There shall be one disclosure statement for each facility.

(1) No representation shall be made on the cover page or elsewhere in any disclosure statement as to the validity of the disclosure statement, a period of time during which the disclosure statement remains valid or effective, or which in any manner indicates, infers, or represents that the disclosure statement is effective or valid.

(2) The disclosure statement must include a cover page, table of contents, and the information required by the Act and these regulations.

(3) In addition to such other items as a provider may wish to list therein, the Table of Contents must include the following headings, in prominent type, to identify where in the disclosure statement, or the continuing-care contract, the information required by the Act is located: (Numerical reference is to the subsections of C.G.S. Section 17b-522 (a).): NAME AND ADDRESS OF PROVIDER(1)OFFICERS, DIRECTORS, AND TRUSTEES(2)BUSINESS EXPERIENCE(3)JUDICIAL PROCEEDINGS(4)AFFILIATION(5)DESCRIPTION OF PROPERTY(6)BENEFITS INCLUDED(7)INTEREST ON DEPOSITS(8)TERMINATION OF CONTRACT(9)RIGHTS OF A SURVIVING SPOUSE(10)MARRIAGE OF A RESIDENT(11)DISPOSITION OF PERSONAL PROPERTY(12)TAX CONSEQUENCES(13)RESERVE FUNDING - ESCROWS(14)FINANCIAL STATEMENTS(15)SOURCE OF FUNDS (if facility is not in operation)(16)PRO FORMA INCOME STATEMENTS(17)ENTRANCE FEES/PERIODIC CHARGES(18)PRE-PAID OBLIGATIONS, ACTUARIAL VALUE(19)DEPARTMENT ON AGING - FILINGS(20)CONTINUING-CARE CONTRACT(21) (c)

(4) A disclosure statement may utilize a table of contents other than as set forth in subsection (3) if, when submitted for filing, the disclosure statement is accompanied by an index which cross-references the requirements of subsection (3) above with the table of contents in the disclosure statement.

(5) The disclosure statement may include the required information in any order, at the discretion of the provider, provided that the Table of Contents or separate index clearly sets forth the location of the required information.

(6) The disclosure statement shall be assembled into one document, except if a provider shall determine that financial and actuarial data can be more conveniently or logically combined into one separate document, then two documents may be submitted as the disclosure statement.

(b) A disclosure statement submitted to the department for filing may be accompanied by an actuarial certificate, signed by a member in good standing of the American Academy of Actuaries, stating that financial and actuarial projections have been made upon an actuarially sound basis in accordance with accepted actuarial principles. In that event, the initial requirements for filing in regard to actuarial soundness shall be deemed to have been met.

(c)

(1) Actions initiated by the Attorney General against a provider in regard to non-compliance with the Act or these regulations shall, if not concluded, be affirmatively disclosed in disclosure statements filed subsequent to the initiation of such action by inclusion of a statement, under the heading JUDICIAL PROCEEDINGS, to the effect that such an action or actions have been instituted and are continuing. In such event, the provider shall initiate the filing of a revised disclosure statement not later than one (1) year from the date on which any such action is initiated.

(2) The requirements set forth in subsection (c) (1), above, may be waived by the commissioner upon application in writing by a provider, if the commissioner determines that the action or actions instituted arose by reason of the existence of a good faith dispute as to the scope or applicability of the Act or the regulations.

(3) If there are no proceedings to be reported under the heading JUDICIAL PROCEEDINGS, the disclosure statement shall contain an affirmative statement to that effect. Both the heading and this statement shall be omitted from the disclosure statement if the only disclosure required had been in regard to actions brought by the Attorney General, and the disclosure of such action had been waived pursuant to subsection (c) (2), above.

(d) If the manner in which periodic charges or other recurring fees may be adjusted is not set forth with specificity in the contract, by formula or otherwise, but rather indicates a general basis therefor, such as, "increases in taxes, and maintenance costs of the facility," then the disclosure statement shall include a statement to the effect that periodic charges (or other recurring fees) may be made at the discretion of the provider. Such a statement shall be included under the heading "Entrance Fees/Periodic Charges."

(e) A disclosure statement for a continuing care retirement community at which any incident of ownership is or may be transferred in whole or in part shall meet the foregoing requirements, and in addition, the proposed documents which would transfer any incident of ownership shall be included under item "(21)."

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-4 Escrow accounts

(a) No escrow agreement entered into pursuant to this section shall be deemed to meet the requirements of the Act or these regulations if it provides either for withdrawals contrary to the terms of the Act, or for changes in terms of the escrow agreement in regard thereto without prior notification to the commissioner of the proposed changes.

(b) Every escrow agreement shall contain, either in the original agreement, or in an amendment thereto, the requirement of prior notification to the commissioner as set forth in subsection (a), above.

(c) In the event the commissioner determines that an escrow agreement filed with the department does not meet the requirement of the Act and this section of the regulations, the commissioner may take such action as is consistent with the Act and these regulations.

(d) A provider may submit any existing or proposed escrow agreement to the department for an informal review. Notwithstanding either favorable or adverse comments thereon, such informal review or comments shall in no way be construed to be the position of the department, which can only be determined after such instrument is formally reviewed.

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-5 Reserve fund escrow

(a) Upon written application by a provider, the commissioner may authorize a facility to maintain a reserve fund escrow or escrows in an amount less than required pursuant to the computation set forth in C.G.S. Sec. 17b-525, if the commissioner finds that the contractual liabilities of the provider and the best interests of the residents may be adequately protected by a reserve fund escrow or escrows in a lesser amount.

(b) The written application by the provider shall contain sufficiently detailed supporting information, including that relating to contracts, deposit agreements, and other material necessary to fully disclose to the commissioner the scope and status of such matters, and the basis for the application.

(c) Matters that will be considered by the commissioner in regard to the application include, but are not limited to, the following:

(1) Whether any separate fund which the provider wishes to have considered is maintained with an escrow agent pursuant to a written agreement;

(2) Whether the portion which would be withdrawn monthly from the reduced Section 17b-525 escrow without approval of the commissioner is substantially in accordance with the following formula:

Portion Authorized to be Withdrawn monthly = A/S × 1/12

Where A = The reduced escrow amount; and

Where S = The statutory escrow amount.

(3) Whether the combined total amount proposed to be withdrawn from all such reserve or operating funds without the prior approval of the commissioner, does not exceed 1/12 of the combined amount of such funds.

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-6 Annual filings

(a) A provider operating any facility located in this state shall file with the department the following financial and actuarial information pertaining to residents under continuing-care contracts for each facility located in this state and operated by the provider or by a manager under contract to the provider:

(1) The facility's current rate schedule;

(2) Residential turnover rates for the most recently completed fiscal year, and anticipated for the next five years;

(3) The projected average age of the residents for the next five years;

(4) Health-care utilization rates, including admission rates and days per one hundred residents by level of care for the most recently completed fiscal year, and anticipated for the next five years;

(5) Occupancy rates for the most recently completed fiscal year, and anticipated for the next five years;

(6) The number of Health care admissions pursuant to continuing-care contracts for the most recently completed fiscal year, and anticipated for the next five years;

(7) The days of care per year for the most recently completed fiscal year, and anticipated for the next five years;

(8) The number of permanent transfers to a facility that provides medical or nursing services or other health-related benefits for the most recently completed fiscal year;

(9) A statement of source and application of funds for the five-year period beginning the year of initial filing pursuant to C.G.S. section 17b-528 or subsequent filing pursuant to C.G.S. section 17b-528;

(10) Financial statements including certified current balance sheets and certified income statements, changes in financial position, and pro forma statements for the next five years as provided in C.G.S. section 17b-522, and either such information as is necessary to assess the actuarial soundness thereof or an actuarial certificate as provided below in subsection (i) (2) of this section;

(11) The basis for amortization assumptions for the provider's capital cost;

(b) The financial and actuarial information shall be filed annually, within one hundred fifty days following the end of the fiscal year of the provider. At the discretion of the provider, the first such statement may be filed simultaneously with the initial revised disclosure statement as set forth in section 17b-533-7 hereof.

(c)

(1) If a provider is required to submit an annual financial and actuarial filing, a valid filing shall be supplemental to, and a prerequisite for, the continued effectiveness of a provider's latest disclosure statement on file with the department.

(2) In the event that an annual filing is not submitted as required, the provider's latest disclosure statement on file with the Department shall cease to be effective for the purposes of the Act, and such disclosure statement shall remain ineffective until the provider receives acknowledgement of the filing of the financial and actuarial information required by this section.

(d) The commissioner shall acknowledge in writing the filing of the financial and actuarial information within ten business days of the date it is received, if the information either meets the requirements of the Act or contains only technical discrepancies.

(e) The commissioner shall set forth the initial determination of the department in conjunction with such acknowledgement, in the same manner as provided in section 17b-533-2 of these regulations regarding disclosure statements.

(f) If the commissioner determines that the information filed does not on its face meet the requirements of the Act or these regulations, and will not be accepted for filing, the provider shall be notified in writing within ten business days of receipt of the financial and actuarial information of such determination and the reasons therefor. Such notification will not be accompanied by return of the documents.

(g) If neither an acknowledgement of filing nor notification of non-acceptance for filing is made within ten business days, a provider may, until notification to the contrary, deem that the financial and actuarial information has been accepted for filing.

(h) Upon a determination that the financial and actuarial information will not be accepted for filing, the commissioner may notify the Office of the Attorney General of the deficiency and request that appropriate legal action be initiated to compel compliance with the Act, recover an appropriate fine therefor, or for such other relief as may be deemed appropriate; provided, that no such request shall be made for non-material technical discrepancies with respect to the Act or these regulations.

(i)

(1) Required financial and actuarial information shall be filed in one document which shall consist of a cover page, a table of contents, and the information in such order as may be convenient for the provider; provided, that the table of contents adequately identifies by number, words, or both, the material included in the filing for ready comparison with the information required by the Act and these regulations.

(2) Any filing under this section which is accompanied by an actuarial certificate signed by a member in good standing of the American Academy of Actuaries stating that the financial and actuarial projections have been made on an actuarially sound basis in accordance with accepted actuarial principles shall be deemed to have met the initial requirements for filing in regard to actuarial soundness.

(j) Notwithstanding acknowledgement of acceptance for filing, the commissioner may at any time thereafter review and investigate the financial and actuarial information filed pursuant to this section to determine the accuracy and completeness thereof.

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-7 Disclosure statements: revisions

(a) Within one hundred fifty days following the end of the first fiscal year of a provider in which a registration is filed, and if that registration has not been withdrawn, a provider shall file a revised disclosure statement.

(b) Subsequent to the mandatory submission of the first revision of its disclosure statement, a provider need only initiate the filing of such revised disclosure statements as it deems necessary to prevent a disclosure statement from containing a material misstatement of fact or from omitting a material fact required to be stated therein. Filings of optional disclosure statements shall be accompanied by a written statement from the provider setting forth why it deemed such a revision to be necessary.

(c) Acknowledgement of filing or rejection of revised disclosure statements, shall be in the same manner as set forth in Section 17b-533-2 of these regulations.

(d) The form and content of revised disclosure statements shall be the same as set forth in Section 17b-533-3 of these regulations.

(e) Notwithstanding an acknowledgement of acceptance for filing, the commissioner may at any time thereafter review and investigate the information contained in revised disclosure statements accepted for filing to determine accuracy and completeness thereof.

(f) In the event that a subsequent review determines that a revised disclosure statement does not in fact meet the requirements of the Act and of these regulations then the commissioner may take such actions as are set forth in Section 17b-533-2 (d) (2).

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-8 Investigations

(a) Investigations, inquiries, and investigatory hearings as are deemed necessary by the commissioner to develop information for the use of the department may be conducted for the following purposes:

(1) To determine whether any person has violated any provision of the Act or of these regulations, relating to registration, disclosure, or escrow provisions relating to continuing-care contracts;

(2) To aid in the enforcement of the Act, including the regulations promulgated pursuant thereto; and

(3) To aid in the prescribing of regulations by the commissioner.

(b)

(1) Notice of investigatory hearings shall be given in such manner and to such persons as appropriate in order to afford adequate, timely knowledge of the proceeding to any person specifically affected thereby; provided, that in hearings pertaining to providers or continuing-care contracts in general, no general notifications to all providers need be made.

(2) Notice of investigatory hearing shall provide for a hearing date not less than ten calendar days from the date of mailing the notice. The hearing date may be changed by the commissioner, for good cause shown, upon the request of any person.

(3) The commissioner, or any presiding officer authorized by the commissioner to conduct any inquiry, investigation or hearing shall have power to administer oaths and take testimony under oath relative to the matter of inquiry or investigation. At any investigatory hearing ordered by the commissioner, the commissioner or such presiding officer having authority by law to issue such process may subpoena witnesses and require the production of records, papers and documents pertinent to such inquiry. If any person disobeys such process or having appeared in obedience thereto, refuses to answer any pertinent question put to him by the commissioner or by the presiding officer or to produce any records and papers pursuant thereto, the commissioner or the presiding officer as the commissioner's agent may apply to the superior court for Hartford county or for the county wherein the person resides or wherein the business has been conducted, or to any judge or said court if the same is not in session, setting forth such disobedience to process or refusal to answer, and said court or such judge shall cite such person to appear before said court or such judge to answer such question or to produce such records and papers.

(4) Any person subpoenaed to attend a hearing may be accompanied by an attorney and may, not less than five days prior to such hearing, request that a transcript of the hearing be made by an official stenographer or court reporter.

(5) It shall be the sole responsibility of any person desiring a copy of a hearing transcript to obtain a copy from the reporter or stenographer.

(c) If, as the result of an investigation, inquiry, or investigatory hearing conducted for the purposes set forth in the Act and these regulations, the commissioner determines that any provider has violated any provision of the Act, the commissioner may, without further action, request the attorney general to seek a temporary or permanent injunction and such other relief as may be appropriate to enjoin such provider from continuing such violation or violations.

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-9 Receivership: rehabilitation, and liquidation

(a) The commissioner shall give not less than five calendar days written notice to a provider or a facility of an intention to request the Attorney General to apply for an order appointing a receiver to rehabilitate or liquidate a facility.

(b) Such notice shall be sent by certified mail, return receipt requested, or delivered personally to the business or other office of the provider at the facility, or elsewhere within the state, in which event an affidavit of service shall be executed.

(c) Such notice shall include a summary of the basis for the action, and the date on which the commissioner will request the Office of the Attorney General to initiate action, together with the following statement:

YOU MAY REQUEST A HEARING

ON THIS MATTER NOT LATER THAN

(one day prior to the date on which

the commissioner is to take action.)

SUCH A REQUEST MUST BE IN WRITING.

FAILURE TO REQUEST SUCH A HEARING WILL

RESULT IN LEGAL ACTION FOR THE APPOINTMENT

OF A RECEIVER TO REHABILITATE OR LIQUIDATE YOUR FACILITY.

(d)

(1) A request for a hearing must be in writing, and shall be delivered to the commissioner.

(2) The provider or the facility may propose a date for the hearing which shall not be more than ten days from the date of the request, and may also request that a verbatim transcript be made of the proceeding, and that all testimony be taken under oath.

(3) Such request for a hearing shall specify the names of attorneys who will represent the facility.

(4) The commissioner shall, not more than 3 business days after receiving the request, notify the facility of the time and date of the hearing, which shall not be less than five business days from the date of the request.

(5) The commissioner shall, not more than 5 business days from the close of the hearing, make a determination which shall be communicated to the facility, and if appropriate simultaneously request the Attorney General to initiate action.

(6) Notwithstanding the foregoing limitations on the commissioner in regard to requesting action to have a receiver appointed, the commissioner may request the Office of the Attorney General to initiate such other action as the Attorney General may deem appropriate in the circumstance.

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-10 Miscellaneous

(a) Continuing-care:

A determination by the department that an arrangement in regard to existing or prospective shelter, and medical or nursing services or other health-related benefits constitutes a continuing care contract and the site or sites at which provision of services and benefits is made constitutes a continuing care retirement community, will be made after consideration of the following guidelines:

(1) The resident's right to occupy shelter does not solely constitute either an ownership interest, or a usual and customary leasehold;

(2) There are specific commitments for present or future medical or nursing services or other health-related benefits;

(3) A present or future transfer of assets is required, a specific part of which may be applicable to the obligation to provide medical or nursing services or other health-related benefits, and part of which may be applicable to the obligation to provide shelter;

(4) There are periodic charges or a part thereof which may be applicable to the obligation to provide medical or nursing services or other health related benefits;

(5) There are limited rights to transfer shelter to another person whether or not to or through the provider, or no such rights of transfer at all;

(6) There may be, in the event of the departure or death of a resident subsequent to the occupation of the shelter, limitations on return to a resident or his estate of any advance payments or transfers of funds made by him.

(7) The provision of qualifying medical or nursing services or other health related benefits is a condition of occupancy of any residential unit.

(b) Filing of documents:

(1) Three copies of disclosure statements, financial and actuarial data, and any other documents or information required to be filed, shall be submitted by certified mail, return receipt requested, or delivered by hand to the Department on Aging, 175 Main Street, Hartford, CT 06106, Attn: Office of the Commissioner.

(2) All documents shall, upon receipt by the Department, be date stamped on the cover page and on one inside page.

(3) (A) A date-stamped receipt shall be given for any documents hand delivered, but such a receipt shall not constitute "acknowledgement" within the meaning of the Act.

(B) Any receipt shall also specify the name of the provider, and shall identify the documents delivered.

(c) Annual fees:

(1) Each provider having an accepted disclosure statement or an accepted revised disclosure statement on file with the department shall pay an annual fee equal to twenty four dollars ($24.00) multiplied by the number of residential units at the facility to which the disclosure statement applies. Said fee shall be paid not later than five business days after the first day of January in each year, and shall be accompanied by a signed letter from the provider specifying the number of residential units at the facility. Acknowledgment, in writing, of receipt of the required fee shall be promptly issued by the department. If the fee is not paid as herein set forth, the disclosure statement for the facility shall cease to be effective for the purposes of the act until the provider has received the department's written acknowledgment of payment of the fee.

(2) Initial disclosure statements: An initial disclosure statement submitted for filing shall not be accompanied by any fee. Acknowledgment by the commissioner of acceptance for filing in accordance with Section 17b-533-2 (a) (1) of these regulations shall specify the amount of the fee which is due, based on the formula set forth in (1) above. Notwithstanding acknowledgment of acceptance for filing, the disclosure statement shall not be effective for purposes of the act until notification to the provider from the department that the required fee has been received.

(d) Fiscal year:

(1) When an initial disclosure statement is filed, the provider shall state the fiscal year of the provider either in the transmission letter, or on the cover page of the disclosure statement.

(2) In the event a provider changes its fiscal year it shall notify the commissioner thereof. The commissioner may, on such terms and conditions in regard to required filings as the commissioner deems appropriate, require interim filings or bridge reports.

(e) Informal reviews:

(1) A provider may, at any time, seek the informal advice or views of the department in regard to any matter pertaining to the provisions of the Act or these regulations, but in no event shall any views given or advice rendered informally by the department be deemed binding on actions or determinations of the department which may subsequently be undertaken or rendered in a formal determination.

(2) Actions taken by a provider in good faith reliance or informal advice shall not be subject to any penalty, or action by the commissioner other than as may be necessary to provide for full disclosure.

History

• Effective January 31, 1996

Regs., Conn. State Agencies § 17b-533-11 Advisory committee

(a) The name of the committee established by the Act shall be

THE CONTINUING-CARE ADVISORY COMMITTEE.

(b) The committee shall have the following purposes:

(1) To assist the commissioner in the various reviews and the registration functions to be performed under the Act and these regulations;

(2) To report to commissioner on developments in the field of continuing-care;

(3) To report to the commissioner any special problems in the field of continuing care;

(4) To recommend changes in relevant statutes, and these regulations; and

(5) To advise on any other matters referred to the committee by the commissioner.

(c) The committee shall be composed of not more than twelve (12) members.

(1) In the event a vacancy occurs on the committee by virtue of death, resignation, inability to serve, or termination by the commissioner, any such vacancy shall be filled by the commissioner for the balance of the unexpired term.

(2) Members of the committee may be re-appointed to additional terms, without limitation.

(d) The advisory committee shall be comprised of professionals such as accountants, actuaries, insurance representatives, representatives of the continuing-care industry, and may include residents of continuing-care facilities and others knowledgeable in the field of continuing-care and familiar with the provisions of the Act. Members of the committee shall be appointed in accordance with the provisions of C.G.S. Section 4-9a.

(1) The commissioner may seek recommendations for membership on the committee from any individual, business entity, association or group, in order to meet the requirements for membership established by the Act.

(e) Meetings of the committee shall be held at such times and places as may be established by the commissioner, with the advice of the chairman.

(1) The committee shall meet at least four (4) times in each calendar year, with at least one meeting in each quarter, if possible.

(2) The commissioner may as deemed necessary, or upon a request in writing from a majority of members, call additional meetings.

(3) Meetings shall be attended by the commissioner, or the designee of the commissioner.

(4)

(A) The agenda for regularly scheduled meetings must be approved by the commissioner, and such agendas shall be submitted to the commissioner by the chairman for approval.

(B) The agenda for any special or additional meetings shall be prepared by the commissioner.

(C) Meetings of the committee shall be conducted in accordance with all applicable provisions of the Freedom of Information Act.

(f) Staff support for the committee shall be provided by the department, by such individuals as may be designated by the commissioner to perform such functions.

(g) The committee shall remain in existence until terminated by act of the General Assembly.

History

• Effective January 31, 1996

17b-605 Personal Care Assistance Program

Regs., Conn. State Agencies § 17b-605-1a—17b-605-9a Reserved

Sec. 17b-605-1a—17b-605-9a. Reserved

Regs., Conn. State Agencies § 17b-605-10a Definitions (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Effective July 3, 1996; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-605-11a Eligibility for personal care assistance (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Effective July 3, 1996; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-605-12a Elements of the application filing (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Effective January 31, 1996; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-605-13a Application review and determination of eligibility (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Effective July 3, 1996; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-605-14a Waiting list and payments (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Effective January 31, 1996; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-605-15a Recordkeeping and verification of service (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Effective July 3, 1996; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-605-16a Overpayment recovery procedure (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Effective January 31, 1996; Repealed June 11, 2014

Regs., Conn. State Agencies § 17b-605-17a (Repealed)

Repealed July 3, 1996.

Regs., Conn. State Agencies § 17b-605-18a Fair hearings (Repealed)

Repealed June 11, 2014.

Notes: For 2014 repeal, see Sec. 54 of Public Act 14-187. (June 11, 2014)

History

• Effective January 31, 1996; Repealed June 11, 2014

17b-616 Family Support Grant Program

Regs., Conn. State Agencies § 17b-616-1—17b-616-14 Reserved

Sec. 17b-616-1—17b-616-14. Reserved

Regs., Conn. State Agencies § 17b-616-15 Definitions

For purposes of Sections 17b-616-15 through 17b-616-26:

(a) "Child with a disability" means any child under the age of 18 who has a developmental disability but does not include any child with mental retardation.

(b) "Commissioner" means the Commissioner of the Department of Human Resources.

(c) "Department" means the Department of Human Resources.

(d) "Developmental disability" means a severe, chronic disability of a person 5 years of age or older which:

(1) Is attributable to a mental or physical impairment or combination of mental and physical impairments;

(2) Is manifested before the person attains age twenty-two;

(3) Is likely to continue indefinitely;

(4) Results in substantial functional limitations in three or more of the following areas of major life activity;

(A) self-care;

(B) receptive and expressive language;

(C) learning;

(D) mobility;

(E) self-direction;

(F) capacity for independent living;

(G) economic self-sufficiency; and

(5) Reflects the person's need for a combination and sequence of special, interdisciplinary, or generic care, treatment, or other services which are of lifelong or extended duration and are individually planned and coordinated; except that such term, when applied to infants and young children means individuals from birth to age 5, inclusive, who have substantial developmental delay or specific congenital or acquired conditions with a high probability of resulting in developmental disabilities if services are not provided.

(e) "Disability-related expenses" means those costs incurred on behalf of the child with a disability directly associated with his or her disability and may include, but are not limited to, the following expenses not covered or reimbursable by insurance or other funding sources: disability-related medical supplies, equipment, prescriptions, medical and dental care, and related transportation costs, and other disability-related costs as determined by the Commissioner.

(f) "Extraordinary financial impact" is defined as substantial ongoing monthly expenses which meet or exceed the level of the grant, which are not reimbursable and which are related to the unique needs and/or care of a child with a disability.

(g) "Family applicant" means any parent or other family member who resides in the same residence as the child with a disability and who has primary responsibility for providing continuous care to the child with a disability.

(h) "Family Support" means the monthly grant provided to a recipient.

(i) "Grant Reduction Recoupment" is a method of recoupment in which the Department reduces the recipient's monthly grant totalling the amount of the overpayment.

(j) "Gross Income" means all income, from whatever source derived, including, but not limited to:

(1) Earned income such as compensation paid by an employer to an employee for personal services and includes wages, salaries, tips, commissions, bonuses, and earnings from self-employment or contractual agreements;

(2) Unearned income such as pensions, annuities, dividends, interest, rental income, estate or trust income, royalties, social security or supplemental security income, unemployment compensation, workers' compensation, alimony, child support, and cash assistance from federal, state or municipal assistance programs.

(k) "Income" means the gross income of the family applicant, any legally liable relative in the household of the child with a disability, and the income of the child with a disability, less the disability-related expenses listed in subsection (e) of this section.

(l) "Installment Recoupment" is a method of recoupment in which the recipient makes monthly installment payments to the Department totalling the amount of the overpayment.

(m) "Lump-sum Recoupment" is a method of recoupment in which the recipient makes payment to the Department of the entire amount of the overpayment in one payment.

(n) "Overpayment" is the amount of financial assistance paid on behalf of a recipient in excess of the amount to which he or she is properly entitled. The overpayment may be caused by:

(1) The Department's incorrect action or failure to act within the appropriate time limits;

(2) The recipient's failure to report excess income;

(3) The recipient's failure to verify expenditures of the Family Support Grant;

(4) The recipient's failure to notify the Department that a child who was initially found eligible for the program has been diagnosed as having mental retardation or;

(5) The recipient's failure to notify the Department of any change in circumstances affecting eligibility.

(o) "Recipient" means a person who has been determined eligible and is receiving a Family Support Grant.

(p) "Recoupment" is a process by which the Department recovers an overpayment from the recipient.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-16 Eligibility criteria

In order to be eligible for a Family Support Grant under this program the requirements of both subsection (a) for the family applicant and of subsection (b) for the child with a disability must be met.

(a) In order to be eligible, the family applicant must meet the following criteria:

(1) Be a parent or adult family member;

(2) Be a resident of Connecticut;

(3) Reside in the same household as the child with a disability;

(4) Have primary responsibility for providing continuous care to the child with a developmental disability other than mental retardation;

(5) Have income not greater than 140% of the previous year's median family income for Connecticut as determined annually by the U.S. Department of Housing and Urban Development (HUD) pursuant to Section 3 (b) (2) of the U.S. Housing Act of 1937 as amended; and

(6) Comply with the requirements of sections 17b-616-19 to 17b-616-25, inclusive.

(b) In order to be eligible, the child with a disability must meet the following criteria:

(1) Be a resident of Connecticut;

(2) Be under the age of 18;

(3) Have a developmental disability as defined in Section 17b-616-15 (d) of this regulation; the developmental disability must be other than mental retardation as defined in Conn. Gen. Stat. Section 1-1g and this developmental disability must result in extraordinary financial impact for the family applicant, as defined in Section 17b-616-15 (f).

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-17 Grandfathered cases

(a) Participants in the Department's Pilot Phase of the Family Support Program during the calendar years 1990, 1991 and 1992 shall be grandfathered onto this program.

(b) Such cases shall be added effective January 1, 1993 when funding from the Developmental Disabilities Council ends.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-18 Waiting list and termination of funding in the event of inadequate appropriation

(a) The Family Support Grant Program is not an entitlement program. Funding shall be provided within available appropriations. The Department has established a waiting list as follows:

(1) The initial waiting list consists of a randomly ordered list of all persons who submitted their names to the Department as of June 30, 1992, and were not selected for the program.

(2) Thereafter, additional names will be submitted by the district offices in writing, or by any other person either orally or in writing, to the Bureau of Field Operations and will be added to the waiting list as received.

(b) In the event that the Commissioner determines that there is not sufficient funding to provide grants throughout the fiscal year on behalf of families who are receiving assistance under the program, the Commissioner may elect to:

(1) Remove families in order of greatest income from the program so that the program may operate through the remainder of the year or;

(2) Maintain all families on the program as long as funding is available and terminate the program for the current fiscal year when funding is exhausted.

(c) Families denied assistance due to the lack of sufficient funding pursuant to this subsection shall not be entitled to a Fair Hearing pursuant to Section 17b-616-26.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-19 Application filing

(a) Application forms shall be available at the Department's district offices and shall be mailed to the next family applicant on the waiting list as funds become available.

(b) Upon request of the family applicant, a Department worker shall assist with the application and arrange for a social study at the same time. If no assistance has been requested, a Department worker shall, upon receipt of the completed application form, contact the family applicant and arrange for a home visit in order to prepare a social study.

(c) A properly completed and signed application form and other documents as may be necessary to determine eligibility shall be submitted to enable the Department to conduct a thorough review of the family applicant's eligibility for family support under this program.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-20 Elements of the application

(a) The Family Support Program application shall include, but is not limited to, the following information:

(1) Nature of the child's disabling condition;

(2) A statement of the diagnosis and medical needs signed by the child's health care professional; including verification that the child does not have mental retardation;

(3) Verification of Income: wage stubs for the last six (6) weeks, and a complete copy of the I.R.S. Federal Income Tax Return for the previous calendar year; and

(4) Expected use of the family grant including information as to the ongoing extraordinary financial expenses.

(b) The Department shall conduct a social study in order to evaluate the home and family situation and to determine eligibility. The elements of the social study shall include but not be limited to: family members and relationships, description of the child with a disability, financial information and a description of the home environment.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-21 Application review, notification and funding

(a) Within forty five (45) days of the receipt of a completed application as described in Section 17b-616-20 (a) and other supplementary material, the Department shall determine the eligibility of the family applicant and notification of acceptance or non-acceptance into the program shall be mailed to the family applicant.

(b) It shall be the responsibility of the recipient to notify the district office within fifteen (15) days of any change in circumstances affecting eligibility. Failure to do so may be cause for discontinuance from the program.

(c) Funding shall be provided within available appropriations at the rate of $250 per month.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-22 Family support payments

(a) Family Support payments shall be used to pay for disability-related expenses incurred on behalf of the child with a disability.

(b) The Department shall require a written participant agreement between the Department and the family applicant accepted into the program. The terms of the participant agreement shall include:

(1) The recipient must reside in the same household and have primary responsibility for the continuous care of a child, who has a developmental disability other than mental retardation. The child must be under the age of eighteen (18).

(2) The recipient must agree to provide information about the expenditures made with the Family Support Grant to the Department.

(3) The recipient must notify the Department within fifteen (15) days of any change in income or any other circumstances which affect eligibility.

(4) The Department will redetermine eligibility at least semi-annually.

(5) Upon full execution of the participant agreement the Department shall provide the family applicant with a monthly check for the agreed upon amount of family support.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-23 Department review

(a) All conditions of eligibility shall be subject to review semi-annually. Semiannual review shall include verification of expenditures of the Family Support Grant received for the previous six months. Failure to provide such verification may be cause for discontinuance from the program. Prior to discontinuance of the Family Support Grant a recipient shall be given thirty (30) days written notice.

(b) If the Department's worker finds, at the time of review or at any other time that a child who was initially found eligible for the program is thereafter diagnosed as having mental retardation, that child shall be discontinued from the program upon thirty (30) days written notice to the recipient. A referral will be made to the Department of Mental Retardation which administers a similar program for families with children who have mental retardation.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-24 Recordkeeping and verification of service

The recipient shall maintain records verifying that the Family Support Grant payments from the Department have been expended for the care of the child with a disability.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-25 Overpayment recovery procedure

(a) Program recipients and former recipients are obligated to reimburse the Department for any overpayment received.

(b) The Commissioner may waive recoupment of an overpayment if in his/her judgment the imposition of recoupment measures would result in unnecessary hardship for the recipient's family.

(c) Prior to the Department initiating any recoupment process, the recipient shall be notified of the amount of the overpayment, the reason the overpayment occurred, the time period covered by the overpayment, the proposed method for recovering the overpayment and the process for appealing the recoupment action in accordance with Section 17b-616-26.

(d) Method of Recoupment:

(1) The Department shall attempt to recover overpayments from recipients and former recipients by the lump-sum recoupment method.

(2) If the recipient or former recipient who owes the overpayment is unable to make a lump sum repayment, the Department will attempt to recover the money through the installment recoupment method. Recipients may agree to the grant reduction recoupment method in lieu of installment recoupment.

(3) In cases where the recipient who owes the overpayment fails or refuses to make a lump sum payment, sign an installment agreement, or comply with the provisions of an installment agreement, the Department may utilize the grant reduction recoupment method by reducing each subsequent payment made to the recipient by up to 25% of the total amount owed until such overpayment is recovered.

(4) When there is failure to agree to an appropriate repayment plan, the Commissioner shall take whatever action he/she deems appropriate to recover such overpayment including referral to the office of the Attorney General.

History

• Effective November 30, 1995

Regs., Conn. State Agencies § 17b-616-26 Fair hearings

An aggrieved person shall be given an opportunity for a fair hearing in accordance with the Connecticut General Statutes Sections 17-603 and 17-604, as same may be amended. The Department of Human Resources fair hearing procedures are governed by applicable provisions of the Uniform Administrative Procedures Act and the agency's separate fair hearing regulations.

History

• Effective November 30, 1995

17b-653 Bureau of Rehabilitation Services

Regs., Conn. State Agencies § 17b-653-1 Description

Sections 17b-653-2 to 17b-653-24, inclusive, of the Regulations of Connecticut State Agencies shall apply to the state Department of Social Services, Bureau of Rehabilitation Services in its implementation of vocational rehabilitation services as described in Section 17b-650 through 17b-665 of the Connecticut General Statutes, the Rehabilitation Act of 1973, as amended, and implementing regulations.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-2 Definitions

(a) The definitions provided by Section 17b-650 of the Connecticut General Statutes shall govern the interpretation and application of this section and sections 17b-653-3 to 17b-653-24, inclusive, of the Regulations of Connecticut State Agencies.

(b) In addition thereto, the following definitions shall apply:

(1) "Act" means the Rehabilitation Act of 1973, as amended (29 USC 701 et seq.);

(2) "Applicant" means a person who has applied for vocational rehabilitation services from the Bureau of Rehabilitation Services;

(3) "Architectural alteration services" means services provided to adapt or modify a client's home or small business. These services may include architectural consultation, design, construction and inspection to determine whether the services meet the necessary building and accessibility codes and client needs;

(4) "Assistive technology device" means any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve the functional capabilities of an individual with a disability;

(5) "Assistive technology service" means any service that directly assists an individual with a disability in the selection, acquisition, or use of an assistive technology device, including:

(A) the evaluation of the needs of an individual with a disability, including a functional evaluation of the individual in his or her customary environment;

(B) purchasing, leasing, or otherwise providing for the acquisition by an individual with a disability of an assistive technology device;

(C) selecting, designing, fitting, customizing, adapting, applying, maintaining, repairing, or replacing assistive technology devices;

(D) coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs;

(E) training or technical assistance for an individual with a disability or, if appropriate, the family members, guardians, advocates, or authorized representatives of the individual; and

(F) training or technical assistance for professionals (including individuals providing education and rehabilitation services) employers, or others who provide services to, employ, or are otherwise substantially involved in the major life functions of individuals with disabilities, to the extent that training or technical assistance is necessary to the achievement of an employment outcome by an individual with a disability;

(6) "Bureau" means the Bureau of Rehabilitation Services;

(7) "Client" means a person who has been determined to be eligible for vocational rehabilitation services from the bureau;

(8) "Client Assistance Program" (CAP) is a unit within the Office of Protection and Advocacy of the State of Connecticut. The purpose of the Client Assistance Program is to provide information and advice to applicants and clients of all available benefits under the act.

(9) "Commensurate" means, with respect to the comparison of various programs or services, those programs or services which will enable the applicant or client to, as applicable:

(A) complete the assessment for determining eligibility and priority for services;

(B) complete the assessment for determining rehabilitation needs; or

(C) achieve an employment outcome.

(10) "Community rehabilitation program" means a program that provides directly or facilitates the provision of vocational rehabilitation services to individuals with disabilities, and that provides, singly or in combination, for an individual with a disability to enable the individual to maximize opportunities for employment, including career advancement:

(A) medical, psychiatric, psychological, social, and vocational services that are provided under one management;

(B) testing, fitting, or training in the use of prosthetic and orthotic devices;

(C) recreational therapy;

(D) physical and occupational therapy;

(E) speech, language, and hearing therapy;

(F) psychiatric, psychological, and social services, including positive behavior management;

(G) assessment for determining eligibility and vocational rehabilitation needs;

(H) rehabilitation technology;

(I) job development, placement, and retention services;

(J) evaluation or control of specific disabilities;

(K) orientation and mobility services for individuals who are blind;

(L) extended employment;

(M) psychosocial rehabilitation services;

(N) supported employment services and extended services;

(O) services to family members when necessary to the vocational rehabilitation of the individual;

(P) personal assistance services;

(Q) services similar to the services described in paragraphs (A) through (P) of this subdivision. For the purposes of this definition, the word program means an agency, organization, or institution, or unit of an agency, organization, or institution, that provides directly or facilitates the provision of vocational rehabilitation services as one of its major functions.

(11) "Comparable services and benefits" means services and benefits that are:

(A) provided or paid for, in whole or in part, by other federal, state, or local public agencies, by health insurance, or by employee benefits;

(B) available to the individual at the time needed to achieve the employment outcome in the individual's employment plan, in accordance with section 17b-653-11; and

(C) commensurate to the services that the individual would otherwise receive from the bureau;

(12) "Competitive employment" means work,

(A) in the competitive labor market that is performed on a full-time or part-time basis in an integrated setting; and

(B) for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals who are not disabled.

(13) "Counselor" means the bureau employee who is responsible for obtaining, analyzing, and evaluating pertinent applicant and client information, determining eligibility for rehabilitation services, developing and implementing rehabilitation plans with applicants or clients, providing counseling, guidance, and placement services, and recommending closure where appropriate;

(14) "Department" means the state Department of Social Services;

(15) "Director" means the director of the Bureau of Rehabilitation Services;

(16) "Eligible" or "Eligibility" when used in relation to an applicant's qualification for rehabilitation services means a certification that:

(A) the applicant is an individual with a disability, as defined in subsection (b)(22) of this section; and

(B) the individual requires vocational rehabilitation services to prepare for, enter, engage in or retain gainful employment;

(17) "Employment outcome" means, with respect to an individual, entering or retaining full-time or, if appropriate, part-time competitive employment in the integrated labor market, supported employment, self-employment, telecommuting, or business ownership;

(18) "Employment plan", also known as the individualized plan for employment, means a plan which is designed to achieve an employment outcome and approved by the bureau;

(19) "Experimental procedure" means a medical, rehabilitation, educational or related service, device or methodology which is unproven or is not generally accepted as effective within the professional discipline best able to evaluate the procedure;

(20) "Family member" means any relative by blood or marriage of an applicant or client with a disability and other individuals living in the same household with whom the applicant or client with a disability has a close interpersonal relationship;

(21) "Impartial hearing officer" means an individual who

(A) is not an employee of a public agency (other than an administrative law judge, hearing examiner, or employee of an institution of higher education). An individual is not an employee of a public agency solely because the individual is paid by that agency to serve as a hearing officer;

(B) has not been involved previously in the vocational rehabilitation of the applicant or client;

(C) has knowledge of the delivery of vocational rehabilitation services, the federal and state rules governing the provision of such services and has received training with respect to the performance of official duties;

(D) has no personal or financial interest that would be in conflict with the individual's objectivity; and

(E) is not a member of the state rehabilitation advisory council for the bureau;

(22) "Individual with a disability" means an individual who,

(A) has a physical or mental impairment which for such individual constitutes or results in a substantial impediment to employment; and

(B) can benefit in terms of an employment outcome from the provision of vocational rehabilitation services;

(23) "Individual with a most significant disability" means an individual with a significant disability who:

(A) has serious limitations in a total of three or more functional areas (such as mobility, communication, self-care, interpersonal skills, work tolerance or work skills) in terms of an employment outcome; or

(B) will require significant ongoing disability-related services on the job in order to maintain employment following case closure with the bureau;

(24) "Individual with a significant disability" means an individual with a disability who has a severe physical or mental impairment which seriously limits one or more functional capacities (such as mobility, communication, self-care, self-direction, interpersonal skills, work tolerance, or work skills) in terms of an employment outcome, whose vocational rehabilitation can be expected to require multiple vocational rehabilitation services over an extended period of time, and who has one or more physical or mental disabilities resulting from amputation, arthritis, autism, blindness, burn injury, cancer, cerebral palsy, cystic fibrosis, deafness, head injury, heart disease, hemiplegia, hemophilia, respiratory or pulmonary dysfunction, mental retardation, mental illness, multiple sclerosis, muscular dystrophy, musculoskeletal disorders, neurological disorders (including stroke and epilepsy), paraplegia, quadriplegia, and other spinal cord conditions, sickle cell anemia, specific learning disability, end-stage renal disease, or another disability or combination of disabilities determined on the basis of an assessment for determining eligibility and vocational rehabilitation needs to cause comparable substantial functional limitation;

(25) "Individualized written rehabilitation program" means an employment plan;

(26) "Informal review" means an informal procedure through which the bureau affords an opportunity to a client or applicant for vocational rehabilitation services, or if appropriate, his or her parent, guardian or other representative, to express and seek remedy for dissatisfaction with any determinations made by the bureau concerning the provision or denial of such services. An informal review does not constitute a "contested case" within the meaning of section 4-166(2) of the Connecticut General Statutes;

(27) "Informed choice" means that the individual:

(A) has meaningful options from which to choose;

(B) understands his or her abilities, capabilities and interests related to the employment outcome; and

(C) participates in a planning process with bureau staff which considers such issues as:

(i) relevant factors regarding choices made in the rehabilitation process. This includes, but is not limited to, service provider effectiveness and consumer satisfaction, relative cost of service options and labor market trends; and

(ii) applicable laws, regulations, state plan provisions and policy which establish parameters within which choices shall be made;

(28) "Institution of higher education" means a university, college, junior college, community college, vocational school, technical school or other post secondary institution legally authorized to provide a program of education beyond secondary education;

(29) "Integrated setting"

(A) with respect to the provision of services, means a setting typically found in the community in which applicants or eligible individuals interact with non-disabled individuals other than non-disabled individuals who are providing services to those applicants or eligible individuals.

(B) with respect to an employment outcome, a setting typically found in the community in which applicants or eligible individuals interact with non-disabled individuals, other than non-disabled individuals who are providing services to those applicants or eligible individuals, to the same extent that non-disabled individuals in comparable positions interact with other persons;

(30) "Maintenance" means monetary support provided to an applicant or eligible individual for those expenses, such as food, shelter, and clothing, that are in excess of the normal expenses of the individual and that are necessitated by the individual's participation in a program of vocational rehabilitation services;

(31) "Ongoing support services" means services

(A) provided to individuals with the most significant disabilities;

(B) provided, at a minimum, twice monthly:

(i) to make an assessment, regarding the employment situation, at the worksite of each such individual in supported employment, or, under special circumstances, especially at the request of the client, off site; and

(ii) based on the assessment, to provide for the coordination or provision of specific intensive services, at or away from the worksite, that are needed to maintain employment stability; and

(C) consisting of:

(i) a particularized assessment supplementary to the assessment for determining rehabilitation needs described in section 17b-653-8(e);

(ii) the provision of skilled job trainers who accompany the individual for intensive job skill training at the worksite;

(iii) job development, job retention, and placement services;

(iv) social skills training;

(v) regular observation or supervision of the individual;

(vi) followup services such as regular contact with the employers, the individuals, the individuals' representatives, and other appropriate individuals, in order to reinforce and stabilize the job placement;

(vii) facilitation of natural supports at the worksite;

(viii) any other vocational rehabilitation service, as defined in section 17b-653-2(b)(44);

(ix) a service similar to another service described in this subparagraph;

(32) "Party" means an applicant, a client or a representative of the bureau who is seeking remedy under an informal review or administrative hearing;

(33) "Personal assistance services" means a range of services designed to assist an individual with a disability to perform daily living activities on or off the job that the individual would typically perform without assistance if the individual did not have a disability. The services shall be designed to increase the individual's control in life and ability to perform everyday activities on or off the job. The services shall be necessary to the achievement of an employment outcome and may be provided only while the individual is receiving other vocational rehabilitation services. The services may include training in managing, supervising and directing personal assistance services;

(34) "Post-employment services" means one or more of the services identified in subsection (b)(44) of this section that are provided subsequent to the achievement of an employment outcome and that are necessary for an individual to maintain, regain, or advance in employment, consistent with the individual's strengths, resources, priorities, concerns, abilities, capabilities, and interests;

(35) "Rehabilitation engineering" means the systematic application of engineering sciences to design, develop, adapt, test, evaluate, apply, and distribute technological solutions to problems confronted by individuals with disabilities in functional areas, such as mobility, communications, hearing, vision, and cognition, and in activities associated with employment, independent living, education, and integration into the community;

(36) "Rehabilitation technology" means the systematic application of technologies, engineering methodologies, or scientific principles to meet the needs of, and address the barriers confronted by, individuals with disabilities in areas that include education, rehabilitation, employment, transportation, independent living, and recreation. The term includes "rehabilitation engineering" as defined in subsection (b)(35) of this section, "assistive technology devices" as defined in subsection (b)(4) of this section, and "assistive technology services" as defined in subsection (b)(5) of this section;

(37) "Reviewer" means a person designated by the director to conduct informal reviews and render decisions;

(38) "Reviewing official" means the commissioner of the Department of Social Services, as the designated official authorized to review the decision rendered by an impartial hearing officer, pursuant to section 17b-653-23;

(39) "State agency" means the state Department of Social Services;

(40) "State plan" means the plan for vocational rehabilitation services submitted by the bureau on behalf of the State of Connecticut to the Rehabilitation Services Administration of the United States Department of Education pursuant to 34 CFR Sec. 361.2;

(41) "Substantial impediment to employment" means that a physical or mental impairment (in light of attendant medical, psychological, vocational, educational, and other related factors) hinders an individual from entering into, engaging in, retaining or preparing for employment consistent with the individual's capacities and abilities;

(42) "Supported Employment" means:

(A) competitive work in an integrated work setting or employment in integrated work settings in which individuals are working toward competitive work with ongoing support services for individuals with the most significant disabilities,

(i) for whom competitive employment has not traditionally occurred or has been interrupted or intermittent as a result of a significant disability; and

(ii.) who, because of the nature and severity of their disabilities, need intensive supported employment services from the bureau and extended services after transition in order to perform this work; or

(B) transitional employment for individuals with the most significant disabilities due to mental illness;

(43) "Supported employment services" means ongoing support services and other appropriate services needed to support and maintain an individual with a most significant disability in supported employment that:

(A) are provided singly or in combination and are organized and made available in such a way as to assist an eligible individual to achieve competitive employment;

(B) are based on a determination of the needs of an eligible individual, as specified in an employment plan; and

(C) are provided by the bureau for a period of time not to extend beyond 18 months, unless under special circumstances the eligible individual and rehabilitation counselor or other appropriate bureau staff jointly agree to extend the time in order to achieve the rehabilitation objectives identified in the employment plan;

(44) "Vocational rehabilitation services" means any services described in an employment plan necessary to an individual with a disability in preparing for, securing, retaining, or regaining an employment outcome consistent with the strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice of the individual, including:

(A) assessment for determining eligibility and priority for services in accordance with section 17b-653-8(a);

(B) assessment for determining vocational rehabilitation needs in accordance with section 17b-653-8(e);

(C) vocational rehabilitation counseling and guidance, including information and support services to assist an individual in exercising informed choice in the development of an employment plan;

(D) referral and other services necessary to help applicants and eligible individuals secure needed services from other agencies and to advise those individuals about the client assistance program;

(E) physical and mental restoration services in accordance with section 17b-653-12;

(F) vocational and other training services in accordance with sections 17b-653-14 and 17b-653-15;

(G) maintenance, in accordance with section 17b-653-16 and the definition of that term in section 17b-653-2(b)(30);

(H) transportation, in accordance with section 17b-653-18;

(I) vocational rehabilitation services to the family of an individual with a disability necessary to assist the individual to achieve an employment outcome;

(J) interpreter services for individuals who are deaf or hard of hearing and tactile interpreting services for individuals who are deaf-blind;

(K) reader services, rehabilitation teaching services, and orientation and mobility services for individuals who are blind;

(L) job search and placement assistance and job retention services;

(M) supported employment services in accordance with the definition of that term in section 17b-653-2(b)(43);

(N) on-the-job or other related personal assistance services, in accordance with the definition of that term in section 17b-653-2(b)(33), provided while an individual is receiving other vocational rehabilitation services;

(O) post-employment services in accordance with the definition of that term in section 17b-653-2(b)(34);

(P) occupational licenses, tools, equipment, initial stocks, and supplies;

(Q) rehabilitation technology in accordance with section 17b-653-13 and the definition of that term in section 17b-653-2(b)(36), including vehicular modification, telecommunications, sensory and other technological aids and devices;

(R) transition services for students with disabilities that facilitate the achievement of the employment outcome identified in the employment plan;

(S) self-employment services, in accordance with section 17b-653-20;

(T) homemaker services, in accordance with section 17b-653-21;

(U) other goods and services determined necessary for the individual with a disability to achieve an employment outcome; and

(45) "Vocational training" means instruction designed to prepare a client to perform a particular skill or occupation.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-3 Administration

(a) Designated State Unit. The designated state unit to administer this plan shall be the Bureau of Rehabilitation Services of the state Department of Social Services.

(b) Staffing. The designated State unit shall have a full-time director and a staff, all or almost all of whom are employed full time on the rehabilitation work of the designated state unit.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-4 Standards and prohibited practices

The following practices and standards shall apply to every phase of the administration of the vocational rehabilitation program including the determination and certification of eligibility or ineligibility for vocational rehabilitation services:

(a) Creed, Race, Age, Color, Ancestry, National Origin, Gender or Physical or Mental Disability

The bureau shall not discriminate against an applicant or client on the grounds of creed, race, age, color, ancestry, national origin, gender or physical or mental disability.

(b) Native Americans

The bureau shall apply the same eligibility requirements to Native Americans as is applied to the rest of the client population.

(c) Standards of Reasonableness

Sections 17b-653-1 to 17b-653-24, inclusive, of the Regulations of Connecticut State Agencies will be governed by a standard of reasonableness and all interpretations shall be based on what is reasonably necessary and cost efficient when considering both the applicant or client and the entire client population. In such cases where an applicant or client chooses goods or services which are beyond those necessary to render the individual employable or which are at a higher cost to the bureau than necessary in providing a commensurate service, the bureau shall not be responsible for the additional cost.

(d) Payment for Experimental Procedures

The bureau shall not be responsible for the provision of procedures which are determined by the bureau to be experimental. In cases where the bureau has made such a determination, the applicant or client shall have the burden of proving by clear and convincing evidence that the procedure is not experimental.

(e) Preference for In-State Services

Preference shall be given to services provided within the state of Connecticut. Exceptions may be made when either:

(1) there are no commensurate services offered within the state of Connecticut, or

(2) out-of-state services can be provided at a lower total cost to the bureau. In such cases where a commensurate service is available to the client within the state of Connecticut at a lower cost than an out-of-state option, a client may choose to pay the additional cost of the out-of-state option.

(f) Authorization for Services

A written authorization shall be made before the provision of goods or services. Verbal authorization may be made before or at the time of the provision of goods or services with the approval of the director or his/her designee. The bureau shall not be responsible for retroactive authorization of goods or services unless it is determined by clear evidence that preauthorization of services was not made due to bureau error.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-5 Order of selection

(a) The intent of this section is to establish a contingency plan to be utilized in the event that services cannot be provided to all eligible persons who apply.

(b) An order of selection shall be invoked in the event that the funding needed by eligible persons exceeds the funding available to the bureau.

(c) The following shall be followed:

(1) A priority selection forecast shall be completed at the discretion of the director based on the cost of current services provided, the budgeted appropriations, grants for the current year, and the projected client population and cost of services. The priority selection forecast shall, if applicable, state a date prospectively in which the priority selection shall be invoked. The forecast may be revoked at the discretion of the director when money from all sources shall meet the cost of current and projected services.

(2) Clients who are determined eligible for services shall be assigned a priority level, in descending order of priority, as follows:

(A) all individuals with the most significant disabilities;

(B) all individuals with significant disabilities;

(C) all individuals with non-significant disabilities;

(3) All individuals shall be placed in the highest priority level for which they are eligible.

(4) Every individual within a particular priority level shall be served before individuals in the next highest priority level are served.

(5) In the event that all individuals within the same priority level cannot be served, individuals in that priority category shall be served chronologically based on the date of eligibility determination.

(6) At least 30 days prior to invoking priority selection, all individuals shall be notified in writing of their priority level and their right to appeal.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-6 Confidentiality

(a) All client and applicant information shall be kept confidential to the extent allowed by law. All clients or their representatives shall be informed that applicant and client information shall be kept confidential to the extent allowed by law.

(b) When information held by the bureau is requested and is not exempted by law from the requirement for written consent in order to be released, the authorization to so release shall be obtained from the client or applicant, or their legal guardian, prior to release of the information.

(c) Medical, psychological or other information which the bureau believes may be harmful to the client or applicant shall not be released directly to the client or applicant but shall be provided through his or her designated representative.

(d) Notwithstanding any provision of the regulations of Connecticut state agencies, including the Department of Social Services' uniform policy manual, information regarding a change of circumstances reported by a client to the bureau shall not constitute the reporting of such a change to the department for recipients of any department assistance or services, except those administered directly by the bureau.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-7 Applicants for services

(a) An individual is considered to have applied for services at such time as she or he:

(1) has completed and signed an agency application form or has otherwise requested services;

(2) has provided information necessary to initiate an assessment to determine eligibility and priority for services; and

(3) is available to complete the assessment process.

(b) if application is completed by or on behalf of an individual who has not attained the age of eighteen (18), the individual's parent or guardian shall also sign the application form.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-8 Eligibility/ineligibility

Upon application to the bureau, an applicant shall be evaluated by the bureau and, pursuant to the criteria and procedures established by sections 17b-653-1 to 17b-653-24, inclusive, of the Regulations of Connecticut State Agencies, shall be certified as either eligible or ineligible for vocational rehabilitation services.

(a) Assessment for Determining Eligibility and Priority for Services

(1) For the purpose of determining whether an applicant is eligible for vocational rehabilitation services and assigning the individual's priority under an order of selection, the bureau shall provide an assessment for eligibility and priority for services which shall include a review of existing data and a preliminary review of any additional data needed to make such determinations.

(2) The determination of the applicant's eligibility shall be based only on the following criteria:

(A) a determination that the applicant is an individual with a disability, as defined in section 17b-653-2(b)(22); and

(B) a determination that the applicant requires vocational rehabilitation services to prepare for, secure, retain or regain employment.

(3) It shall be presumed that an individual can benefit in terms of an employment outcome with respect to section 17b-653-2(b)(22)(B), unless the bureau determines that there is clear and convincing evidence that the individual is incapable of benefiting from vocational rehabilitation services in terms of an employment outcome due to the severity of the individual's disability. In making such a determination, the bureau shall explore the individual's abilities, capabilities and capacities to perform in work situations through the use of trial work experiences, except under limited circumstances when an individual cannot take advantage of such experiences.

(4) If the individual has a disability under Title II or Title XVI of the Social Security Act, the bureau will presume that,

(A) the applicant is eligible for vocational rehabilitation services (provided that the individual intends to achieve an employment outcome consistent with the unique strengths, resources, priorities, concerns, abilities, capabilities, interests and informed choice of the individual), unless the bureau determines by clear and convincing evidence that the applicant is incapable of benefiting in terms of an employment outcome from vocational rehabilitation services due to the severity of the disability, and

(B) the individual has a significant disability, in accordance with the definition of that term in section 17b-653-2(b)(24).

(5) The bureau shall make the determination whether the individual is eligible within a reasonable period of time, not to exceed 60 days after the individual has submitted an application, unless:

(A) exceptional and unforeseen circumstances beyond the control of the bureau preclude making an eligibility determination within 60 days and the bureau and individual agree to a specific extension of time, or

(B) the bureau is exploring an individual's abilities, capabilities and capacity to perform in work situations under subsection (a)(3) of this section.

(b) Eligibility Determination

(1) At the completion of the assessment for determining eligibility and priority for services, a determination will be made as to whether the applicant has satisfied the criteria for eligibility.

(2) No service other than diagnostic services and services to determine eligibility and priority for services may be provided by the bureau prior to completion of the certificate of eligibility.

(3) Certificate of Eligibility. In the event that all eligibility criteria are satisfied, the applicant will be accepted for vocational rehabilitation service and, simultaneously with this, a dated certificate stating the applicant has met the eligibility requirements shall be completed and signed by the appropriate representative of the bureau.

(c) Certification of Ineligibility

(1) When a determination is made that an applicant for vocational rehabilitation services is ineligible for services, a dated certificate shall be completed and signed by the appropriate representative of the bureau stating:

(A) that the applicant is ineligible for service; and

(B) the reasons for the determination of ineligibility.

(2) The bureau may make such an ineligibility determination only after providing an opportunity for full consultation with the individual or, as appropriate, with the individual's representative.

(3) The bureau shall notify the applicant in writing, supplemented as necessary by other appropriate means of communication consistent with the informed choice of the individual, of the determination. Such notice shall include the reason for that determination, his or her rights and means by which he or she may express and seek remedy for any dissatisfaction, including procedures for informal review and administrative hearing, the services offered by the Client Assistance Program (CAP) and how to contact that program.

(4) When appropriate the applicant shall be referred to other agencies or facilities.

(d) Review of Ineligibility

When an applicant for vocational rehabilitation services has been determined to be ineligible because of a finding that he or she is incapable of achieving an employment outcome, the determination will be reviewed by the bureau within twelve (12) months and annually thereafter if requested by the individual except that such review need not be conducted:

(1) when the applicant is no longer present in the state;

(2) when the applicant has refused it;

(3) when the applicant's whereabouts are unknown; or

(4) when the applicant's medical condition is rapidly progressive or terminal.

(e) Assessment for Determining Rehabilitation Needs

(1) The bureau shall provide an assessment for determining vocational rehabilitation needs for clients who are certified as eligible for vocational rehabilitation services and for whom the bureau is able to provide services under an order of selection, if applicable;

(2) The purpose of an assessment for determining vocational rehabilitation needs is to determine,

(A) the employment outcome and the objectives, nature and scope of vocational rehabilitation services to be included in the employment plan, designed to achieve the employment outcome; and

(B) the individual's unique strengths, resources, priorities, concerns, abilities, capabilities, career interests, and informed choice.

(3) To the extent possible, the assessment for determining vocational rehabilitation needs shall consist of existing data and data used for the assessment for determining eligibility and priority for services.

(4) The assessment for determining vocational rehabilitation needs may include to the degree needed, an appraisal of the client's personality, interests, interpersonal skills, intelligence and related functional abilities, educational achievements, work experience, vocational aptitudes, personal and social adjustment, emotional adjustment, employment opportunities and other pertinent data helpful in determining for each client, as appropriate, his or her capabilities to perform adequately in the work environment through an appraisal of the client's pattern of work behavior, abilities to acquire occupational skills and capacity for suitable job performance including the utilization of work in real job situations.

(f) Closure without Eligibility Determination

The bureau may close a case without any determination of eligibility when the bureau determines that an applicant or client has declined to participate in, or is unavailable to complete an assessment for determining eligibility and priority for services, and the bureau has made a reasonable number of attempts to contact the applicant or, if appropriate, the applicant's representative to encourage the applicant's participation.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-9 Employment plan

The following standards and procedures shall apply in the development, amendment and use of the employment plan.

(a) Timing and Initiation of the Employment Plan

The employment plan shall be initiated after certification of eligibility for individuals for whom the bureau is able to provide services under an order of selection, if applicable.

(b) Plan Development and Approval

(1) The employment plan may be developed by the client or in conjunction with the appropriate representative of the bureau and the client with a disability and, as appropriate, his or her parent, guardian or other representative.

(2) The plan shall be jointly reviewed by the client and counselor, or other appropriate bureau representative.

(3) The plan shall be approved by the client, counselor and, as deemed necessary by the bureau, other representative of the bureau. Reasons for which the bureau may deny approval of an employment plan, in whole or in part, may include but shall not be limited to a determination by the bureau that:

(A) The employment outcome chosen by the client is inconsistent with the individual's unique strengths, resources, priorities, concerns, abilities, capabilities, interests or informed choice;

(B) The nature, scope or duration of one or more of the services contained within the plan are not necessary to achieve the employment outcome or otherwise not appropriate to the vocational rehabilitation needs of the client; or

(C) The plan is otherwise inconsistent with federal or state statute, regulations or the state plan.

(c) Provision for Copy of Employment Plan to the ClientThe client or, as appropriate, his or her parent, guardian or other representative shall be provided with a copy of the employment plan and any amendments thereto and shall be advised by the bureau of the procedures and requirements affecting the development and review of the employment plan.

(d) The client shall cooperate in applying for or otherwise securing comparable benefits and services, benefits available as a legal right under state or federal law or other resources that may be necessary in order to achieve the employment outcome. Except as provided in subsection 17b-653-23(g) of sections 17b-653-1 to 17b-653-24, inclusive, of the Regulations of Connecticut State Agencies, the bureau may deny or terminate services in such cases where a client fails to cooperate in the securing of such benefits and services. Services may be included under an employment plan only after consideration of comparable benefits and services, in accordance with section 17b-653-11.

(e) Review

The employment plan shall be reviewed as often as necessary but at least every twelve months. Each client or, as appropriate, his or her parent, guardian or other representative shall be given an opportunity to review the plan and, if necessary, jointly redevelop and agree to its terms.

(f) Ineligibility Determination for Persons Receiving Services under an Employment Plan

(1) If services are to be terminated under an employment plan because of a determination that the client is no longer eligible for services, the bureau shall:

(A) complete a certificate of ineligibility and inform the client, in accordance with section 17b-653-8(c); and

(B) review the decision, in accordance with section 17b-653-8(d).

(2) A determination that the individual is no longer eligible due to a finding that the client cannot benefit from vocational rehabilitation services shall be based on the bureau determining that there is clear and convincing evidence that the individual is incapable of benefiting in terms of an employment outcome from such services.

(g) Content of the Employment PlanThe employment plan shall:

(1) include a statement of the specific employment outcome based on an assessment for determining vocational rehabilitation needs;

(2) include a statement of the specific vocational rehabilitation services that are needed to achieve the employment outcome, and the projected date for the initiation of services and the projected time lines for the achievement of the individual's employment outcome;

(3) include the entity that will provide services and the methods used to procure services;

(4) include a description of criteria to evaluate progress toward achievement of the employment outcome;

(5) include the terms and conditions of the employment plan, including, as appropriate, information describing:

(A) the responsibilities of the bureau;

(B) the responsibilities of the eligible individual, including:

(i) the responsibilities the eligible individual will assume in relation to the employment outcome of the individual;

(ii) if applicable, the participation of the eligible individual in paying for the costs of the plan; and

(iii) the responsibility of the eligible individual with regard to applying for and securing comparable benefits;

(C) the responsibilities of other entities;

(6) for individuals with the most significant disabilities for whom the employment outcome is supported employment, include the nature and source of extended services needed after completion of services provided by the bureau; and

(7) be reviewed annually.

(h) Except as provided in section 17b-653-23(g), an employment plan can be modified or discontinued in whole or in part under any of the following conditions:

(1) by mutual agreement by the parties;

(2) a determination by the bureau that:

(A) the client is no longer eligible;

(B) the client has failed to comply with the terms of the employment plan;

(C) the employment outcome is no longer deemed appropriate;

(D) the duration, nature or scope of services contained within the plan is no longer appropriate; or

(E) services have been obtained through misrepresentation, fraud, collusion or criminal conduct on the part of the client or the client's representative; or

(3) budgetary shortfall or other circumstances beyond the control of the bureau which necessitate a discontinuation or modification of the plan.

(i) Clients shall have the responsibility of being actively involved in treatment or other interventions which the bureau determines necessary in order for the individual to achieve an employment outcome. In such cases where the client fails to comply with such treatment or intervention, the bureau may decline to approve or, except as provided in subsection 17b-653-23(g), may discontinue services contained within an employment plan.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-10 Counseling and guidance services

(a) Counseling and guidance services will be provided by the bureau to each applicant or client throughout the vocational rehabilitation process, to the extent appropriate, for the purpose of:

(1) developing an appropriate employment plan towards the employment outcome;

(2) reviewing the applicant's or client's progress towards the vocational goal, amending the employment plan if necessary; and

(3) developing the applicant's or client's ability to seek and maintain employment.

(b) counseling and guidance services may also include, as appropriate, counseling to resolve a specific problem that is interfering with the applicant's or client's progress towards the vocational goal and referral to other agencies as appropriate.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-11 Comparable services and benefits

(a) Definitions. The terms used in this section shall, unless the context otherwise requires, have the following meanings.

(1) "Eligible", when used in relation to an applicant's or client's qualification for comparable services and benefits, means legal entitlement or the applicant's or client's ability to meet the criteria for obtaining services from other programs.

(2) "Program" means an organized, ongoing form of service or assistance, whether public or private, free or requiring a deductible, coinsurance feature, token payment, or personal claim.

(b) Services Subject to Consideration of Comparable Services and Benefits All vocational rehabilitation services, except as noted in subsections (c) and (d) of this section, shall be subject to consideration of comparable services and benefits.

(c) Services excepted from consideration of comparable benefits and services include:

(1) an assessment for determining eligibility and vocational rehabilitation needs by qualified personnel;

(2) counseling, guidance and referral services.

(d) The bureau may elect to utilize comparable services and benefits for the following services, when the bureau determines that these resources are known to be readily available at the time the service is needed to accomplish the employment outcome:

(1) placement in suitable employment; and

(2) rehabilitation technology services.

(e) Criteria for the Use of Comparable Services and Benefits

The bureau shall determine whether comparable services and benefits are available under any other program, unless such a determination would interrupt or delay:

(1) the progress of the individual toward achieving the employment outcome identified in the employment plan;

(2) an immediate job placement; or

(3) the provision of such service without which would place the individual at extreme medical risk.

(f) Application to Provision of Physical and Mental Restoration Services and Maintenance Services.

Full consideration shall be given to any comparable service or benefit available under any other program to an applicant or client to meet, in whole or in part, the cost of physical and mental restoration services and maintenance services provided to such an applicant or client.

(g) Application to the Provision of Training Services

The bureau shall require that applicants or clients make maximum effort to secure grant assistance, in whole or in part, to pay for training and training services in institutions of higher education. Applicants or clients approved to attend institutions of higher education shall be required to apply for federal and/or state grants where available.

(h) If comparable services or benefits exist under any other program, but are not available to the individual at the time needed to achieve the employment outcome in the individual's employment plan, the bureau shall provide vocational rehabilitation services until those comparable services and benefits become available.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-12 Physical and mental restoration services

(a) The treatment of disability is not the primary focus of the bureau of rehabilitation services program. Physical and mental restoration services are provided only insofar as the bureau determines they will benefit the client in removing or adjusting to barriers to an employment outcome. Disabling conditions that do not or are not expected to adversely affect the attainment of the employment outcome are not to be remediated through the provision of physical or mental services by the bureau.

(b) Restoration services provided by the bureau shall, within a reasonable period of time, be expected to correct or modify substantially an impairment which constitutes a substantial impediment to employment. In estimating "a reasonable period of time", the following factors shall be considered: (1) the nature of the disability; (2) prognosis with respect to life expectancy; (3) employment potential, and; (4) other contributing factors such as age, work and premorbid personality. In general, restoration services provided by the bureau should not exceed six months in duration.

(c) Periodic evaluations of progress shall be made, at least every 90 days, and further decision made at those times.

(d) The bureau may seek consultation from a bureau medical consultant or other appropriate expert, particularly when any unusual, non-traditional, long-term or very costly procedure is being discussed, recommended or seriously considered for a client.

(e) Physical and mental restoration services may include, but are not limited to, the following:

(1) corrective surgery or therapeutic treatment of a mental or physical impairment;

(2) diagnosis for mental or emotional disorders by a physician skilled in the diagnosis of such disorders or by a licensed psychologist;

(3) treatment of mental or emotional disorders by a physician skilled in the treatment of such disorders, a psychologist, or social worker who is licensed in the state of Connecticut;

(4) dentistry;

(5) nursing services;

(6) necessary hospitalization (either inpatient or outpatient care) in connection with surgery or treatment and clinic services;

(7) drugs and supplies;

(8) prosthetic, orthotic or other assistive devices essential to obtaining or retaining employment;

(9) eyeglasses and visual services, including visual training and the examination and services necessary for the prescription and provision of eyeglasses, contact lenses, microscopic lenses, telescopic lenses and other special visual aids as prescribed by a physician skilled in diseases of the eye or by an optometrist, as appropriate;

(10) podiatry;

(11) physical therapy;

(12) occupational therapy;

(13) speech or hearing therapy;

(14) mental health services;

(15) treatment of either acute or chronic medical complications and emergencies which are associated with or arise out of the provision of physical and mental restoration services, or are inherent in the condition under treatment;

(16) special services for the treatment of individuals with end-stage renal disease, including transplantation, dialysis, artificial kidneys, and supplies;

(17) other medical or medically related rehabilitation services.

(f) Physical or mental restoration services may be provided to the extent that financial support is not available from a source (such as health insurance of the individual or through comparable services and benefits) other than the bureau.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-13 Rehabilitation technology services

(a) Rehabilitation technology services are provided only insofar as they will benefit the client in removing, adjusting, or adapting to functional limitations that are barriers to required assessments in accordance with subsections (a), (b) or (e) of section 17b-653-8 or the achievement of an employment outcome, in accordance with section 17b-653-9(g). Functional limitations that are not expected to adversely affect the attainment of the vocational objective are not to be addressed through the provision of rehabilitation technology services by the Bureau of Rehabilitation Services.

(b) Scope of Services - Rehabilitation technology services may include one or more of the following:

(1) rehabilitation engineering services

(2) assistive technology services

(3) assistive technology devices

(c) Modification/Adaptation of a Motor Vehicle - Subject to the conditions listed herein, motor vehicle modification may be authorized when vehicle modifications are necessary in order for the client to enter, maintain or regain competitive employment.

(1) Vehicle modifications should be considered only after every other transportation option has been explored and only after it has been determined that vehicle modification is the most cost efficient approach for the client and the bureau.

(2) Vehicle modifications are only provided to those clients who have been determined eligible for vocational rehabilitation services and are entering, maintaining or regaining competitive employment.

(3) The bureau shall not participate financially to equip a vehicle with anything that was available to the client as a factory/dealer option at the time the vehicle was ordered and was recommended to the client by the bureau.

(4) The bureau may arrange for a thorough mechanical inspection of any vehicle before determining whether or not it is feasible for the vehicle to be modified, remodified or adapted.

(5) The financial participation and expenditure of the bureau shall be as follows:

(A) first time up to 100%

(B) remodification of same vehicle or another vehicle may be provided under the following conditions, provided the client has maintained appropriate insurance on the original adaptive equipment:

(i) within three (3) years and 54,000 miles following the most recent modification funded by the bureau, the client shall be expected to bear the complete cost. The bureau shall bear none of the cost.

(ii) more than three (3) years and at least 54,000 miles following the most recent modification- the bureau may provide up to 50% of the transfer or remodification. The client shall bear the cost of the balance.

(iii) more than five (5) years and at least 90,000 miles following the most recent modification funded by the bureau, the bureau may provide up to the entire cost.

(6) The bureau's participation in modifying or adapting a vehicle will be limited to the least expensive type of vehicle modification that will accomplish the goal of enabling the client to enter, maintain or regain employment, based on evaluations performed by the bureau's central office consultant and the Department of Motor Vehicle's handicapped drivers consultant or other entity deemed qualified by the bureau.

(7) The client shall cooperate in undergoing evaluation and testing as necessary to determine the client's ability to drive and needs for special equipment and vehicle modification. The bureau may deny the provision of vehicle modification services where a client fails to cooperate in such evaluations.

(8) Vehicle modification shall be provided only in conjunction with and to support the attainment of a specific vocational goal.

(9) Basic vehicle repairs and routine maintenance including special adaptive equipment shall be the sole responsibility of the client.

(10) Insurance on the vehicle, including any insurance on the vehicular adaptive equipment, shall be the sole responsibility of the client.

(11) If the client or the client's family have entered into negotiations or contracts for services with particular vendors, it shall not be binding upon the bureau to provide services through said vendor(s). Any work that has been initiated or equipment that has been installed or ordered prior to approval under an employment plan will not be retroactively authorized by the bureau.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-14 Vocational and other training services

The bureau may provide vocational and other training services, when necessary to achieve an employment outcome, as part of an employment plan approved by the bureau.

(a) Scope of Services - Vocational and other training services may include one or more of the following types of training:

(1) personal and vocational adjustment training;

(2) training in the use of artificial limbs, hearing aids or other appliances;

(3) remedial training;

(4) literacy training;

(5) vocational training;

(6) academic training;

(7) speech and hearing training which is not medically directed;

(8) lip reading;

(9) mobility training;

(10) rehabilitation teaching;

(11) transitional employment;

(12) on-the-job training;

(13) any other kind of organized training needed to meet the rehabilitation needs of the client being served.

(b) Provider of Training. Training may be provided at schools, colleges or universities, through community rehabilitation programs, by tutor or correspondence, apprenticeship or in an on-the-job training situation or by bureau staff or some other organized training program.

(c) Length of Training. The length of time required by a client to complete training is to be determined by the time necessary in each case to acquire sufficient knowledge and skill to meet the demands of the employment outcome. Training time should be designed, however, to ensure the minimum time required to accomplish a reasonable individual training program.

(d) Training material and supplies include necessary books and such training supplies as are necessary in order for the individual to participate in training services.

(e) Training is provided to prepare the client to achieve to an employment outcome.

(f) Trainees and students are expected to maintain grade averages or such reasonable progress as to enable them to complete the course successfully and attain the employment outcome.

(g) Vocational training will be provided only in accordance with an appropriately completed employment plan. The employment plan shall be designed to ensure the lowest cost to the bureau in providing a reasonable training service.

(h) Progress in training shall be evaluated on no less than a semester or term basis for educational institutions that operate on that basis and no less than a monthly basis for all other training programs and continued authorization of training shall be based on achievement of significant progress by the applicant or client in relation to the planned employment outcome.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-15 Training in institution of higher education or vocational training facilities

(a) Financial participation by the bureau in providing training in institutions of higher education or vocational training facilities shall be made to assure that the cost to the bureau will not exceed the cost of a program at a public Connecticut state supported college, university, community technical college or similar program which the bureau determines to be commensurate, unless an alternative program is necessary because of the individual's disability.

(b) Financial participation by the bureau in providing training in institutions of higher education or vocational training facilities shall be made only in accordance with an appropriately completed employment plan and shall be limited to support of training that is needed to achieve the employment outcome.

(c) No training in institutions of higher education shall be paid for by the bureau unless maximum efforts have been made to secure comparable benefits or other assistance in whole or in part from other sources to pay for such training. These benefits shall include family contribution, basic grant entitlement under student financial aid programs, private or institution-based scholarships, tuition waiver, work-study and earnings. The amount of bureau support, together with institutional aid, shall not exceed the cost of the education. A client will be encouraged but not required to apply for student loans.

(1) In pursuing a determination of available comparable benefits and assistance from other sources, the applicant or client shall make application to the training institution's financial aid office (FAO) and shall cooperate in the provision of all information required by the financial aid office in its calculation of the applicant's or client's eligibility for financial assistance.

The bureau shall presume the correctness of the computation made by the FAO at the post-secondary training institution which the client is attending regarding the amount of parental and family contribution which can be expected to be applied toward the cost of the client's post-secondary training. However, where evidence is presented that the computation made by the FAO is clearly erroneous, and when time or other circumstances make it impossible or impractical for the client to have the computation by the FAO corrected, the bureau will not allow these factors to adversely affect the amount of assistance to the client.

The bureau will assume primary responsibility for disability-related expenses, such as personal care, personal assistants, or specialized tutoring, as appropriate to the successful completion of program, provided such services are not covered under Title II or III of the Americans with Disabilities Act of 1990. In no case shall the bureau assume the role or responsibility as employer of the personal assistant, tutor or other individual assisting the client.

(2) The applicant or client shall give written authorization to the bureau and the financial aid office to exchange information relevant to the determination of eligibility for financial assistance.

(3) Application by the applicant or client to the financial aid office will be made in sufficient time to permit a decision to be rendered by the financial aid office prior to the starting date of training (and in no case less than sixty (60) days prior to the starting date of training).

(4) The bureau may deny support of training services in cases where a client fails to apply for financial aid in a timely manner or otherwise cooperate with the financial aid office or bureau in order to make a determination of the client's financial needs.

(d) The bureau shall not be required to provide post-secondary education services beyond the baccalaureate level unless,

(1) the client requires graduate training to enter employment within the profession which is identified and agreed upon in the employment plan and is consistent with the client's strengths, resources, priorities, concerns, abilities, capabilities, interests and informed choice; and

(2) the severity of the client's disability limits his/her ability to function in an appropriate initial career position while simultaneously completing additional training at the graduate level required to advance in the profession.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-16 Maintenance services

(a) Maintenance may be provided under the following conditions:

(1) Maintenance payments shall be limited to the increased cost directly attributable to the applicant's or client's participation in the vocational rehabilitation program.

(2) Maintenance after employment has started may be continued or paid to an eligible client up to the date of receipt of his or her first pay or, in the case of self-employment, up to thirty (30) days.

(b) Payments for maintenance services are limited to expenses that are needed in order to participate in other vocational rehabilitation services to the applicant or client and shall not be made if said other rehabilitation services have been discontinued or never started.

(c) Amount of maintenance required by the applicant or client shall be determined by the bureau in consultation with the client and shall be based on:

(1) the published rates for room and board for applicants or clients living away from home when such service is made available by the provider;

(2) the average cost to the applicant or client to be calculated on the experience of actual cost gathered over a two-week base period by the client and the bureau; or

(3) the individual circumstances of the applicant or client to meet his/her unique needs.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-17 Alterations to client housing or small business property

Subject to the conditions listed below, architectural alteration services may be provided to enable a client to accomplish safe egress from and ingress to the home or the workplace, or to enable a client to function vocationally within the home or workplace.

(a) The bureau's participation in alterations shall be limited to those determined by the bureau to meet the functional needs of the client at the least cost. Ramps, grab bars, lifts, or bathroom modifications are examples of such services.

(b) Alterations to work sites or business properties shall only be considered when they are not covered under the Americans with Disabilities Act of 1990, 29 U.S.C. § 12101 et seq.

(c) Exempted Services

(1) Except as provided in subsection (c)(2) of this section, the bureau shall not be responsible for financial participation in extensive or elaborate reconstruction, structural modifications, the addition of a room or rooms, or any other alteration that adds appreciable value to the property.

(2) The director or his/her designee may approve bureau participation in a structural addition or reconstruction in such cases where the bureau determines that, with respect to removing the architectural barriers which need to be eliminated in order for the individual to achieve an employment outcome:

(A) there is no other alternative; or

(B) such addition or reconstruction is the least costly alternative for the bureau.

(3) In any case where the bureau makes an exception under subsection (c)(2) of this section, the bureau's participation shall be limited to the minimum cost necessary to eliminate such architectural barriers.

(d) Architectural alterations will only be provided to the extent necessary for the successful completion of the client's employment plan. The case record will contain the following:

(1) Limitation of activities and functioning, due to the client's disability, shall be explained specifically and in detail and should be supported by reports from appropriate sources recognized by the bureau;

(2) The client's vocational impediment or barrier to employment that will be eliminated or reduced by the provision of the architectural modification service shall be thoroughly explained and supported; and

(3) The architectural barriers of the present site shall be clearly and carefully delineated in the case record together with an explanation as to how they impede the successful attainment of the client's employment outcome. It shall be explained how these barriers will be eliminated or reduced through the planned alteration services.

(e) The bureau will not be required to participate in alterations that are anticipated to meet the client's needs for a period of less than two years after the completion of the alterations, due to factors either related to the living situation or the client's disability. Alterations to a site may be made only after the client has provided written agreement that the client's planned occupancy is a minimum of two years beyond completion of alteration services.

(f) The client shall provide a signed agreement by the owner of the site to be modified, giving consent and authorization for the bureau to provide or participate in the provision of the necessary modifications to the property occupied by the client. Without such written consent, the bureau cannot provide or participate in the provision of such services.

(g) If the client or his/her family is building a home where the client is to reside, necessary alterations will be the responsibility of the client or his/her family. The bureau will not participate in the financing of such construction.

(h) If the client or the client's family have entered negotiations with a vendor for alteration work to be done or for equipment or materials to be supplied, any resulting agreements shall not be binding upon the bureau.

(i) The bureau shall not assume and is not responsible for the full restoration of structures or grounds that are disturbed in the process of alterations. Such areas will be functionally restored to the minimum level allowable by applicable codes. The bureau shall not be responsible for the matching of finishes, trims, and accessories when special sizing, tooling, and construction methods and materials would be required to do so.

(j) The bureau's financial participation in alterations for a client will be limited to a one-time basis, with the exception of cases where there are changes in the client's disability, employment or other circumstances beyond the control of the client which warrant additional modifications in accordance with this section of the regulations.

(k) Once the alterations are completed, the client is thereafter responsible for upkeep, maintenance, insurance and repairs. The bureau shall not pay for such expenses nor be responsible for the cost of removing ramps and restoration of property back to its original state after the accessibility-related construction is no longer needed.

(l) As determined necessary by the bureau, when it anticipates that alteration services may be part of a client's employment plan and may require financial participation by the bureau, the bureau will secure consultation by a licensed architect or other qualified technical consultant approved by the bureau.

(m) The bureau requires that a local building permit be issued for each project, which shall be provided to the bureau upon demand. Any zoning variance or other requirements necessary to secure such permit are the sole responsibility of the property owner.

(n) If a bureau representative discovers a structural defect or building code violation on the property that has direct bearing on the proposed modifications, the bureau will not proceed until corrective action or repair has occurred. Any cost of repair will be the sole responsibility of the property owner. Documentation of sufficient corrective action shall be submitted to the bureau before proposed modifications can resume.

(o) The bureau may deny assistance with any architectural modifications that it determines to be unsafe, unstable, in violation of applicable building codes or where, due to the nature of the site to be modified, the costs will be unreasonable.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-18 Transportation and related expenses

The following standards and procedures shall apply in the provision of transportation services and related expenses to clients and applicants:

(a) Transportation service may be provided only:

(1) in connection with the provision of another vocational rehabilitation service and needed by the individual to achieve an employment outcome, or

(2) to enable the client or applicant to participate in the informal review or administrative hearing procedures.

(b) Transportation service may include:

(1) fares or travel costs associated with the use of public or private conveyances including parking fees and tolls;

(2) subsistence during travel;

(3) relocation and moving expenses necessary for achieving an employment outcome identified in the employment plan; or

(4) other expenses related to travel.

(c) Rates of payment shall be determined by the bureau in consultation with the client or applicant and shall be based, at the discretion of the director, upon the following as applicable:

(1) published rates for public transportation;

(2) maintenance costs related to travel, up to the amount allowed to management personnel of the bureau; or

(3) mileage costs, up to the rate established by the state for mileage reimbursement of management employees of the bureau using personally owned automobiles.

(d) Selection of mode of transportation shall be made on the basis of the circumstances and special needs of the client or applicant and at the least cost.

(e) Personal assistants. The use of a personal assistant or escort by a client or applicant in transit shall be limited to individuals with significant disabilities and payment for such service will be based on the state minimum wage. Payment to a family member acting as a personal assistant shall be limited to costs of travel and subsistence during travel established by sections 17b-653-1 to 17b-653-24, inclusive, of the Regulations of Connecticut State Agencies. In no case shall the bureau assume the role or responsibility as employer of the assistant.

(f) Transportation in support of placement service may be provided to a client who has been placed in employment until the client has received his or her first pay.

(g) Transportation service may be provided to a client who has been closed as rehabilitated to enable the client to benefit from a post-employment service as needed and if provided for in an employment plan.

(h) The bureau shall not provide financial assistance in the purchase of a vehicle.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-19 Purchase of tools and equipment

Subject to the conditions listed below, tools and equipment may be provided to enable a client achieve the employment outcome identified in the employment plan.

(a) Tools and equipment provided for a client shall become the property of the client.

(b) The client will be responsible for maintenance, repair and insurance of all tools and equipment so provided.

(c) Tools and equipment shall be provided only in conjunction with and to support the attainment of a specific employment outcome.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-20 Self-employment services

(a) The bureau may provide services to individuals for the development of self-employment or a small business enterprise under the following conditions:

(1) A business plan shall be developed by the client and approved by a Connecticut Small Business Development Center as an economically viable proposal. In lieu of the Small Business Development Center, an alternative small business resource that is acceptable to both the bureau and the client may be used. The bureau may provide self-employment services without such approval where the director or his/her designee determine that, in his/her opinion, there is clear and convincing evidence that the business is likely to be successful within a reasonable period of time. In such cases, the client shall bear the burden of proving the likelihood of the success of the business.

(2) Before providing any services under an employment plan to achieve an employment outcome of self-employment, the bureau shall approve both the employment outcome and the business plan. The bureau may disapprove a business plan where it determines that the employment outcome is not feasible, as a result of:

(A) the earning potential of the business; or

(B) inconsistency with the client's strengths, resources, priorities, concerns, abilities, capabilities, or informed choice.

(3) The limits of the bureau's contribution toward the establishment of a small business, excluding training costs and excluding any needed costs for vehicle or work site modifications necessitated by the individual's disability, shall be as follows:

(A) ten thousand dollars, in cases where the net income that the business is projected to generate after two or more years in operation following the anticipated completion of services is at or above the amount recognized by the Social Security Administration as substantial gainful activity;

(B) five thousand dollars, in cases where the net income the business is projected to generate after two or more years in operation following the anticipated completion of services is less than substantial gainful activity level, as determined by the Social Security Administration.

(4) Clients will be required to make a contribution toward the self-employment venture, in cash, materials, or in-kind labor, in an amount valued at no less than ten percent of the bureau's contribution as defined in subsection (a)(3) of this section. Except as provided in subsection (c) of this section, the bureau may deny the provision of self-employment services in cases where the client will not fulfill their responsibility under this subdivision.

(b) Self-employment services may include start-up services and goods such as business consultants, bookkeeping, advertising, initial stocks, insurance, permits, fees, equipment, supplies, rent, utilities, transportation, telephone, and postage.

(c) If a bureau representative determines that there are circumstances in an individual case that warrant an exception to the provisions in subsection (a)(4) or the cost limits established in subsections (a)(3)(A) or (a)(3)(B) of this section, a full explanation and justification shall be presented to the director or his/her designee for consideration. The director may grant an exception in such cases as he/she determines that:

(1) client hardship requires such exception; and

(2) without such exception, there are no viable alternatives that would allow the client to achieve the employment outcome.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-21 Homemaker services

(a) The bureau may provide services that will enable a client to achieve an employment outcome of homemaker within the client's home, only in such situations where the client:

(1) is required to care for his/her dependant children who are under the age of eighteen or who have a severely disabling condition; or

(2) is required to perform homemaker duties in order for another member of the household to enter full-time competitive employment.

(b) Services provided by the bureau to clients with an employment outcome of homemaker will be limited to those which eliminate the barriers to performing the functions which,

(1) are essential functions of the role of homemaker; and

(2) cannot reasonably be expected to be performed by other members of the client's household.

(c) In cases where the bureau makes a determination that the requirements under subsection (a) or (b) of this section are not met, the client shall have the burden of proving by a preponderance of the evidence that the requirements under (a) and (b) are met.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-22 Informal review

(a) An informal review is a procedure through which the bureau affords an opportunity to a client or applicant for vocational rehabilitation service or the individual's representative, as appropriate, to express and seek remedy if the individual is aggrieved by a decision made by the bureau. An informal review is not a "contested case" within the meaning of section 4-166(2) of the Connecticut General Statutes.

(b) The request for an informal review shall be in writing, or other mode of communication appropriate to the applicant or client's disability needs, and contain a clear and concise statement of the issue for which remedy is sought. Such request shall be addressed to the respective bureau district director and received by the bureau not more than 30 days after the date of notification by the bureau of the decision for which the client seeks redress.

(c) Reviewer: An informal review shall be conducted by a member or members of the bureau's staff to be designated by the director.

(d) Opportunity for an Informal Review.

(1) The bureau shall afford the opportunity to request an informal review to every client or applicant.

(2) Clients or applicants may be granted an informal review in any of the following situations:

(A) the denial of an applicant or, the denial of the right to apply or reapply for services provided by the bureau;

(B) any bureau action concerning the development, implementation, denial, suspension, reduction or termination of services under an employment plan; or

(C) unresolved disputes pertaining to the scope of services provided to the client or the applicant by the bureau.

(3) If the applicant or client is represented by legal counsel, lay advocate, relative or other spokesperson, any fees incurred by such representation are the responsibility of the client or applicant.

(e) Scheduling and Location of Informal Review: An informal review shall be:

(1) Scheduled within a timely manner upon receipt of the written request for review.

(2) Held during bureau working hours, or at a time mutually agreed upon by the parties and approved by the reviewer, and

(3) Conducted at a bureau office or at an accessible location mutually agreed upon by the parties and approved by the reviewer.

(f) Use of Client's or Applicant's Case Record. When requested in writing by the involved client or applicant or his or her designated representative, the bureau shall make available all information in the case record accessible to the client or applicant or release it to him or her or a designated representative in a timely manner. Medical, psychological or other information which the bureau determines may be harmful to the client or applicant shall not be released directly to the client or applicant but shall be provided through his or her designated representative.

(g) Default. Failure to appear at a scheduled review shall be deemed a waiver of a right to a review. Upon such failure, the reviewer at his or her option may issue an order disposing of the matter or may, if requested by the defaulted party within ten (10) days of default, reschedule the review for good cause shown.

(h) Adjustment of Matters Related to an Informal Review. The fact that a request for an informal review has been filed does not prohibit the parties from making an adjustment by agreement in the matters at issue prior to an informal review. If, as a result of an adjustment, the client or applicant is satisfied and wishes to withdraw all or part of his or her petition for informal review, the client or applicant or his or her authorized representative shall transmit to the reviewer his or her signed written withdrawal. However, neither the bureau representative(s) nor the reviewer may delay or cancel an informal review because of a possible adjustment that is under consideration unless the bureau and the applicant or client agree to a delay or cancellation.

(i) Rights of the Client or Applicant. The client or applicant shall have the opportunity to present relevant facts by oral or written statement on his or her behalf.

(j) Duties and Authority of the Reviewer.

(1) The reviewer shall have the duty to conduct a fair review to assure equitable treatment to all parties, to define the issues, to receive and consider all relevant evidence, to exclude irrelevant or redundant evidence and to reach a fair and impartial decision based upon the issues and evidence presented and in accordance with the law and good professional practices in vocational rehabilitation.

(2) The reviewer shall have the authority to schedule or reschedule the review, request a statement of the issues, define the issues and regulate the proceedings including the introduction of evidence and to render a decision.

(k) Basis of Decision. The reviewer's decision shall be based upon the applicable law and evidence presented at the review unless the evidence is in the nature of additional reports requested by the reviewer at the review.

(l) Decision.

(1) The reviewer shall accept a settlement of the issues as agreed to by the parties or may decide in favor of the client or applicant or in favor of the bureau. In lieu of a decision in favor of either party, the reviewer may recommend that the bureau and the applicant or client be involved in mediation, if agreed to by both parties. If the parties do not agree to mediation, the reviewer shall issue a decision in favor of one of the parties.

(2) The reviewer may accept a withdrawal of the claim or default any party who fails to appear.

(m) Form of Decision. The decision shall be a statement of the issues involved in the review, a finding of fact and a statement of the conclusions including the basis for the conclusions.

(n) Notice of Decision. The reviewer shall mail a copy of the decision to appropriate bureau staff, the client or applicant and, as applicable, the authorized representative.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-23 Administrative hearing and mediation

(a) Clients or applicants who have been aggrieved by a decision made by the bureau have a right to an administrative appeal. For purposes of this subsection, an applicant or client for whom the bureau has denied mediation, in accordance with subsection (e) of this section, shall not be considered as aggrieved by a decision made by the bureau. Clients or applicants who have been aggrieved by a decision made by the bureau have a right to an administrative hearing in any of the following situations:

(1) the denial of an applicant or the denial of the right to apply or reapply for services provided by the bureau;

(2) any bureau action concerning the development, implementation, denial, suspension, reduction or termination of services under an employment plan; or

(3) unresolved disputes pertaining to the scope of services provided to the client or the applicant by the bureau.

(b) Administrative hearings shall be conducted in accordance with the Administrative Procedures Act, Connecticut General Statutes sections 4-176e to 4-181. Unless otherwise specified in sections 17b-653-1 to 17b-653-24, inclusive, of the Regulations of Connecticut State Agencies, the applicant or client has the burden of proving by a preponderance of the evidence that the bureau's decision does not comply with state or federal law or is clearly erroneous.

(c) Applicants and clients shall be informed of the right to an administrative hearing and mediation, including the name and address to which the request for an administrative hearing is to be forwarded:

(1) at the time the individual applies for vocational rehabilitation services;

(2) at the time the employment plan for the individual is developed; and

(3) upon reduction, suspension, or cessation of vocational rehabilitation services for the individual.

(d) Request for an Administrative Hearing. The client or applicant may request an administrative hearing, including mediation, in accordance with the following criteria:

(1) The request for an administrative hearing, which may include a request for mediation, shall be in writing or other mode of communication appropriate to the applicant or client's disability needs.

(2) The request shall contain a clear and concise statement of the issue for which remedy is sought.

(3) The request shall be received by the bureau director within 30 days of the latter of, as applicable:

(i) the date of notification of the bureau decision for which the client seeks redress;

(ii) mailing of the informal review decision, in accordance with section 17b-653-22; or

(iii) completion of mediation, in accordance with subsection (e) of this section.

(e) Mediation

(1) Applicants or clients who request an administrative hearing in accordance with this section may request that mediation be held prior to an administrative hearing. The bureau shall consider all such requests, and shall grant the applicant or client's request, provided both the bureau and the applicant or client agree to mediation.

(2) The bureau may deny a request for mediation where it determines that mediation is not likely to resolve the issue for which remedy is sought. In such cases, the applicant or client may request to pursue an administrative hearing.

(3) The mediation shall be conducted by an individual deemed qualified by the bureau who is trained or otherwise skilled in conducting mediation and is knowledgeable of the vocational rehabilitation program.

(4) An agreement by the bureau and the applicant or client shall be set forth in writing.

(5) The mediation shall be considered completed at such time as the signing of an agreement by the parties or formal termination of the mediation, whichever is later. In the absence of a signed agreement or formal termination, mediation shall be considered completed on the date of the last mediation session concerning the issue for which remedy is sought.

(6) Discussions that occur during the mediation process shall be confidential and shall not be used as evidence in any subsequent hearing or civil proceeding.

(7) The bureau shall choose a mediator from a list of qualified individuals maintained by the bureau.

(8) The bureau may, at its discretion, offer mediation as an option to applicants or clients other than those who have requested an administrative hearing. With the exception of subsections (e)(5), (e)(6) and (e)(9) of this section, none of the requirements in this section shall apply in such cases where the bureau is not required to offer mediation.

(9) The bureau shall not be bound by terms in a mediation agreement where the issues for which the applicant or client requested mediation are subsequently appealed in an administrative hearing or civil proceeding.

(f) Disclosure of Agency Case Record. The client or applicant may request access and disclosure of the case record in accordance with applicable laws.

(g) Service Provision During Pending Administrative Hearing.

(1) Unless the applicant or client so requests, or, in an appropriate case, the individual's representative, so requests, pending a decision by a mediator, hearing officer, or reviewing official under this section, the bureau shall not institute a suspension, reduction, or termination of services being provided for the individual, including evaluation and assessment services and plan development, unless such services have been obtained through misrepresentation, fraud, collusion, or criminal conduct on the part of the individual or the individual's representative.

(2) For purposes of this subsection, "services being provided" means:

(A) as applies to evaluation and assessment services, services needed to complete the assessment for determining eligibility and priority for services which had begun as of the time of the director's receipt of the request for a review under this section;

(B) as applies to plan development, assessment for determining rehabilitation needs which had begun at the time of the request for a review is received by the director;

(C) as applies to services under an employment plan, the specific services identified in the plan which had begun prior to the request for a review is received by the director. It includes the scope, time frames and providers specified in the employment plan.

(h) Scheduling.

(1) An administrative hearing and mediation, if requested, shall be held within a timely manner of the receipt of the request by the director;

(2) Administrative hearings and mediation shall be conducted during bureau working hours or at a time mutually agreed upon by the parties and approved by the impartial hearing officer or mediator and at an accessible location mutually agreed upon by the parties and approved by the hearing officer or mediator.

(i) Evidence in Administrative Hearing. Evidence in administrative hearing cases shall be in compliance with Section 4-178 of the Connecticut General Statutes. The client or applicant shall be afforded the opportunity to present additional evidence, information, and witnesses to the impartial hearing officer.

(j) Representation. Any applicant or client who requests an administrative hearing or mediation shall have the right to representation by counsel or other appropriate advocate of their choice. The fee for said counsel or advocate is the sole responsibility of the applicant or client.

(k) Impartial Hearing Officer. The impartial hearing officer shall conduct the administrative hearing and prepare a decision.

The impartial hearing officer shall render a written decision based on the provisions of the approved state plan, the federal Rehabilitation Act, federal regulation, and the state statutes, regulations and policy governing this program. The decision shall contain a full written report of the findings and the grounds for the decision and shall be provided to the client or applicant or, if appropriate, the individual's parent, guardian, or other representative, and to the director not more than thirty (30) calendar days of the completion of the hearing.

(l) Review of Decision:

(1) The department may establish procedures for review of the impartial hearing officer's decision by the Commissioner of Social Services. If such a procedure is established, the following shall apply:

(A) Not later than 20 days after the decision by the impartial hearing officer is rendered, either party may request that the reviewing official review the decision.

(B) Factors which the reviewing official may consider in determining whether an impartial hearing officer's decision should be reviewed include, but are not limited to:

(i) whether the initial decision is arbitrary, capricious, an abuse of discretion or otherwise unreasonable;

(ii) whether the initial decision is supported by substantial evidence, consistent with facts and applicable federal and state policy and law;

(iii) in reaching the initial decision, whether the impartial hearing officer has given appropriate and adequate interpretation to such factors as federal statutes and law; the state plan as it applies to the specific issues in question; the state procedures manual as it applies to the specific issues in question; key portions of conflicting testimony; state agency options in the delivery of services; federal or bureau policy as it relates to the issues in question.

(m) Kinds of Decisions. In rendering the decision the impartial hearing officer may, and in making the final decision the reviewing official may, take one of several courses of action which include, but are not limited to, the following:

(1) find in favor of the client or applicant;

(2) uphold the action or inaction of the bureau;

(3) accept a written withdrawal of the appeal which is signed by the client or applicant, or her or his authorized representative;

(4) accept a settlement of the issues agreed to by the parties; or

(5) default any party who fails to appear. Upon such failure, the impartial hearing officer at his or her option may issue an order disposing of the matter or may, if requested by the defaulted party within ten (10) days of default, reschedule the hearing for good cause shown.

(n) Notice of Final Decision.

(1) The decision of the impartial hearing officer shall be a final decision, unless a review is completed pursuant to subsection (l) of this section, in which case the decision of the commissioner shall become the final decision.

(2) The director shall mail a copy of the final decision to appropriate bureau staff, the client or applicant and her or his authorized representative.

(o) Extensions of Time. Except for the time limitations established in subsection (l)(1)(A) of this section, the director may grant reasonable time extensions for good cause shown at the request of a party or at the request of both parties.

(p) Appeal. Section 4-183 of the Connecticut General Statutes shall apply to appeals of the final decision in an administrative hearing.

History

• Adopted effective June 6, 2000

Regs., Conn. State Agencies § 17b-653-24 Case closure

(a) Reasons for which the bureau may close an applicant or client's case shall include, but not be limited to, a determination by the bureau that:

(1) the applicant or client is not eligible for services;

(2) the applicant or client has been rehabilitated;

(3) the applicant or client is not available to receive services, due to his/her having moved or inability to otherwise be located or contacted, refusal of services, failure to cooperate in participation in services, institutionalization, or death;

(4) transportation is not available or feasible to obtain or maintain employment; or

(5) extended support services are not available to an individual who requires supported employment services.

(b) The following standards and procedures are the requirements when determining that a client has been rehabilitated and his or her case record is closed as rehabilitated:

(1) The employment outcome is consistent with the individual's strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice;

(2) The employment outcome is in the most integrated setting possible, consistent with the individual's informed choice;

(3) Rehabilitation services provided in accordance with an employment plan have contributed to the achievement of the employment outcome;

(4) It has been determined that the client has maintained the employment outcome for at least 90 days; and

(5) At the end of the 90-day period, the client and appropriate bureau staff consider the employment outcome to be satisfactory and agree that the individual is performing well on the job.

(c) Post Employment Services

After a client has been determined to be rehabilitated, post employment services may be provided to assist a client to maintain or regain employment.

History

• Adopted effective June 6, 2000

17b-666 Employment Opportunities

Regs., Conn. State Agencies § 17b-666-1 Description

Sections 17b-666-2 to 17b-666-6, inclusive, of the Regulations of Connecticut State Agencies shall apply to the state Department of Social Services in its implementation of the employment opportunities program, as described in Section 17b-666 of the Connecticut General Statutes.

History

• Adopted effective November 17, 2003

Regs., Conn. State Agencies § 17b-666-2 Definitions

The following definitions shall govern the interpretation and application of this section and sections 17b-666-3 to 17b-666-6, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Bureau" means the Bureau of Rehabilitation Services of the Department of Social Services;

(2) "Client" means an individual who has been determined eligible for services under the employment opportunities program;

(3) "Coaching and other related services" means services provided by a skilled job trainer that are based on an assessment, which provide for the coordination or provision of specific services that are necessary to maintain employment stability. These services are provided at the worksite, or under special circumstances, especially at the request of the client and agreed to by the bureau, may be provided offsite. The term consists of:

(A) job skill training;

(B) regular observation or supervision of the individual; and

(C) facilitation of natural supports.

(4) "Competitive employment" means work,

(A) in the competitive labor market that is performed on a full-time or part-time basis in an integrated setting; and

(B) for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals who are not disabled.

(5) "Department" means the Department of Social Services;

(6) "Director" means the director of the Bureau of Rehabilitation Services;

(7) "Integrated site" means a setting typically found in the community in which the client would interact with non-disabled individuals, other than non-disabled individuals who are providing services to the client, to the same extent that non-disabled individuals in comparable positions interact with other persons;

(8) "Individual with the most significant disabilities" means an individual who, due to a physical or mental impairment,

(A) has serious employment limitations in a total of three of more functional areas including, but not limited to, mobility, communication, self-care, interpersonal skills, work tolerance or work skills, or

(B) will require significant ongoing disability-related services on the job in order to maintain employment;

History

• Adopted effective November 17, 2003

Regs., Conn. State Agencies § 17b-666-3 Administration

The employment opportunities program shall be administered by the Bureau of Rehabilitation Services.

History

• Adopted effective November 17, 2003

Regs., Conn. State Agencies § 17b-666-4 Eligibility

(a) A determination of eligibility for the employment opportunities program shall be based on a determination by the bureau that the individual:

(1) is an individual with the most significant disabilities;

(2) requires ongoing coaching and other related services in order to maintain supported employment; and

(3) is ineligible for coaching and other related services from the Department of Mental Retardation, Department of Mental Health and Addiction Services or other entity providing the coaching and other related services available through the employment opportunities program. This means that:

(A) The individual has made application, as applicable, to the Department of Mental Retardation, Department of Mental Health and Addiction Services or other entity providing services covered by the employment opportunities program and has been determined by that department or entity to not meet the respective agency's eligibility criteria, including eligibility to be placed on the respective agency's waiting list; or

(B) The bureau has determined that it is unlikely that the individual would meet the eligibility criteria for coaching and other related services through the Department of Mental Retardation, Department of Mental Health and Addiction Services or other entity providing services covered by the employment opportunities program.

(b) Clients served by this program shall have the responsibility of being actively involved in treatment or other interventions which the bureau determines necessary in order for the individual to maintain employment and minimize the amount of services needed under this program. In such cases where the individual fails to comply with such treatment or intervention, the bureau may decline to approve or may discontinue services.

History

• Adopted effective November 17, 2003

Regs., Conn. State Agencies § 17b-666-5 Services provided

(a) Services provided under the employment opportunities program are limited to coaching and other related services that are necessary in order for the eligible individual to maintain employment:

(1) that is in an integrated site; and

(2) for which the average weekly compensation to the eligible individual is, at a minimum, the dollar equivalent of fifteen hours of work at the minimum wage for the State of Connecticut.

(b) Notwithstanding subdivisions (a)(1) and (a)(2) of this section, the bureau may continue providing coaching and other related services which were being provided to an individual as of the effective date of this section in an employment site which does not meet the requirements established in subdivisions (a)(1) and (a)(2) of this section. Clients for whom this subsection applies who become unemployed shall be eligible to reenter the employment opportunities program under the provisions of this subsection within one year of termination from that employment.

(c) The level of services provided by the employment opportunities program shall not exceed that which the client is expected to need once intensive support services have been completed.

(d) Services will be rendered to an individual by a provider approved by the bureau which meets the needs and is consistent, to the extent practicable, with the informed choice of the client. In such cases where the client or his or her representative chooses services which will be at a higher cost than the bureau determines is reasonably necessary in order for the individual to maintain employment, the bureau will not be responsible for the additional cost.

History

• Adopted effective November 17, 2003

Regs., Conn. State Agencies § 17b-666-6 Administrative review

Individuals aggrieved by a decision concerning their eligibility for, or services rendered to them by, the employment opportunities program may request an administrative review, which shall be conducted by the director of the Bureau of Rehabilitation Services or his or her designee. Such request shall be in writing and received by the director not later than 30 days after the date of notification by the bureau of the decision for which the individual seeks redress. The review shall be scheduled in a timely manner upon receipt of the request. The reviewer shall issue a written decision of his or her findings and mail a copy of the decision to the appropriate bureau staff and the individual. An administrative review is not a "contested case" within the meaning of section 4-166(2) of the Connecticut General Statutes.

History

• Adopted effective November 17, 2003

17b-749 Child Care Assistance Program

Regs., Conn. State Agencies § 17b-749-01 Definitions as used in section 17b-749-01 to 17b-749-23 of the Regulations of Connecticut State Agencies, inclusive

(1) "Actual charge" means the fee charged by the provider for all children attending the same program as determined in subsection (a) of section 17b-749-13 of the Regulations of Connecticut State Agencies;

(2) "Accredited provider" means a child care provider whose program has earned national accreditation or who has completed approved course or degree work pursuant to subsection (d) of section17b-749-13 of the Regulations of Connecticut State Agencies;

(3) "Applicant" means the person with whom the child resides who is the child's parent as defined in subsection (32) of this section who submits the request for assistance to the Child Care Assistance Program;

(4) "Application" means the form prescribed by the department used to apply for child care assistance;

(5) "Assistance unit" means the group of individuals who live together whose circumstances are taken into consideration when determining eligibility or benefits for the Temporary Family Assistance (TFA) program pursuant to section 8500 of the Uniform Policy Manual;

(6) "Attending high school" means enrollment in and regularly attending classes at a state day program accredited by the State Department of Education or the New England Association of Schools and Colleges, a general equivalency diploma program, or an adult education, technical high school or vocational secondary school program which shall lead to a high school level diploma or certificate;

(7) "Cash assistance" means financial assistance provided by the department to families with dependent children under the Temporary Family Assistance program (TFA), including families assigned to the control group or who receive Diversion Program assistance pursuant to section 8500 of the Uniform Policy Manual;

(8) "Certificate of payment" means the document issued by the CCAP administrator authorizing payment of CCAP assistance for a specific child to a specified child care provider;

(9) "Child care" means the care and supervision of an eligible child for not more than twelve hours in a twenty-four hour day, excluding therapy, medical treatment and public or private school or academic programs;

(10) "Child care assistance" means a subsidy for child care expenses authorized under the Child Care Assistance Program;

(11) "Child Care Assistance Program (CCAP)" means the program that provides child care assistance in accordance with sections 17b-749-01 to 17b-749-23 of the Regulations of Connecticut State Agencies, inclusive;

(12) "Child care agreement" means the form prescribed by the department used to collect and document information concerning provider eligibility and the agreement between the parent and the provider for the provision of child care services;

(13) "CCAP administrator" means the unit designated by the department or an organization acting under contract with the department and acting under its direction that is responsible for the day-to-day administration of the CCAP program;

(14) "Child with special needs" means a child under the age of nineteen who meets the requirements of subsection (b) of section 17b-749-11 of the Regulations of Connecticut State Agencies;

(15) "Commissioner" means the commissioner of the Department of Social Services or his designee;

(16) "Countable income" means gross income less allowable deductions and excluded income;

(17) "Department" means the Department of Social Services;

(18) "Earned income" means compensation for personal services, including but not limited to wages, salaries, commissions, bonuses and earnings from self-employment or contractual agreements;

(19) "Eligible child" means a child residing with the applicant who is under the age of thirteen or under the age of nineteen with special needs, who needs child care during the hours the parent is participating in employment or an approved employment services activity;

(20) "Eligible provider" means a licensed child care provider or child care provider who is exempt from licensing that meets the requirements specified in section 17b-749-12 of the Regulations of Connecticut State Agencies;

(21) "Employment services activity" means education, training, job search or other activity pursued by a parent receiving cash assistance which is designed to eliminate barriers to employment or increase earnings and which has been approved by the Department of Social Services, the state Department of Labor or the designee of either agency in accordance with the requirements of the TANF State Plan submitted by the Department pursuant to section 402 (a) of Public Law 104-193;

(22) "Family" means the group of individuals who live together in the same household whose circumstances are taken into consideration when determining eligibility for the CCAP program pursuant to section 17b-749-03 of the Regulations of Connecticut State Agencies;

(23) "Foster child" means a child placed in a foster home by the Connecticut Department of Children and Families for whom the parent receives foster care payments;

(24) "Good cause" means circumstances or events outside the control of the family, including but not limited to severe weather, illness or the death of an immediate family member, that reasonably prevent or delay the parent from complying with a CCAP program requirement or other good cause circumstances specified in sections 17b-749-02 to 17b-749-23 of the Regulations of Connecticut State Agencies, inclusive;

(25) "Household" means all of the individuals who live together at the same address, including individuals not included in the CCAP family unit for eligibility purposes;

(26) "Income" means the gross countable earned and unearned income;

(27) "In loco parentis" means a person with whom the child lives who is responsible for the day-to-day care and custody of the child when the child's parent by blood, marriage, adoption or court order is not performing such duties;

(28) "Issued" means the date a notice, payment or other correspondence is mailed, sent electronically or delivered in person by the department or the CCAP administrator;

(29) "Licensed provider" means a day care center, group or family day care home licensed by the Department of Public Health to provide child day care services pursuant to section 19a-77 of the Connecticut General Statutes;

(30) "Minor parent" means the child's natural parent by blood who is under the age of eighteen;

(31) "Missing Information" means verification, forms, documentation or other information used in determining eligibility for the program, a provider, payment eligibility or the amount of assistance that is absent;

(32) "Parent" means a person with whom the child resides who is either the child's parent by blood, marriage, adoption or a spouse or former spouse of such individuals, a legal guardian, a caretaker relative under the cash assistance program or other person standing in loco parentis;

(33) "Provider" means the person, facility or program chosen by the parent(s) to provide child care;

(34) "Relative" means a person of any of the degrees of kinship as specified in subdivision (b)(5) of section 19a-77 of the Connecticut General Statutes;

(35) "Residing with" means living with on a regular basis, including taking meals together and sleeping in the same home;

(36) "Self-employed" means working for pay either full or part-time where the individual is not considered an employee of another entity for purposes of reporting social security tax or unemployment compensation;

(37) "School-based child care program" means a child care program operated by a public or private school pursuant to the requirements of subdivision (b)(1) and (b)(2) of section 19a-77 of the Connecticut General Statutes;

(38) "State median income" means the state median income standards which are promulgated by the United States Department of Health and Human Services;

(39) "Teenage parent" means a parent under the age of twenty;

(40) "Temporary Family Assistance" means the program that provides assistance to needy families with children pursuant to section 17b-112 of the Connecticut General Statutes;

(41) "Unlicensed child care provider" means any provider operating legally in Connecticut that is exempt from licensing as a child day care services provider pursuant to subsection (b) of section 19a-77 of the Connecticut General Statutes;

(42) "Unearned income" means pensions, annuities, dividends, interest, rental income, lottery winnings, royalties, Social Security, supplemental security income, unemployment compensation, workers' compensation, alimony, child support, foster care payments, income from means tested programs, gifts and other cash income that is not compensation for employment or self-employment;

(43) "Verification" means documentation or other evidence sufficient to enable the department or CCAP administrator to determine the veracity of information pertinent to establishing eligibility for the program, a provider, payments or the amount of assistance;

(44) "Victim of domestic violence" means a person who has been battered or subjected to extreme cruelty by physical acts that resulted in or were threatened to result in physical injury; sexual abuse; sexual activity involving a child in the home; being forced to participate in nonconsensual sexual acts or activities; mental abuse; or neglect or deprivation of medical care; and

(45) "Working" means employment in one or more jobs as an employee of another individual, a partnership, corporation or self-employment, for which compensation is paid in the form of earned income.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-02 Rights and responsibilities

(a) Rights of Parents and Providers

(1) Parents shall have the right to apply for assistance or withdraw an application, to request discontinuance or reapply for CCAP at any time.

(2) Parents shall have the right to choose a child care provider who meets the requirements of section 17b-749-12 of the Regulations of Connecticut State Agencies.

(3) Parents and providers shall have the right to be treated fairly without regard to race, color, religion, sex or sexual orientation, marital status, national origin, ancestry, age, political beliefs, or disability.

(4) Parents and providers who speak Spanish shall have the right to request and receive forms and notices in Spanish. They shall have the right to have the CCAP Administrator provide an interpreter when contacting the CCAP program. Other non-English speaking individuals or persons with limited-English proficiency shall have the right to request an interpreter provided by the CCAP administrator.

(5) Individuals with vision or hearing impairments shall have the right to request auxiliary aids or other accommodations.

(6) Parents and providers who are not satisfied with actions taken by the case worker shall have the right to speak to a supervisor, a grievance mediator or other individual not directly involved with the parent's case.

(7) Parents shall have the right to an administrative hearing or an administrative disqualification hearing as set forth in sections 17b-749-21 and 17b-749-22 of the Regulations of Connecticut State Agencies.

(8) Parents shall have the right to appeal to the U.S. Department of Health and Human Services Office of Civil Rights if they feel that the Department or the CCAP administrator has violated their civil rights.

(9) Parents receiving TFA cash assistance shall be informed of the availability of exemptions from mandatory participation in employment services activities if appropriate child care is not available, affordable or cannot be accessed.

(10) Parents who state that they or their children have been victims of domestic violence or who state that they are at risk of further domestic violence shall be informed of the available community services that assist victims of domestic violence and how to voluntarily and confidentially access these services.

(b) Responsibilities of Parents and Providers

(1) Parents and providers shall be responsible for supplying all requested forms, information and verification needed to determine eligibility and calculate the amount of benefits within fifteen days of the date the information was initially requested or by the date specified by the department.

(2) Parents shall permit the department to verify information independently whenever necessary to determine eligibility or calculate the amount of benefits.

(3) Parents shall report changes in household circumstances and child care arrangements within ten days of the date of the change, including but not limited to the following circumstances:

(A) residency;

(B) address;

(C) household composition;

(D) citizenship or non-citizen status;

(E) countable income of a family member;

(F) employment status, including a change in employers, income, work schedule or work hours;

(G) any change in the child care arrangements, including changes in providers or the location where care is given, a change in the relationship of the provider to the child, cost, or the need for child care;

(H) employment service activities, including changes in schedule or the hours of participation; and

(I) high school attendance.

(4) Parents shall not be required to report changes in a child's age provided the child's date of birth has been accurately reported.

(5) Parents shall report changes in household circumstances or child care arrangements in writing, by phone or in person directly to the CCAP administrator within ten days of the date of the change. Changes that are not reported timely may result in ineligibility, the loss of benefits or in an overpayment pursuant to the requirements of sections 17b-749-02 through 17b-749-23, inclusive.

(6) To be eligible for CCAP, parents and providers shall cooperate in taking any actions necessary to establish eligibility or payment level. Parents and providers shall cooperate with the department's fraud investigation and quality control divisions by completing any required forms, responding to scheduled interview appointments and by making requested records or information available. Parents and providers who do not cooperate may be determined to be ineligible for CCAP until they cooperate.

(7) Providers shall submit invoices to the CCAP administrator that accurately report information about attendance and the cost of care.

(8) Providers shall report changes in the child care arrangements, including but not limited to changes in the hours of care, actual charges, changes in programs due to a change in the age group of the child, the location where care is given and any changes in licensing or accreditation status pursuant to subdivision (b)(5) of section 17b-749-12 of the Regulations of Connecticut State Agencies.

(c) Responsibilities of the CCAP Administrator

(1) The CCAP administrator shall assure that the rights of parents and providers are upheld in accordance with the requirements of this section.

(2) The CCAP administrator shall give parents the opportunity to file an application at any time.

(3) The CCAP administrator shall take timely action within the time frames established in sections 17b-749-1 through 17b-749-23 of the Regulations of Connecticut State Agencies, inclusive, to process applications, redeterminations and changes in household circumstances and child care arrangements and to determine the impact on eligibility or benefits.

(4) The CCAP administrator shall give parents and providers written notice of actions they are required to take to establish program or payment eligibility.

(5) The CCAP administrator shall provide parents and providers with written notice of any decisions that affect eligibility or benefits.

(6) The CCAP administrator shall provide parents or their legal representatives with reasonable access to case record information, including computer information that is part of the parents case record, subject to the limitations established in subsection (d) of this section. Parents shall submit a written statement granting their legal representative access to case record information. The information shall be made available within a reasonable period of time following submission of the written request at a location mutually agreed to by both parties, unless the information can only be accessed at a specific location. If an administrative hearing has been scheduled, the information shall be made available prior to the hearing.

(7) The CCAP administrator shall inform parents of their rights and of any benefits that may be available to them under the CCAP program.

(d) Safeguarding Information

(1) Information about the family shall not be disclosed by the department except when disclosure is authorized by law, including but not limited to the following reasons:

(A) when directly connected with the administration of CCAP or other programs administered by the department or the administration of other state or federally assisted programs that are needs based;

(B) for purposes related to performing quality assurance audits or fraud investigations; or

(C) when necessary to determine the suitability of child care arrangements.

(2) By making application, parents and families shall grant the CCAP administrator permission to share information with the child care provider to the extent necessary to determine eligibility, the level of benefits or to notify the provider of information concerning eligibility or payments. Personal family information not relevant to such determinations shall not be disclosed and not be shared with the provider. Providers for whom a current child care agreement form is on file with the CCAP administrator may contact the administrator to determine the status of an application.

(3) Information about the provider shall be shared with the parent if the information is considered public information, or as needed to determine payment eligibility or to inform the parent of the reason the provider does not meet the eligibility requirements. By enrolling in the CCAP program, providers shall grant the CCAP administrator permission to share information concerning compliance with the program health and safety standards with the parent, including the results of criminal and child abuse or neglect background checks.

(4) Application information shall be disclosed to a landlord, employer or other third party only to the extent necessary to obtain specified information or verification from such parties.

(5) Information may be disclosed to any authorized representative of the Commissioner of the Department of Administrative Services (DAS), the Commissioner of the Department of Public Safety (DPS), the Office of the Chief State's Attorney, local police departments, the Office of Attorney General, or the Judicial Department, Support Enforcement Division for the purpose of collection of overpayments, investigating fraud, collection of child support or the location of absent parents or for any other purpose for which disclosure of such information is permitted by law.

(6) Information shall be disclosed to any authorized representative of the Commissioner of Mental Health and Addiction Services when necessary for the implementation and operation of the basic needs supplement program or for the management of and payment for behavioral health services for applicants and recipients of general assistance.

(7) Information shall be released to any authorized representative of the Commissioner of the Department of Labor or to his official designee when required for the administration of the Unemployment Compensation or employment services programs or activities.

(8) Information shall be released to any authorized representative of the Commissioner of Children and Families concerning a child's health, safety or welfare if the same is determined to be in imminent danger as determined by the Department of Children and Families or the Department of Social Services. Notwithstanding a request for information, the department shall notify the commissioner of Children and Families or his official designee if there is reason to believe that any child under the age of eighteen is being subjected to physical or mental abuse or neglect while in the care of a parent or child care provider.

(9) The current address of an applicant or recipient of benefits shall be disclosed to federal, state, or local law enforcement officers under the following conditions:

(A) if such officer provides the department with a name of such applicant or recipient of benefits; and

(B) if the family member is fleeing to avoid prosecution, or custody or confinement after conviction; and

(C) the law enforcement officer provides the family member's name and indicates that the conditions listed above in (A) and (B) exist and verifies that the location or apprehension of the recipient is within his or her official duties.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-03 Individuals included in the family

(a) CCAP program and payment eligibility shall be determined based on the circumstances of the individuals who reside together in the same household. Parents who state that they are not living together, but maintain separate residences in the same building or adjacent apartments shall be considered to be residing together if they routinely sleep in the same home, take meals together and continue to function as a family unit. Evidence of separation of financial responsibilities and the pursuit or payment of child support from the non-custodial parent shall be considered when making this determination.

(b) A person who is temporarily absent from the household shall be considered to be a family member if the person intends to return to the home, does not establish a permanent residence elsewhere and the absence is not expected to continue for more than ninety consecutive days. A minor dependent shall be considered to be a family member if the parent retains custody or primary responsibility for the child during the absence. A minor dependent who is temporarily absent while attending school outside the home shall be considered to be a family member if the parent maintains living quarters for the child and the child is expected to return to the home following completion of the school activity. Other temporary absences of a household member shall not affect the determination of the composition of the family, as long as the person is absent for not more than ninety consecutive days.

(c) If the child's parents are separated and have joint custody of the child, the child shall be considered living with the parent with whom the child resides at least fifty percent of the time. If the child lives with each parent for an equal amount of time, the parents shall be required to reach an agreement concerning which parent shall apply for CCAP as a condition of eligibility. If the parents cannot reach an agreement, the child shall be considered to be living with the parent who applied for CCAP first. Only one parent shall be eligible to receive assistance for the child in any month unless the child goes to live with the other parent during the month on a permanent basis.

(d) The following individuals shall be included in the family, unless otherwise specified in this section:

(1) parents of the children for whom assistance is requested as defined in subsection (32) of section 17b-749-01 of the Regulations of Connecticut State Agencies;

(2) the parent's spouse and their minor dependents; and

(3) any individuals who receive cash assistance together as part of the same TFA assistance unit.

(e) If the household contains a minor parent, the legal guardian or parents of the minor parent through blood, marriage or adoption and their current or former spouses shall be included in the family together with their minor dependents.

(f) If a minor parent lives with someone acting in loco parentis who is not his or her legal guardian or parent through blood, marriage or adoption or the current or former spouse of such individuals, the family shall include the individual acting in loco parentis, his or her current or former spouse and their minor dependents under the following conditions:

(1) if the person acting in loco parentis receives TFA cash assistance as part of the same assistance unit as the minor parent; or

(2) if the person acting in loco parentis requests child care assistance to support his or her own work, school or employment services activity or that of his or her spouse.

(g) If a minor parent lives with someone acting in loco parentis who is not his or her legal guardian or parent through blood, marriage or adoption or the current or former spouse of such individuals, the family shall include only the minor parent, the minor parent's children and the other parent of the minor parent's children under the following conditions:

(1) if assistance is requested only for the children of the minor parent(s); and

(2) assistance is requested only to support the work, school, or employment services activity of the minor parent(s).

(h) A separate family unit shall be established for children receiving foster care payments from the Connecticut Department of Children and Families. The foster parent and other household members shall not be included in the same family unit with the foster child or children for purposes of determining income eligibility or benefits. The CCAP administrator shall establish a separate family unit if the foster parent requests assistance for another child in the household who is not a foster child.

(i) A child who is adopted from Connecticut Department of Children and Families shall continue to be treated as his or her own family unit for twelve months following the date of the adoption. After twelve months following the date of adoption, the adoptive parent and other household members shall be included in the family unit.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-04 Non-financial eligibility requirements

(a) Residency

(1) To be eligible for assistance, the family members shall be residing in Connecticut. The department shall not apply a durational requirement when making a determination of residency or require the family to live in a permanent dwelling or to have a fixed mailing address.

(2) Family members shall be considered residing in Connecticut under the following conditions:

(A) if they intend to remain in the state permanently or for the foreseeable future; or

(B) if they entered the state with a job commitment or for the purpose of seeking employment.

(4) Temporary absence from the state does not constitute a change in residency if the family member intends to return to Connecticut within thirty days and the individual maintains his or her residence in Connecticut. The commissioner may extend the thirty-day limit for up to ninety days if the family member is absent due to a temporary military duty assignment. A child who is temporarily absent from the home while attending school out of the state shall be considered a resident if the parent maintains living quarters for the child and the child intends to return home following completion of the school activities.

(5) Family members who apply for or receive cash assistance, Food Stamps, Medical Assistance or other public benefits from another state shall be not considered residents of Connecticut.

(b) Social Security Numbers

(1) Disclosure of the Social Security number of a family member shall be mandatory only for children whose CCAP subsidy is or will be claimed by the Department as an expense under the TANF program or other federal programs that require recipients to disclose a Social Security Number. This requirement shall not apply to children who are not citizens of the United States who are not eligible to obtain a Social Security number (SSN) from the Social Security Administration. Disclosure of the Social Security numbers of other family members shall be voluntary. If the SSN is not disclosed, the CCAP administrator may obtain and use the SSN of a family member for whom disclosure is voluntary to the extent the number is available from other programs or agencies with whom the Department shares such information.

(2) Assistance shall not be delayed pending verification of an SSN unless there is a discrepancy between a number given and other available information that causes the CCAP administrator to question the identity of the individual. The parent shall have thirty days from the date assistance is granted to verify that an application has been submitted to the Social Security Administration for a child who does not have an SSN for whom such number is mandatory.

(3) Parents shall disclose the SSN of any member who did not have a valid number by the first redetermination following the onset of initial eligibility.

(4) Child care providers shall disclose their SSN or a Connecticut Tax ID as a condition of eligibility for the provider.

(5) An individual who has more than one SSN shall disclose all of the numbers.

(6) Disclosure may be from a number which has been committed to memory, a written document, such as a wage stub, Social Security award or denial letter, income tax return, or Social Security card.

(7) If disclosure is mandatory, the individual child shall be ineligible if the parent fails to disclose or apply for an SSN for the child. Ineligibility shall continue until such time that the parent applies for or discloses the SSN.

(c) Securing Child Support

(1) If a child for whom assistance is requested is deprived of financial support from the child's natural or adoptive parent, the custodial parent or person acting in loco parentis shall agree to apply for services and cooperate with the Bureau of Child Support Enforcement (BCSE) in obtaining support from the non-custodial parent, unless support is actively being pursued through private legal means or an exemption from cooperation is granted pursuant to section 17b-179(a)-4 of the Regulations of Connecticut State Agencies.

(2) The custodial parent shall not be required to apply for support services for children for whom assistance is not being requested or children who are emancipated pursuant to sections 46b-150b and 46b-150e of the Connecticut General Statutes. The department shall waive the fee charged to non-assistance recipients pursuant to 17b-179(i)-1 of the Regulations of Connecticut State Agencies.

(3) Parents who apply for or receive cash or medical assistance from the department for a child for whom child care assistance is requested shall not be required to apply for support for the child as long as the parent complies with the requirements of the other program. The family, however, shall become ineligible for child care assistance until proof of cooperation is provided if a sanction is imposed for noncompliance with the support requirements of the other program.

(4) The application for support shall be made pursuant to section 17b-179 (h) of the Connecticut General Statutes. Parents shall verify that an application was filed not later than the first redetermination conducted after the initial date of eligibility for the child. The CCAP administrator shall provide written information about the procedure for applying for support to the parent.

(5) The parent shall cooperate with the department as provided in section 17b-179(a)-4 of the Regulations of Connecticut State Agencies. The parent shall supply accurate and complete information about the non-custodial parent(s). When paternity has not been established for a child, the parent shall supply accurate and complete information about the putative father and take part in any legal proceedings as requested by the department unless an exemption is granted under section 17b-179(a)-4. Parents shall not be required to take additional action if an exemption is granted or if the department decides not to pursue support for reasons other than non-cooperation.

(6) The entire family shall be determined ineligible if the parent does not comply with the requirements of this section and shall remain ineligible until such time that the parent complies.

(d) Citizenship

(1) To be eligible for CCAP, the child for whom assistance is requested shall meet the citizenship requirements established under section 431 of Public Law 104-193, the Personal Responsibility and Work Opportunity Reconciliation Act, as amended. The citizenship status of the child's parents or other family members shall not be taken into consideration when determining eligibility for CCAP.

(2) To be eligible for assistance, the child shall be a United States citizen, a national of the United States pursuant to 8 U.S.C. section 1101, or an eligible non-citizen who is a lawfully residing immigrant.

(3) Citizens shall include the following individuals:

(A) individuals born in the United States or a US territory;

(B) a naturalized citizen;

(C) individuals under the age of 19 whose parents are citizens; and

(D) individuals who meet specific Immigration and Naturalization Service conditions for citizenship including a foreign born individual with at least one parent who is a citizen and the foreign born spouse of a U.S. citizen.

(4) Eligible non-citizens shall include, but not be limited to the following individuals as determined by the Immigration and Naturalization Service:

(A) a non-citizen lawfully admitted for permanent residence under the Immigration and Nationality Act;

(B) a non-citizen granted asylum under section 208 of the Immigration and Nationality Act;

(C) a refugee admitted to the United States under section 207 of the Immigration and Nationality Act;

(D) a non-citizen paroled into the United States under section 212 (d)(5) of the Immigration and Nationality Act for a period of at least one year;

(E) a non-citizen whose deportation is being withheld under section 243 (h) of the Immigration and Nationality Act as in effect prior to April 1, 1997, or whose removal is being withheld under section 241 (b)(3) of the Act;

(F) a non-citizen who is a Cuban or Haitian entrant as defined in section 501 (e) of the Refugee Education Assistance Act of 1980; or

(G) a non-citizen whose child has been battered or subjected to extreme cruelty in the United States and otherwise satisfies the requirements of 8 U.S.C. 1641 (c).

(5) Parents shall be required to disclose the citizenship status of the child, provide requested verification of the child's immigration status and to report any changes in the child's status within 10 days of the date of the change as a condition of eligibility. Where federal law prohibits copying naturalization papers, the CCAP administrator shall make arrangements to schedule a meeting with the parent to review the naturalization documents. The meeting shall be conducted in the local regional office of the department or other mutually agreed upon location.

(6) If assistance is denied because a child does not meet the citizenship requirements, the CCAP administrator shall provide written notice to the parent explaining the reason for the denial and how to contact the Immigration and Naturalization Service to seek correction if the parent believes the information regarding the child's citizenship status to be erroneous. If the parent requests an administrative hearing to appeal the determination to deny assistance, the CCAP administrator shall contact the Immigration and Naturalization Service for assistance if the parent challenges the determination of the child's citizenship status. The CCAP administrator shall not be required to contact the Immigration and Naturalization Service if the parent does not contest the child's status, but disputes whether the status makes the child ineligible.

(e) Need for Care

(1) The parent shall have at least one eligible child residing in the home who needs child care assistance. Families with no eligible children shall be ineligible for CCAP. The approved hours of care shall be determined in accordance with the requirements of subsection (b) of section 17b-749-13 of the Regulations of Connecticut State Agencies.

(2) To be eligible for assistance, child care shall be needed to allow parents to participate in the following approved activities:

(A) employment for which the individual receives wages as opposed to goods or services for compensation;

(B) a self-employment activity as defined in subsection (f) of this section;

(C) for individuals receiving cash assistance, an employment services activity approved by the Department of Social Services, the Department of Labor or the designee of either agency in accordance with the State Plan requirements for the TFA cash assistance program; or

(D) for teenage parents under the age of twenty whom do not receive cash assistance, attending high school as defined in subsection (6) of section 17b-749-01 of Regulations of Connecticut State Agencies.

(3) Parents who were participating in an employment services activity at the time their TFA cash assistance benefits were discontinued shall be eligible for child care services to support completion of the activity for up to twelve months after TFA assistance is discontinued, provided that the parent is employed and all other eligibility requirements are satisfied. Eligibility based on the employment services activity shall end if the parent stops participating in the activity or if the activity ends.

(4) Parents shall maintain continuous involvement in an approved work or employment services activity. Assistance shall be available only during the hours the parent or family member is participating in an activity listed in subdivision (2) of this subsection.

(5) A child shall not be eligible for assistance if the applicant's spouse or the child's other parent is living in the home and is available and capable of providing care. The spouse or other parent shall be considered unavailable if the individual is participating in an activity defined in subdivision (2) of this subsection during hours that exclude the possibility of providing care. The spouse or other parent shall be considered incapable of providing care if the individual has a significant physical or mental condition, disability or impairment that would prevent him or her from caring for the child for a period which is expected to last for at least one calendar month.

(6) The parent shall demonstrate that his or her spouse or the other parent is not available to provide care by certifying that the spouse or other parent does not reside in the household or by verifying participation in an activity listed in subdivision (2) of this subsection.

(7) Parents working at home shall be considered unavailable to provide care only if the nature of the employment or self-employment activity prevents the parent from providing adequate care or supervision, or if the parent routinely operates equipment or machinery that would be hazardous if the child was in the same room or area with the parent.

(8) The applicant shall be required to verify that the spouse or the other parent is incapable of providing care by submitting verification from a treating physician or state certified mental health professional. The verification shall provide details of the nature and degree of the person's disability or impairment, the reason the condition prevents the individual from providing care and the expected duration of the disability or impairment. The CCAP administrator may refer, but shall not require the individual to apply for disability benefits with the Social Security Administration if the condition is expected to last for more than twelve months. The evidence shall clearly establish that the spouse or other parent is not capable of providing safe and competent care. The CCAP administrator may request additional verification if the information submitted is not conclusive. In determining that an individual is not capable of providing safe and competent care, the department shall consider the age of the child, special needs, the degree of supervision required, medical information and all other available evidence.

(f) Specific Requirements for Self-Employed Family Members

(1) Child care assistance shall be approved to support a self-employment activity only if the activity is carried on to create a livelihood and in good faith to make a profit as evidenced by business and financial records and tax returns. The parent shall be required to provide documentation of continuous activities that are not passive or casual, or more appropriately associated with a hobby or volunteer work. Family members who own multiple or multi-family properties shall not be considered self-employed unless the individual actively manages the properties and can demonstrate work hours that justify the need for care.

(2) Parents working at home as child care providers shall be considered available to provide care for their own children during their work hours, except under the following conditions:

(A) if the parent is a licensed family day care home provider; and

(B) if caring of his or her own children would cause the parent to exceed the licensed capacity established by the Department of Public Health.

(3) The self-employment business activity shall be producing some taxable income at the time assistance is requested as reported as net profit on Schedule C of IRS form 1040. After six months, the taxable earnings for each family member involved in the activity shall equal or exceed the state minimum wage times the number of hours the family member purports to be working on the activity on a continual basis. Child care needs related to the activity shall be disapproved if income from the activity does not meet the income standards. Any subsequent requests for assistance made by the family related to self-employment shall be approved only if the gross taxable income produced equals or exceeds the state minimum wage times the number of hours each family member spends working on the activity.

(4) The parent shall be responsible for submitting tax returns, estimated tax filings and business records documenting the income, business deductions and hours of participation where appropriate. Upon request, families with reported income that does not appear sufficient to meet basic daily living expenses shall provide verification of how the expenses are being met, including checking account, savings or loan records or an alternate means of financial support. The gross income from the self-employment business activity shall be used to determine eligibility and the amount of assistance if the information submitted by the parent is not sufficient to adequately determine the net profit.

(g) Availability of Other Child Care Resources

(1) Payments shall not be made for the hours the child attends school, home schooling or other academic programs, or for the hours the child attends an after-school program or other state, federal or privately funded program for which the parent does not incur a fee.

(2) If the family receives a direct subsidy or funds for child care expenses from a source other than CCAP, including support payments from a non-custodial parent earmarked specifically for child care, this funding shall be applied first as payment toward the approved cost of care as determined in subsection 17b-749-13 of the Regulations of Connecticut State Agencies. Scholarships, Pell grants and other awards provided directly to students shall be exempt and shall not be applied toward the approved cost of care.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-05 Financial eligibility requirements

(a) Gross Income Eligibility

(1) Gross countable family income for applicants and recipients shall be less than fifty percent of the state median income level for the appropriate family size as established by the Department of Health and Human Services. The commissioner shall have discretion to increase the income limit to up to seventy-five percent of the state median income level for all CCAP recipients or for both applicants and recipients. The commissioner may also, upon the request of the commissioner of Children and Families, waive the gross income limit for families who need child care assistance for a child who was adopted from the Department of Children and Families after October 1, 1999 and whose countable income does not exceed the maximum level established for participation pursuant to 42 CFR section 98.20 of the federal Child Care and Development Fund Regulations. Adoptive families for whom the income limit is waived shall be responsible for paying the maximum fee required pursuant to subsection (f) of section 17b-749-13 of the Regulations of Connecticut State Agencies.

(2) A family whose income equals or exceeds the established income limit shall be ineligible for CCAP, unless the income exceeds the limit for not more than one calendar month due to an extra pay period or other temporary increase.

(3) Income shall be counted in the month it is received by the family member, except to the extent the income is averaged in accordance with requirements of subsection (d) of this section.

(4) The department shall adjust the state median income standards annually. For new applicants, the adjusted standards shall take effect beginning on or after July 1 of each year. For families receiving child care assistance on June 30, the adjusted standards shall take effect not later than the first redetermination completed after July 1 of each year.

(b) Countable Income

(1) In determining the gross income, the following types of income shall be counted except as specified in subdivision (2) of this section:

(A) unearned income of all adult and child family members; and

(B) gross earnings of all parents and adult family members.

(2) The following types of income shall be excluded from the gross income determination:

(A) TFA cash assistance benefits;

(B) child support payments;

(C) income paid by the Census Bureau to low-income temporary census workers;

(D) the value of Food Stamp benefits;

(E) the earnings of a family member who is under the age of eighteen who is not the parent of a child for whom assistance is requested;

(F) earned income credit payment, including advanced payments;

(G) cash contributions from non-profit charitable agencies or organizations;

(H) interest and dividends totaling less than six hundred dollars per calendar year;

(I) lump sum payments from unearned income sources totaling less than six hundred dollars per calendar year;

(J) income tax refunds;

(K) special need payments issued by the department on behalf of a cash assistance recipient that are paid to a vendor;

(L) income from the sponsor of a non-citizen;

(M) grants, loans and scholarships paid to students;

(N) cash gifts received on an irregular basis, the aggregate of which does not exceed twelve hundred dollars per calendar year;

(O) the value of goods and services given as in-kind income rather than cash payments;

(P) reimbursements for expenditures that do not represent a benefit or gain to the recipient;

(Q) disaster assistance paid under the Disaster Relief Act of 1974, as amended, including the Individual and Family Grant (IFG) program, and comparable disaster assistance provided by states, local governments and private organizations, and any interest earned on funds from this source;

(R) payments made by the Department of Labor to meet the cost of pursuing employment;

(S) state or federal government rental subsidies;

(T) security deposits returned by a landlord to the family;

(U) payments made under means-tested energy assistance programs and utility subsidies; and

(V) payments received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970.

(c) Income Deductions

(1) Self-employed individuals shall be entitled to standard deductions for business expenses permitted under the Internal Revenue Code. Deductions shall be allowed only after submission of appropriate documentation using applicable Internal Revenue Service forms and schedules.

(2) Payments made for child support shall be deducted from the gross income of the individual who makes the support payment. A representative average shall be used if the amount of the support payments fluctuates.

(d) Income Calculations

(1) Gross income shall be calculated based on the best estimate of the income the family is expected to receive. Income received monthly or over a more frequent period shall be annualized based on the amount received in the four week period immediately prior to the date of the income calculation. If the income fluctuates in an unpredictable manner, the income shall be averaged over a longer more representative period. If income is received regularly according to a schedule, the income shall be annualized based on such schedule.

(2) School or other employees who are under contract shall have income annualized over the contract period. Income received less frequently than monthly shall be averaged over the period which it is intended to cover.

(3) If the income is expected to change or when a family member is beginning new employment or changing work schedules, gross income shall be calculated based on the best estimate of the income the family is expected to receive over the next six months. The CCAP administrator shall use all available documentation to make the determination.

(4) Self-employed family members shall have income calculated based on the prior years income tax return or current business records, whichever is most representative of the current projected earnings. Standard business deductions shall be allowed in accordance with the requirements of subdivision (1) of subsection (c) of this section.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-06 Verification

(a) Responsibilities for Providing Verification

(1) The parent shall have primary responsibility for supplying, on a timely basis, information sufficient to determine eligibility and the level of benefits. The CCAP administrator shall allow parents to submit any evidence they believe will support a factor that needs to be verified.

(2) The CCAP administrator shall assist in obtaining verification of application information on behalf of the family under the following conditions:

(A) when the CCAP administrator has the capacity to obtain the information internally by accessing the department's computer records or through other direct access; or

(B) when the parent has been unable to obtain the needed verification after making a bona fide effort and the assistance unit has requested help; and

(C) when the CCAP administrator has the capability to obtain the verification needed without undue administrative hardship.

(3) Providers shall be responsible for providing verification requested from them by the CCAP administrator.

(4) The CCAP administrator shall consider all evidence submitted or received from other sources.

(b) Standard of Proof

A statement or condition shall be considered verified when the available evidence indicates that it is more likely to be true than not.

(c) Verification Requirements

(1) The CCAP administrator shall require verification of information when required by federal or state law, when necessary to confirm any circumstances pertaining to eligibility for the family, a child care provider or the amount of benefits. The CCAP administrator shall not require parents or providers to verify circumstances not relevant to the case.

(2) Applicants assigned to the waiting list pursuant to section 17b-749-10 of the Regulations of Connecticut State Agencies shall be required to provide verification of information upon request of the CCAP administrator.

(3) Self-employed individuals shall be required to provide copies of federal and state income tax returns and business records upon request. If the reported income does not appear sufficient to meet family needs, the CCAP administrator may require the parent to verify current living expenses and document any alternate means of financial support, such as a loan or credit card expense.

(4) The CCAP administrator may conduct an investigation if the gross or net income reported from rental property or a self-employment enterprise is not consistent with the income produced by other similar rental properties or businesses.

(5) The CCAP administrator shall not require parents or providers to verify a negative or nonexistent condition or circumstance, unless evidence exists to suggest that the information provided is erroneous.

(6) The CCAP administrator shall issue a written notice whenever verification of information is requested. The notice shall specify the information that is needed, the date the information is due, that assistance may be available if the parent is unable to obtain the requested information and a statement that eligibility or benefits may be affected if the information is not submitted timely by the due date.

(d) Effect of Not Providing Verification

(1) If establishing eligibility for the program depends directly upon a factor or circumstance for which verification is required, not providing the requested information shall result in ineligibility for the entire family.

(2) If establishing eligibility for an individual child depends directly upon a factor or circumstance for which verification is required, not providing verification shall result in ineligibility only for the child. The entire family shall be ineligible if there are no other eligible children in the home.

(3) If the eligibility of the provider depends directly upon a factor or circumstance for which verification is required, not providing verification shall result in ineligibility for the provider.

(4) If only the approved hours of care or benefit calculation is affected, not providing verification shall result in the disallowance or non-consideration of the unverified factor or circumstance.

(e) Good Cause

(1) The department shall not deny assistance, discontinue or reduce a family's benefits if the parent can establish good cause for not providing requested verification. A parent shall be considered to have good cause for not providing verification under the following circumstances:

(A) if the parent has had difficulty obtaining information requested from a third party source other than a family member or the parent's child care provider and the parent has made all reasonable attempts to obtain the verification and is complying with the CCAP administrator's request; or

(B) if the CCAP administrator has taken responsibility for assisting the parent in obtaining the verification; or

(C) if extenuating circumstances, including but not limited to a death in the immediate family, severe illness or other mitigating circumstances prevented the parent from timely submitting the verification.

(2) To be eligible for good cause, the parent shall contact the CCAP administrator and request a good cause exemption within ten days of the date the notice of denial or adverse action is issued in accordance with section 17b-749-07 of the Regulations of Connecticut State Agencies.

(f) Methods of Verification

(1) Parents shall be required to submit written documentation as the primary method or source of verification, except where self-declarations are requested on the application or other program forms.

(2) In the absence of written documentation or where the verification submitted is questionable, the CCAP administrator shall have the option of verifying information by contacting other disinterested third party sources or persons who are not members of the household or the child care provider.

(3) Whenever possible, the CCAP administrator shall use information obtained through on-line computer interfaces or other automated resources to verify eligibility factors or circumstances to the extent the information is reliable, current and is readily available.

(4) Parents shall submit written documentation from reliable independent sources whenever such documentation is available. Parents may submit affidavits or self-declarations as verification. Such documentation shall be evaluated together with all other available evidence to determine if a circumstance has been verified. The CCAP administrator shall obtain a notarized statement on a form prescribed by the department prior to replacing a lost, stolen or destroyed check and may require parents and providers to submit affidavits in other situations where documentation is insufficient or not available.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-07 Notice requirements

(a) Requirements of the CCAP Administrator

(1) Parents shall be notified of their rights and responsibilities as specified in section 17b-749-2 of the Regulations of Connecticut State Agencies, including but not limited to the need to report changes in household circumstances to the CCAP administrator within ten days of the date of the change. Providers shall be notified of their responsibility to report changes in accordance with requirements of subdivision (b)(5) of section 17b-749-12 of the Regulations of Connecticut State Agencies.

(2) Parents shall be notified of the receipt of an initial or reopened application, of any actions they are required to complete and the effect of any reported or requested changes on eligibility or the level of benefits.

(3) When a Social Security number is requested, parents shall be notified if the disclosure of the number is not mandatory.

(4) Parents and their current providers for whom a completed child care agreement form has been submitted shall be notified of the following circumstances:

(A) action to grant or deny assistance;

(B) assignment to the wait list;

(C) the scheduling of a redetermination and the results of the redetermination;

(D) changes affecting program eligibility, provider eligibility or eligibility of an individual child;

(E) a change in the payee; and

(F) increases or decreases in benefit or payment amounts.

(5) Parents shall be notified when their case is assigned to a specific worker and when their case is reassigned to a different worker.

(6) Parents assigned to the wait list shall be notified of changes in their priority status, if they are removed from the wait list and of any actions necessary to maintain eligibility for the wait list.

(7) All notices of actions taken by the CCAP administrator or actions required by the parent or provider shall be given in writing. Written notice shall include documents and forms delivered by mail, in person, by facsimile machine or through formalized electronic communication processes established with the parent or provider. Each notice shall contain sufficient information to allow the parent or provider to clearly understand the reason for the action and the relevant state statute or regulation upon which the action is based.

(8) Parents shall be notified of their rights to an administrative hearing whenever an action is taken that affects eligibility, benefits, provider eligibility or eligibility for the wait list. Parents shall be notified of their right to an administrative disqualification hearing pursuant to section 17b-749-22 of the Regulations of Connecticut State Agencies.

(9) Parents and providers shall be notified of their right to speak to a CCAP supervisor or someone not directly involved with the case if they are not satisfied with the actions taken by the case worker.

(b) Date of Notification

The date of notification shall be the date a notice is issued by the CCAP administrator.

(c) Adverse Action Notice Requirements

(1) Parents and their approved provider(s) shall be notified when a change in circumstances results in the discontinuance, termination or reduction in benefits.

(2) Adverse action notices shall contain a reference to the relevant statute or regulation upon which such action was based.

(3) Notice shall be given at least ten days prior to the effective date of the intended action, except as specified in subdivision (4) of this subsection.

(4) Notice shall be given no later than the effective date of the action under the following circumstances:

(A) when the a child who is receiving child care assistance is deceased;

(B) when a parent who is the only adult member of the family is deceased;

(C) when the Department receives a written request to discontinue benefits from the parent;

(D) when changes are made following completion of a redetermination;

(E) when mail is returned with no forwarding address and the CCAP administrator is not able to determine the whereabouts of the family from other department records;

(F) when the parent or a child for whom assistance was requested is granted public benefits in another state;

(G) when a child who receives assistance is removed from the home by the Department of Children and Families or is placed in foster care;

(H) when assistance is granted for a specific period of time and written notice was given at the time of the grant explaining that eligibility or benefits will terminate at the end of the specified period;

(I) when an application for benefits is denied;

(J) when the parent or provider informs the CCAP administrator that the child is no longer receiving care or has changed providers;

(K) when a provider becomes ineligible for payment incentives for accreditation or professional development pursuant to subsection (d) of section 17b-749-13 of the Regulations of Connecticut State Agencies;

(L) when the Department of Public Health notifies the CCAP administrator that the provider's licensed has been revoked; and

(M) when the CCAP administrator has obtained reliable evidence that the child care provider does not meet the health and safety requirements of the CCAP program specified in subsection 17b-749-12 (c) to subsection 17b-749-12 (f) of the Regulations of Connecticut State Agencies, inclusive.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-08 Prioritization for child care funding

(a) Each family shall be assigned to an applicable priority group. Within available funding, the department shall accept applications and authorize payments based on the following order of priorities:

(1) parents receiving TFA cash assistance who are employed or participating in an approved employment services activity and working parents who are completing an approved employment services activity that started before the family's TFA cash assistance was discontinued pursuant to subdivision (e)(3) of section 17b-749-04 of the Regulations of Connecticut State Agencies;

(2) working parents whose cash assistance benefits were discontinued within six calendar months prior to the date of application for CCAP;

(3) parents under the age of twenty not receiving cash assistance who attend high school;

(4) working parents with gross countable family income below fifty percent of the state median income;

(5) working parents with gross countable family income between fifty and seventy-five percent of the state median income who request assistance for a child who was adopted from the Department of Children and Families; and

(6) all other working parents with gross countable family income between fifty and seventy-five percent of the state median income.

(b) A family's priority status shall not be affected if the parent is removed from cash assistance due to the application of a TFA program sanction.

(c) The commissioner may establish additional priority groups from time to time based on exceptional public need that results from unforeseen circumstances. When establishing additional priority groups, the commissioner shall designate a target expenditure level for each additional priority group created if such level is not otherwise specified by legislative action. Additional priority groups may be added or deleted based on available funding.

(d) The CCAP administrator shall maintain a list of any additional priority groups established. The list shall include the expenditure level specifically allocated to each additional priority group. A copy of the listing of additional priority groups shall be made available to the public upon written request.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-09 Application process

(a) Filing an Application

(1) The parent shall apply for assistance by submitting an application to the CCAP administrator using a form prescribed by the department. The parent may use a copy of the application form, provided the information submitted on the form is original and not copied. If the form submitted is obsolete or inadequate, the CCAP administrator may require the parent to complete a new application. The date of application shall be the date the initial application was filed.

(2) If the family contains a minor parent, the minor or the minor's parent may submit the application. The parent of the minor parent shall be considered the applicant and shall be required to sign the application form before assistance is granted, unless the minor parent is emancipated by marriage or court decree.

(3) The application form shall be submitted to the address specified by the department for the submission of applications. Applications received by the department at an address other than the one specified for the submission of CCAP applications shall be forwarded to the CCAP administrator within one business day of the date the application was received.

(4) Parents may apply or reapply for the program at any time. The parent shall be required to complete a new application form with each application, except under the following circumstances:

(A) when an application is reopened in accordance with the requirements of subsection (e) of this section, the CCAP administrator shall not require the parent to submit a new application form if the original application form submitted by the parent is not more than sixty days old; or

(B) if the original application was denied because the parent did not comply with a request for missing information or verification, the CCAP administrator shall waive the requirement for submitting a new application form if the parent submits some or all of the missing information within sixty days of the previous application date.

(5) Telephone contacts or other requests for assistance not utilizing the prescribed application form shall be considered inquiries and do not constitute an application.

(6) At a minimum, the application form filed shall include the full name and address of the parent, the date and the parent's signature. Applicants shall not be required to submit a child care agreement form or other documentation with the application.

(7) Application forms may be requested from the CCAP administrator by phone or in writing. Application forms requested by phone shall be mailed to the parent by the next business day following the date of the request. Application forms shall also be made available in local offices of the department at sites designated for the coordination of employment services activities for cash assistance recipients. Upon request, the CCAP administrator shall make application forms available in reasonable quantities to licensed child care providers, legal assistance organizations or other entities that regularly assist low and moderate income families.

(8) Parents may be required to complete a telephone interview as part of the application process. Interviews may be scheduled by contacting the parent by phone, except that written notice shall be issued before an application is denied because the parent did not comply with attempts to complete the interview. Interviews shall be scheduled within thirty days of the date of application at a time mutually agreed to by the parent and the CCAP administrator.

(b) Date of Application

(1) The date of application shall be the date the signed and dated application form is received by the CCAP administrator at the address specified by the department for filing child care applications. If the application form is sent to the department, but to an incorrect address, the date of application shall be the earlier of the date the application is received by the CCAP administrator or the next business day following the date the application form was received by the department.

(2) If the requirement to file a new application form is waived in accordance with the requirements of subdivision (a)(4)(B) of this subsection, the date of application shall be the date upon which the CCAP administrator receives documentation sufficient to reopen the applicant's case using a previously submitted application form.

(3) For applications reopened in accordance with the requirements of subsection (e) of this section, the application date shall be the date the original application form was filed.

(c) Application Processing

(1) Applications shall be processed and eligibility determined within thirty days of the date that the CCAP administrator receives the application form, unless otherwise specified in this subsection. The first day of the processing period shall begin on the day following the date the application form was received. The parent shall be notified of the eligibility decision in accordance with the requirements of section 17b-749-07 of the Regulations of Connecticut State Agencies. The provider shall also be notified if a completed child care agreement form was submitted with the application.

(2) Eligibility shall be determined when sufficient information exists to determine if the family is eligible or ineligible. If the application is incomplete, the CCAP administrator shall issue a notice to the parent requesting the information that is missing. The parent shall be given a minimum of fifteen days from the date the notice is issued to return the information to the CCAP administrator. The first day of the fifteen-day period begins on the day the notice was issued.

(3) If the parent has not selected a provider by the time eligibility is determined, the CCAP administrator shall determine if the family is eligible for the program without regard to eligibility for payments. The parent shall be notified of the decision and informed that eligibility will be terminated if a provider is not selected and the information needed to enroll the provider is not submitted within thirty days. The CCAP administrator shall determine if a child is eligible for payment within ten days of the date the provider information is submitted. The family shall become ineligible if the information needed to determine payment eligibility for at least one child is not submitted within thirty days of the date assistance was granted.

(4) Incomplete applications shall be denied only if the parent has been given at least fifteen days to comply with an initial request for missing information.

(5) Parents shall be given additional time to respond to a request for missing information if good cause exists for not providing the information in accordance with the requirements of subsection (e) of section 17b-749-06 of the Regulations of Connecticut State Agencies. Applications that remain incomplete after the fifteen day notice period has expired shall be processed without regard to the missing information if good cause does not exist. If eligibility has not been established, the application shall be denied and the parent notified.

(6) The processing period shall be extended beyond thirty days under the following conditions as long as the parent continues to cooperate with the application process:

(A) if good cause exists for not providing verification in accordance with the requirements of subsection (e) of section 17b-749-06 of the Regulations of Connecticut State Agencies, and the delay causes the application to remain pending for more than thirty days;

(B) if the parent or provider was not given at least fifteen days to respond to an initial request for information;

(C) if the parent responds timely to a request for missing information and the information submitted is either incomplete or requires additional verification before the application can be processed; or

(D) if the CCAP administrator has assumed responsibility for obtaining missing information and has not been able to obtain the information.

(7) The application shall continue to be processed if a good cause extension is granted or while the CCAP administrator is waiting to obtain additional verification. The extension shall continue for as long as necessary provided that the parent continues to cooperate and responds to written requests for verification in a timely manner. Additional verification or reverification of circumstances that have already been verified may be required if the application remains pending more than thirty days. The delay in processing the application shall be considered the responsibility of the parent as long as the CCAP administrator has taken prompt action to request the missing information in time to process the application within thirty days.

(d) Application Dispositions

(1) If the family is eligible and funding is available for the parent's priority group, the application shall be approved. A notice of eligibility for the program shall be issued to the parent if the information needed to enroll the provider and determine payment eligibility has not been submitted. The notice shall identify any action the parent is required to take to determine payment eligibility and the specified time frames.

(2) If at least one child has been determined eligible for payment, a certificate of payment eligibility shall be issued to the parent and the approved provider. The parent shall also be notified of any actions that need to be completed to secure payment eligibility for other children in the home and the date for completing such actions.

(3) If a family is eligible but funding is not available for the parent's priority group, the family shall be assigned to the wait list if the wait list is open pursuant to section 17b-749-10 of the Regulations of Connecticut State Agencies. If the wait list is closed, the application shall be denied.

(4) If the application is denied, a copy of the notice shall be sent to any provider for whom a completed child care agreement form was submitted with the application.

(e) Reopening Denied Applications

(1) A denied application shall be reopened retroactive to the original date of application under the following conditions:

(A) if the application was denied because the parent did not comply with a request for missing information; and

(B) the parent is able to establish good cause for not submitting missing information within ten days of the date the application was denied in accordance with the requirements of subsection (e) of section 17b-749-06 of the Regulations of Connecticut State Agencies; or

(C) if some or all of the missing information is submitted to the CCAP administrator within ten days of the date the application was denied; or

(D) if the application was denied in error.

(2) Applications that are reopened shall be given priority over other pending applications. The CCAP administrator shall have thirty days from the date the application is reopened to complete the eligibility determination.

(f) Applications Assigned to the Wait List

(1) The CCAP administrator shall maintain a wait list if sufficient funding is not available to keep the program open for all priority groups. If a family meets the eligibility requirements for the program but funding is not available for the parent's priority group, the family shall be assigned to the wait list unless the wait list is closed pursuant to section 17b-749-10 of the Regulations of Connecticut State Agencies. Parents and their providers shall be notified if the family is placed on the wait list.

(2) If the commissioner chooses to close the wait list to some or all priority groups, applicants who fall into priority groups to whom the wait list is closed shall be denied. Action to close the wait list shall not be subject to an administrative hearing.

(g) Eligibility Period

(1) For families approved without assignment to the wait list, including families whose applications are reopened pursuant to subsection (e) of this section, eligibility shall be granted eligibility retroactive for up to fifteen days prior to the date of application if the family is otherwise eligible and using child care services as of that date.

(2) Families selected from the wait list shall be granted retroactive for up to fifteen days prior to the date on which the parent submits required documentation in response to a notice of selection from the wait list or on the date specified by the CCAP program administrator, whichever is later.

(3) If the parent did not timely submit information or verification needed to determine eligibility for a particular child without good cause, eligibility for the child shall begin on the date the parent provides some or all of the requested information or verification.

(4) Eligibility shall be approved for up to a maximum of six months from the month of application. The CCAP administrator shall schedule a redetermination within six months in accordance with the requirements of subsection (b) of section 17b-749-18 of the Regulations of Connecticut State Agencies.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-10 Wait list

(a) Assignment to the Wait List

(1) Families shall be assigned to a wait list based on their priority group and the date of application. Families qualifying for more than one priority group shall be assigned to the priority group with the highest likelihood of selection for CCAP participation.

(2) Families assigned to the wait list shall be required to notify the CCAP administrator of changes in address and to submit updated documentation of eligibility upon request by the CCAP administrator. The parent shall have a minimum of fifteen days to supply the requested documentation. Where updated information indicates a change in family circumstances, the CCAP administrator may reassign eligible families to the appropriate priority group or remove ineligible families from the wait list. The parent shall be notified of any changes made to their priority group status or eligibility for the wait list.

(3) Parents shall inform the CCAP administrator in writing of any changes in address.

(b) Selection from the Wait List

(1) As funding becomes available, the CCAP administrator shall select families from the wait list beginning in order of the highest priority group. The family's application shall be processed in accordance with the requirements of section 17b-749-09 of the Regulations of Connecticut State Agencies. If the program is not opened to all families within a particular priority group or groups, the CCAP administrator shall select families based on the date of the original application upon which assignment to the wait list was based. Selection from the next lower category may begin only after all families in the higher priority categories have been given an opportunity to participate.

(2) Families shall be notified of their selection from the wait list, of any required actions and the specified time frames for completing the actions. The CCAP administrator shall have the option to specify the effective date of initial eligibility based on funding or other administrative considerations. If a date is specified, the family shall also be notified of the effective date.

(3) The parent shall have a minimum of fifteen days to respond in writing to the notice of selection from the wait list. The family shall be denied if the parent does not respond timely.

(4) Families selected from the wait list may be required to submit a new application and updated verification of family circumstances. Applications of families selected from the wait list shall be processed in a manner identical to applications not assigned to the wait list.

(c) Removal from the Wait List

(1) Families shall be removed from the wait list under the following circumstances:

(A) when the family is selected from the wait list;

(B) if the parent requests removal;

(C) if the parent does not update information when requested or reply timely to the notice of selection from the wait list;

(D) if any mail sent to the parent is returned due to an unreported change in address;

(E) when a change in family circumstances renders the family ineligible; or

(F) if a change in CCAP regulations renders the family ineligible.

(2) At the discretion of the commissioner, families may be removed from the wait list if CCAP is expected to remain closed to the family's priority group for at least twelve months.

(3) Families removed from the wait list shall be issued a denial notice if they are not selected for participation in CCAP.

(d) Closing the Wait List

(1) The commissioner shall have discretion to close the wait list for some or all priority groups. The decision to close the wait list shall be based on available funding, the number of families already assigned to the wait list and the likelihood of selecting newly added families from the list within twelve months.

(2) If the wait list is closed, families for whom funding is not available shall have their application denied.

(3) The commissioner shall have the option of reopening the wait list to some or all of the priority groups if additional funding becomes available or if a sufficient number of families are selected from the list to warrant reopening the list.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-11 Eligible children

(a) The child shall be less than thirteen years old or less than nineteen years of age, if the child has special needs. A child shall remain eligible through the last day of the month in which the child reaches the appropriate age limit, provided the child was eligible on the first day of that month. A child whose thirteenth or nineteenth birthday falls in the same month for which assistance is initially requested is not eligible for CCAP.

(b) A child shall be considered to have special needs if the child's independence, self-sufficiency and safety is dependent on others and the child requires extra supervision, care, or assistance in the child care setting due to the following physical, mental, behavioral or emotional conditions, including but not limited to:

(1) a physical handicap or health impairment that causes chronic or acute health problems, such as a heart condition, orthopedic impairment, tuberculosis, asthma, epilepsy, cerebral palsy, leukemia or congenital abnormality that has been diagnosed by a physician;

(2) mental retardation or autism spectrum disorder as diagnosed by a physician, pediatrician or psychologist;

(3) a behavioral or emotional disturbance, maladjustment or developmental delay that causes the child to exhibit marked and inappropriate behaviors or characteristics over extended periods that has been diagnosed by a psychologist, psychiatrist or other clinically trained and state-certified mental health professional acting within his or her scope of practice;

(4) a speech, language, vision or hearing impairment that has been diagnosed by a physician or state certified health care professional acting within his or her scope of practice; or

(5) multiple handicaps that cause problems or interfere with the child's ability to function in the child care setting without extra care or supervision.

(c) Parents shall be required to notify the CCAP administrator and the provider if a child has special needs. A determination that a child has special needs shall not guarantee eligibility for additional or increased payments. The child's payment rate and eligibility for a special needs supplement shall be subject to the requirements of subsection (c) of section 17b-749-13 and subsection (b) of section 17b-749-16 of the Regulations of Connecticut State Agencies, respectively.

(d) The child shall meet the citizenship requirements established in subsection of section 17b-749-04 of the Regulations of Connecticut State Agencies.

(e) The child shall have age-appropriate immunizations in accordance with the childhood immunization schedule established by the Department of Public Health pursuant to section 19a-7 of the Connecticut General Statutes. Parents and providers shall certify that the child has had age-appropriate immunizations and has had age-appropriate comprehensive health screening examinations required by the Early and Periodic Screening and Diagnostic Treatment Program established under 42 U.S.C. § 1396d(r) or according to the schedule recommended by the American Academy of Pediatrics. Parents shall provide documentation of age-appropriate immunizations and other health information to the provider and the CCAP administrator upon request, including the name and address of the child's physician, primary health care provider and health insurance company.

(f) If a child who receives care has not been immunized, the parent shall have sixty days from the date assistance is granted to verify that the child has begun the immunization process. The child's benefits shall be terminated if the parent does not provide the required verification within sixty days. The child shall remain ineligible until such time that the parent verifies that the child has been or is in the process of being immunized. If there are no other eligible children in the home, the family shall become ineligible.

(g) The CCAP administrator shall waive the immunization requirement if the parent is able to demonstrate that the child's medical condition or the parent's sincere religious beliefs preclude the child from being immunized.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-12 Eligibility requirements for child care providers

(a) Eligible Settings

(1) To be eligible for payments, care shall be given in one of the following settings located and operating legally within Connecticut:

(A) the child's home;

(B) a family day-care home licensed by the Department of Public Health;

(C) a day-care center licensed by the Department of Public Health;

(D) a group day-care home licensed by the Department of Public Health;

(E) the home of a relative as defined in subsection (34) of section 17b-749-01 of the Regulations of Connecticut State Agencies;

(F) the home of a non-relative provider, if care is provided for less than three hours per day;

(G) a public or private school-based child care program as defined in subsection (37) of section 17b-749-01 of the Regulations of Connecticut State Agencies;

(H) a recreational program operated by a library, boys' and girls' club, church-related organization, scouting, camping or community youth program or other similar entity that is legally exempt from separate licensing by the Department of Public Health pursuant to section 19a-77 of the Connecticut General Statutes, and that provides stable and regular care; or

(I) a drop-in supplemental child care program where parents are present on-site, for which the parent is charged a fee for child care services.

(2) The commissioner shall have discretion to approve payments for child care services given by a licensed provider located and operating legally in an adjoining state on an exception basis. Approval shall be based on the circumstances of the individual family, including, but not limited to the availability of licensed child care services in the area where the family lives, the need to utilize out-of-state services due to the location of the child's school or the parent's work, education or employment services activity and any special needs of the child. The provider shall be licensed and in good standing with the state agency responsible for regulating child care services in the adjoining state. In addition, the provider shall be subject to all other relevant requirements specified in section 17b-749-01 to17b-749-23 of the Regulations of Connecticut State Agencies, inclusive, and shall cooperate with the department in providing or obtaining any verification needed to establish the eligibility of the child care arrangement. The determination by the commissioner shall be considered final and is not subject to an administrative hearing.

(3) When determining if a provider is eligible, the department shall give full force and effect to any decision rendered by another agency concerning a license or application for a license to provide child care.

(4) The following individuals shall not be eligible to receive payments from CCAP for providing child care because of their relationship to the child:

(A) a person who is a mandatory inclusion in the family unit for CCAP eligibility purposes pursuant to section 17b-749-03 of the Regulations of Connecticut State Agencies;

(B) the natural or adoptive parent or legal guardian of the child, or the current or former spouse of such individual;

(C) if the child's parent is a minor who is not emancipated, the natural or adoptive parent or legal guardian of the minor parent, or the current or former spouse of such individual if living in the same household as the minor parent;

(D) the child's sibling through blood, marriage or adoption if living in the same household as the child regardless of the sibling's age;

(E) an adult, regardless of relationship, living in the same household with the child who provides care between the hours of eleven o'clock p.m. and seven o'clock a.m., unless the child is less than three years of age or has special needs; and

(F) an individual who has been designated as the caretaker relative of the child under the cash assistance program and the individual's spouse.

(5) A child care provider who has been convicted of vendor fraud pursuant to section 17b-99 of the Connecticut General Statutes shall not be eligible to receive payments from the CCAP program for providing child care services.

(b) Provisions Applicable to all Providers

(1) The department shall not be considered a licensing authority or the employer of the provider. The agreement to provide care is an arrangement between the parent and the provider and shall not be considered a legal contract between the department or the CCAP administrator and the provider. Parents shall be responsible for selecting a provider who can provide safe, appropriate and suitable care for their child. The Department or the CCAP administrator shall only determine whether the provider has submitted evidence of compliance with the requirements of section 17b-749-12 of the Regulations of Connecticut State Agencies and is therefore eligible to participate in the CCAP program. Neither the Department nor the CCAP administrator shall undertake any duty of care that can be reasonably relied upon by any person that a provider is suitable or appropriate to provide child care.

(2) Neither the department nor the CCAP administrator shall be considered the employer of the provider. The Department or the CCAP administrator, by making benefit payments on behalf of an eligible family to a provider that has been selected by the family, does not undertake any of the responsibilities of an employer, including, but not limited to, tax withholding, unemployment compensation or worker's compensation. The Department's responsibility shall be limited to making child care assistance payments to providers who are eligible to receive payment for child care services provided on behalf of eligible families, in accordance with the terms, conditions and limitations of sections 17b-749-01 to 17b-749-23 of the Regulations of Connecticut State Agencies, inclusive.

(3) Providers shall allow parents unlimited access to their children and to the location where child care is provided.

(4) Providers shall certify that they will report any instances of suspected child abuse or neglect to the appropriate protective service agency in a manner required by section 17a-101a of the Connecticut General Statutes.

(5) In order to maintain eligibility for payments, providers shall provide the following information to the CCAP administrator upon request:

(A) the name, address, photo identification, Social Security number and telephone number of the provider and all adults who work for or reside at the location where care is provided;

(B) the name and address of the child's doctor or primary care provider and health insurance company;

(C) whether the child is immunized and has had appropriate health screens; and

(D) the number of children cared for by the provider.

(6) Providers shall notify the CCAP administrator of any changes in the child care arrangements, including but not limited to changes in the hours of care, actual charges, changes in programs due to the age group of the child, the location where care is given and changes in licensing or accreditation status. Changes shall be reported in writing or by phone by the time the first invoice is submitted following the date of the change. This requirement shall not relieve the parent of the responsibility to report these changes to the CCAP administrator within ten days of the date of the change.

(7) Providers shall report actual charges and attendance accurately in the format required by the CCAP administrator. Providers shall maintain records of such figures on-site for at least one year and make such records accessible to the department for inspection upon request.

(8) Providers shall not charge or report charges for CCAP participants at a rate that is higher than the rate charged to a comparable family not participating in the CCAP program. The charges reported to CCAP shall be the actual amount charged to the parent for services, unless the child attends a state-supported day care center or school readiness program funded under section 8-210(b) or sections 10-16p(8)(c) or 10-16p(8)(d) of the Connecticut General Statutes respectively. For children attending such state-supported programs, the charges reported to CCAP for use in determining the benefit calculation and payment shall be the lesser of the provider's full charge for the program or the approved cost of care as determined in subsection (a) of section 17b-749-13 of the Regulations of Connecticut State Agencies.

(9) Providers shall not increase charges to CCAP parents to offset a reduction in payments due to an overpayment that was caused by the provider that is being recouped by the department.

(c) Requirements for Providers Subject to Licensing by the Department of Public Health

(1) Child care providers that are required to be licensed by the Department of Public Health in accordance with section 19a-77 of the Connecticut General Statutes shall be licensed and in good standing before any payments to the provider are approved.

(2) Providers shall report changes in licensing status to the CCAP administrator by phone or in writing by the time the first invoice is submitted following the date the Department of Public Health informs the provider of the change. Changes in accreditation status shall be reported within ten days of the date of the change.

(3) Payments shall not be made for child care services provided during periods the provider did not possess or maintain the required license, except when the provider has timely taken steps to renew a license but the Department of Public Health has not completed the renewal process. Providers shall not be entitled to advance notice if payments are terminated because the provider is not licensed.

(4) The CCAP administrator shall withhold any payments that have not already been issued for periods during which the provider was determined to be operating illegally without a license. Any payments issued for services provided during periods the provider was operating without a required license shall be considered overpayments caused by the provider.

(5) The CCAP administrator shall report providers who appear to be over capacity to the Department of Public Health for investigation of regulatory violations.

(d) Requirements for Unlicensed Child Care Providers

(1) Unlicensed child care providers shall be eighteen years of age or older. Parents receiving benefits for care given by a provider who is less than eighteen years old shall have up to ninety days from the effective date of this regulation to locate a new provider. Payments shall continue during the ninety-day period provided the family is otherwise eligible.

(2) The provider shall disclose his or her full name, residence address, date of birth and social security number or any other information necessary to verify identity. Upon request, the provider shall provide identification that includes the provider's photograph, date of birth and signature.

(3) The provider shall not be working another job during the hours that the child is in care or engage in an activity that distracts his or her attention from providing child care services.

(4) No child care subsidy shall be paid to an unlicensed child care provider if such provider has been convicted of any crime involving sexual assault of a minor or serious physical injury to a minor or any crime committed in any other state or jurisdiction the essential elements of which are substantially the same as such crimes pursuant to section 17b-750 of the Connecticut General Statutes. The commissioner shall have discretion to refuse payments to any provider if the person has been convicted in this state or any other state of any crimes specified in section 17b-749k of the Connecticut General Statutes or has a criminal record or was the subject of a substantiated report of child abuse or neglect in this state or in any other state that the commissioner reasonably believes renders the person unsuitable to provide child care.

(5) The commissioner shall have discretion to refuse payments under the following conditions:

(A) if the provider has an outstanding arrest warrant for any offense that is classified as a felony;

(B) if the provider has a child abuse or neglect allegation pending;

(C) if the provider is physically or mentally incapable of providing safe or competent care to the child; or

(D) whenever the commissioner has obtained information from a reliable source that a provider has not been providing or is not capable of providing safe or competent care, including but not limited to a record of an outstanding arrest for child abuse or neglect, risk of injury or impairing the morals of a minor, the illegal use, sale or possession of controlled substances, a crime against persons or other similar offenses.

(6) The parent and provider shall both certify that the provider is capable of providing safe and competent care as a condition of payment eligibility, including the ability to feed, bathe and toilet the child as appropriate, the ability to respond to potential emergencies and the ability to provide adequate care and supervision. The department may deny payment if sufficient evidence exists to support a conclusion that the child's needs may not be satisfied or that the child's health and safety may be at risk in the child care setting. In making this determination, the department shall consider information obtained from police records, medical records and information obtained from other agencies, physicians, health care workers, social workers health officials or other sources. The hours of care, the child's age and special needs shall be taken into consideration when assessing the ability of the provider to properly care for and supervise the child.

(7) The provider shall certify in writing that he or she has not been convicted of any crime or subject to any of the conditions listed in subdivisions (4) and (5) of this subsection.

(8) The provider and parent shall certify by signing the child care agreement form that the child care location meets the following requirements:

(A) there is an operating fire extinguisher available at the child care location;

(B) there is an operating smoke alarm installed at the child care location;

(C) there is an operating hard wired telephone at the child care location or a cellular phone owned and operated by the provider with emergency telephone numbers posted; and

(D) the child care location complies with all applicable local and state fire, zoning and building codes.

(9) The child care arrangements shall not be approved if care is provided in a location that does not meet the requirements of subdivision (8) of this subsection.

(10) An unlicensed child care arrangement shall not be approved if care is provided by an in-home child care provider or a relative who provides child care services to more than six children during substantially the same hours. Up to three children under the age of two may receive child care services together at a time, as long as they are the only children in the provider's care. No more than two infants may receive care at any one time if the provider cares for any other preschool or school age children during the same hours.

(e) Criminal and Child Abuse Background Checks for Unlicensed Providers

(1) The department shall check the state's child abuse registry at application and periodically according to a schedule established by the department to determine if the provider has a substantiated history of child abuse or neglect.

(2) The department shall check the state and national criminal history of any unlicensed provider that is suspected of having a conviction for sexual assault of a minor or other related crime in accordance with the requirements of section 17b-750 of the General statutes.

(3) The department shall conduct criminal background checks for unlicensed providers pursuant to the requirements of sections 17b-749k and 17b-750 of the Connecticut General Statutes.

(4) Providers shall be informed of the requirements to conduct criminal and child abuse background checks and shall supply the department with fingerprints and any other information required to conduct the background check when requested by the CCAP administrator. Providers shall be given a minimum of thirty days to return the requested information to the department.

(5) The department may charge the provider for any fees charged by the State Police or the FBI for conducting the criminal background check. The department may deduct the fee from payments made to the provider or require the submission of payment with the fingerprints. A provider who does not submit fingerprints, fees or other information when requested shall be ineligible for payments until such time the provider complies with the request.

(6) Assistance shall not be delayed pending the completion of a criminal or child abuse background check unless evidence exists to warrant a delay, except as specified in subdivision (f) of this section.

(f) Termination of Payments

(1) No child care subsidy shall be paid to any licensed or unlicensed child care provider if there is evidence that a child's needs are not being met, or that the child is not receiving or is not likely to receive safe and competent care from the provider. Parents and providers shall be notified of the denial or termination of payments to the provider. Disclosure of information obtained from the child abuse registry shall be in accordance with the requirements of subsection (d) of section 17b-749-02 of the Regulations of Connecticut State Agencies.

(2) Providers who disagree with the results of the background check shall be referred to the Departments of Children and Families or Public Safety if they wish to dispute the findings of those agencies. If the findings are reversed, payments may be authorized as of the date verification of the decision by the Department of Children and Families or Public Safety is submitted to the department.

(3) Providers may ask the department to reconsider the decision to deny or discontinue payments if they feel the decision was made in error. The decision by the department shall be considered final and shall not be subject to an administrative hearing request by the provider. Parents may appeal the decision to deny or discontinue payments pursuant to the requirements of section 17b-749-21 of the Regulations of Connecticut State Agencies.

(4) The request for reconsideration shall be made in writing by the provider and contain the details the department is being asked to consider. The department shall reach a decision within ten days of the date of the written request for reconsideration or the date that all necessary documentation has been submitted or obtained. The parent and provider shall be provided with a written response concerning the request for reconsideration..

(g) Enrollment of the Provider

(1) To be eligible for payment, the child care provider shall enroll in the CCAP program as the child's provider. To enroll, the provider shall complete the following actions:

(A) submit a completed child care agreement using a form prescribed by the department that provides details of the child care arrangements, including but not limited to information about the provider's licensing and accreditation status, the relationship of the provider to the child, the location where care is given, the days and hours of care and the actual charges for the care provided;

(B) certify that the child care provider and the facility meet the licensing and health and safety standards outlined in this section;

(C) provide any additional documentation required by the CCAP administrator, including but not limited to verification of identity;

(D) agree to report changes in the child care arrangements or licensing and accreditation status by the date the first invoice is submitted following the date of the change, whichever is earlier; and

(E) submit a completed W-9 form or other documentation of tax identification number as specified by the department.

(2) The parent shall be required to co-sign the child care agreement form. The parent's signature confirms the child care arrangements and serves as a release to allow the department to share information with the provider or as necessary for the administration of the CCAP program in accordance with the requirements of subsection (d) of section 17b-749-02 of the Regulations of Connecticut State Agencies.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-13 Payment calculations

(a) Calculating the Approved Cost of Care

(1) The CCAP administrator shall calculate the approved monthly cost of care for each eligible child based on the activity schedule, the need for care, the applicable payment rate and eligibility for increased payments due to an ongoing special needs supplement. The approved cost of care shall represent the maximum ongoing CCAP payment, excluding adjustments for supplements, accreditation and professional development incentives or underpayment corrections. The approved cost shall not exceed the amount charged by the provider, except to the extent that weekly charges are converted to an average monthly amount as specified in subdivision (2) of this subsection.

(2) In calculating the approved cost, the weekly payment rate and the provider's actual weekly charges shall be converted to average monthly amounts by multiplying by a factor of four and three tenths weeks per month. The results may be rounded to the nearest whole dollar amount.

(3) The approved monthly cost of care shall be the lesser of the following amounts:

(A) the maximum payment rate based on the authorized hours of care, the type of child care setting, the age of the child, the location where care is given or the location of the family's residence in cases were payment is approved for an out-of-state provider pursuant to subdivision (a)(2) of section 17b-749-12 of the Regulations of Connecticut State Agencies, plus

(B) fifteen percent of the amount determined in subparagraph (A) for a child with special needs who is eligible for an increase in the standard payment rate pursuant to the requirements of subdivision (b)(3) of section 17b-749-16 of the Regulations of Connecticut State Agencies; or

(C) the provider's actual monthly charges.

(4) The actual charge shall be the amount charged to the parent for services, unless the child attends a state-funded day care center or a school readiness program that charges families according to a sliding income scale pursuant to subdivision (b)(7) of section 17b-749-12 of the Regulations of Connecticut State Agencies. For children attending such programs, the actual charge shall be considered to be the lesser of the following amounts:

(A) provider's full charge for the program; or

(B) the maximum CCAP payment rate based on the authorized hours of care, the type of child care setting, the age of the child and the location where care is given; plus

(C) fifteen percent of the amount determined in subparagraph (B) for a child with special needs who is eligible for an increase in the standard payment rate pursuant to the requirements of subdivision (b)(3) of section 17b-749-16 of the Regulations of Connecticut State Agencies.

(5) Actual charges shall not exceed the amount charged by the provider for children attending the same program who do not receive assistance from CCAP.

(b) Authorized Hours of Care

(1) The CCAP administrator shall calculate the number of hours of care that are needed for each eligible child. The number of hours of care authorized shall be based on all of the following factors and shall be limited to not more than twelve hours in a twenty-four hour period:

(A) hours of the work or employment services activity;

(B) the availability of a parent who is living with the child to provide care;

(C) the hours the child is in school;

(D) travel time to and from the approved activity; and

(E) the hours of care specified on the child care agreement form.

(2) Care shall not be authorized during the hours the child is in school, an academic or home schooling program, when a parent living in the home is available and capable of providing care or outside the activity schedule, including travel and lunch time.

(3) The time needed to commute to and from the activity shall be taken into consideration when determining the actual number of hours of care that is needed. Travel time shall be limited to a maximum of one hour per day, unless the parent verifies that additional time is needed.

(4) Households where both parents participate in approved activities at different times shall be required to arrange their home schedules, including sleep time, in a manner that maximizes each parent's availability to provide care. If after making reasonable efforts to adjust their schedules child care is needed, care shall be authorized for the part of the day the parents are not able to supervise the child.

(5) A maximum of four hours per day may be approved to allow a parent who works third shift or an equivalent schedule to sleep if the child does not attend school or if the other parent is not available to provide care.

(6) Care shall not be authorized between the hours of eleven p.m. and seven a.m. if the child care provider is a person who resides in the same home as the child, unless the child is less than three years of age or has special needs.

(7) Weekly schedules shall be converted to monthly figures by multiplying by a factor of four and three tenths weeks per month. The result may be rounded to the nearest half-hour.

(8) If the hours of the activity fluctuate in an unpredictable manner, the CCAP administrator shall calculate the authorized hours by using a representative average of number of hours the individual is expected to participate in the activity over the period of the certificate.

(9) For parents beginning a new employment services activity, employment or changing schedules, the number of hours authorized shall be based on documentation provided by the parent, the employer or entity responsible for coordinating the employment services activity.

(10) The number of hours authorized shall not exceed the number of hours specified on the child care agreement form.

(11) The number of hours of care authorized shall be used as the basis for determining the level of care needed and the applicable payment rate. The maximum number of hours approved for any one child shall not exceed sixty-five hours per week or two hundred eighty hours per calendar month, except to the extent the child is eligible for a supplemental payment for an alternate child care provider pursuant to section 17b-749-16 of the Regulations of Connecticut State Agencies.

(c) Payment Rates

(1) The commissioner shall establish payment rates pursuant to the requirements of this subsection. The payment rates shall be updated periodically in accordance with state and federal requirements after consideration of local market conditions, or for unlicensed providers, changes in the minimum wage. The rates shall be established with the intention of providing participating parents with reasonable access to child care services available to the general public in a variety of settings. The payment rates shall be made available to the general public upon request.

(2) The payment rates for all providers shall be based on four levels of care. Each level shall cover a range of hours. The number of hours authorized in subsection (b) of this section shall be converted to an average monthly amount and used to determine the maximum allowable payment rate for each certificate of payment. The lower and upper limits of the four levels of care shall be as follows:

(A) for care in excess of full-time care, fifty one to sixty-five hours per week;

(B) for full-time care, thirty-five to fifty hours per week;

(C) for half-time care, sixteen to thirty-four hours per week; and

(D) for quarter-time care, one hour to fifteen hours per week.

(3) The commissioner shall have discretion to modify the payment rate structure to establish daily rates or other payment levels as necessary to approximate the manner in which child care providers charge for care in the open market, including supplemental payments for extended nontraditional hours.

(4) Payment rates for school-based child care programs and providers licensed by the Department of Public Health shall depend on the age of the child in care. Children shall be classified into the following age groups:

(A) infants/toddlers under the age of three;

(B) preschool children ages three through five; and

(C) school age children age six and older.

(5) The child's age group shall be established as of the date the certificate of payment is issued and shall remain the same until the family's next redetermination or until the certificate is cancelled and a new certificate of payment is issued for the child.

(6) Separate rates shall be established for the following types of child care providers:

(A) licensed child day care centers;

(B) licensed group day care homes;

(C) licensed family day care homes; and

(D) relatives, in-home care providers and other types of unlicensed providers.

(7) Payment rates for licensed providers shall be established for geographic regions as defined by the commissioner based on a review of local market conditions. The regional payment rate for a particular child shall be determined by the location at which child care is provided.

(8) With the exception of school-based child care programs, payment rates for unlicensed providers shall be based on the state minimum wage. The weekly payment rate for the full-time care of one child shall be equal to one third of the state minimum wage times forty hours. Payment rates for school-based child programs shall be determined in the same manner as rates for child day care centers, group and family day care homes licensed by the Department of Public Health.

(9) Providers who have attained national accreditation or completed professional development course work shall be entitled to bonus payments pursuant to subsection (d) of this section.

(10) The commissioner may take other market factors into consideration when establishing payment rates, including discounts given by providers who care for more than one child from the same family. The commissioner may establish payment limits or differentials for children who are cared for in their own homes pursuant to 45 CFR 98.30 based on the additional cost of providing care in a licensed setting, including insurance, facility and business expenses, staffing, professional certifications and early childhood education programming.

(11) The payment rate shall be increased by fifteen percent for a child with special needs who meets the requirements established in subsection (b) of section 17b-749-16 of the Regulations of Connecticut State Agencies.

(12) Payment rates may be modified at any time. Changes in rates shall be made effective on the date specified by the commissioner. A minimum of thirty days advance notice shall be given to parents and providers with active certificates of payment if the payment rates are decreased.

(d) Payment Incentives for Accreditation and Professional Development

(1) Licensed child care providers whose programs meet the standards promulgated by state or national accrediting agencies recognized by the commissioner shall be entitled to a payment incentive as long as they maintain their accreditation. The payment incentive shall be equal to five percent of the amount calculated in subdivision (b)(1) of section 17b-749-15 of the Regulations of Connecticut State Agencies prior to any deductions for fees, overpayments or any mandated withholding. Accrediting agencies recognized by the commissioner shall include but not be limited to:

(A) the National Academy of Early Childhood Programs, a division of the National Association for the Education of Young Children;

(B) the National School Age Child Care Alliance;

(C) the National Association of Family Child Care; and

(D) the Council on Accreditation of Services for Families and Children, Inc.

(2) The commissioner may establish additional payment incentives for licensed and unlicensed providers eligible for CCAP based on completion of course work toward achieving a Child Development Associate credential, a degree program or other professional development courses or credentials or other quality standards. Incentives may be paid as a lump sum bonus, a flat amount added to the monthly payment or as an increase in the payment rate.

(3) Providers shall apply for payment incentives in a manner specified by the CCAP administrator and shall provide satisfactory documentation. Incentives for eligible providers shall become effective in the month following the month in which the application and all required documentation are submitted to the CCAP administrator. Providers may be required to submit updated documentation confirming their current accreditation or professional development status. Providers shall notify the CCAP administrator if their accreditation is revoked or expires, or if the conditions that qualified the provider for the incentive pursuant to subdivision (2) of this subsection change. Incentives shall continue to be paid until the end of the month in which such status changes.

(e) Maximum Payments

(1) Payments for a child who is cared for by a single provider shall not exceed the established payment rate for fifty-one to sixty-five hours of care per week, excluding incentive payments for accreditation and professional development authorized under subsection (d) of this section and supplemental payments authorized under subsection (b) of section 17b-749-16 of the Regulations of Connecticut State Agencies.

(2) If a child receives care from two or more providers, the payment rate shall be calculated independently for each provider. The payment rate for each certificate of payment shall be based on the hours of care authorized for the provider, except that the total hours authorized for all providers shall not exceed sixty-five hours per week or two hundred eighty hours per month. To determine the level of care, the CCAP administrator shall first calculate the weekly number of authorized hours of care for the provider with whom the child spends the majority of time or the provider for whom an existing certificate is already in effect. The authorized hours for this provider shall be subtracted from the sixty-five to determine the maximum number of hours available for the other or new provider. If the hours are approximately equal, the CCAP administrator may consult with the parent to determine how the hours will be allocated. The CCAP administrator shall not be required to cancel a certificate that is already in effect.

(f) Parent Fee and Financial Responsibilities

(1) The parent shall be responsible for all costs not reimbursed by CCAP on behalf of the parent. In addition, families with earnings or self-employment income shall be responsible for paying a portion of the authorized cost of care based on a monthly sliding fee scale.

(2) To determine the monthly fee, the family's gross countable annual income shall be compared to the state median income standard (SMI) for the family size as promulgated annually by the Department of Health and Human Services. The fee shall be equal to the following percentage of the family's gross countable income:

(A) for families with income below twenty percent of the SMI, two percent;

(B) for families with income of twenty percent to less than thirty percent of the SMI, four percent;

(C) for families with income of thirty percent to less than forty percent of the SMI, six percent;

(D) for families with income of forty percent to less than fifty percent of the SMI, eight percent; and

(E) for families with income of fifty percent of SMI to less than seventy-five percent of SMI, ten percent.

(3) The fee may be rounded to the nearest whole dollar amount and applied against the approved cost of care as determined in subsection (a) of this section.

(4) The fee shall be allocated to the youngest child first or in a manner that will avoid the need to allocate a portion of the fee across multiple certificates. If the fee exceeds the approved cost for a child, the remaining amount shall be allocated to the next oldest child until the full parent share has been allocated. If payment is terminated, the CCAP administrator shall apply the unallocated fee to the remaining active children or to the new certificate issued for the same child after giving appropriate notice to the parent and provider.

(5) The family shall be ineligible if the monthly fee exceeds the approved cost for all of the eligible children.

(6) The monthly fee shall be determined at the time of application and when a redetermination is conducted. The fee shall remain the same until the next redetermination, unless an ongoing decrease in income occurs that is expected to last for at least two or more months. The fee shall not be increased between redeterminations if the family's income increases, except to correct an error in the prior calculation. Families shall be subject to the gross income limit and shall report increases in income exceeding fifty dollars per month even if the change does not immediately affect the fee.

(7) Decreases in the monthly fee shall be implemented in the month following the month in which the change is reported if the change is verified timely. If the change is not verified timely, the decrease shall take effect in the month following the month in which the change is verified, unless good cause exist for not providing timely verification pursuant to subsection (e) of section 17b-749-06 of the Regulations of Connecticut State Agencies.

(8) Parents shall be responsible for paying the fee to the provider. The family's eligibility shall not be affected if the fee is not paid to the provider.

(g) Compliance with Applicable Labor and Tax Laws for In-Home Care

Parents shall be responsible for compliance with applicable laws governing in-home domestic services. The CCAP administrator may withhold the parent's share of any mandated unemployment compensation, Social Security or Medicare taxes from payments issued to an in-home provider to the extent that benefits are paid to the in-home provider instead of the parent.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-14 Certificates of payment

(a) Authorizing Payments

(1) The CCAP administrator shall determine payment eligibility at the time assistance is granted if the information needed to enroll the provider was submitted with the application. If the information needed to determine payment eligibility was not submitted with the application, payment eligibility shall be determined within ten days of the date the completed child care agreement form and other information needed to determine payment eligibility is received.

(2) The CCAP administrator shall issue a certificate of payment to the parent and the provider if payment is approved. The certificate of payment is evidence of payment eligibility. Certificates of payment shall be issued for a particular child, provider and location of care, number of hours of care and for a specified period. Child care services provided outside the scope of the certificate shall not be eligible for payment by CCAP. A certificate of payment shall not be considered a grant or contract between the department and the child care provider.

(3) Certificates of payment shall include the names of the parent, the child and the provider, the number of authorized hours of care, the certificate authorization period, the maximum approved cost, the monthly fee where applicable, the approved payment amount and the payment authorization period.

(4) Certificates of payment shall be issued even when the authorized payment is zero due to the application of the monthly fee, provided another child is eligible to receive a payment.

(b) Payment Authorization Period

(1) Payment shall be limited to child care services provided between the start and end dates of the certificate of payment. The payment authorization period shall not exceed six months for any individual certificate.

(2) Payments may be authorized for up to ten days prior to the start of an activity if the parent is required to pay for services before the activity starts to secure a child care slot with a licensed provider. Payment shall be authorized prior to the start of the activity only if the slot would otherwise be filled because of a lack of vacancies in the program. Payments shall not be authorized in advance of the activity if care is given by an unlicensed provider.

(3) For families newly approved for participation in the CCAP program, the payment start date shall be the later of the following dates:

(A) the date the family becomes eligible for the program pursuant to subsection (g) of section 17b-749-09 of the Regulations of Connecticut State Agencies;

(B) the date child care services begin; or

(C) fifteen days prior to the date the completed child care agreement is submitted to the CCAP administrator if the application was granted without an approved provider for the child.

(4) For active families, the payment start date shall be the applicable date specified in section 17b-749-19 of the Regulations of Connecticut State Agencies.

(c) Payment End Date

(1) Eligibility for payment shall terminate automatically as of the date printed on the certificate of payment. Additional notice shall not be required.

(2) A certificate of payment shall be cancelled prior to the date indicated on the certificate under the following circumstances:

(A) if the family or child becomes ineligible for CCAP;

(B) if the child care provider becomes ineligible for CCAP; or

(C) if changes in household circumstances, the activity schedule or provider arrangements require recalculation of the benefit.

(3) Notice shall be given pursuant to the requirements of subsection (c) of section 17b-749-07 of the Regulations of Connecticut State Agencies.

(4) Payment eligibility shall end on the earlier of the following dates:

(A) the date specified on the certificate of payment;

(B) the last day services are provided;

(C) six calendar months from the start of the payment authorization period, but not later than the last day of the month family is scheduled for redetermination;

(D) the day the ten day advance notice of adverse action expires; or

(E) the date the notice of adverse action is issued if advance notice is not required.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-15 Payment process

(a) Monthly Invoices

(1) Payments shall be post-paid on a monthly basis. Payments shall be considered assistance to the parent, not assistance to the provider.

(2) The CCAP administrator shall issue a monthly invoice to the provider by the first day following the end of the service month or at the time the certificate of payment is issued to the provider for a retroactive period of payment eligibility.

(3) Providers shall return the completed invoice. By submitting the invoice, the provider shall attest to the services performed and the actual amount charged to the parent. The parent may also be required to sign the invoice as confirmation of the amount and cost of services performed. Invoices shall be submitted after the end of the service month. The provider shall have one hundred twenty days from the end of the service month or from the date the CCAP administrator issued the invoice to return the invoice to the department, whichever is later. Invoices submitted more than one hundred twenty days after the end of the service month shall not be paid unless the invoice is submitted late due to a CCAP administrative error or delay.

(4) The completed invoice shall reflect the provider's actual charges and shall be signed and dated by the provider. Weekly charges shall be converted to an average monthly amount by multiplying by a factor of four and three tenths. Providers shall also report attendance or other information as required by the CCAP administrator. The parent may be required to co-sign the invoice for all or specific types of child care settings.

(5) Payment shall be issued within fifteen days of the date the properly completed invoice is submitted to the CCAP administrator.

(b) Payment Calculations

(1) Payments for the service month shall be calculated based upon submission of the completed invoice. The amount of the CCAP payment shall be determined by adding or subtracting the amounts listed in subdivisions (2) and (3) of this subsection to the lesser of the following amounts:

(A) the approved cost of care calculated in subdivision (a)(3) of section 17b-749-13 of the Regulations of Connecticut State Agencies; plus

(B) any supplemental payments authorized for the provider under subsection (a) and subdivision (b)(4) of section 17b-749-16 of the Regulations of Connecticut State Agencies; or

(C) the provider's actual charges for the service month.

(2) Incentives for accreditation and professional development authorized under subsection (d) of section 17b-749-13 of the Regulations of Connecticut State Agencies that are paid as a percentage increase in the payment shall be added to the amount calculated in subdivision (1) of this subsection. Lump sum and flat rate incentives may be issued together with the regular monthly payment or paid separately.

(3) The allocated monthly fee determined in subsection (f) of section 17b-749-13 of the Regulations of Connecticut State Agencies and any reductions due to the recoupment of an overpayment or mandated withholding shall be deducted from the sum of the amounts calculated in subdivisions (1) and (2) of this subsection. The resulting total shall be the CCAP payment amount. Payments shall be prorated if the child is eligible for payment for only part of the month. Parents shall be responsible for any costs not covered by CCAP.

(c) Payee

(1) Unless otherwise specified in this section, benefit payments shall be made to the order of the child care provider or to the provider's fiduciary if the provider is a subcontractor or part of a network of child care providers. Benefit payments shall be mailed to the provider's home or business address or issued through direct deposit, except that the department shall have the option of paying the parent directly for care that is provided in the child's own home. In such cases, the benefit payment shall be issued to the parent's home address. If the department elects to make benefit payments through direct deposit, parents and providers shall cooperate in establishing a bank account as a condition of payment eligibility.

(2) Benefit payments issued by mail may be sent to a post office box address under the following conditions:

(A) if the provider is not a relative or in-home provider, and the provider's business address is a post office box; or

(B) if the parent or provider has submitted adequate verification of residence and the postal authority confirms that mail is not delivered to the home address.

(3) Benefit payments may be issued to an alternate payee under the following conditions if the individual acting on the behalf of the provider can verify that services were provided:

(A) if the provider is deceased at the time the payment is issued, payment shall be issued to the fiduciary of the provider's estate appointed by the probate court; or

(B) if the provider becomes incapacitated or incompetent, payment shall be issued to a conservator appointed by probate court or other individual acting with power of attorney.

(4) Benefit payments may be issued to the parent on an exception basis if an administrative error caused payment to be delayed for three or more months and the parent was required to pay the provider for the full cost of care while waiting for the department to correct the error. The parent and provider shall be required to verify that the parent has already reimbursed the provider for the services and that payment should be remitted to the parent rather than the provider.

(d) Stale Dated Checks

Checks issued as payment for child care services shall become void if they are not cashed within sixty days.

(e) Lost, Stolen or Destroyed Checks

(1) The payee may request replacement of a lost, stolen or destroyed check within ninety days of the date the original check was issued. If the CCAP administrator determines that the original check was signed or cashed by the provider, the parent or a member of the family, no replacement check shall be issued. Payments issued through direct deposit shall not be replaced under any conditions.

(2) The payee shall be required to submit a notarized affidavit using a form specified by the CCAP administrator prior to replacing the lost, stolen or destroyed check, unless the check has been returned and has not been transacted. The payee shall also file a police report if requested by the CCAP administrator, and cooperate with any investigations conducted by the department or the police.

(3) The CCAP administrator may withhold replacement checks for up to fourteen days from the date the affidavit is submitted if payment of the original check could not be stopped or if the original check has not been recovered or has been cashed. In the event of an ongoing investigation, the replacement check may be withheld indefinitely pending completion of the investigation.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-16 Supplemental payments

(a) Supplements for Additional Hours of Care

(1) Parents shall be entitled to request a supplemental payment for increased care with the same provider when the child care needs temporarily exceed the authorized hours of care reflected on the certificate by more than twenty hours in a calendar month as the result of the following circumstances and the parent is charged for the additional hours:

(A) school closes for vacation or other reasons;

(B) the child is required to attend child care instead of school for three or more consecutive days due to illness or other reasons;

(C) there is a temporary increase in work hours or the hours of an employment services activity; or

(D) there is a temporary change in the availability of a parent who usually provides care.

(2) Supplemental payments for the additional hours of child care with the same provider shall be approved if all of the following conditions are satisfied:

(A) the additional hours of care needed exceed the authorized hours as determined in subsection (b) of section 17b-749-13 of the Regulations of Connecticut State Agencies by more than twenty hours in a calendar month; and

(B) the hours of care fall within the work or employment services activity schedule including travel time; and

(C) the hours do not coincide with hours covered by an existing certificate of payment; and

(D) the additional charges reflect the provider's customary policy for all children attending the program.

(3) In addition to supplemental payments authorized under subdivision (1) of this subsection, the CCAP administrator may approve payments for a temporary alternate child care provider for up to twenty hours in a calendar month if the parent is required to use a different provider for the following reasons:

(A) the child does not attend school due to illness or other reasons and the child's regular provider can not provide the care;

(B) a temporary increase in work hours or the hours of the employment services activity that fall outside the normal operating hours of the child's regular provider; or

(C) during holiday vacations or periods during which the child's normal provider is closed or does not offer care.

(4) The parent shall submit a child care agreement form for the alternate provider and have the provider enrolled pursuant to the requirements of section 17b-749-12 of the Regulations of Connecticut State Agencies.

(5) In any calendar month, the parent shall be responsible for all costs associated with the first twenty hours of additional care. Payment shall be authorized only for the additional hours of care with the same or alternate provider that exceed twenty hours separately or in combination. The additional hours may be rounded to the nearest half hour.

(6) The amount of the supplement shall be calculated by multiplying the additional needs in excess of the twenty hours by the special hourly supplemental payment rate. The hourly supplemental payment rate shall be the weekly payment rate for full-time care established in subdivision (c) of section 17b-749-13 of the Regulations of Connecticut State agencies, divided by forty. The payment amount shall be the lower of the calculated amount or the amount of the provider's additional charges.

(7) The total number of regularly authorized hours plus the additional hours shall not exceed sixty-five hours per calendar week or two hundred eighty hours in a calendar month. Once the approved additional hours of care exceed twenty hours, the additional hours approved for that month shall be eligible for payment.

(8) Parents shall request supplemental payments by contacting the CCAP administrator by phone or in writing, except during periods of extended school vacations where the CCAP administrator shall have the discretion to authorize payments based on information submitted by the provider for a school age child already in the provider's care. To be eligible for payment, all requests for supplemental payments shall be made within thirty days following the end of the month in which the additional hours were provided. The parent and provider shall submit any verification requested as a condition of payment eligibility. The CCAP administrator shall have thirty days to process the request for a supplemental payment once all required documentation has been submitted.

(b) Supplemental Payments for Children with Special Needs

(1) Parents shall be entitled to request additional payments for an eligible child with special needs pursuant to section 17b-749-11 of the Regulations of Connecticut State Agencies. Supplemental payments shall be approved to the extent the provider cannot serve the child in his or her regular program after implementing reasonable accommodations as may be required by the Americans with Disabilities Act, 42 U.S.C. § 12132 et. seq.

(2) Payments shall not be made for services provided by a program operated by any state or local government agency. The parent shall apply and take steps necessary to receive assistance from such programs upon the request of the CCAP administrator. The request for a special needs supplement shall be denied if the parent does not apply and take the necessary steps to obtain services.

(3) An increase in the payment rate may be granted if the child's condition requires a marked increase in the amount of care or supervision needed or special care, including but not limited to the use of special equipment, assistance with movement, feeding, toileting or the administration of medications that require specialized procedures. The child's special needs shall be clearly documented to the satisfaction of the CCAP administrator by an Individualized Education Program (IEP), or an Individualized Family Service Plan (IFSP), the child's physician or another certified health care professional who is directly involved with the child. Additional documentation may be required as necessary to establish the need for special care in the child care setting. The amount of the increase shall be equal to fifteen percent of the payment rate for a child with no special needs as determined in subsection (c) of section 17b-749-13 of the Regulations of Connecticut State Agencies. The supplement shall be included in the approved cost of care as determined in subsection (a) of section 17b-749-13 of the Regulations of Connecticut State Agencies for the purpose of calculating the monthly payment.

(4) A child with special needs may be eligible for supplemental payments for identifiable costs charged to the parent by the provider for services specifically associated with the provision of child care to the individual child. Payments for identifiable costs shall be in addition to any increase in the payment rate authorized pursuant to subdivision (3) of this subsection. Services and costs that may be eligible for payment shall include, but not be limited to the following:

(A) rental of equipment needed to provide appropriate care, such as maintenance apparatus that assists in breathing, feeding or toileting as prescribed by a therapist, physician or other state certified specialist and that is not transportable and cannot be provided by the parent;

(B) special furniture, materials or supplies used on a routine basis as prescribed by a therapist, physician or other certified specialist and that are not provided by the parent; and

(C) a personal child care attendant for prescribed periods;

(D) specialized training needed to care for the child that is not otherwise available without charge.

(5) Supplemental payments for identifiable costs shall not be approved for special transportation services, special education, therapeutic services or other costs not directly related to the provision of child care, the cost of diapers, supplies or other items provided by the parent, facility improvements, equipment, materials or expenses for services or accommodations that are or would be available to all children enrolled in the facility and that cannot be categorized as assistance to the parent.

(6) The maximum payment for identifiable costs in any month shall not exceed twenty percent of the standard payment rate for a child of the same age and approved hours of care with no special needs as determined in subsection (c) of section 17b-749-13 of the Regulations of Connecticut State Agencies. Any costs incurred during a month that exceed twenty percent of such rate shall be the responsibility of the parent and shall not carry over as billable charges to the department in subsequent months. The commissioner may disapprove payments for identifiable costs where the cost of supporting the child in the child care setting is determined unreasonable or excessive relative to services available from other similar providers, vendors or through other means.

(7) The parent and provider shall submit a written request to the CCAP administrator that includes a description of the additional services, why they are needed, verification of the cost of the services and the payment schedule where applicable. The request shall be co-signed by the parent.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-17 Payment adjustments

(a) Child's Attendance

(1) Occasional absences from care shall not affect the amount of the payment unless the provider charges less due to the reduced hours. Providers shall, however, report the number of days the child attended care and any reduction in charges due to absence. Providers shall charge parents in accordance with the provider's customary attendance policy for children who do not receive CCAP assistance.

(2) Parents may be required to document the reason the child did not attend care if the child is frequently absent for twenty-five percent or more of the scheduled days. Continued absences equal to or exceeding the twenty-five percent threshold may cause the approved hours of care to be recalculated based on the child's utilization pattern if the absences continue for two or more months. The approved hours shall be readjusted if the condition that caused the recurring absences changes.

(b) Liens, Overpayment Recoupments and Child Support Wage Executions

The CCAP administrator shall reduce payments as necessary to fulfill legal responsibilities related to properly filed liens, overpayment recoupments and child support wage executions. Overpayments shall be recouped in accordance with the requirements of section 17b-749-20 of the Regulations of Connecticut State Agencies.

(c) Discretion to Withhold for Employment Related Obligations

(1) Parents shall be informed that there may be state and federal requirements to withhold employment related obligations from wages paid by parents to in-home child care providers to the extent the provider is not considered to be self-employed or a self-contractor, and is considered to be the employee of the parent.

(2) The CCAP administrator may, if requested by commissioner, deduct amounts for employment related obligations from benefit payments for in-home child care services if parent of the child for whom the benefit is paid is determined to be the employer of the provider. Any amounts withheld shall be properly deposited with the appropriate federal or state agency. Parents and providers shall receive notice of all deductions made in accordance with this subdivision.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-18 Continued eligibility

(a) Optional Monthly Verification of Participation in Activities

(1) The commissioner may require parents to submit verification of their activity schedules monthly. The decision to require more frequent verification of participation in activities shall be based on the following criteria:

(A) CCAP case error profiles; or

(B) whether the activity schedule or the parent's history of participation fluctuates in a manner that requires frequent or continuous monitoring.

(2) Verification shall be due on the tenth day of each month. The requirement may be waived in the redetermination month based on verification submitted with the redetermination. Families not submitting verification by the end of the month shall become ineligible.

(3) The CCAP administrator shall issue a reminder notice to all parents who did not submit verification by the tenth day of the month. The notice shall inform parents that assistance will be discontinued if the verification is not received by the last day of the month. Discontinued families who submit the required verification within ten days of the discontinuance date shall be reinstated retroactive to the date of discontinuance if continued eligibility is established.

(b) Redeterminations

(1) Eligibility shall be redetermined at intervals not to exceed six months from the month assistance is granted or from the last redetermination. The CCAP administrator shall establish the length of the redetermination period based on the stability of family circumstances and may conduct unscheduled reviews due to anticipated changes in household circumstances. Eligibility shall terminate at the end of the redetermination month unless the redetermination is completed and the family is determined eligible.

(2) Parents shall complete a new application using a form specified by the CCAP administrator and shall submit verification and have their redeterminations processed in the same manner as at the time of initial application. Parents shall not be required to re-verify circumstances that have already been verified and are not questionable or subject to change.

(3) Parents and their child care provider(s) shall be notified of the redetermination between forty-five and sixty days prior to the last day of the redetermination month. Parents shall have a minimum of fifteen days from the date the redetermination form is mailed to return the form to the CCAP administrator. The redetermination form shall be due on the first day of the redetermination month.

(4) Redeterminations forms submitted timely shall be processed by the end of the redetermination month. Redetermination forms submitted after first day of the redetermination month shall be considered late and shall be processed in the same manner as a new application. The CCAP administrator shall have thirty days from the date the form is received to process a redetermination that is submitted late, unless processing is delayed in accordance with the requirements of subsection (c) of section 17b-749-09 of the Regulations of Connecticut State Agencies. Parents shall be issued a reminder notice if the redetermination is not submitted on time. The CCAP administrator shall give priority to processing redeterminations forms that are submitted late.

(5) Families who submit redeterminations forms late, but by the tenth day following end of the redetermination month, shall not be assigned to the wait list if the CCAP program is closed to the family's priority group at the time eligibility is determined. If eligible, the family shall be approved for participation. Families who are denied shall be entitled to have their redeterminations reopened in accordance with the requirements of subsection (e) of section 17b-749-09 of the Regulations of Connecticut State Agencies. Redeterminations are denied and later reopened shall be granted retroactive to the first day of the month following the end of the prior redetermination period if the family is eligible.

(6) Parents and providers shall be notified of the results of the redetermination.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-19 Changes in eligibility or benefits

(a) Reporting and Processing Changes

(1) Parents shall report changes in household circumstances and child care arrangements to the CCAP administrator within ten days of the date of the change. Changes may be reported by phone, in writing, or electronically as authorized by the department.

(2) Program and payment eligibility shall continue in accordance with the requirements of this section. Families shall remain eligible until the parent withdraws from the program or until the family no longer meets the eligibility requirements of the CCAP program. Providers shall remain eligible as long as they meet the requirements of section 17b-749-12 of the Regulations of Connecticut State Agencies.

(3) Changes in eligibility or benefits shall be processed in accordance with the requirements of this section and sections 17b-749-02 to 17b-749-23 of the Regulations of Connecticut State Agencies, inclusive. Prompt action shall be taken to determine the effect of a change whenever the CCAP administrator becomes aware that a change has occurred. To be considered prompt, action shall be taken within ten days of the date of the CCAP administrator becomes aware of the change in circumstances.

(b) Termination of Program Eligibility

(1) Eligibility for the program shall end if the family no longer meets the CCAP eligibility requirements, if eligibility cannot be established because the parent did not provide requested information or if the parent did not comply with the eligibility or quality control processes. Eligibility for the program shall end on the last day of the month in which the change occurs, unless advance notice is required pursuant to subsection (c) of section 17b-749-07 of the Regulations of Connecticut State Agencies. If advance notice is required, program eligibility shall end on the last day of the month in which the notice of adverse action expires.

(2) Families who were granted assistance without an approved provider shall become ineligible for CCAP if they do not submit the information needed to determine payment eligibility for at least one child within thirty days pursuant to the requirements of subdivision (c)(4) of section 17b-749-09 of the Regulations of Connecticut State Agencies. Eligibility shall end at the end of the month in which the thirtieth day falls.

(c) Determinations of Provider Ineligibility by the Department

(1) Eligibility for payment shall end if the department determines that the child care provider does not meet the requirements specified in section 17b-749-12 of the Regulations of Connecticut State Agencies. Eligibility for payment shall terminate on the date the parent and provider are notified of the change. Any outstanding payments to the provider may be withheld pursuant to subdivision (c)(4) of section 17b-749-12 of the Regulations of Connecticut State Agencies.

(2) A provider shall be considered ineligible as of the date the provider did not meet the eligibility requirements established for providers. Payments issued during a period when the provider was ineligible shall be considered overpayments and shall be subject to recoupment pursuant to the requirements of section 17b-749-20 of the Regulations of Connecticut State Agencies.

(3) Parents shall be given thirty days from the date of notification to submit a child care agreement form for the new provider. Payment for the new provider may begin retroactive to the date the services started if the information needed to enroll the provider is submitted timely. If the information is not submitted timely, payment shall begin on the date the information is submitted or the date the services begin, whichever is later. Eligibility for the program shall end on the last day of the month in which the thirtieth day falls if the child care agreement form is not submitted by the end of that month and there are no other children in the family who are eligible for payment.

(d) Decreasing Benefits or Terminating Payments

(1) Changes that cause payments to be reduced or terminated shall take effect on the following dates, unless otherwise specified in this section:

(A) the date the action is taken if advance notice is not required; or

(B) the day after the notice of adverse action expires if advance notice is required; or

(C) within ten days of the date of an administrative hearing decision if action was delayed pending the hearing, and the department's decision is upheld.

(2) Increased fees shall take effective on the first day of the family's next redetermination period pursuant to subsection (f) of section 17b-749-13 of the Regulations of Connecticut State Agencies.

(3) If benefits are terminated because a child reaches the maximum age limit for the program, payments shall end on last day of the month in which the child turns age thirteen, or age nineteen for a child with special needs. Eligibility shall continue for the family unless there are no other eligible children in the home.

(e) Adding Children and Increasing Payments

(1) With the exception of benefit increases that are due to a reduction in the family fee, changes that result in increased payments or payment eligibility for a new child shall take effect on the date the change is reported if the change is verified timely. If the change is not verified timely, the change shall take effect on the date the change is verified unless good cause exists for not providing timely verification pursuant to subsection (e) of section 17b-749-06 of the Regulations of Connecticut State Agencies. The parent shall not be eligible for a supplemental payment to replace any benefits that would otherwise have been paid if the parent had submitted the verification timely.

(2) Decreases in fees shall be implemented in accordance with the requirements of subsection (f) of section 17b-749-13 of the Regulations of Connecticut State Agencies.

(f) Changing Providers

(1) Parents may change providers at any time. The certificate of payment for the current provider shall expire on the date services ended or the date the CCAP administrator issues written notice to the provider if the change is reported after services ended. Payments for the new provider shall not begin prior to the date the current certificate of payment expires. To avoid a lapse in coverage, parents shall report changes in providers to the CCAP administrator at least ten days in advance of the date of the change.

(2) Parents who change providers shall be given fifteen days to submit a child care agreement form for the new provider. Eligibility shall terminate at the end of the month in which the fifteenth day falls if the child care agreement form is not submitted by the end of that month and there are no other children in the family who are eligible for payment. If the child care agreement form is submitted late but before eligibility is terminated, the change shall be effective on the date the form is submitted or the date services began, whichever is later. Good cause provisions shall not apply. If eligibility is terminated, the parent shall reapply for the program.

(g) Extended Program or Payment Eligibility

(1) Otherwise eligible families who timely report the loss or interruption of employment, an employment services activity or attendance in a high school program shall, upon request, be granted an extended period of program eligibility pursuant to the requirements of this subsection. To qualify, the parent shall report the change to the CCAP administrator within ten days of the date of the interruption without exception. Eligibility for payments during the extended eligibility period shall be determined separately in accordance with the requirements of subdivision (6) of this subsection.

(2) If employment is terminated or unpaid leave is taken due to pregnancy, an additional four months of program eligibility shall be granted if the parent intends to return to work by the end of the four month period.

(3) If employment is terminated or leave is taken due to an extended illness or other circumstances covered under the Family and Medical Leave Act, an additional three months of program eligibility shall be granted if the parent intends to return to work on a regular basis by the end of the three month period.

(4) If the activity is interrupted when school closes for the summer vacation, an extended period of program eligibility shall be granted to cover the period of time school is closed.

(5) In all other circumstances where a parent timely reports a temporary interruption in employment or an employment services activity, an additional month of program eligibility shall be granted under the following conditions:

(A) if the parent is expected to resume the activity by the end of the month following the month in which the interruption occurred; or

(B) if the parent terminated employment and is actively seeking a new job or has received a bona fide offer of employment that is scheduled to begin by the end of the month following the month in which the prior activity ended; or

(C) if the parent is expected to begin a new employment services activity by the end of the month following the month in which the current activity ended and the parent continues to receive TFA cash assistance during this period; and

(D) if the parent is capable of participating in the activity.

(6) Parents who meet the conditions specified in subdivision (5) of this subsection shall be eligible for payments during the period of extended eligibility if the parent verifies that payment is needed to prevent the loss of a slot in a school-based child care program or a licensed child care setting and the child continues to attend child care. Payments shall not be approved for families granted extended program eligibility pursuant to subdivisions (2) through (4) of this subsection, if the child does not attend care, or if care is given in a setting that is not school-based or licensed.

(7) Otherwise eligible families who timely report the loss of the need for care during the summer while their children attend temporary no cost alternative child care, such as a summer camp, shall remain eligible for the program for up to three calendar months if assistance will be needed by the end of the summer period.

(h) Changes during Extended School Vacations or Affecting the General Caseload

The department may establish special procedures for processing changes that occur as the result of school vacation periods or other changes that affect the general caseload, including specific reporting deadlines, timeframes for processing changes and issuing payments. The CCAP administrator shall provide adequate notice to parents and providers of any actions they are required to complete under this subsection.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-20 Benefit errors

(a) Underpayments and Overpayments

(1) The CCAP administrator shall take prompt action in accordance with the requirements of this section whenever an error occurs that causes benefits to be underpaid or overpaid.

(2) Underpayments occur when the parent does not receive all the benefits to which the family is entitled due to an administrative error made by the department, the CCAP administrator or upon submission of satisfactory documentation of an error made by the Department of Labor or its designee for a family participating in an employment services activity. The evidence shall clearly demonstrate that an administrative error occurred. Errors caused by the family or the provider shall not be considered underpayments, except when a provider makes a billing error on an invoice and the CCAP administrator is notified of the error within thirty days of the date the payment is issued to the provider.

(3) Overpayments occur whenever the amount paid exceeds the benefit that would have been paid if the payment had been calculated correctly based on accurate information that was reported, verified and acted on in a timely manner. The cause of each overpayment shall be classified as administrative, parent or provider caused. Parent and provider caused overpayments shall be further classified as intentional or unintentional.

(4) No overpayment shall exist if the difference between the benefits paid on behalf of the family and the correct benefit amount is less than ten dollars in any month.

(b) Administrative Errors

(1) An overpayment or underpayment shall be classified as an administrative error if the error was caused solely by actions taken by the department, the CCAP administrator or the Department of Labor or its designee. Administrative errors shall include, but not be limited to the following types of errors:

(A) errors caused by delays in processing applications or taking prompt action on changes that were reported timely;

(B) errors in determining eligibility, the benefit amount or the payment authorization period;

(C) data entry errors;

(D) errors caused by the incorrect application of state regulations, policy or procedures; and

(E) fraud committed by an individual who works for the CCAP program.

(c) Errors Caused by Parents and Providers

(1) Overpayments that are not due to administrative error shall be classified as parent or provider caused.

(2) Overpayments caused by the parent shall include, but not be limited to errors caused by reporting false or inaccurate information, delays in reporting changes in household circumstances or provider arrangements, or excess payments made as the result of a request to continue benefits pending an administrative hearing.

(3) Overpayments caused by the provider shall include, but not be limited to the following types of errors:

(A) inaccurate reporting of information concerning licensing status, age or other provider eligibility requirements;

(B) inaccurate reporting of the provider's relationship to the child or the location at which care is given;

(C) inaccurate reporting of household circumstances;

(D) committing an illegal act, such as cashing a replacement check after falsely claiming that the original check was lost, stolen or destroyed;

(E) inaccurate reporting of actual charges, attendance or dates of service; and

(F) any other false claim for goods or services provided as enumerated in section 53a-290 of the Connecticut General Statutes.

(4) The error shall be classified as both parent and provider caused if the parent and the provider both had knowledge and actively participated in the action that caused the overpayment to occur.

(5) The CCAP administrator shall make a preliminary determination of whether the overpayment was intentional or unintentional pursuant to guidelines established by the department. Overpayments shall be classified as intentional if the parent or provider knowingly withheld or provided false information on matters affecting eligibility, benefits or a claim for services. An overpayment shall be considered unintentional under the following circumstances:

(A) if there was clearly no intent to commit fraud or to obtain benefits or payments under false pretenses;

(B) if the parent or provider did not purposefully withhold or provide erroneous information;

(C) if illness, a family emergency or other good cause reasons exist for not reporting information timely or accurately; or

(D) if the error was due to a delay in taking action as the result of an administrative hearing request.

(6) Where the CCAP administrator makes a preliminary determination that a parent or provider may have committed fraud, the case may be referred as appropriate to the Office of the Attorney General, the Office of the Chief State's Attorney or for an administrative disqualification hearing. Administrative disqualification hearings shall be conducted in accordance with the requirements of section 17b-749-22 of the Regulations of Connecticut State Agencies.

(7) A final determination that an error was intentional shall be made only as the result of a decision by a court or administrative hearing official, or if the parent waives his or her right to an administrative hearing. If the error was intentional, the CCAP administrator shall disqualify the family or the provider from participating in CCAP for the period specified in subsection (h) of this section.

(d) Calculating the Error

(1) Benefit errors shall be calculated by comparing the benefits paid during the applicable benefit period to the payment that would have been payable if eligibility and payment had been calculated correctly. The difference between the correct benefit and the amount actually paid shall be the amount of the error.

(2) If benefits are underpaid due to an administrative error, the amount owed shall be paid within sixty days of the date the error was discovered, unless information needed to calculate the correct payment is pending or if the family or provider has an outstanding overpayment. The amount of the underpayment shall first be used to offset an outstanding overpayment.

(3) Underpayments shall be corrected regardless of whether the family's case is active or closed. The parent and provider shall be notified of the determination.

(4) For overpayments caused by the parent or provider that are unintentional, the error shall begin on the first day of the month following the month in which the circumstances that caused the overpayment occurred.

(5) For administrative overpayments, the overpayment shall begin on the first day of the month following the month in which the circumstances that caused the overpayment occurred, unless action would have been taken after that date due to a required period of advance notice. If advance notice would have been required, the overpayment shall begin on the day after the period of notice of adverse action would have expired. To determine this date, the CCAP administrator shall assume that the notice of adverse action would have been issued on the day sufficient information existed to warrant taking the proposed action.

(6) For intentional errors, the overpayment shall begin on the date the circumstances that caused the overpayment occurred without regard to advance notice requirements. If the CCAP administrator fails to take timely action to correct the overpayment following discovery of the error, any benefits overpaid as the result of the administrative delay shall be considered administrative error.

(e) Responsibility for Repayment

(1) The parent shall be responsible for repaying the overpayment unless the overpayment was caused solely by the provider. If the parent is responsible for the overpayment and recoupment is initiated by reducing the parent's monthly benefits, the provider may require the parent to pay the difference between the regular payment and the reduced amount.

(2) If the provider is solely responsible for the error, the provider shall repay the overpayment. Providers shall not increase charges for children subsidized by CCAP to compensate for the loss of income due to the recoupment of an overpayment caused by the provider.

(f) Notice of Overpayment

The party responsible for the overpayment shall be provided with advance notice of the overpayment, the amount and repayment options. The responsible party shall be asked to select a repayment method as outlined in subsection (g) of this section. If the parent is responsible for repaying the overpayment, the provider shall be notified in advance of the proposed change in benefits. Written notice to the parent shall not be required if the provider is responsible for repaying the overpayment.

(g) Methods of repayment

(1) If the recoupment method and rate has not been set by a court, the CCAP administrator shall first attempt to recover overpayments by a lump sum repayment or by offsetting the amount of the overpayment against any benefits owed as the result of an underpayment. If the parent or provider does not agree to a lump sum repayment, the CCAP administrator shall reduce the parent's or the provider's ongoing payments by the lessor of the following amounts until the overpayment has been recouped:

(A) ten percent of the parent's monthly benefits or the provider's monthly payment if the overpayment was due to an administrative or unintentional error; or

(B) twenty-five percent of the parent's monthly benefits or the provider's monthly payment if the overpayment was due to an intentional error.

(2) The percentage reduction shall be applied to each child for whom the parent receives CCAP assistance or who are in the provider's care. Recoupment shall be initiated automatically if the parent or provider does not respond to the advance notice.

(3) If the parent or provider do not actively receive CCAP payments, the department shall attempt to recover the overpayment by establishing a monthly billing schedule.

(4) If the parent or provider does not comply with the repayment plan, the commissioner may, to the extent allowed by law, take whatever action deemed appropriate to recover such overpayment.

(h) Disqualification Penalties in Fraud Cases

(1) Parents who are overpaid due to an intentional error may be referred to an administrative disqualification hearing or to a court of appropriate competent jurisdiction if the CCAP administrator determines that the parent may have committed fraud. Child care providers shall not have the right to an administrative hearing.

(2) The CCAP administrator shall impose a disqualification penalty on the family if the parent is found to have knowingly committed fraud in connection with obtaining benefits from CCAP. A penalty shall be imposed only after a final determination that the parent committed fraud has been made pursuant to the requirements of subsection (a) of section 17b-749-22 of the Regulations of Connecticut State Agencies.

(3) For the first finding of fraud committed by a parent, the period of ineligibility shall be three months from the date the notice of disqualification is issued or from the date the family's benefits are discontinued, whichever is later. For the second finding of fraud, the disqualification period shall increase to six months. For any subsequent finding, the disqualification period shall be one year for each occurrence.

(4) Child care providers convicted of committing vendor fraud by an appropriate court of competent jurisdiction shall be permanently disqualified from participation pursuant to the requirements of sections 17b-99 and 53a-290 of Connecticut General Statutes.

(5) Parents may reapply and be approved for assistance at the conclusion of the disqualification period.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-21 Administrative hearings

(a) Hearing Authority

Administrative Hearings shall be conducted by the department in accordance with the provisions of Chapter 54 of the Connecticut General Statutes.

(b) Right to an Administrative Hearing

(1) Parents shall have the right to request an administrative hearing if they are aggrieved by an action taken by the department, except in situations specified in subdivision (d)(2) of this section. Child care providers shall not have the right to an administrative hearing. A parent may request an administrative hearing if the parent is aggrieved by an action taken against a child care provider to the extent such action was not the result of a decision by the Department of Public Health to deny, suspend or revoke the provider's license.

(2) The request for an administrative hearing shall be made within sixty days of the date the parent was provided with written notice of the action.

(c) Aid Continuing Pending a Hearing

(1) Action to discontinue or reduce benefits shall be delayed until the administrative hearing decision is rendered under the following circumstances:

(A) if the parent requests a hearing within ten calendar days of the date the notice of adverse action is issued;

(B) if the action being taken is subject to an administrative hearing;

(C) if the action does not involve termination of payments due to the ineligibility of the child care provider; and

(D) if the parent requests benefits to continue.

(2) If the administrative hearing officer rules in favor of the Department, any benefits paid in error as the result of the delayed action shall be subject to recoupment.

(d) Reasons for Requesting an Administrative Hearing

(1) An administrative hearing may be requested if the family disagrees with any of the following actions, except where otherwise specified in subdivision (2) of this subsection:

(A) an application is denied or not acted upon timely;

(B) benefits are denied, reduced or discontinued;

(C) the receipt of benefits is adversely affected in any way;

(D) an eligibility requirement is imposed incorrectly;

(E) the amount of the income, fee or benefit calculation is incorrect;

(F) disapproval of an in-state child care provider for a reason not related to a violation of the Department of Public Health licensing requirements;

(G) a request for replacement of a lost, stolen or destroyed check was refused; or

(H) a requested good cause exemption of the child support requirements was denied.

(2) Families shall not be entitled to an administrative hearing for the following actions:

(A) when changes required by state or federal law are implemented that affect the general caseload or a specific priority group;

(B) if benefits are affected due to a change in the sliding fee scale or changes in the regional payment rates;

(C) if the commissioner opens or closes the wait list for a specific priority group or removes a priority group from the wait list;

(D) if the commissioner denies payment for a provider located in an adjoining state; or

(E) if the CCAP program is closed.

(e) Notice Requirements

(1) Parents shall be informed in writing of the following information any time action is taken to grant, deny, discontinue or modify benefits:

(A) the right to request an administrative hearing and the method by which an administrative hearing can be requested;

(B) that action may be delayed if a hearing is requested within ten days of the date the notice of adverse action is issued, and that any benefits paid in error as the result of the delay will be subject to recoupment if the administrative hearing official upholds the department's decision;

(C) that the family may represent itself or be represented by legal counsel, a relative, friend, or other spokesperson;

(D) the right to request resolution of the issue through someone not directly involved with the parent's case; and

(E) the availability of legal services and the toll free telephone number of statewide legal service organizations.

(2) The administrative hearing official shall notify the parent and the parent's representative of the following information:

(A) the time and place of the administrative hearing;

(B) the department's contact person;

(C) circumstances under which the hearing request may be dismissed;

(D) administrative hearing procedures; and

(E) the right to examine the case record prior to and during the administrative hearing.

(3) The CCAP administrator shall prepare a written summary of actions over which the parent is aggrieved and the reason for taking the action. The summary shall be distributed at least three business days prior to the date of the scheduled hearing to the administrative hearing officer and the parent or the parent's representative.

(f) Scheduling and Location of the Administrative Hearing

(1) The department shall schedule the administrative hearing within thirty days of the date the request is received. One continuance shall be granted to the parent for good cause as determined by the administrative hearing official. Additional continuances may be granted at the discretion of the administrative hearing official. The deadline for issuing a decision shall be extended by the length of the continuance.

(2) If the issue is resolved prior to the administrative hearing, the hearing shall be held unless the parent or his or her representative withdraws the request in writing or through other communication with the administrative hearing official.

(g) Delegation of Authority to an Administrative Hearing Official

(1) The commissioner may delegate authority to conduct administrative hearings, find facts, reach conclusions and make final decisions on his behalf to a discrete unit of the department or other person not personally involved in the decision that is the subject of the administrative hearing. The commissioner may limit the scope of the delegated authority in a directive that the authority is limited to conducting an administrative hearing.

(2) The administrative hearing official shall be an employee of the department who has not personally acted as an investigator in the contested case, including an eligibility supervisor, caseworker or other individual with a personal interest in the case. The role of the administrative hearing official shall consist of scheduling the hearing and conducting the hearing, facilitating the hearing process and rendering a decision on behalf of the department.

(3) If the administrative hearing issue concerns a medical condition, disability or a child with special needs, the hearing official may order an independent medical assessment or evaluation from a source mutually satisfactory to the parent and the department. The department shall be responsible for paying for the independent assessment.

(h) Rights at an Administrative Hearing

(1) Subject to the limitations specified in subsection (e) of section 17b-749-02 of the Regulations of Connecticut State Agencies, the parent or his or her representative shall have the right to examine the case record and all documents to be used by the department at the administrative hearing before and during the administrative hearing.

(2) The parent may present his or her case or have it presented by legal counsel or another person representing the family.

(3) The parent shall have the opportunity to question or refute testimony, to present evidence, to confront and cross-examine adverse witnesses or to bring witnesses.

(4) The parent shall have the opportunity to present an argument without undue interference.

(i) Attendance at the Hearing

(1) The hearing shall be attended by an individual representing the department, the parent or the parent's representative pursuant to section 17b-60 of the Connecticut General Statutes.

(2) Both parties may call witnesses, except the administrative hearing official may restrict attendance when necessary to protect confidentiality.

(j) The Administrative Hearing Record

(1) The administrative hearing record shall consist of the hearing request, notices issued by the administrative hearing official, the transcript or recording of testimony, exhibits, all papers and requests filed in the proceeding and the hearing decision.

(2) The administrative hearing record shall be made available to the parent at a reasonable time for copying and inspection.

(k) Hearing Decision

(1) A decision shall be rendered within sixty days of the close of the hearing record based exclusively on evidence introduced at the hearing and contained in the hearing record.

(2) The decision shall be issued in writing to the parent, the parent's representative and to the CCAP administrator.

(3) The decision shall be considered binding upon the department, unless the department elects to reconsider the decision as described in subsection (l) of this section.

(4) The decision shall serve as a final resolution to the issue unless the parent appeals to a court of competent jurisdiction within forty-five days of the date the decision is issued pursuant to subsection (n) of this section.

(5) The hearing record shall be available for public inspection and copying, subject to the limitations of subsection (e) of 17b-749-02 of the Regulations of Connecticut State Agencies.

(l) Reconsideration of the Decision

(1) The parent or his or her representative shall have fifteen days from the date the hearing decision is issued to request the commissioner or his designee to reconsider the decision. Pursuant to section 4-181a of the Connecticut General Statutes, an administrative hearing decision shall warrant reconsideration if an error or fact of law should be corrected, if new evidence is discovered that materially affects the merits of the case which was not presented at the administrative hearing for good reason or if there is other good cause for reconsidering the decision.

(2) The commissioner or his designee shall have twenty-five days from the date the request is received by him to decide whether reconsideration is warranted.

(3) The Department may on its own initiative decide to reconsider the decision within forty days of the date of the decision was issued.

(4) If reconsideration is warranted, the parent and his or her representative shall be notified that the department plans to conduct additional proceedings as may be necessary to render a new decision.

(m) Implementation of Administrative Hearing Decision

(1) The department shall implement the appropriate changes or corrections within the timeliness standards for processing changes, unless otherwise specified by the administrative hearing official. Any benefits owed to the family shall be promptly restored.

(2) If the department is upheld, action shall be taken to recover any benefits that the family may have improperly received.

(n) Appealing the Decision

The parent or his or her representative has the right to appeal an administrative hearing decision to superior court in accordance with the requirements of section 17b-61 of the Connecticut General Statutes.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-22 Administrative disqualification hearings

(a) Hearing Process

(1) The department shall have the option of referring a case for an administrative disqualification hearing if the CCAP administrator determines that an overpayment was caused as the result of an intentional error by the parent to commit fraud in obtaining benefits from CCAP. The purpose of the administrative disqualification hearing is to determine if the error was intentional. The standard of proof that the administrative hearing officer shall use in making his or her decision is by clear and convincing evidence. The administrative disqualification hearing process shall be conducted in the same manner as an administrative hearing and is subject to requirements of section 17b-749-21 of the Regulations of Connecticut State Agencies, except as otherwise stated in this section.

(2) The CCAP administrator shall treat overpayments caused by the parent as unintentional until an appropriate authority has confirmed the preliminary decision that the error was intentional. The CCAP administrator shall not impose a disqualification penalty until the decision that the error was intentional becomes final. The decision that the error was intentional shall become final under the following conditions:

(A) if a court of competent jurisdiction finds that the parent has committed fraud or grants accelerated rehabilitation; or

(B) if an administrative hearing officer determines that the error was intentional; or

(C) if the parent waives his or her right to an administrative disqualification hearing.

(3) If the administrative hearing officer determines that the error was not intentional, the overpayment shall be treated as unintentional or as an administrative error based on the results of the hearing. If the parent is found to have committed an intentional error, the family shall be subject to a disqualification penalty as specified in subsection (h) of section 17b-749-20 of the Regulations of Connecticut State Agencies.

(b) Cases Referred for Administrative Disqualification Hearings

(1) A parent's case may be referred for an administrative disqualification hearing under the following circumstances:

(A) if a preliminary determination has been made that the parent knowingly and willfully intended to commit fraud to obtain benefits from CCAP; and

(B) if the case is not being referred to the state police, a prosecuting authority or to the attorney general; or

(C) if the case was referred and has been rejected for prosecution.

(2) The parent's case shall not be referred for an administrative disqualification hearing while the case is under consideration for referral to the state police, a prosecuting authority or the attorney general, or if a court of competent jurisdiction has determined that the parent is not guilty or has dismissed the case.

(c) Notification

(1) The administrative hearing official shall notify the parent in writing that an administrative disqualification hearing has been scheduled. The notice shall be sent to the parent by certified mail at least thirty days prior to the scheduled hearing date. Notice shall be assumed to have been given unless the certified mail return receipt is returned stamped as "undeliverable as addressed" or "forwarding address has expired."

(2) The notice shall contain the following information:

(A) the time, date, and place of the hearing;

(B) a statement of the reasons for the hearing;

(C) a summary of the evidence upon which the hearing is being held and how and where the evidence can be examined;

(D) a warning that the decision will be based solely on the information provided by the CCAP administrator if the parent does not appear at the hearing;

(E) a statement of the parent's administrative hearing rights;

(F) a statement that the hearing does not preclude additional civil or criminal action;

(G) a statement of the availability of free legal representation;

(H) a statement of the availability of a new hearing in the event there is good cause for the individual not to attend the scheduled hearing; and

(I) an invitation to contact the department if additional information is needed.

(d) Pre-Hearing Interview

(1) The CCAP administrator shall send parents referred for an administrative disqualification hearing a notice scheduling a pre-hearing interview and a waiver of administrative disqualification hearing form. The pre-hearing interview shall be conducted by the CCAP administrator at an office of the department closest to where the parent lives. The CCAP administrator shall make a reasonable attempt to accommodate a request made by the parent with regard to the hearing date and time.

(2) The purpose of the pre-hearing shall be to provide the parent with the opportunity to review the evidence supporting the CCAP administrator's allegations, to receive an explanation of the hearing process and to dispute the CCAP administrator's findings. The CCAP administrator shall provide the parent with a detailed explanation of the following information:

(A) the evidence supporting the overpayment and the determination that the error was intentional;

(B) the administrative hearing process and the parent's administrative hearing rights;

(C) the waiver process, including that the parent's right to waive the hearing, the right to change the decision to waive the hearing within 10 days, and the fact that signing the waiver is not an admission of guilt; and

(D) the recoupment or disqualification penalty that will be applied if the parent signs the waiver.

(3) Failure to appear at the pre-hearing interview shall not serve as a basis for delaying the administrative disqualification hearing. A parent who does not appear at the pre-hearing interview shall be sent a formal notice of the scheduled hearing, unless the parent has submitted a signed waiver of his or her right to a hearing.

(e) Waiver of Right to Administrative Disqualification Hearing

(1) The parent shall have the option to waive his or her right to an administrative disqualification hearing. Waiver of the right to a hearing shall result in the same penalties as would be imposed if a determination of guilt had been rendered by an administrative disqualification officer or a court of law, including benefit reduction and discontinuance penalties. The CCAP administrator shall provide the parent with a waiver form. The form shall include the following information:

(A) the date by which the waiver shall be signed and returned to the department;

(B) the address where the form shall be returned;

(C) a statement of the right of the individual to remain silent and avoid self-incrimination;

(D) an option to select admission or denial of guilt;

(E) a place for the parent's signature and date;

(F) that a benefit reduction or disqualification penalty will automatically be imposed if the waiver is signed, even if the parent does not admit guilt;

(G) that waiver of the right to an administrative disqualification hearing results in the same penalties as would be imposed in the event of a determination of guilt by an administrative disqualification hearing officer or a court of law, regardless of whether or not the waiver form indicates an admission of guilt;

(H) the fact that the individual may withdraw the waiver within 10 days of the date signed; and

(I) telephone numbers for additional information and for free legal services.

(2) The parent may withdraw the waiver by submitting a written statement to the administrative hearing officer within ten days of the date the waiver form was signed. If the parent does not withdraw the waiver in a timely manner, the department shall proceed with scheduling the hearing.

(f) Time Limits

(1) The hearing shall be held and a decision rendered within ninety days from the date the notice of the hearing is mailed to the parent, barring continuances and extensions of the close of the hearing record.

(2) The parent or the parent's representative may request and receive a postponement of the scheduled hearing for good cause as determined by the administrative hearing official. The hearing shall not be postponed for more than thirty days.

(g) Consolidation of Administrative Hearings with Administrative Disqualification Hearings

(1) The administrative hearing officer may combine an administrative hearing and an administrative disqualification hearing into a single hearing if the factual issues arise out of the same or related circumstances and the parent receives prior notice that the hearings will be combined.

(2) If the single hearing is held for the purpose of settling the amount of the overpayment as well as determining whether intentional recipient error occurred, the parent shall not be entitled to a separate hearing to contest the amount of the overpayment.

(h) Hearing Format

(1) The hearing shall be conducted in accordance with the requirements of section 17b-749-21 of the Regulations of Connecticut State Agencies.

(2) The hearing official shall advise the parent or the parent's representative of the right to remain silent during the hearing.

(3) If the parent or the parent's representative cannot be located or fails to appear at a hearing without good cause, the hearing shall be conducted without the parent being represented. If the parent does not appear at the hearing and is not represented by another person, the hearing official shall make a decision based on the evidence presented.

(i) Good Cause for Failure to Appear at Hearing

(1) A new hearing shall be scheduled if the parent had good cause for failing to appear. The parent or his or her representative shall submit a good cause request to the administrative hearing official within ten days of the date of the original hearing.

(2) Good cause reasons for not appearing at the hearing shall include, but not be limited to illness of the individual or immediate family member, a family emergency, severe weather or the unavoidable loss of transportation where there was no alternative immediately available.

(3) The administrative hearing official shall decide if good cause exists and enters the decision into the hearing record. If good cause exists, the administrative hearing official who presided at the initial hearing shall schedule a new hearing. The decision reached as the result of the original hearing shall be rendered null and void when a new hearing is scheduled.

(j) Hearing Decision

(1) The administrative hearing official shall issue a written decision within ninety days from the date the notice scheduling the hearing was mailed to the parent. The decision shall identify the evidence used to make the decision, specifies the reasons for the decision, cites relevant policy or regulation, responds to the reasoned arguments made by the parent or his or her representative and specifies the penalty.

(2) If a disqualification penalty is imposed, the effective date and length of the disqualification period shall be specified.

(k) Appealing the Decision

(1) The parent shall be entitled to an administrative hearing to dispute an intended action to reduce or terminate benefits or if the parent disagrees with the recoupment plan. The parent shall not be entitled to an administrative hearing to dispute the findings of the administrative disqualification hearing official or the penalty imposed.

(2) The parent may contest the hearing official's decision by appealing to the Superior Court within forty-five days of the date the hearing official issues the decision. The disqualified individual shall follow the appeal procedures described in subsection (n) of section 17b-749-21 of the Regulations of Connecticut State Agencies concerning appeals of administrative hearing decisions.

(3) If a court reverses the finding of guilt of an intentional recipient error, the CCAP administrator shall reinstate the case if the family is currently eligible and issues payments for any underpayment that may have occurred.

History

• Adopted effective July 10, 2001

Regs., Conn. State Agencies § 17b-749-23 Implementation

The requirements of sections 17b-749-01 to 17b-749-22 of the Regulations of Connecticut State Agencies, inclusive, shall take effect on January 1, 2002. Families who apply for benefits prior to January 1, 2002 shall be subject to the requirements of the regulations that are in effect on the date eligibility is determined. Families determined eligible prior to January 1, 2002 shall receive the same benefits as would have been received under the regulations in effect prior to January 1, 2002, until the next eligibility determination conducted on or after January 1, 2002.

History

• Adopted effective July 10, 2001

17b-800 Emergency Shelter Services

Regs., Conn. State Agencies § 17b-800-1 Definitions

As used in sections 17b-800-1 to 17b-800-7, inclusive, of the Regulations of Connecticut State Agencies:

(1) “Applicant” means a public or private organization or agency that has submitted an emergency shelter grant application to the Department of Social Services;

(2) “Client” means a homeless individual eighteen years of age or over, homeless family or emancipated minor, who is in need of and requests emergency shelter services;

(3) “Commissioner” means the Commissioner of Social Services;

(4) “Dangerous weapon” means any instrument, article or substance that is capable of causing death or serious bodily injury;

(5) “Department” means the Department of Social Services;

(6) “Emergency” means a situation in which immediate action must be taken to meet the needs of individuals or families who do not have sufficient resources to secure shelter;

(7) “Emergency shelter” means housing in a single, accessible location that provides, at a minimum, sleeping and bathroom facilities for homeless individuals and families in a facility that meets local building, health, fire, safety and handicapped persons access codes and zoning requirements. “Emergency shelter” does not include residential treatment centers for drug or alcohol abuse, youth shelters, halfway houses or transitional living programs;

(8) “Emergency shelter services” means the social, health, educational, legal, financial and related services that an emergency shelter operator provides to clients. “Emergency shelter services” does not include the operation of residential treatment centers for drug or alcohol abuse, youth shelters, halfway houses or transitional living programs;

(9) “Grant application” means a request for funds to develop, maintain or renovate an emergency shelter or provide emergency shelter services;

(10) “Grantee” means an emergency shelter that receives department funding for the provision of emergency shelter services;

(11) “Homeless” means lacking a fixed, regular and adequate nighttime residence;

(12) “Operator” means an applicant, or an applicant’s designee, responsible for the on-site management and operation of an emergency shelter or the administration of emergency shelter services;

(13) “Physical assault” means a willful touching of a person by another person with intent to do harm with any instrument, article or substance, or any portion of the body, and shall include the attempted use of a dangerous weapon by one person against another; and

(14) “Threat” means a verbal or physical expression of an intent to harm, or otherwise cause bodily injury to another person or to damage property.

History

• Effective February 1, 1993; Transferred from § 17-590-1, June 28, 2013; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-800-2 Application process

(a) In order to receive department funding for emergency shelter services, an applicant shall submit, biannually or more frequently based upon a schedule established by the department, an application that includes:

(1) Evidence of demand for emergency shelter services at a proposed or existing shelter location;

(2) Evidence of the applicant’s administrative and managerial capability to establish and operate an emergency shelter or provide emergency shelter services in a sensitive, humane and cost effective manner;

(3) Evidence of the applicant’s ability to collect and submit client data for the department’s homeless management information system;

(4) the following written information:

(A) An organizational chart and by-laws of the organization;

(B) Written operating and admission policies;

(C) Written grievance procedures;

(D) House rules;

(E) A description of emergency shelter staffing, whether paid or volunteer, that indicates a minimum staff to client ratio of one staff member per twenty-five clients;

(F) A description of the emergency shelter services that the applicant will provide;

(G) A description of the physical facility including location; accessibility to transportation, health, social and related services; type and size of building; access for disabled persons; any available parking area; space allocation for shelter activities and shelter capacity;

(H) Evidence of compliance with local zoning ordinances, local building codes and state fire and health regulations;

(I) Schedule of the daily operation of the emergency shelter and services offered;

(J) Completed departmental budget forms; and

(K) If applicable, a report on the number of grievances filed pursuant to the shelter grievance procedure, the reasons for each grievance, and the disposition of each grievance;

(5) Operating policies that comply with sections 17b-800-4 and 17b-800-5 of the Regulations of Connecticut State Agencies.

(6) Grievance procedures that comply with sections 17b-800-6 and 17b-800-7 of the Regulations of Connecticut State Agencies.

(b) The commissioner may, at the commissioner’s discretion, accept, reject or modify any grant request. The commissioner’s decision may not be appealed.

(c) The department shall notify an applicant in writing of the acceptance or rejection of an application not later than sixty days after the department receives the application.

History

• Effective February 1, 1993; Transferred from § 17-590-2, June 28, 2013; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-800-3 Financing and program review

(a) The department shall allocate funds pursuant to a contract that sets forth the specific conditions under which the grant is awarded.

(b) Sections 17b-800-1 through 17b-800-7, inclusive, of the Regulations of Connecticut State Agencies comprise the minimum standards of eligibility for department funding. Meeting the minimum requirements does not guarantee that an applicant or grantee will receive department funding, nor that funding will be provided in subsequent fiscal years.

(c) The department may seek recovery of any grant funds not used consistently with the terms of a grant.

(d) The grantee shall submit periodic program and progress reports to the department and shall maintain records of the use of the grievance procedure. Such records shall be available to the department for review upon request.

(e) The department shall, at least annually, review and evaluate the performance of each grantee. Such reviews and evaluations may include an examination of the grantee’s documents and reports, site visits by department staff, or both. Such reviews and evaluations shall also include a review of:

(1) The grantee’s compliance with sections 17b-800-1 through 17b-800-7, inclusive, of the Regulations of Connecticut State Agencies and the terms and conditions of its contract; and

(2) The grantee’s financial reports to the department and the grantee’s annual audit.

(f) If the department determines that the grantee has failed to meet its obligations under subdivisions (1) and (2) of subsection (e) of this section, the department may place the grantee on probation or, when the failure is serious or repeated, terminate its contract.

History

• Effective February 1, 1993; Transferred from § 17-590-3, June 28, 2013; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-800-4 Operating policies of shelters

(a) An emergency shelter receiving department funding shall adhere to an admissions policy that includes the following requirements:

(1) The shelter shall not discriminate in the acceptance of clients on the basis of race, creed, color, religion, national origin, ancestry, sex, sexual orientation, gender identity or expression, marital status, age or disability and shall not reject clients on the basis of past conduct unconnected to the shelter or shelter program, except that a shelter serving homeless families shall not admit a person who is listed on the registry of sex offenders maintained pursuant to chapter 969 of the Connecticut General Statutes;

(2) The shelter shall maintain a process for screening all persons entering the shelter for obvious signs of illness, injury or intoxication from drugs or alcohol, and a process for referring those exhibiting such signs to an appropriate facility;

(3) The shelter shall ensure that any policy concerning a search of a person prior to admission is conducted so that the search does not unduly infringe upon the privacy rights of the individual;

(4) The shelter shall keep a confidential record of all clients admitted, referrals made, and services offered and the number of individuals who are refused admittance and the reasons for refusal, except in the case of refusal because of insufficient beds, in which case the shelter shall keep a record of the number of people turned away;

(5) The shelter shall not deny access to a client due to the client’s inability to pay a fee; and

(6) The shelter shall establish a procedure for the release of information concerning a client who is listed on the registry of sexual offenders maintained pursuant to chapter 969 of the Connecticut General Statutes to a law enforcement officer in accordance with subsection (b) of section 17b-800 of the Connecticut General Statutes.

(b) House rules:

(1) The house rules shall be posted in a conspicuous location in a public area of the facility. Each client seeking admission to a shelter shall sign a form provided by the shelter indicating that the client was advised of the house rules and the penalties of violating the rules, and that the client agrees to abide by the rules. This form shall be part of the client’s case file. The rules shall be clear, explicit and administered fairly. The house rules shall include the penalty for infringement of house rules. The penalty shall be clearly stated and enforced equally among the shelter’s clients. The house rules and their penalties shall be periodically reviewed by the shelter, with input from shelter clients. Copies of the shelter’s house rules and any subsequent revision thereof shall be made available to staff and clients and shall be provided to the department.

(2) House rules shall be reasonable, and shall address, at a minimum, the following:

(A) Daily schedule;

(B) Permitted length of stay and conditions under which extensions shall be granted;

(C) Client fees or contributions;

(D) Bed reservation or daily reapplication;

(E) Bathing;

(F) Laundry facilities;

(G) Meals, if served;

(H) Safe storage of client food supplies;

(I) Services offered;

(J) Supervision and discipline of children;

(K) Duties expected of clients;

(L) A description of policies covering violent or disruptive behavior;

(M) Privacy and confidentiality;

(N) Fire evacuation and safety procedures;

(O) Use and handling of prescribed medication;

(P) Use or possession of alcohol, drugs or weapons;

(Q) Visits from people who are not shelter clients;

(R) Access to telephones;

(S) Arrangements for safekeeping of client financial interests and personal belongings;

(T) Policies for group meetings of clients;

(U) Provisions for mail distribution; and

(V) Access to medical services.

(c) Grantees shall ensure that clients:

(1) Shall not be suspended or expelled from the shelter except for good cause;

(2) Shall be afforded hearings on grievances in accordance with sections 17b-800-6 and 17b-800-7 of the Regulations of Connecticut State Agencies;

(3) Shall be offered decent, safe, and sanitary shelter;

(4) Shall have shelter or shelter service matters pertaining to the client kept confidential;

(5) Shall have access, directly or through the client’s designated representatives, to the client’s shelter or shelter service records;

(6) Shall be treated by staff with consideration, respect, and dignity and without physical or mental abuse; and

(7) Shall be entitled to equal application of shelter or shelter services rules.

History

• Effective February 1, 1993; Transferred from § 17-590-4, June 28, 2013; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-800-5 Expulsion and suspension of shelter clients

(a) All rules and policies of the shelter, including the shelter’s grievance procedures, shall be posted in a conspicuous place and shelter clients shall be given a copy upon request. The shelter’s grievance procedures shall include information on how to initiate the grievance process and shall also include a clear notice to clients identifying the house rules that carry a penalty of suspension or expulsion if violated, and, if applicable, the length of any suspension.

(b) All rules and policies shall be written in plain language and, when feasible, translated for clients who do not speak English. If the shelter has reason to believe a client is illiterate, the shelter shall provide the rules and procedures orally.

(c) A client shall not be expelled or suspended, except for good cause. Good cause includes, but is not limited to, the following kinds of events:

(1) Violations, after a warning, of posted house rules that seriously or materially impede the operation of a shelter;

(2) Behavior that poses a threat to the health or safety of other clients, shelter staff, or other people on the premises of the shelter, or to the physical property of the clients or the shelter or anyone on the premises of the shelter. This may include the possession or use of illegal drugs or alcohol;

(3) Violations, after a warning, of case plans or contracts, when the client has committed in writing to follow such plan or contract;

(4) Expiration of a defined length of stay, unless, according to the shelter’s own rules, the client qualifies for an extension;

(5) Theft or destruction of property in or on the grounds of the shelter; or

(6) Sexual harassment or sexual activity in violation of shelter rules.

(d) Except as provided in subsection (e) or (f) of this section, as applicable, if a shelter client violates a rule or policy that might lead to suspension or expulsion:

(1) The client shall receive written and oral notice of the infraction prior to suspension or expulsion. This notice shall state the consequences of having violated the rule or regulation; and

(2) The client shall have an opportunity to request the review of this decision through the shelter grievance procedure prior to the suspension or expulsion. The notice in subdivision (1) of this subsection shall inform the client of his or her rights to a grievance review and how to request a grievance review.

(e) In cases where the behavior of the client poses a threat to the health or safety of other clients, shelter staff, or anyone on the grounds of the shelter, or to the physical property of the clients of the shelter or anyone on the premises of the shelter, the client may be suspended or expelled without any prior warning, or the prior opportunity for a hearing under the shelter grievance procedure. A staff person who has decided to expel or suspend a client shall, whenever possible, consult with an impartial staff person on whether the decision is appropriate.

(f) A client may be suspended without prior warning or a prior opportunity for a hearing if he or she poses a threat to the health of other clients, shelter staff or anyone on the grounds of the shelter because the client is reasonably believed to be infected with a disease that is easily spread through casual contact or by airborne means only if:

(1) Contamination with the disease could cause serious health problems for others;

(2) The shelter does not have adequate means to isolate the infected clients; and

(3) The shelter, if possible, has attempted to place the client in an alternative facility.

(g) Behavior that constitutes a threat to health and safety shall be defined by the shelter and shall include, but not be limited to, the following:

(1) Possession, distribution, or use of illegal drugs or alcohol;

(2) Possession of a dangerous weapon;

(3) Physical assault or the threat of physical violence when there is reason to believe such a threat indicates a genuine possibility of actual physical assault directed at anyone in or on the grounds of the shelter; and

(4) Arson or attempted arson.

(h) The shelter shall clearly identify the infractions that can lead to suspension or expulsion without prior notice or a prior hearing in the notice provided under subsection (a) of this section.

(i) The client shall have an opportunity to have any decision to expel or suspend him or her reviewed under the shelter grievance procedure. The burden shall be on the shelter to show that the client was in violation of the shelter rules. In the case of expulsion or suspension under subsection (e) or (f) of this section, as applicable, the review may be conducted after expulsion or suspension.

(j) Any client who is suspended or expelled shall, whenever possible, be given information on any other facilities available to him or her, and the name and phone number of the person to contact at any appropriate public agency.

(k) If the expelled or suspended client was originally placed at the shelter by a state agency, that agency shall be informed of the expulsion or suspension within one business day.

History

• Effective February 1, 1993; Transferred from § 17-590-5, June 28, 2013; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-800-6 Shelter grievance procedures

(a) Each shelter shall create a shelter grievance procedure. The shelter shall consult with clients of the shelter when creating the grievance procedure.

(b) The shelter grievance procedure shall be available to any client who is aggrieved by any adverse action including, but not limited to, suspension or expulsion. The shelter grievance procedure shall also be available to an individual who has been initially refused admittance.

(c) The shelter grievance procedure shall contain the following minimum requirements:

(1) Unless an extension of time is agreed to by both parties, the grievance review shall take place within three business days of the request for a review, except that, in the case of someone who is suspended or expelled without a prior opportunity for a hearing, the grievance review shall take place by the next business day if the client is placed in an alternative facility pending the review, or within twenty-four hours of the suspension or expulsion if no other placement is available, or later if an extension of time is requested by the client;

(2) The grievance review shall be conducted by an impartial person who has the authority to modify, affirm or reverse the decision that is being grieved;

(3) The client may be represented by any person of his or her choosing;

(4) The client shall be allowed to review, confront and refute any evidence relied upon in any decision relating to the grievance, by any appropriate means including, but not limited to, the use of witnesses.

(5) Any decision shall be in writing, shall be based on the evidence presented at the review, and shall explain the parties’ rights to an appeal, pursuant to section 17b-800-7 of the Regulations of Connecticut State Agencies.

(d) As used in this section and section 17b-800-7 of the Regulations of Connecticut State Agencies, an impartial person shall be any person, including an employee of the shelter, who did not take part in the decision or procedure which is being grieved.

History

• Effective February 1, 1993; Transferred from § 17-590-6, June 28, 2013; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-800-7 Appeal panels

(a) Any decision of a grievance review may be appealed to:

(1) A panel of three people, consisting of a shelter client or former client, a shelter staff person or a member of the board of directors, and another person not employed by the shelter or receiving shelter services. The panel chairperson shall be the person not employed by the shelter or receiving shelter services; or

(2) An appeal panel consisting of one impartial person who is mutually agreeable to both parties.

(b) The shelter shall maintain a list of people in each of the above categories, to be updated as necessary, and shall select a person from each list for each grievance review. All panel members shall be impartial.

(c) The shelter shall ensure that panel members receive training about the grievance procedure, as appropriate.

(d) An appeal shall take place within five business days of the request for a hearing. Other than cases falling under subsection (e) or (f) of section 17b-800-5 of the Regulations of Connecticut State Agencies, as applicable, a decision to suspend or expel shall be stayed pending the appeal.

(e) The chairperson shall have overall administrative responsibility for conducting the appeal hearing. The chairperson shall:

(1) Instruct the other panel members on procedures prior to the hearing;

(2) Ensure that the hearing is conducted in an orderly manner;

(3) Afford all parties the opportunity to present information fully; and

(4) Permit parties to question each other when it is appropriate to do so.

(f) A simple majority vote of the panel shall be sufficient to render a decision.

(g) The decision of the panel to reverse, modify or affirm the decision of the shelter shall be sent in writing to all parties involved within ten days of the hearing and shall be binding.

History

• Effective February 1, 1993; Transferred from § 17-590-7, June 28, 2013; Amended June 28, 2013

17b-802 Security Deposit Program

Regs., Conn. State Agencies § 17b-802-1 Definitions

As used in to 17b-802-12, inclusive, of the Regulations of Connecticut State Agencies:

(1) “Applicant” means a person age eighteen or older who has completed, signed and submitted an application to the department or to any entity so designated under section 17b-802-5 of the Regulations of Connecticut State Agencies to obtain a security deposit guarantee or security deposit grant that, if approved, will allow the person to move into a dwelling unit;

(2) “Application” means a form prescribed by the commissioner to be used by an applicant to apply for a security deposit guarantee or a security deposit grant. Such form shall contain information that the commissioner or the commissioner’s designee deems necessary to determine an applicant’s eligibility for a security deposit guarantee or security deposit grant;

(3) “Administrative hearing” means a formal review of a decision of the Commissioner of Social Services pursuant to section 17b-60 of the Connecticut General Statutes;

(4) “Catastrophic event” means a situation that arises due to a natural or manmade disaster that results in destruction or loss of housing, as determined by appropriate local or state officials or by the department;

(5) “Commissioner” means the Commissioner of Social Services;

(6) “Current income status” means the household’s gross income for, at a minimum, the 30 days immediately preceding the date of application;

(7) “Department” means the Department of Social Services;

(8) “Departmental review” means an informal review by the department of a reimbursement claim made by a landlord for damages if requested by the tenant in accordance with section 17b-802-7 of the Regulations of Connecticut State Agencies;

(9) “Designee” means an individual appointed by the commissioner to act on behalf of the commissioner;

(10) “Dwelling unit” means any house or building, including a mobile manufactured home in a mobile manufactured home park, as such terms are defined in section 21-64 of the Connecticut General Statutes, or portion thereof, that is occupied, is designed to be occupied, or is rented, leased or hired out to be occupied as a home or residence of one or more persons;

(11) “Emergency housing” means a temporary residential facility, other than an emergency shelter, such as a state institution or shelter for victims of domestic violence. Emergency housing includes, but is not limited to, a hotel, motel or the private residence of a friend or relative that temporarily houses individuals or families displaced due to an eviction, catastrophic event or domestic violence;

(12) “Emergency shelter” means a privately or publicly supported structure designed to shelter homeless persons on a temporary basis pending relocation to permanent housing;

(13) “Eviction” means one of the following:

(A) An applicant is forced to relocate after receiving a legal notice to quit;

(B) An applicant is sharing a dwelling unit with a lessee and the lessee has received a legal notice to quit or has been evicted through court action;

(C) An applicant is an owner or a tenant of a dwelling unit and is being forced to relocate as a result of a foreclosure judgment in a foreclosure action completed in court; or

(D) An applicant is illegally locked out of a dwelling unit by the landlord and the applicant has filed a complaint with the police concerning such lockout;

(14) “Gross income” means the total income of all household members, before deductions, derived from earned and unearned income. Earned income includes any compensation payable by an employer to an employee for personal services and includes wages, salaries, tips, commissions, bonuses and earnings from self-employment or contractual agreements. Unearned income includes, but is not limited to: pensions, annuities, dividends, interest, rental income, estate or trust income, royalties, social security or supplemental security income, unemployment compensation, workers’ compensation, alimony, child support and cash assistance from federal or state funded assistance programs;

(15) “Household” means one or more individuals living together as a unit;

(16) “HUD” means the United States Department of Housing and Urban Development;

(17) “Landlord” means the owner of a dwelling unit. “Landlord” includes a licensee, permittee or any person who owns, operates or maintains a mobile manufactured home park, as such term is defined in section 21-64 of the Connecticut General Statutes. “Landlord” does not include a tenant who is a lessor or sublessor;

(18) “Lessee” means an individual who rents property from another;

(19) “Lessor” means an individual who rents property to another;

(20) “Recipient” means any individual or household that has received a security deposit guarantee or a security deposit grant by meeting the criteria set forth in section 17b-802-2 of the Regulations of Connecticut State Agencies;

(21) “Security deposit grant” means a security deposit, as defined in section 47a-21 of the Connecticut General Statutes, that is paid by the department on behalf of an eligible applicant to a landlord pursuant to subsection (e) of section 17b-802 of the Connecticut General Statutes;

(22) “Security deposit guarantee” means a written agreement between the commissioner, the commissioner’s designee or the department’s agent and a landlord that provides that the department shall pay the landlord for damages up to the amount of the security deposit if the tenant fails to comply with the tenant’s obligations, as defined in section 47a-21 of the Connecticut General Statutes;

(23) “Sublessor” means an individual who rents property from a lessor and leases that property to a third party; and

(24) “Tenant” means the lessee or person entitled under a rental agreement to occupy a dwelling unit or premises to the exclusion of others.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-2 Eligibility Criteria

Before an applicant may participate in the security deposit guarantee or security deposit grant program, an applicant shall satisfy the department that the criteria established in this section are met:

(1) The applicant shall submit to the department a completed application packet that complies with the requirements of section 17b-802-4 of the Regulations of Connecticut State Agencies.

(2) The applicant shall meet one of the following requirements of financial eligibility:

(A) The applicant is a current recipient of temporary family assistance (TFA), state-administered general assistance (SAGA), or state supplement program benefits; or

(B) The annual gross income of the applicant and the applicant’s household does not exceed 150% of the federal poverty income guidelines as established by the United States Department of Health and Human Services.

(3) The applicant shall meet one of the following requirements of categorical eligibility:

(A) The applicant holds a federal Section 8 housing choice voucher or holds a certificate from the Rental Assistance Program, the Transitionary Rental Assistance Program or any other rental assistance program operated by the department;

(B) The applicant is currently residing in emergency housing or an emergency shelter in Connecticut;

(C) The applicant has been served a writ, summons and complaint in a summary process action instituted pursuant to chapter 832 of the Connecticut General Statutes; or

(D) The applicant cannot remain in permanent housing due to any reason specified in subsection (a) of section 17b-808 of the Connecticut General Statutes.

(4)(A) The dwelling unit shall be located in the state of Connecticut, meet all applicable local, state and federal housing code requirements, and be occupied by the applicant as permanent housing.

(B) Prior to the applicant moving into the dwelling unit, the landlord shall verify compliance with subparagraph (A) of this subdivision by providing the department with a copy of any certificate of occupancy required by any borough, city or town pursuant to section 47a-5 of the Connecticut General Statutes, and, if available, any Housing Quality Standards report issued by HUD to the landlord for the dwelling unit pursuant to 24 CFR 982.401.

(5) The landlord and the applicant shall conduct an inspection of the dwelling unit together and shall complete a form documenting the condition of the dwelling unit prior to the applicant moving into the dwelling unit. The department may require that a dwelling unit also be inspected by a department designee prior to the applicant moving into the dwelling unit.

(6) The department shall determine that the applicant’s household can reasonably be expected to afford the monthly rental charge of the dwelling unit.

(7) The department shall determine whether the applicant is precluded from occupying the otherwise affordable dwelling unit due to a security deposit requirement that is beyond the current financial means of the applicant.

(8) If the applicant is applying for a security deposit grant, the commissioner shall determine, at the commissioner’s discretion, whether emergency circumstances exist that threaten the health, safety or welfare of a child that lives with the applicant in order for the applicant to be eligible for a security deposit grant.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-3 Verification of Eligibility

(a) An applicant seeking eligibility for a security deposit guarantee or a security deposit grant based on financial need pursuant to subparagraph (B) of subdivision (2) of section 17b-802-2 of the Regulations of Connecticut State Agencies shall verify the household’s monthly gross income in a manner that is acceptable to the department. Acceptable forms of verification include, but are not limited to:

(1) Current wage stubs;

(2) A completed department form W-35 for disclosure of gross wages, salary or commission paid; or

(3) A copy of a Social Security check or any other benefit check.

(b) The department may require an applicant seeking a security deposit guarantee or security deposit grant to provide documentation that demonstrates that the applicant meets the eligibility requirements of section 17b-802-2 of the Regulations of Connecticut State Agencies.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-4 Elements of Application

A completed application requesting the equivalent of up to two months’ rent as a security deposit guarantee, or the equivalent of up to one month’s rent as a security deposit grant and up to one month’s rent as a security deposit guarantee shall include:

(1) A completed application form signed by the applicant. The application form shall stipulate that the applicant agrees to notify the department no more than ten days after vacating the dwelling unit for which payment is being requested;

(2) Any documents that the department determines are necessary to verify eligibility;

(3) A written agreement between the department and the prospective landlord that shall include one or both of the following:

(A) A written security deposit guarantee agreement signed by the prospective landlord. Such agreement shall stipulate that the department shall pay the landlord for any damages suffered by the landlord due to the tenant’s failure to comply with the tenant’s obligations, as such obligations are defined in section 47a-21 of the Connecticut General Statutes, provided the amount of any such payment shall not exceed the amount of the security deposit guarantee; or

(B) In the case of a security deposit grant, a waiver form completed and signed by the prospective landlord. The waiver form shall stipulate that if the tenant for whom a security deposit payment is made vacates the dwelling unit, any return of the security deposit or accrued interest to which the tenant is entitled shall be paid directly to the department.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-5 Application Filing

Completed applications for security deposit guarantees or security deposit grants shall be made by applicants in person either to the department at one of its regional offices or to any entity under contract with the department to administer the Security Deposit Guarantee program.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-6 Application Review and Notification

The department shall review the completed application and shall send the applicant written notice of the applicant’s eligibility status not more than ten days from the date the department receives the completed security deposit guarantee or security deposit grant application form as set forth in section 17b-802-4 of the Regulations of Connecticut State Agencies. If an application for a security deposit guarantee or security deposit grant is denied at this stage, the department shall include in the written notice an explanation of the reason for the denial and of the applicant’s right to request an administrative hearing from the department.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-7 Security Deposit Guarantee and Claim for Damages

(a) In order for a landlord to be reimbursed for damages pursuant to a security deposit guarantee agreement, the claimed damage shall have been caused by a tenant’s failure to comply with a tenant’s obligations, as such obligations are defined in section 47a-21 of the Connecticut General Statutes, and the landlord shall comply with all of the provisions of said section 47a-21 and subsection (b) of this section. If the landlord or the landlord’s agent sends a notice to the department regarding a request for reimbursement pursuant to a security deposit guarantee agreement then the landlord or the landlord’s agent shall also send such notice to the tenant on the same day.

(b) In order to receive reimbursement for a claim for damages, the landlord shall, not later than forty-five days after the date of the termination of the tenancy, submit to the department a written claim that includes receipts for repairs made. The department shall only pay reimbursements for claims that include receipts for repairs made. No reimbursement shall be paid for claimed damages to a dwelling unit that a tenant vacated because substandard conditions made the dwelling unit uninhabitable, as determined by a local, state or federal regulatory agency.

(c) The department reserves the right to refuse payment for a claim for damages to a dwelling unit if any local, state or federal regulatory agency has cited the landlord for any violations of any law, regulation or ordinance pertaining to such dwelling unit and such violations were not timely remediated.

(d) The department may inspect the dwelling unit to determine the extent of any damages.

(e) When the department receives a claim for damages, the department shall send written notice of such claim to the tenant not later than five days after the date the department receives the claim. Such notice shall include the opportunity for the tenant to request a departmental review to dispute the claim.

(f) A request for a departmental review shall be made by the tenant in writing and received by the department not later than fourteen days after the date on the department’s notice to the tenant regarding the landlord’s claim for damages. Upon receipt of a timely request for departmental review, the department shall withhold payment to the landlord pending such review.

(g) The department shall conduct a departmental review within a reasonable amount of time after receiving the tenant’s request and the landlord’s submission of the written claim with receipts. The reviewer shall issue a written decision and mail a copy of the decision to the tenant and the landlord.

(h) The decision made by the department reviewer shall be based on all the information presented to the reviewer prior to or at the time of the scheduled review. Such information may include, but is not limited to, documentation of any post-tenancy inspection done by the tenant and the landlord, and receipts for repairs made. The decision of the reviewer shall be final.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-8 Security Deposit Grants, Claim for Damages and Refund

(a) Not later than thirty days after the date of the termination of a tenancy for which the department has provided a security deposit grant, the landlord shall submit to the department the balance of such security deposit grant, plus accrued interest, after deduction for any damages suffered by the landlord due to the tenant’s failure to comply with the tenant’s obligations, as such obligations are defined in section 47a-21 of the Connecticut General Statutes.

(b) If the landlord claims the right to withhold any portion of any security deposit grant that the department has paid directly to the landlord on the recipient’s behalf, the landlord shall comply with all of the provisions of section 47a-21 of the Connecticut General Statutes and subsection (b) of section 17b-802-7 of the Regulations of Connecticut State Agencies. If the landlord or the landlord’s agent sends a notice to the department regarding a claim against a security deposit grant then the landlord or the landlord’s agent shall also send such notice to the tenant on the same day.

(c) The department reserves the right to refuse payment for a claim for damages to a dwelling unit if any local, state or federal regulatory agency has cited the landlord for any violations of any law, regulation or ordinance pertaining to such dwelling unit and such violations were not timely remediated.

(d) If the landlord does not return the balance of the security deposit grant within thirty days after the termination of the tenancy, and legal action is necessary to collect the balance, the landlord shall pay the costs associated with such legal action and shall also be liable for twice the amount or value of the security deposit grant pursuant to section 47a-21 of the Connecticut General Statutes.

(e) The department may inspect the dwelling unit to determine the extent of any damages.

(f) The rights of the tenant to the refund of the security deposit grant shall be subrogated to the department.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-9 Assistance Limitations

(a) The department shall consider completed security deposit guarantee applications and security deposit grant applications in the order in which the department receives the applications. The approval of applications is subject to the availability of funds. In the absence of funds, the department may close the program and refuse to accept applications.

(b) For security deposit guarantee and security deposit grant recipients aged sixty-two years of age or older, the department shall limit assistance to the equivalent of one month’s rent pursuant to subdivision (2) of subsection (b) of section 47a-21 of the Connecticut General Statutes.

(c) Security deposit guarantees for recipients under the age of sixty-two shall be limited to the equivalent of two months’ rent, except if the commissioner has determined that the health, safety or welfare of a child who resides with an applicant is threatened due to an emergency, in which case the security deposit guarantee shall be limited to the equivalent of one month’s rent combined with a security deposit grant that is limited to the equivalent of one month’s rent.

(d) The department shall approve and sign the contract with the landlord before the applicant moves into the dwelling unit.

(e) The department may deny eligibility for the security deposit guarantee program to an applicant for whom the department has paid two claims by landlords.

(f) The commissioner may establish priorities based on funding availability for allocating security deposit guarantees between eligible persons described in subdivision (2) of section 17b-802-2 of the Regulations of Connecticut State Agencies.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-10 Subsequent Security Deposit Guarantees

(a) A person shall be eligible for a second or subsequent security deposit guarantee if, at the time of re-application, the person meets the criteria for eligibility as set forth in section 17b-802-2 of the Regulations of Connecticut State Agencies.

(b) A person shall be eligible for a subsequent security deposit guarantee only once within an eighteen calendar month period, except for the circumstance identified in subsection (c) of this section.

(c) A person who applies for a second or subsequent security deposit guarantee within eighteen calendar months of the date of completion of an application for a previous security deposit guarantee or security deposit grant that was approved shall obtain authorization from the commissioner for a second or subsequent security deposit guarantee. For a person who applies for a second or subsequent security deposit guarantee within eighteen calendar months of the date of any payment to a landlord for damages claimed to have been caused by the person, the amount of the second or subsequent security deposit guarantee shall be reduced by:

(1) The amount of any previous security deposit grant that has not been returned to the department pursuant to section 47a-21 of the Connecticut General Statutes; and

(2) The amount of any payments made under a security deposit guarantee by the department to the landlord for a tenant’s failure to comply with the tenant’s obligations, as such obligations are defined in subsection (a) of section 47a-21 of the Connecticut General Statutes.

(d) Any person with income exceeding one hundred fifty percent of the federal poverty level, who is eligible to receive a security deposit guarantee and for whom the department has paid a claim by a landlord, shall contribute five per cent of one month’s rent to the payment of the security deposit. The commissioner may waive such payment for good cause.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-11 Landlord Participation

(a) A landlord who engages in program fraud, misrepresentation or a violation of any aspect of the landlord’s written agreement with the department shall be subject to civil or criminal penalties to the extent authorized by the law.

(b) The commissioner may decline to enter into an agreement with a landlord under the security deposit guarantee or grant program for any reason, including, but not limited to: noncompliance with provisions of the security deposit guarantee or grant program, prior misrepresentation of the extent of damages or costs for repairs, failure to remediate housing code violations, or if the landlord has been cited by any local, state or federal regulatory agency for violating any housing law, regulation or ordinance.

(c) The landlord shall notify the department not later than three days after the lease commencement date if the tenant has not moved into the dwelling unit by such date. Failure to notify the department may result in the termination of the agreement with the landlord and the denial of any subsequent security deposit guarantee or grant applications made by applicants for dwelling units owned by the landlord.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

Regs., Conn. State Agencies § 17b-802-12 Administrative Hearings

The department shall give a person aggrieved by a denial or reduction of a security deposit guarantee an opportunity for an administrative hearing.

History

• Adopted effective May 24, 2004; Amended June 28, 2013

17b-811a Transitionary Rental Assistance Program

Regs., Conn. State Agencies § 17b-811a-1 Definitions

As used in sections 17b-811a-1 to 17b-811a-8, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Adjusted gross income" means the gross income of all adults residing in the dwelling unit less allowable deductions in accordance with section 17b-811a-6 of the Regulations of Connecticut State Agencies;

(2) "Agent" means any entity designated by the department to operate the transitionary rental assistance program;

(3) "Commissioner" means the Commissioner of the Department of Social Services;

(4) "Contract rent" means the total monthly rent payable to the owner for the dwelling unit. The contract rent is the sum of the tenant contribution plus the transitionary rental assistance payment to the owner;

(5) "Department" means the state of Connecticut Department of Social Services;

(6) "Dependent" means a member of the family household (excluding foster children) other than the family head or spouse, who is under 18 years of age or is disabled or is a full-time student 18 years of age or older;

(7) "Dwelling unit" means any house or building, including a mobile manufactured home in a mobile manufactured home park as defined in section 21-64 of the Connecticut General Statutes, or portion thereof, which is occupied, is designed to be occupied or is rented, leased or hired out to be occupied, as a home or residence of one or more persons;

(8) "Eligible family" means a family which meets the eligibility requirements set forth at 17b-811a-3 of the Regulations of Connecticut State Agencies;

(9) "Eligible housing" means privately owned rental housing located in any municipality in the state, which meets federal housing quality standards as cited in 24 CFR 982.401, and local and state health, housing, building and safety codes;

(10) "Gross rent" means the sum of the contract rent and any allowance for utilities established by the commissioner;

(11) "Income" means gross income (from whatever sources derived);

(12) "Owner" means any person(s) or entity having the legal right to lease or sublease housing and includes an owner's designated representative;

(13) "Request for tenancy approval" means the document submitted by the eligible family to the department or its agent requesting approval of a dwelling unit for tenancy by the family;

(14) "TFA" means the temporary family assistance program established under section 17b-112 of the Connecticut General Statutes;

(15) "TFA payment standard" means the monthly amount of cash assistance received by a family with no income that is collecting TFA subject to the twenty-one month time limit;

(16) "Tenant contribution" means the amount payable monthly by the family as rent to the owner; and

(17) "Transitionary rental assistance certificate" means the document issued by the department or its agent that defines the terms, conditions and eligibility requirements for participation in the transitionary rental assistance program.

History

• Adopted effective March 9, 2006

Regs., Conn. State Agencies § 17b-811a-2 Program administration and description

(a) Subject to the availability of funds, the commissioner shall implement and administer a transitionary rental assistance program for families that meet the eligibility requirements of section 17b-811a-3 of the Regulations of Connecticut State Agencies.

(b) An eligible family, whether or not it has received a transitionary rental assistance certificate, shall not receive assistance under this program if funds are not available.

(c) The department may administer the transitionary rental assistance program directly or it may designate one or more agents to administer the program. If an agent is designated to administer the program, the department shall enter into a contract with that agent. Such agent shall be required by contract to keep records in accordance with applicable state requirements.

(d) The commissioner may provide, on a one-time basis, up to twelve consecutive months of transitionary rental assistance.

(e) The department or its agent shall make transitionary rental assistance payments directly to an owner on behalf of an eligible family. No payment shall be made until (1) a lease has been executed by the family and the owner; (2) tenancy has been approved by the department or its agent; (3) the dwelling unit has passed a housing quality standard inspection; and (4) the department or its agent and the owner have entered into and executed a transitionary rental assistance contract. An eligible family shall make a monthly tenant contribution directly to the owner pursuant to an executed lease. The amount of the tenant contribution shall be determined in accordance with section 17b-811a-6 of the Regulations of Connecticut State Agencies.

(f) The commissioner shall develop a schedule of maximum allowable rent. Except as provided in section 17b-811a-6 (c) of the Regulations of Connecticut State Agencies, the department or its agent shall not grant a request for tenancy approval if it determines that the proposed rent under the lease is greater than the amount allowed pursuant to the schedule of maximum allowable rent. In developing the schedule, the commissioner shall consider the cost of rent in the different municipalities in which rental property is located; the type of housing (e.g., single family, apartment building); and the number of, and size of, bedrooms in the dwelling unit. The maximum allowable rent shall include a utility allowance that the commissioner shall develop. Said utility allowance shall include an allowance for all utilities paid by the eligible family except telephone service. The department or its agent shall use the utility allowance when determining the tenant contribution pursuant to section 17b-811a-6 of the Regulations of Connecticut State Agencies.

(g) Administrative responsibilities for the transitionary rental assistance program shall include family selection, family and landlord briefings, family and landlord outreach, family mobility counseling, promotion of housing choice and encouragement of racial and economic integration, dwelling unit inspection for compliance with housing and health codes, income and rent verifications, maintenance of records and other responsibilities as required by the commissioner.

(h) Participation by a landlord and by the department or its agent in the transitionary rental assistance program shall require compliance with all applicable federal and state fair housing law, rules and regulations.

(i) In accordance with section 17b-811a-3(a) of the Regulations of Connecticut State Agencies, a family may be eligible for transitionary rental assistance if an adult member is employed at the time the family leaves the TFA program and either; (1) has income which exceeds the TFA payment standard or (2) is employed for a minimum of 12 hours per week. The commissioner may determine at any time, in his discretion, that funding limitations require a priority to be established for allocating limited transitional assistance benefits. In such an eventuality, families with income that exceeds the TFA payment standard shall be afforded priority over families with an adult member who is employed for a minimum of 12 hours per week.

History

• Adopted effective March 9, 2006; Amended June 1, 2010

Regs., Conn. State Agencies § 17b-811a-3 Eligibility requirements

(a) A family shall be eligible for transitionary rental assistance if an adult member is employed at the time the family leaves the TFA program and either: (1) has income which exceeds the TFA payment standard or (2) is employed for a minimum of twelve hours per week. A family whose income does not exceed fifty percent of the median family income for the area of the state in which such family lives shall be eligible as determined by the commissioner. A family that has left the TFA program may submit an application for transitionary rental assistance not more than six months after leaving TFA. Transitionary rental assistance benefits shall not be provided before the first day of the month following the month during which the family's TFA benefits end.

(b) To maintain eligibility for transitionary rental assistance, a family shall:

(1) supply information that is accurate and complete to the department or its agent;

(2) comply with the provisions of the transitionary rental assistance certificate;

(3) supply information that the department or its agent requests to determine the household composition and the income of any household member;

(4) provide social security numbers of household members and provide social security cards for verification;

(5) sign and submit consent forms that allow the department or its agent to obtain relevant information about household members;

(6) supply any information that the department or its agent requests concerning whether the family is living in the dwelling unit or information related to a family's absence from the unit;

(7) promptly notify the department or its agent in writing when the family is away from the dwelling unit for four or more continuous weeks;

(8) allow the department or its agent to inspect the dwelling unit at reasonable times and after reasonable notice;

(9) notify the department or its agent and the owner in writing before moving out of the dwelling unit or terminating or amending a lease;

(10) pay utility bills and supply appliances that the owner is not required to pay for or supply under the terms of the lease;

(11) give the department or its agent a copy of any eviction notice it receives; and

(12) use the dwelling unit as its sole residence.

(c) To maintain eligibility for transitionary rental assistance, a family (including each household member) shall not:

(1) own or have any interest in the dwelling unit; however, a family shall not be ineligible for assistance if it has an ownership interest in a cooperative, or if it owns a manufactured home for which it leases a manufactured home space;

(2) commit any serious or repeated violation of the lease;

(3) commit fraud, bribery or any other corrupt or criminal act in connection with the transitionary rental assistance program;

(4) participate in any illegal drug or violent criminal activity in the dwelling unit or on the premises on which the dwelling unit is located;

(5) sublease or rent the dwelling unit to another party, assign or transfer the lease of the dwelling unit to another party;

(6) receive transitionary rental assistance while receiving another housing subsidy for the same dwelling unit or a different dwelling unit under any other state, federal or local housing assistance program;

(7) willfully damage the dwelling unit or premises or cause serious or repeated damage to the dwelling unit or premises through negligence or permit any guest to willfully damage the dwelling unit or premises or permit any guest to cause serious or repeated damage to the dwelling unit or premises through negligence; or

(8) receive TFA.

(d) If the department or its agent determines that a family or household member receiving transitionary rental assistance has violated any subdivision of subsections (b) or (c) of this section, it may terminate the family's participation in the transitionary rental assistance program.

History

• Adopted effective March 9, 2006

Regs., Conn. State Agencies § 17b-811a-4 Family referral, application and selection process

(a) Any family approaching the end of the twenty-one month time limit on TFA is scheduled to have an interview conducted under section 17b-112 (f) of the Connecticut General Statutes during month twenty for the purpose of being informed of services that may continue to be available to them. Any family in a six month extension of TFA after the twenty-one month time limit is scheduled to have an interview conducted under section 17b-112 (f) of the Connecticut General Statutes during month five for the aforementioned purpose.

(b) A transitionary rental assistance certification and referral form shall be issued to any family that is determined to be potentially eligible, or appears at the time of the interview conducted pursuant to section 17b-811a-4(a) of the Regulations of Connecticut State Agencies to be potentially eligible, for participation in the transi-tionary rental assistance program by way of meeting initial eligibility criteria. Other families leaving TFA may also apply for transitionary rental assistance. For any such family that appears eligible, the department shall assist the family in filling out an application form. This application form shall include, but not be limited to, information on family size and composition and the amount and sources of all current income for all family members who will reside in the dwelling unit which the family will occupy. The department or its agent shall obtain verification of the family's income prior to that family's receipt of transitionary rental assistance.

(c) The department or its agent shall accept an application for transitionary rental assistance from a family provided it is received by the department or it's agent no later than six months from the date the family has been discontinued from TFA.

(d) If an application for transitionary rental assistance from a family that appears to meet initial eligibility criteria is substantially completed, as determined by the department or its agent, the department or its agent shall accept the application and place the family in the pool for selection of transitionary rental assistance program participants.

(e) If an application for transitionary rental assistance is not substantially completed, the department or its agent shall notify the applicant in writing or telephonically of the information that is needed to complete the application. After such notification, the applicant shall respond to the department or its agent not later than twenty business days after the date on which the applicant was notified. If the applicant fails to respond, the department or its agent shall deem said application to have been withdrawn and the department or its agent shall notify the applicant in writing no later than five business days after said application has been deemed withdrawn. The applicant may request, in accordance with section 17b-811a-8 of the Regulations of Connecticut State Agencies, that the department or its agent review its determination that an application has been withdrawn. The department or its agent shall not provide transitionary rental assistance payments before a family's application is completed.

(f) If the department or its agent denies an application for transitionary rental assistance, it shall notify the applicant in writing of the reasons for the denial no later than five business days after the denial. The applicant may request the department or its agent to review the denial in accordance with section 17b-811a-8 of the Regulations of Connecticut State Agencies.

(g) The department or its agent shall, on a monthly basis and dependent on the amount of funds available and the number of referrals made, conduct a lottery to select a pre-determined number of families to participate in the program. Families not selected shall remain in the pool for a period not to exceed six months. Selected families shall be issued a transitionary rental assistance certificate. Such certificate allows a family to locate a dwelling unit and submit a request for tenancy approval to the department or its agent. Neither the department nor its agent shall approve tenancy for a family that is not in receipt of a valid certificate. The department or its agent shall not provide transitionary rental assistance unless tenancy has been approved in accordance with section 17b-811a-5 of the Regulations of Connecticut State Agencies.

(h) A transitionary rental assistance certificate shall be valid for sixty calendar days. The first day of the sixty days shall begin on the calendar day following the day that the department or its agent issued the certificate. The department or its agent may extend the certificate's validity, in one or more increments, by up to sixty additional days. The department or its agent may extend the certificate's validity for more than one-hundred-twenty total days if it determines that good cause existed for the family's failure to locate a dwelling unit or submit a request for tenancy approval.

(i) No day shall count toward the sixty-day or subsequent limit if the department or its agent is in receipt of a submission by a certificate holder of a request for tenancy approval. If tenancy is not approved the department shall give the family prompt notice by mail or telephonically. The first calendar day following the day of department notification of its non-approval shall be the first day on which the sixty-day or subsequent limit shall resume.

History

• Adopted effective March 9, 2006

Regs., Conn. State Agencies § 17b-811a-5 Approval of tenancy and payment of benefits

(a) The department shall develop a "request for tenancy approval" form and shall provide each applicant for transitionary rental assistance with five copies of the form at the time the applicant receives his or her transitionary rental assistance certificate. In addition to any other information required by the commissioner, the form shall include: (1) a statement that the applicant requests approval of tenancy; (2) a statement indicating that the owner agrees to rent the dwelling unit to the applicant; and (3) a place for the signatures of the owner and the applicant.

(b) When an eligible family has located an available rental dwelling unit and the owner is willing to rent the dwelling unit to the family, the family shall submit to the department or its agent a request for tenancy approval that is signed by the applicant and the owner, along with the proposed lease. The lease that the family submits to the department or its agent shall be for a term of twelve consecutive months and for the rental of a dwelling unit that qualifies as eligible housing as defined in section 17b-811a-1(9) of the Regulations of Connecticut State Agencies.

(c) Prior to approving tenancy, the department or its agent shall inspect the dwelling unit for compliance with the standards as cited in 24 CFR 982.401, and local and state health housing, building and safety codes. If there are defects that require correction, the department or its agent shall advise the owner of the work required to be done. If defects are claimed to be corrected, the dwelling unit shall be re-inspected and tenancy approved before a contract is executed.

(d) The department or its agent shall not approve tenancy if the owner of the dwelling unit resides in the available rental dwelling unit.

(e) An eligible family may submit a request for tenancy approval for the dwelling unit that it already occupies if the unit qualifies as eligible housing as defined in section 17b-811a-1(9) of the Regulations of Connecticut State Agencies.

(f) If the department or its agent grants a request for tenancy approval, the department or its agent shall notify the owner and the family of its approval of tenancy no later than five business days after approval. The department or its agent shall provide the owner with: (1) two copies of a transitionary rental assistance contract, which shall be a written and binding agreement between the department or its agent and the owner that contains the terms and conditions under which the owner shall rent the dwelling unit to an eligible family and under which the department or its agent shall make monthly transitionary rental assistance payments directly to the owner on behalf of the eligible family in a specified amount; and (2) a copy of the lease between the eligible family and the owner, which has been approved by the department and specifies any and all of the terms and conditions under which the owner shall rent to the eligible family and specifies the contract rent. The owner shall execute both contracts and return them to the department or its agent along with a copy of the executed lease between the owner and the eligible family. The department or its agent shall execute the transitionary rental assistance contracts and provide the owner and the eligible family with one copy each.

(g) The department or its agent shall provide transitionary rental assistance payments to the owner in accordance with the rental assistance contract for the dwelling unit under the lease. These payments shall cover the difference between the contract rent and the tenant contribution. However, the amount may not exceed the maximum allowable rent established by the commissioner pursuant to section 17b-811a-2 of the Regulations of Connecticut State Agencies, except as provided in 17b-811a-6 of the Regulations of Connecticut State Agencies.

History

• Adopted effective March 9, 2006

Regs., Conn. State Agencies § 17b-811a-6 Computation of assistance amount

(a) The amount of monthly transitionary rental assistance that the department or its agent provides on behalf of an eligible family shall be the difference between the tenant contribution and the contract rent.

(b) The tenant contribution shall be ten percent of the family's monthly income or forty percent of the family's monthly adjusted gross income less a utility allowance, whichever is greater. A family's monthly adjusted gross income shall be reduced by the following deductions, up to maximum amounts that the commissioner establishes:

(1) a deduction for dependents;

(2) childcare costs paid by and not reimbursed to, or on behalf of, the certificate holder which enable one or more adults in the family to work, to attend school or to actively seek employment;

(3) unreimbursed medical expenses which exceed three percent of the family's annual income;

(4) allowable disability assistance expenses deducted for attendant care or an auxiliary apparatus for person(s) with disabilities if needed to enable the individual or an adult family member to work, when these are paid by, and not reimbursed to or on behalf of, the transitionary rental assistance certificate holder; and

(5) any other deduction that the commissioner may establish.

(c) Notwithstanding section 17b-811a-4 of the Regulations of Connecticut State Agencies, the gross rent for the unit shall not exceed the maximum allowable rent, as determined by the commissioner, unless the transitionary rental assistance certificate holder decides to remain in his or her current dwelling unit and the owner agrees to participate in the transitionary rental assistance program. If the transitionary rental assistance certificate holder decides to remain in his or her current dwelling unit, the new contract rent shall not exceed the rent paid by the tenant holding the transitionary rental assistance certificate prior to the beginning of the transitionary rental assistance contract term.

(d) An eligible family that receives transitionary rental assistance may, during the term of said family's lease, request that the department or its agent conduct a re-determination of its contribution to the gross rent because of changes in its income or household composition.

History

• Adopted effective March 9, 2006

Regs., Conn. State Agencies § 17b-811a-7 Reporting requirements and audits

(a) Any agent designated by the department to administer this program shall submit monthly financial and program reports to the department in accordance with the terms specified in its contractual agreement with the department.

(b) An entity that has been designated as an agent of the department to administer this program shall be subject to an audit of all books and records related to this program. Audits shall be performed by independent public accountants registered to practice in the state of Connecticut or by qualified department personnel. All audits shall be in accordance with procedures and timetables established by the department.

History

• Adopted effective March 9, 2006

Regs., Conn. State Agencies § 17b-811a-8 Appeals

(a) The department or its agent shall give transitionary rental assistance program applicants prompt written notice of a decision denying assistance to an applicant, and shall give families participating in the program prompt written notice of a decision changing the terms of, or denying continued assistance to, a participant. This notice shall contain a brief statement of the reason(s) for the decision, shall state that the applicant or family participating in the program may request an informal conference to review the decision and shall describe how to obtain such an informal conference.

(b) A written request for an informal conference shall be made to the department's agent where the program is locally administered or, if there is no such agent, to the department. The request shall be postmarked no later than seven days after the date of the notice of the decision from the administering agent or the department. The department's agent, if in receipt of such a request, shall forward a copy to the department's Housing Services Unit.

(c) The department or its agent shall continue to provide rental assistance as provided in the transitionary rental assistance contract to those families who have requested an informal conference to review a decision changing the terms of, or discontinuing, their assistance until a report has been issued following such conference, provided: (1) the request for the informal conference is received or postmarked no later than seven days after the date of notice from the department or its agent; (2) the program has sufficient funds to provide such assistance and; (3) the decision under review is not one that affects all program applicants or families participating in the program equally. Under no circumstances shall more than twelve months of benefits be provided under this subsection.

(d) The department or its agent shall schedule an informal conference no later than thirty days from the receipt of the request and shall inform the applicant or family participating in the program of the conference by written notice. The notice of informal conference shall include the date, time and place for the conference; a reference to the particular sections of the statutes and regulations involved; and a short and plain statement of the matters asserted. The informal conference shall be conducted by any person or persons designated by the department or its agent, other than a person who recommended or approved the decision under review or a subordinate of such person.

(e) In lieu of holding an informal conference, the department or its agent may take one of the following actions:

(1) Acceptance of a withdrawal of the request by the person who made it. This action shall be voluntary and may be made at any time before the informal conference by a written statement of withdrawal addressed to the department or its agent;

(2) dismissal of the request by the department or its agent. This action shall be taken if:

(A) The applicant or family participating in the program who has requested the informal conference fails to appear at the designated time and place for the conference; or

(B) the issue is resolved prior to the informal conference.

(f) Not later than thirty days from the date of the informal conference, the department or its agent shall issue a written report of its findings, which may modify the decision that was reviewed by the conference. Factual determinations relating to the individual circumstances of the applicant or family participating in the program who requested the informal conference shall be based on information presented at the informal conference. A copy of the report shall be provided promptly to the applicant or family participating in the program who requested the informal conference and shall include copies of any documents presented at the informal conference.

(g) If, following an informal conference and report, the decision is unchanged, the department shall provide a desk review of the report, upon written request of the applicant or family participating in the program, to ensure compliance with an agent's contractual obligation. The applicant or family participating in the program shall request said desk review not later than ten days after the decision has been rendered. No new information which could have been presented at the informal conference shall be used by the department for the purposes of such desk review. Requests shall be sent to:

Commissioner, Department of Social Services

25 Sigourney Street

Hartford, CT 06106

Attn: Housing Services Unit

History

• Adopted effective March 9, 2006

17b-812 Rental Assistance Program

Regs., Conn. State Agencies § 17b-812-1 Definitions

As used in sections 17b-812-1 to 17b-812-14, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Adjusted gross income" means the gross income of all adults residing in a dwelling unit less the allowable deductions listed in subsection (d) of section 17b-812-6 of the Regulations of Connecticut State Agencies;

(2) "Agent" means any entity designated by the department to operate the rental assistance program;

(3) "Commissioner" means the Commissioner of Social Services;

(4) "Contract rent" means the total monthly rent payable to the owner for the dwelling unit;

(5) "Department" means the Department of Social Services;

(6) "Dependent" means a member of a family, other than a head of household, spouse or foster child, who is under eighteen years of age or is disabled or is a full-time student eighteen years of age or older;

(7) "Disabled person" means a person who has a disability as defined in the Americans with Disabilities Act, 42 USC 12102;

(8) "Dwelling unit" means a house, building or mobile manufactured home in a mobile manufactured home park, as such terms are defined in section 21-64 of the Connecticut General Statutes, or any portion of a house, building or mobile manufactured home in a mobile manufactured home park, that is occupied, designed to be occupied or rented, leased or hired out to be occupied as a home or residence of one or more persons;

(9) "Elderly person" means a person sixty-two years of age or older;

(10) "Eligible family" means a household consisting of one or more persons, with income that does not exceed fifty per cent (50%) of the median family income for the area of the state where the family lives, as determined by the commissioner. An eligible family shall include at least one citizen or eligible non-citizen;

(11) "Eligible housing" means privately owned rental housing, located in any municipality in the state, that meets federal housing quality standards as cited in 24 CFR 982.401, and local and state health, housing, building and safety codes;

(12) "Eligible non-citizen" means a person who meets the qualification requirements established in subsection (a) of 42 USC 1436a;

(13) "Gross rent" means the sum of the contract rent and any utility allowance established by the commissioner;

(14) "Income" means gross income from whatever sources derived;

(15) "Maximum allowable rent" means the maximum amount of monthly rent that is payable under the rental assistance program, as determined by the commissioner;

(16) "Mixed family" means a household consisting of one or more persons who are citizens or eligible non-citizens and one or more persons who are ineligible non-citizens or who elect not to state that they have eligibility status;

(17) "Occupancy policy" means the standards established by the commissioner for determining the appropriate number of bedrooms for families of different sizes;

(18) "Owner" means a person or entity having the legal right to lease or sublease housing;

(19) "Pre-application" means the form disseminated by the department or its agent by which an applicant submits his or her name into a lottery for establishing the waiting list for the Rental Assistance Program;

(20) "Project-based rental assistance" means rental assistance that is attached to a specific dwelling unit and is non-transferable;

(21) "Rental agreement" means all agreements, written or oral, and valid rules and regulations adopted under section 47a-9 of the Connecticut General Statutes, embodying the terms and conditions concerning the use and occupancy of a dwelling unit and premises between the owner and the tenant;

(22) "Rental assistance certificate" means the document issued by the department or its agent to the tenant that defines the terms, conditions and eligibility requirements for participation in the Rental Assistance Program;

(23) "Rental assistance contract" means a written agreement between the department or its agent and the owner or the owner's designated representative that contains the terms and conditions under which the owner or the owner's designated representative will rent the dwelling unit to an eligible family, and the amount of rental assistance payments to be made by the department or its agent to the owner or the owner's designated representative on behalf of such eligible family;

(24) "Rental assistance payment" means the amount paid by the department on behalf of the tenant to the owner of the dwelling unit toward the contract rent;

(25) "Request for tenancy approval" means the document submitted by an eligible family to the department or its agent requesting approval of a dwelling unit for tenancy by the family;

(26) "Supportive housing" means rental housing, funded by tenant-based rental assistance or project-based rental assistance, that also provides support services to individuals and families experiencing, or at significant risk of, long-term homelessness;

(27) "Tenant" means an eligible family that is leasing a dwelling unit from an owner;

(28) "Tenant-based rental assistance" means rental assistance payments provided to eligible families that are retained by the eligible family even if they subsequently move to another dwelling unit;

(29) "Tenant contribution" means the amount of the monthly contract rent payable by the eligible family to the owner;

(30) "Tenant selection plan" means a plan submitted to the department by a supportive housing provider that specifies the uniform methodology the provider shall use to select tenants for its supportive housing units including, but not limited to, specific eligibility factors, occupancy policy, and application and tenant screening procedures; and

(31) "Utility allowance" means the estimated monthly cost, as determined by the commissioner, for an eligible family for heat and other utilities, excluding telephone, that are not supplied or paid for by the owner of the dwelling unit rented by the family. The utility allowance is added to the contract rent to calculate the gross rent.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-2 Program administration

(a) The commissioner shall implement and administer a non-entitlement program that provides rental assistance for low-income families living in privately owned rental housing, allowing eligible families to afford decent, safe and sanitary housing.

(b) The commissioner or the commissioner's agent shall limit the issuance of rental assistance certificates to eligible families based upon the availability of funds. A certificate does not guarantee a family the right to participate in the program. The commissioner or the commissioner's agent may suspend or cancel an issued certificate if a change in an applicant's circumstances results in ineligibility prior to execution of the rental assistance contract. The commissioner may suspend or cancel issued certificates based on lack of funds.

(c) The department shall administer and oversee the rental assistance program. The department may directly administer the financial assistance provided or may designate one or more agents to administer the program.

(d) Administrative responsibilities for this program, whether undertaken by the department or its agent, shall include: Tenant selection, tenant and landlord briefings, landlord and tenant outreach, mobility counseling, promotion of housing choice, encouragement of racial and economic integration, annual unit inspection for compliance with housing and health codes, initial and annual re-examination of tenant income and rent adjustments, maintenance of records, and other duties as required by the commissioner.

(e) The commissioner may designate a portion of available rental assistance funding under the rental assistance program for supportive housing units. To the extent practicable, rental assistance for supportive housing shall adhere to the requirements of the federal Housing Choice Voucher program, set forth in subsection (o) of 42 USC 1437f, relative to the tenant's share of the rent to be paid. Selection for tenant-based and project-based rental assistance shall be in accordance with subsection (a) of section 17b-812-5 of the Regulations of Connecticut State Agencies or subject to a tenant selection plan approved by the commissioner that designates rental assistance to eligible families who are homeless, or at risk of homelessness, and who would benefit from the support services provided. Such services are provided by programs other than the rental assistance program and include those intended to address mental health disorders, substance use disorders, AIDS and AIDS related disorders and other factors contributing to homelessness. The availability of support services shall be a factor considered by the commissioner for the purposes of tenant selection and site location.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-3 (Repealed)

Repealed December 28, 2012.

Regs., Conn. State Agencies § 17b-812-4 Supportive housing; eligibility and selection of owner participants

(a) The commissioner may select municipalities, housing authorities, private organizations or nonprofit organizations to participate in the supportive housing program based on criteria that shall include, but not be limited to, the following:

(1) Demonstration of the need for housing for low income families in the geographic area served by the municipality, housing authorities, private organization or nonprofit organization;

(2) demonstration of the availability of rental units in the geographic area served by the municipality, housing authorities, private organization or nonprofit organization; and

(3) availability of other public or private funds.

(b) Eligible municipalities, housing authorities, private organizations and nonprofit organizations may participate in other municipal, state or federal housing repair, rehabilitation or financing programs, including the programs of the Connecticut Housing Finance Authority.

(c) Criteria for selecting municipalities, housing authorities, private organizations or nonprofit organizations for the supportive housing portion of the rental assistance program shall include:

(1) Any needs outlined in the five year housing advisory plan;

(2) local housing assistance plans, if in existence;

(3) any statistical data on housing need and marketability;

(4) suitability of the proposed site and project;

(5) the apparent capability of the municipality, housing authority, private organization or nonprofit organization to manage the project;

(6) the availability of funds from sources other than the rental assistance program; and

(7) the availability of funding for support services from other programs.

(d) Any rental assistance payments provided under the supportive housing portion of the rental assistance program shall be provided to the municipality, housing authority, private organization or nonprofit organization through a contract with the department to make one or more dwelling units affordable to low-income families. These dwelling units shall continue to be made available to eligible families for the term of the contract entered into between the department and the municipality, housing authority, private organization or nonprofit organization, so long as funds are available for such purposes.

(e) Rental assistance provided to an eligible family under the supportive housing portion of the rental assistance program is non-transferable and shall remain with the dwelling unit.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-5 Notice, application process, selection of eligible families and issuance of rental assistance certificates; special considerations

(4) protecting witnesses to a crime;

(a) The department shall provide notice to the public in newspapers of general circulation when the waiting list for the rental assistance program will be opened. The notice shall include information regarding where pre-applications can be obtained and submitted, and the dates when the department will be accepting pre-applications. After the period for accepting pre-applications has concluded, the department or its agent shall conduct a lottery using all pre-application forms received. The department or its agent shall place a predetermined number of applicants on the waiting list for the rental assistance program in the order in which they were randomly selected by the lottery.

(b) If selected from the lottery, an eligible family shall complete a rental certificate application form that shall include, but not be limited to, information on family size and composition and the amount and sources of all income. The commissioner or the commissioner's agent shall verify the family's income.

(c) When the department or its agent determines that a family is eligible for rental assistance, the department or its agent shall issue the family a rental assistance certificate. The department or its agent shall inform the family of the family's obligations under the program as well as the responsibilities of the owner of the dwelling unit, and shall provide the family with applicable forms and information that may assist the family in finding a suitable dwelling unit.

(d) The rental assistance certificate shall be used within ninety days of issuance. The department or its agent may extend the expiration date of the certificate in one or more increments, such extensions not to exceed a total of ninety days. The certificate holder shall have a maximum of one hundred eighty days to locate a suitable dwelling unit unless the department or its agent finds good cause to extend the maximum period.

(e) The ninety day time limit stops running on the day the department or its agent receives a request for tenancy approval. If for any reason the dwelling unit cannot be approved, then the certificate holder shall be notified and the time limit shall resume running on the date notice is mailed.

(f) If it is determined that an applicant is ineligible to participate in the rental assistance program, the department or its agent shall notify the applicant, in writing, of the reason why he or she was determined to be ineligible. The applicant shall have the right to appeal this decision in accordance with section 17b-812-14 of the Regulations of Connecticut State Agencies.

(g) The commissioner shall have discretion to grant rental assistance payments, within available funding, to individuals who may or may not be on the waiting list but who are otherwise eligible, and are homeless, have been displaced by governmental action, whose dwelling unit has been extensively damaged or destroyed as a result of a disaster declared or otherwise formally recognized pursuant to federal disaster relief laws, or are participants in programs approved by the commissioner. Programs approved by the commissioner may include, but are not limited to, programs for:

(1) Assisting individuals residing in nursing facilities or public institutions to leave such facilities or institutions;

(2) preventing individuals from becoming institutionalized;

(3) providing housing for children with severe disabilities and their families;

(4) protecting witnesses to a crime; or

(5) addressing the housing needs of individuals and families where lack of housing results in a significant threat to the health or safety of such persons.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-6 Computation of rental assistance payments

(a) The amount of rental assistance paid by the department on behalf of eligible families shall be the difference between the tenant contribution and the contract rent. The tenant contribution shall be ten per cent (10%) of the family's monthly income or forty per cent (40%) of the family's monthly adjusted gross income less a utility allowance, whichever is greater.

(b) The contract rent plus utility allowance for the unit shall not exceed the maximum allowable rent, as determined by the commissioner.

(c) Notwithstanding the basic formula under subsection (a) of this section, the tenant contribution for elderly or disabled persons shall be ten per cent (10%) of the family's monthly income or thirty per cent (30%) of the family's monthly adjusted gross income less a utility allowance, whichever is greater.

(d) The commissioner shall determine the amount of the following allowable deductions, which shall be deducted from a family's income to determine adjusted gross income:

(1) Each dependent;

(2) unreimbursed child care costs that enable all adults in the household to work, to attend school or to actively seek employment. The department or its agent may make exceptions for one or more adults in the household who are precluded by disability from working, attending school or actively seeking employment;

(3) for households with a head of household or spouse who is an elderly or disabled person, annual unreimbursed medical expenses that exceed three per cent (3%) of the family's income;

(4) unreimbursed disability assistance expenses for attendant care or auxiliary apparatus for a household family member with disabilities if such expenses are needed to enable the disabled person or an adult household family member to work; and

(5) any other deduction that the commissioner may establish.

(e) An eligible family that receives rental assistance may, during the term of such family's rental agreement, request that the department or its agent conduct a redetermination of its contribution to the gross rent because of changes in its income or household composition.

(f) The department shall offer pro-rated assistance to a mixed family. The department shall calculate pro-rated assistance by determining the amount of assistance payable if all family members were eligible and multiplying such amount by the percent of family members who are eligible.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-7 Eligible housing

(a) Dwelling units contracted for under the rental assistance program shall meet the definition of eligible housing provided in section 17b-812-1 of the Regulations of Connecticut State Agencies.

(b) A family with a rental assistance certificate is responsible for finding a dwelling unit within the state that suits the needs of the family. A family may select the dwelling unit that it already occupies if the dwelling unit meets the department's occupancy policy and the provisions of section 17b-812-8 of the Regulations of Connecticut State Agencies.

(c) The owner of the dwelling unit shall not reside in the same dwelling unit for which a rental assistance payment is being paid to the owner.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-8 Request for tenancy approval

(a) An eligible family that has located an available dwelling unit for rent shall submit a request for tenancy approval to the department or its agent. The request for tenancy approval shall be signed by the owner or the owner's designated representative and the eligible family. The family shall also submit a copy of the proposed rental agreement between the owner and the family.

(1) The department or its agent shall determine whether the proposed contract rent is in accordance with the schedules established by the commissioner.

(2) Before approving tenancy, the department or its agent shall inspect the dwelling unit for compliance with the standards provided in section 17b-812-7 of the Regulations of Connecticut State Agencies. The department or its agent shall notify the owner of any defects that require correction and shall reinspect the dwelling unit after the owner represents that the identified defects have been corrected. The department or its agent shall not approve tenancy until the dwelling unit is in compliance with the department's occupancy policy for eligible housing.

(b) The term of the rental agreement between the tenant and the owner shall be not less than one year.

(c) The department or its agent shall notify the owner or the owner's designated representative and the family if the request for tenancy is approved. The department or its agent shall provide the owner with two copies of a rental assistance contract. The owner or the owner's designated representative shall sign and return both copies of the rental assistance contract to the department or its agent as well as a copy of the rental agreement signed by the owner or the owner's designated representative and the tenant. The department or its agent shall sign the rental assistance contracts and return one copy to the owner or the owner's designated representative.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-9 Reexamination of family income

(a) The department or its agent shall conduct an annual reexamination of the income and family composition of families participating in the rental assistance program. The department or its agent shall adjust the amount of each family's assistance payment at the time of the annual reexamination to reflect changes in the family's adjusted gross income.

(b) During the term of the eligible family's rental agreement, the eligible family shall report changes in income or any change in family composition to the department or its agent within thirty days.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-10 Disbursement of rental assistance payments

The department or its agent shall pay rental assistance payments directly to the owner or the owner's designated representative. The rental assistance payment shall be the amount stated in the rental assistance contract between the department and the owner.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-11 Reporting requirements and audit

(a) Any agent designated by the department to administer this program shall submit monthly financial and program reports to the department in accordance with the terms specified in its contractual agreement with the department.

(b) An entity that has been designated as an agent of the department to administer this program shall be subject to audit of all books and records related to this program. Audits shall be performed by independent public accountants registered to practice in the state of Connecticut or by qualified department personnel. All audits shall be in accordance with procedures and timetables established by the department.

History

• Effective March 21, 1996; Amended February 9, 2000; Amended May 31, 2007; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-12 Family obligations

(a) A family shall comply with subsections (b) and (c) of this section in order to continue participating in the rental assistance program. Failure to comply may result in termination from the program.

(b) A family shall:

(1) Provide information that is true and complete and in compliance with the provisions of the rental assistance certificate;

(2) provide all forms and documents necessary for use in a regularly scheduled reexamination or interim reexamination of family income and composition;

(3) provide the social security numbers of all household members and sign and submit forms that will allow the department or its agent to obtain information to determine eligibility;

(4) not later than thirty days after a request by the department or its agent, provide the department or its agent information to verify that the family is living in the dwelling unit or information related to family absence from the dwelling unit;

(5) notify the department or its agent in writing before any planned absence of thirty days or more, or on or before the thirtieth consecutive day of any unplanned absence. If the entire family is absent from the unit for more than ninety consecutive days, the department shall consider the unit vacated and shall terminate rental assistance, unless the family has notified the department or its agent on or before the thirtieth day of any absence and can show good cause for the extended absence on or before the ninetieth day of any absence. If the family shows good cause, the department or its agent may permit the family to be absent for up to sixty additional days before considering the unit to be vacated;

(6) notify the department or its agent in writing not later than thirty days before moving out of the dwelling unit or terminating the lease;

(7) use the dwelling unit as the family's sole residence;

(8) notify the department or its agent in writing of the birth, adoption or court-awarded custody of a child, not later than thirty days after such birth, adoption or court-awarded custody;

(9) request written approval from the department or its agent before adding any other adult family member as an occupant of the dwelling unit;

(10) notify the department or its agent in writing if any member no longer lives in the dwelling unit, not later than thirty days after such member leaves;

(11) allow the department or its agent to inspect the dwelling unit at reasonable times and after reasonable notice as part of regularly scheduled reexaminations, interim examinations and on other occasions deemed necessary by the department or its agent;

(12) immediately notify and forward to the department or its agent a copy of any notice to quit received by the tenant; and

(13) pay utility bills and supply appliances that the owner is not required to provide under the rental agreement.

(c) The family, including each family member, shall not:

(1) Own or have any interest in the dwelling unit other than in a cooperative, or as the owner of a mobile manufactured home leasing space in a mobile manufactured home park, as such terms are defined in section 21-64 of the Connecticut General Statutes;

(2) commit any serious or repeated violation of the rental agreement;

(3) commit fraud, bribery or any other corrupt or criminal act in connection with the rental assistance program;

(4) participate in any illegal drug or violent criminal activity leading to the individual's conviction;

(5) sublease the dwelling unit;

(6) receive rental assistance while receiving another housing subsidy for the same dwelling unit or a different dwelling unit under any other state, federal or local housing assistance program; or

(7) willfully damage the dwelling unit or premises or cause serious or repeated damage to the dwelling unit or premises through negligence, or permit any guest to willfully damage the dwelling unit or premises or cause serious or repeated damage to the dwelling unit or premises through negligence.

Notes: Section history note reworded. Former note read: "Adopted as § 17b-812-12, effective March 21, 1996; amended February 9, 2000; renumbered and amended May 31, 2007; amended December 28, 2012." (October 14, 2014)

History

• Adopted effective February 9, 2000; Transferred from § 17b-812-11a, May 31, 2007; Amended May 31, 2012; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-13 Denial or termination of assistance

The department or its agent may deny program assistance to an applicant or terminate assistance to a participant for any of the following reasons:

(1) A household family member fails to comply with the provisions of section 17b-812-12 of the Regulations of Connecticut State Agencies;

(2) a household family member fails to sign or submit required forms;

(3) a family with a rental assistance certificate fails to locate an approved dwelling unit within one hundred eighty days and does not demonstrate good cause for extending the expiration date of the rental assistance certificate;

(4) a household family member has been terminated from a department rental assistance program in the last three years;

(5) a household family member refuses to enter into a repayment agreement for monies owed to the department or its agent as a result of a program violation;

(6) a household family member currently owes rent or other monies to the department or its agent in connection with a rental subsidy program;

(7) a household family member has engaged in or threatened abusive or violent behavior towards the department or its agent's personnel;

(8) a family fails to report income that results in rental assistance overpayment in excess of two thousand five hundred dollars; or

(9) a household family member is subject to a registration requirement under a state or federal sex offender registration program.

History

• Adopted effective March 21, 1996; Transferred from § 17b-812-11a, May 31, 2007; Amended May 31, 2012; Amended December 28, 2012

Regs., Conn. State Agencies § 17b-812-14 Notice, appeals and hearings

(a) The department or its agent shall give program applicants prompt written notice of a decision to deny assistance to an applicant, and shall give program participants written notice of a decision to change the terms of assistance or to discontinue assistance to a participant. Such notice of decision shall: (1) contain a brief statement of the reasons for the decision; (2) state that any person aggrieved by a decision of the commissioner or the commissioner's agent pursuant to the program may request an administrative hearing in accordance with the provisions of section 17b-60 of the Connecticut General Statutes; and (3) describe how to request an administrative hearing. A notice of decision changing the terms of assistance or discontinuing assistance shall be issued not less than thirty days prior to the effective date of the proposed action.

(b) A participant or applicant may make a written request for an administrative hearing to the department's Office of Legal Counsel, Regulations and Administrative Hearings. Such request shall be faxed or postmarked not later than sixty days from the date printed on the notice of decision issued by the department or its agent.

(c) If an aggrieved participant requests an administrative hearing due to a decision to deny assistance, change the terms of assistance or discontinue assistance, the department shall continue to provide rental assistance payments as provided in the participant's rental assistance certificate until a decision has been issued following such hearing, provided: (1) the request for an administrative hearing is faxed or postmarked not later than ten days from the date printed on the notice of decision issued by the department or its agent; (2) the program has sufficient funds to provide such assistance; and (3) the decision under review is not one that affects all program applicants or participants equally. If an aggrieved participant requests an administrative hearing but the participant's grievance is not due to a decision to deny assistance, change the terms of assistance or discontinue assistance, the department shall continue to provide rental assistance payments as provided in the rental assistance certificate until a decision has been issued following such hearing.

(d) An administrative hearing shall be scheduled by the Office of Legal Counsel, Regulations and Administrative Hearings not later than thirty days from the receipt of the request for an administrative hearing. The Office of Legal Counsel, Regulations and Administrative Hearings shall notify the applicant or participant and the department or its agent of the administrative hearing by written notice issued not less than ten days in advance of the scheduled hearing. The notice of administrative hearing shall include the date, time and place for the hearing; reference the particular sections of the statutes and regulations involved; make a short and plain statement of the matters asserted; and advise the participant of the right to be represented by counsel. The administrative hearing shall be conducted by a hearing officer designated by the department.

(e) In lieu of holding an administrative hearing, the Office of Legal Counsel, Regulations and Administrative Hearings may take one of the following actions:

(1) Accept a withdrawal of the request by the person who made it. This action shall be voluntary and may be made at any time before the administrative hearing by a written statement of withdrawal addressed to the Office of Legal Counsel, Regulations and Administrative Hearings; or

(2) dismiss the request if:

(A) The applicant or recipient who has requested the administrative hearing fails to appear at the designated time and place without good cause; or

(B) the point at issue is resolved prior to the administrative hearing.

(f) Not later than sixty days from the date of the administrative hearing, the Office of Legal Counsel, Regulations and Administrative Hearings shall issue a written report of its findings which may order a change to the original decision of which review was sought. Factual determinations relating to the individual circumstances of the applicant or recipient who requested the administrative hearing shall be based on information presented at the administrative hearing. A copy of the decision shall be provided promptly to the applicant or recipient who requested the administrative hearing.

History

• Effective December 28, 2012