Report to the Connecticut General Assembly

From the SustiNet Health Partnership

Board of Directors
January 2011

SustiNet Health Partnership

Acknowledgements
This report reflects the work of many dedicated individuals, agencies and organizations across the state
and beyond. We’d like to acknowledge the work of the Board members:

Nancy Wyman (Co-Chair) • Kevin Lembo (Co-Chair)

Bruce Gould • Paul Grady • Bonita Grubbs • Norma Gyle • Jeffrey Kramer
Estela Lopez • Sal Luciano • Joseph McDonagh • Jamie Mooney*

And members of the five advisory committees and three task forces:
Health Disparities and Equity Advisory Committee
Health Information Technology Advisory Committee
Patient Centered Medical Home Advisory Committee
Preventive Healthcare Advisory Committee
Healthcare Quality and Provider Advisory Committee
Healthcare Work Force Task Force
Tobacco and Smoking Cessation Task Force
Childhood and Adult Obesity Task Force

Outstanding guidance provided by the consultant team comprised of:

Stan Dorn, Urban Institute
Anya Rader Wallack, Arrowhead Health Analytics
Katharine London, University of Massachusetts Medical School, Center for Health Law and Economics
Linda Green, Goddard Associates
Jonathan Gruber, MIT Department of Economics

We thank four foundations for generously supporting the Board’s work:

Connecticut Health Foundation
Universal Health Care Foundation of Connecticut
Jessie B. Cox Charitable Lead Trust
State Coverage Initiatives program, a national program of the Robert Wood Johnson Foundation,
administered by AcademyHealth

And a final note of thanks to the staff of the Office of the State Comptroller and the Office of the Health-
care Advocate who provided continuous support to the Board and its committees and task forces.

This report is hereby submitted to the Connecticut General Assembly on January 7, 2011:

Nancy Wyman, Lt. Governor Kevin Lembo, State Comptroller

* Jamie Mooney recently resigned her Board post; we thank her for her contributions.
Table of Contents

Executive Summary ............................................................................................................... 2

Background .............................................................................................................................4
2009 SustiNet Legislation ............................................................................................4
The Work of the SustiNet Board and Its Committees and Task Forces ....................4
Why Action is Necessary ..............................................................................................5
How this Report is Organized ......................................................................................7
Federal Health Care Reform ...................................................................................................7
Our Findings and Central Recommendations .......................................................................8
Covered Populations ....................................................................................................8
BOARD RECOMMENDATION .....................................................................11
Benefits .........................................................................................................................12
BOARD RECOMMENDATION ....................................................................13
Delivery System and Payment Reform ......................................................................14
BOARD RECOMMENDATION ....................................................................16
Governance and Administration ..................................................................................16
BOARD RECOMMENDATION ....................................................................17
Coverage and Access ...................................................................................................19
BOARD RECOMMENDATION......................................................................21
Prevention and Public Health Investments..................................................................22
BOARD RECOMMENDATION......................................................................22
Coverage and Cost Estimates..................................................................................................23
Coverage.........................................................................................................................23
Cost.................................................................................................................................24
Detailed Recommendations to the General Assembly...........................................................32
Governance and Location Within State Government..................................................32
Policy-making Duties and Responsibilities of the Authority Board...........................33
Administrative Duties and Responsibilities of the Authority......................................34
Reforming Health Care Delivery and Payment...........................................................35
Expanding Medicaid Coverage and Access to Care....................................................38
State Public Health Investments...................................................................................38
Timeline for Implementing SustiNet and Affordable Care Act.............................................40
Conclusion................................................................................................................................42
Endnotes....................................................................................................................................42
 Executive Summary
Connecticut residents, businesses, and state
government face deep and growing problems
with health care and coverage. Costs are rising to
unsustainable levels, hundreds of thousands of people
lack insurance, quality is inconsistent, purchasers are
unsure of the value they receive for their premium
dollar, and disparities along racial and ethnic lines
affect both health status and access to essential care.
If policymakers do nothing and recent trends in
Connecticut continue unabated, the end of this decade
will see private employers spending $14.8 billion
a year on insurance premiums, and nearly 390,000
people will be uninsured.
Fortunately, two developments now put
Connecticut’s leaders in a strong position to
address these longstanding problems, despite the
state’s daunting budget deficit. First, the federal
government passed the Patient Protection and
Affordable Care Act (Affordable Care Act or ACA).
Among its features, this legislation offers substantial
new federal resources to states that aggressively
tackle issues of coverage, cost, and quality. Second,
the General Assembly’s 2009 SustiNet legislation
laid the foundation for using these new federal
resources to effectively address the state’s health
care problems by applying innovative strategies
that will place Connecticut in the front ranks of
American states.
The SustiNet law embodied a distinctive vision.
Uninsured, low-income residents will get the help
they need to afford coverage, and insurers will
no longer be permitted to discriminate against
consumers with preexisting conditions. At the
same time, a new, publicly-administered health
plan—dubbed “SustiNet,” from the state motto—
will implement the country’s best thinking about
reforming health care delivery to slow cost growth
while improving quality. SustiNet will begin
with existing state-sponsored populations, state
employees and retirees as well as Medicaid and
HUSKY beneficiaries. SustiNet will then become
a new health coverage option for municipalities,
private employers, and families.
2
To flesh out this vision in detail, the 2009 law
established the SustiNet Health Partnership Board
of Directors (Board), requiring the Board to develop
recommendations for further legislative action.
After twenty open meetings, two public briefings,
a legislative briefing, and numerous meetings of
advisory committees and task forces staffed by
nearly two hundred volunteer citizen/experts, we
are proud to present our recommendations to the
Connecticut General Assembly and the Governor.
Thanks to the Affordable Care Act, the Legislature’s
vision of SustiNet can now be implemented without
increasing state spending. In fact, the combination
of federal reforms and our proposal for expanding
coverage, slowing cost growth, and improving
quality will reduce state budget deficits, according
to estimates from Dr. Jonathan Gruber of the
Massachusetts Institute of Technology, one of the
country’s leading health economists.
We recommend a policy with the following features:
• The SustiNet health plan will implement
delivery system and payment reforms that move
towards a more coordinated, patient-centered,
evidence-based approach to health care.
• The plan will be administered by a quasi-
governmental agency governed by a board of
directors appointed by the Governor and the
Legislature. Initially, staff and administrative
support will be provided by the Office of the
Comptroller.
• SustiNet will begin by serving state employees
and retirees along with Medicaid and HUSKY
beneficiaries, none of whom will see reduced
benefits or increased costs because of the shift to
SustiNet. However, SustiNet’s delivery system
and payment reforms will immediately seek
to achieve savings for state taxpayers while
improving quality of care and health outcomes
for consumers.
• SustiNet will become a new health insurance
choice for municipalities, private employers,
and households. Connecticut’s cities and towns
will quickly gain the ability to enroll their
 workers in SustiNet. SustiNet will then gear up Even if SustiNet fails to slow cost growth,
to offer commercial-style insurance to small implementing national reform in the way that
employers and non-profits, if possible before we propose will still save Connecticut taxpayers
2014. Effective on January 1, 2014, when most between $226 million and $277 million a year,
federal reforms become operational, SustiNet starting in 2014. Such savings will result from
will offer comprehensive, commercial benefits to substituting newly available federal dollars for
all of the state’s employers and households. This current state spending on health coverage for
new health insurance choice will be available low-income residents. And if SustiNet slows cost
both inside and outside Connecticut’s new growth by just one percentage point per year, the
health insurance exchange, established under state budget will improve by $355 million in 2014,
the ACA. SustiNet will undertake feasibility with gains reaching more than $500 million a year,
studies, develop business plans, conduct a risk starting in 2019.
assessment, and take any other steps needed to
ensure that the new competitive option is viable To support these efforts, we recommend that
and adds value in the marketplace. the Legislature work with state officials to find
the resources needed for vigorous campaigns to
• HUSKY will expand to cover all adults with
reduce obesity and tobacco use, improve the state’s
incomes up to 200 percent of the Federal
infrastructure for furnishing preventive care and
Poverty Level. By drawing down the maximum
promoting healthy behaviors, eliminate health-
possible amount of federal funding, the state
related racial and ethnic disparities, and develop
can extend HUSKY’s current safeguards to
Connecticut’s health care workforce. To address the
additional vulnerable adults while reducing the
access problems that result from low reimbursement
amount state taxpayers must spend to cover low-
rates for HUSKY providers, we recommend that
income residents.
the state comprehensively realign Medicaid and
HUSKY payment, allowing targeted, budget-neutral
As HUSKY expands to cover the lowest-income
payment increases that address particularly serious
uninsured, SustiNet will play two distinct roles. First,
access problems. After that realignment, we urge the
SustiNet will seek to lower the cost and improve
Legislature and the Administration to implement a
the quality of services provided to state-sponsored
multi-year initiative that gradually raises HUSKY
populations. Second, SustiNet will offer all employers
payments to at least Medicare levels.
and families a new, competitive health insurance
option that reforms health care delivery and payment
The baton now passes to the Legislature for further
to improve value and slow premium growth.
progress down the path it began in 2009. We are
confident that 2011 will see Connecticut enact some
These reforms will spark broader change throughout
of America’s most thoughtful and strategic health
Connecticut. Leading by example, SustiNet’s
reforms, benefiting the state’s taxpayers, employers,
innovations will make it easier for others to follow
and families for years to come.
a similar path. Our proposal harnesses the power

of competition, ensuring that successful SustiNet
reforms will be replicated by private insurers seeking
to preserve their market share. SustiNet will also work
collaboratively to implement multi-payer reforms
that help the state’s providers give their patients high-
value, quality care. And by enrolling a large number of
consumers, SustiNet will gain the leverage it needs to
reform health care delivery and payment.

3
 Background
2009 SustiNet legislation
The SustiNet Health Partnership Board of Directors
(Board) was established in 2009 by the Connecticut
General Assembly (Public Act No. 09-148) and
tasked with the responsibility of proposing to the
Legislature a “SustiNet Plan … designed to (1)
improve the health of state residents; (2) improve the
quality of health care and access to health care; (3)
provide health insurance coverage to Connecticut
residents who would otherwise be uninsured; (4)
increase the range of health care insurance coverage
options available to residents and employers; (5)
slow the growth of per capita health care spending
both in the short-term and in the long-term; and (6)
implement reforms to the health care delivery system
that will apply to all SustiNet Plan members…”
The 2009 law provided the broad outline for
the SustiNet plan, but left many details open.
The General Assembly charged the Board with
addressing these details, including how to:
• Structure and govern the plan;
• Launch plan operations;
• Integrate SustiNet with existing state coverage
programs;
• Equip SustiNet to function effectively and add
value within the private insurance marketplace;
• Reduce the number of state residents without
insurance coverage; and
• Integrate SustiNet with the structures to be
created under federal health care reform.
The General Assembly had a clear vision that
SustiNet would offer publicly-sponsored insurance
coverage to many Connecticut residents and embed
in that insurance coverage health care delivery system
reforms that could improve health, reduce disparities,
and slow cost growth. The goal of this new health
insurance option would be to lead by example,
implementing the country’s best thinking about how
to restructure health care delivery and financing.
4
The Work of the SustiNet
Board and Its Committees
and Task Forces
Beginning its work in September 2009, the Board is
co-chaired by Nancy Wyman, State Comptroller, and
Kevin Lembo, State Healthcare Advocate. The Board
includes a physician, representatives of allied health
professions, organized labor, small business, the faith
community, and individuals with expertise in employee
benefit plans, health economics, health information
technology, actuarial science, and racial and ethnic
disparities in health care. To carry out its charge,
the Board appointed advisory committees related
to health disparities and equity, health information
technology, patient-centered medical homes, preventive
health care, and health care quality and providers.
The Board likewise appointed task forces to develop
comprehensive plans to strengthen the state’s health
care work force, prevent tobacco use and increase
effective smoking cessation, and combat obesity.
Embodying an extraordinary breadth of background
and expertise, more than 160 Connecticut residents
volunteered countless hours to serve on these advisory
committees and task forces, which communicated
detailed recommendations to the SustiNet Board and
the General Assembly on July 1, 2010. These reports
were invaluable, and we are grateful for the hard work
of our committees and task forces.
The Board itself held 20 open meetings, each with
advance public notice as well as agendas, background
materials, minutes, and presentations posted on
the internet. We also held two briefings in which
we invited public testimony, and we conducted an
additional briefing for state legislators. Dr. Jonathan
Gruber of the Massachusetts Institute of Technology
(MIT), one of the country’s most respected health
economists, estimated the cost and coverage effects
of policy options under consideration.
Within 60 days of the federal government’s
enactment of the Patient Protection and Affordable
Care Act (Affordable Care Act or ACA), we
issued a report analyzing the impact of this federal are likewise struggling under the weight of burgeoning
legislation on SustiNet.1 We noted the many costs for Medicaid and coverage for state employees
common elements shared by SustiNet and federal and retirees. At the same time, the number of uninsured
reform. At the same time, we raised important residents, in Connecticut and elsewhere, has steadily
questions for further discussion. increased, in good economic times and bad. If recent
trends continue, by the end of this decade, among
Answering both these and other questions, this final Connecticut residents under age 65:
report contains our specific recommendations to the
General Assembly on some, but not all, of the issues • Nearly 390,000 people will be uninsured;
involved in launching and operating SustiNet. We • Net state costs for Medicaid, HUSKY, and state
recommend further analysis to guide decisions on employee/retiree insurance will climb from $3.2
the remaining issues. billion in 2012 to $4.5 billion in 2019; and
• Premiums for private employers will increase
The Board was assisted by consultants who from $9.6 billion a year in 2012 to $14.8 billion
included, in addition to Jonathan Gruber, Stan (Figure 1)—a 55 percent rise.
Dorn of the Urban Institute, Anya Rader Wallack
of Arrowhead Health Analytics, Katharine London
of the University of Massachusetts Medical School
Center for Health Law and Economics, and Linda
Green of Goddard Associates. Their work was
funded by the Connecticut Health Foundation,
the Jesse B. Cox Charitable Lead Trust, the State
Coverage Initiatives program of AcademyHealth,
which is a program office of the Robert Wood
Johnson Foundation, and the Universal Health
Care Foundation of Connecticut. We appreciate the
generous financial support of these funders.

Why action is necessary

SustiNet was conceived in the context of an ever-
worsening health care cost and access crisis. Employers
cannot afford double-digit cost increases even when
economic growth is hardy, much less when it is
negligible. State governments, including Connecticut’s,

5
 Figure 1.
Projected number of uninsured, net state health coverage costs, and private employer
premiums for Connecticut residents under age 65: 2012-2019, without reform

Source: Gruber Microsimulation Model 2010. Notes: State costs shown here are net General Fund outlays. They do not include federal
matching funds that are subject to the state’s spending cap. “SEHP” refers to state employee and retiree coverage. All costs are for residents
under age 65 and shown in 2010 dollars.

These problems are not unique to Connecticut, of
course. But given the resources and talent in this state,
the Board believes that Connecticut can and should
be a national leader in providing consumers with high
quality, affordable health coverage. To achieve this
goal, state government’s health care functions need
to be reorganized and refocused. Our vision is that
$8 billion a year in health care spending on state
employees and retirees, public program beneficiaries,
and others. By improving how we manage these funds
and the coverage we provide, fully implementing
federal health care reform and making SustiNet broadly
available, we can achieve several goals:

1
SustiNet will help lead the way, galvanizing the state’s Slowing the growth of public and private health
efforts to become a national frontrunner in reforming care spending in Connecticut;
health care to slow cost growth, improve quality, and
make affordable, high-value coverage available to all.
2 Ensuring that all residents have access to
affordable, high-quality, comprehensive coverage;
Counting both federal and state dollars, and including
services provided to residents of all ages, Connecticut
state government currently oversees approximately
3 Implementing delivery system and payment
reforms that benefit all residents;

6
4 Providing Connecticut’s employers and families
with a new health plan option—namely, an
independent, transparently managed plan for
Connecticut consumers, health care providers,
and employers;
5 Improving access to care among low-income
residents; and
6 Reducing racial and ethnic disparities related to
health care access and quality.
Like nearly all states, Connecticut is suffering
tremendous fiscal stress. It is our belief that we
can and should achieve SustiNet’s goals without
calling for substantial new infusions of General
Fund dollars. This can be done by making prudent
investments that reap both short- and long-term
dividends, maximizing the state’s utilization of
available federal resources, and carefully managing
the state’s health care expenditures.
How this Report is Organized
The body of this report covers the following topics:
• Key features of federal health care reform;
• Our findings and general recommendations;
• The coverage and cost effects of our
recommended policy direction, based on the
research conducted by Dr. Gruber;
• Our policy recommendations in detail; and
• Our suggested timeline for implementation.
The appendix to this report includes the full
recommendations of the Board’s advisory
committees and task forces; a “cross-walk”
comparing our recommendations to the relevant
provisions of the 2009 SustiNet law; and a brief
description of the model Dr. Gruber used to project
cost and coverage effects.2
Federal Health Care Reform
SustiNet was envisioned prior to the passage of the
ACA, but state legislators were well aware in 2009 that
federal legislative efforts were under way. SustiNet’s
goals and structure are thus consistent with the
framework established by the ACA.
The ACA allows each state to either create a state-based
health insurance exchange or join a federal exchange.
Beginning on January 1, 2014, the exchange will
facilitate comparison-shopping for health insurance.
New federal tax credits and cost-sharing subsidies will
be offered to low-income individuals who purchase
insurance through the exchange. At the same time,
Medicaid coverage of adults will expand to 138 percent
of the federal poverty level (FPL).3 During 2014-
2016, the federal government will pay all the costs of
Medicaid’s newly eligible adults. Beginning in 2017,
the federal share of these expenses will begin falling,
reaching 90 percent in 2020 and staying at that level
thereafter. One important source of new federal dollars
is an increase in the Medicare payroll tax for families
earning more than $250,000 a year.
In addition to new federal subsidies and expanded
Medicaid, the ACA’s mandate for individuals to obtain
and incentives for firms to offer coverage will reduce
the number of uninsured. The latter incentives include
tax credits for small employers that insure their workers
and penalties for larger firms that do not. The ACA also
reforms insurance markets by requiring insurers to devote
at least a minimum percentage of premiums to health
care costs, forbidding discrimination against consumers
based on preexisting conditions, strengthening review
mechanisms for premium increases, etc. In addition,
the Affordable Care Act includes numerous initiatives
to reform health care delivery and payment, including
grants and demonstration projects.
As explained in our earlier report, the General
Assembly’s 2009 vision of a substantial increase in
coverage, accompanied by a new, publicly administered
health insurance option offered to the state’s residents and
employers, can now be implemented more effectively
and with much more favorable fiscal effects than was
anticipated in 2009. The combination of newly available
federal funds to cover low-income consumers and the
potential impact of delivery system and payment reforms
could allow substantial savings to the state General Fund,
as we explain later.
7
 Our Findings and Central
Recommendations
The Board organized its effort to understand options
for SustiNet design into six major subject areas:
covered populations; covered benefits; delivery
system and payment reform; governance and
administration; coverage and access to care; and
public health investments. To examine each subject
area, we conducted major policy meetings at which
our consultants outlined policy options and applicable
trade-offs.
In this section, we describe the policy options we
considered and our central recommendations. Our
full recommendations are detailed in a later portion
of the report.
“
SustiNet represents a unique
opportunity to develop and
nurture a coordinated, cost-
effective health care delivery
system for the state...all
possible efforts should be
made to assure its success
and move it forward.
SustiNet Board Member
“ By contrast, we recommend that the Legislature create
Covered populations
We envision that the SustiNet health plan will provide
a common platform for reforming health care delivery
and payment. The plan will begin by covering those
8
for whom the state is currently responsible—that
is, state employees and retirees as well as Medicaid
and HUSKY beneficiaries. The initial focus of our
recommended proposal will thus involve slowing cost
growth, rather than increasing coverage. However, as
eligibility for Medicaid and HUSKY expands, so too
will SustiNet enrollment.
As an interim step in moving beyond state-sponsored
populations, SustiNet will be offered as an option for
small firms, municipalities, and non-profit corporations.
Municipalities will be the first employer group outside
state agencies to gain access to SustiNet, allowing cities
and towns to purchase the same coverage received by
state employees and retirees. Local taxpayers could
thus benefit from economies of scale and leverage
already exerted by state government. At the same time,
we propose that a municipality and SustiNet should
be allowed to negotiate covered benefits that differ
from those offered to state workers, such as the more
commercial-style coverage that SustiNet will offer to
private firms and individuals.
We recognize that gearing up to offer such commercial
coverage will not be a quick and easy task. Accordingly,
we recommend that SustiNet’s governing entity should
move forward as feasible to serve small firms and non-
profits during the interim stage before 2014, without
statutorily imposed deadlines.
a clear statutory deadline for the final stage of offering
SustiNet as an option to all Connecticut employers
and residents outside state government. Under our
suggested approach, SustiNet will be available for any
state resident or employer to purchase beginning on
January 1, 2014—the date when the main provisions
of the Affordable Care Act go into effect, including
operation of the health insurance exchange. Under our
proposal, SustiNet would be offered both inside and
outside Connecticut’s exchange.4
In serving employers and individuals outside state
government, SustiNet will offer the option of
commercial-style benefits, as explained below.
SustiNet will thus need to meet legal standards that
apply to commercial coverage, including benefit
requirements under state and federal law. To prevent
SustiNet from becoming a magnet for high-risk
enrollees, it will follow the same rules that apply to
other plans in the applicable market, whether group
or individual, including rules that govern premium
variation. With public and private employers large
enough to self-insure, SustiNet will avoid such
adverse selection through steps that could include
experience-rating premiums.

Of course, we understand that work will be required

before offering commercial coverage. A state
insurance license will be needed to offer coverage
in the exchange, for example, but we are convinced
that this should not create an insuperable obstacle.
Publicly administered health plans at the county level
in California have operated with insurance licenses
for many years, even though capital requirements for
licensure are much higher in that state than here. And
SustiNet will need to develop a business plan, with a
feasibility study and risk assessment, to ensure that it
offers a competitive option that adds value, compared
to other choices available to firms and individuals.
For SustiNet to commit to this work and succeed,
we believe the Legislature needs to lay down clear
markers in statute.

We value the role that employers play in offering health

insurance to workers and their families. Our goal is to
strengthen rather than undermine that role by offering
Connecticut businesses a new option for insuring their
employees. We believe that increasing competitive
choices in this way could improve the Connecticut
business climate, particularly if SustiNet slows cost
growth and shares those savings with employers.

9
 Table 1.
Provisions of SustiNet Law Regarding Populations in SustiNet

Population Date of potential Board may or Restrictions or

coverage in shall develop other specifications
SustiNet recommendations

State employees, Not specified May Any changes in benefits

retirees and subject to collective
dependents bargaining agreements

Non-state public On or after July 1, 2012 May

employees

HUSKY Plan Not specified Shall

Part A and B

Medicaid Not specified Shall

Enrollees in state- Not specified Shall

administered
general assistance
(SAGA)

State residents On or after July 1, 2012 Shall Premium variation limited

not offered ESI to that allowed under small
and not eligible group law
for Medicaid,
HUSKY or
SAGA

Employer groups On or after July 1, 2012, Shall

for small firms. No date
specified for larger firms.

State residents Not specified Shall The Board may recommend

offered ESI, mechanism for collecting
whose incomes payments from employers
are below 400%
FPL

10
Coordinating the design of health insurance coverage and
procurement of services across these populations offers
many potential advantages, including the following:
• When applied to a larger population,
synchronized efforts at delivery system and
payment reform can have a greater influence
on provider behavior and the diffusion of
innovation;
• A larger population may give the state added
leverage to lower prices and improve value in
purchasing goods and services; and
• The system will be simplified for both providers
and consumers if reforms are consistent across
multiple populations.
On the other hand, there are major differences between
potential SustiNet populations, including covered
benefits, health care needs, and applicable legal
requirements. Connecticut’s Medicaid and HUSKY
programs cover in excess of 530,000 people, more than
half of whom are children.5 Medicaid benefits, cost-
sharing, eligibility, and administration are governed by
federal statutes and regulations as well as the decisions of
the Centers for Medicare and Medicaid Services (CMS).
Medicaid is also shaped by Connecticut statutes and
judicial decisions that interpret both federal and state law.
The State Employees Health Plan (SEHP) covers
over 200,000 active employees, retirees, and their
dependents. This coverage is governed by collective
bargaining agreements between the state and public
employee unions.
When SustiNet becomes an option in the group
and individual markets, which currently include
approximately 2.1 million and 150,000 non-elderly
residents, respectively,6 the above constraints will not
apply. SustiNet will still need to follow applicable
state and federal laws, however, including state
benefit requirements.
The Board considered a range of options for integrating
SustiNet populations. We learned about examples from
other states, including Washington and Massachusetts,
where joint procurement processes are in place for
multiple state-covered populations.
The Board also considered the advice of our Advisory
Committees on the issue of integration, which included
the following recommendations:
• SustiNet should use common quality
measurement, payment innovations, public
health initiatives, and delivery system reforms
across all populations, to the greatest extent
possible, to achieve maximum impact.
• SustiNet should pursue an integrated approach to
reducing or eliminating health disparities across
all populations.
Put simply, much of the coverage received by these
different groups will continue to differ under SustiNet,
including applicable legal requirements, funding sources,
population characteristics, provider networks and
payment levels, cost-sharing, and covered benefits. At
the same time, key elements of health care delivery can
and, in our view, should be addressed using a common
platform across all of SustiNet’s membership groups.
As later sections of this report make clear, this common
platform will seek to add value and slow cost growth for
both publicly and privately funded health coverage. And
we urge that, as our recommendations (described below)
for increasing HUSKY and Medicaid payment go into
effect, SustiNet should commit to the goal of eliminating
any differential between groups of SustiNet members in
their access to participating health care providers.
BOARD RECOMMENDATION:
We recommend that the future SustiNet governing
board (which will be described later) should
immediately begin working with the State Comptroller
and the Department of Social Services to reform health
care delivery and payment for state employees and
retirees as well as individuals receiving coverage under
Medicaid and HUSKY.
11
 We further recommend that the SustiNet governing board
should take all necessary actions (which may include
conducting a feasibility study and risk assessment,
developing financial projections, and obtaining a state
license as an insurance carrier) to offer a SustiNet health
insurance plan as an option for employers and individuals
to purchase, as follows:
• Beginning as soon as possible, SustiNet should
be offered to Connecticut municipalities,
allowing them to purchase the same coverage
that state employees and retirees receive.
However, a municipality and the SustiNet
governing board can agree on a different package
of covered benefits.
• To the extent feasible before 2014, SustiNet
should be offered to other employers, with a
special focus on small firms and non-profit
corporations.
• Beginning on January 1, 2014, SustiNet should
be offered to all employers and individuals, both
inside and outside the health insurance exchange.
In offering this coverage, every effort should be made
to coordinate the design, delivery, and administration of
benefits to maximize the positive impact of SustiNet on:
• Leveraging delivery system and payment
reforms;
• Slowing health care cost growth;
• Simplifying administration;
• Improving health care quality; and
• Reducing racial and ethnic disparities.
Benefits
The Board examined benefits currently provided
to groups intended for inclusion in SustiNet. We
also examined the extent to which current programs
incorporate prevention and reflect the cutting-edge
of value-based insurance design, thereby providing a
solid foundation for future efforts at cost containment
and quality improvement. In addition, we reviewed the
SustiNet law, which requires:
12
• SustiNet coverage of 15 service categories; 7
• SustiNet compliance with all applicable state
coverage and utilization review mandates;
• No copayments for preventive care;
• Behavioral health parity;
• Dental coverage comparable to that offered by
large employers; and
• Compliance with collective bargaining
agreements for state employee and retiree
coverage.
Lastly, we reviewed benefit requirements under the
federal Affordable Care Act, which include:
• An “essential benefits” requirement, including
various service categories,8 with specific
standards to be set by the U.S. Department of
Health and Human Services based on “typical
employer coverage;”
• A prohibition on lifetime and (beginning in
2014) annual coverage limits;
• A requirement that plans be offered in each
state’s exchange at 60, 70, and 80 percent of the
actuarial value of the essential benefits standard;9
• Limits on out-of-pocket expenditures; and
• Required coverage of preventive services with
no out-of-pocket cost-sharing.
We found that current covered benefits for Medicaid
and state employees are comprehensive in scope. Both
include services like those required under the SustiNet
law and the federal ACA, and both limit or bar cost-
sharing for preventive services.
We found, however, that neither the SEHP nor Medicaid
covers tobacco cessation, nutritional counseling, or
wellness programs, all of which were recommended
by our Preventive Care Advisory Committee and the
Obesity and Tobacco Cessation Task Forces.10
Table 2 compares benefits currently offered to potential
SustiNet groups.
Table 2.
Covered benefits and cost-sharing for
selected coverage categories

BOARD RECOMMENDATION: the role of the Cost Containment Committee in

overseeing collectively bargained benefits for state
In general, we reaffirm the direction given to us in
employees and retirees.
the SustiNet law: benefits under SustiNet should be
comprehensive, emphasize prevention, and integrate
We recommend that insurance plans for the commercial
physical and behavioral health.
marketplace should be approached quite differently.
In that context, the eventual SustiNet governing board
In serving existing state-sponsored membership
should ensure that plan designs:
groups—namely, state employees and retirees as well
as beneficiaries of Medicaid and HUSKY, including
those who qualify for the expanded coverage described
later in this report—SustiNet would not change covered
benefits, premiums, or out-of-pocket costs. Current
a Offer a variety of benefits and out-of-
pocket costs, with each package providing
comprehensive, commercial-style benefits,
consumer safeguards should likewise continue to apply, including dental care and parity of coverage for
including such things as Medicaid appeals and physical and mental health conditions;

13

b Include, to the maximum feasible extent
consistent with commercial viability,
patient-centered medical homes, integration of
medical and behavioral health care, an emphasis
on prevention, encouraging and supporting
individual responsibility for controllable health
risks, and other design features that make
SustiNet stand out as a high-quality option that is
attractive in the marketplace; and
c Include cost-effective preventive services
that address physiological, emotional, mental,
and developmental conditions for members
throughout their life span from birth to the end
of life. SustiNet should review and periodically
revise its coverage of preventive care based on
the most current and reliable evidence available,
including results of SustiNet prevention
initiatives.
In offering commercial coverage that is financed
entirely by premium payments and federal tax credits,
without any state General Fund dollars, we believe the
SustiNet governing board should have the flexibility
to change benefits and cost-sharing arrangements over
time, within the constraints of applicable state and
federal laws, including state benefit mandates, and
based on evidence about the most effective benefit
designs, categories of covered services, and cost-
sharing arrangements.
We further recommend that the design of SustiNet
benefits:
• Encourages personal responsibility for
controllable health risks, while providing the
support that consumers need to exercise that
responsibility effectively; and
• Promotes reductions in health disparities.
14
“
If we can make Connecticut
a healthier place we are all
saving money and having a
better quality of life.
SustiNet Board Member
“
Delivery system and payment
reform
The SustiNet law emphasized three central
components of delivery system reform:
• Patient-centered medical homes (PCMH) that
combine a designated source of primary care
with patient education, coordination of services,
and enhanced access to medical consultation
when the patient is outside the clinician’s office;
• Health information technology (HIT) that
supports cost and quality management; and
• Incentives for providers to practice evidence-
based medicine.
The Board reviewed the evidence that each of these
initiatives would improve quality and control cost
growth. We also reviewed the recommendations
of our Patient-Centered Medical Home Advisory
Committee, our Provider and Quality Advisory
Committee, our Workforce Task Force, and our Health
Information Technology Advisory Committee. Lastly,
we examined federal efforts to encourage and finance
these reforms.
Our Advisory Committees and Task Forces supported
implementation of the PCMH model through SustiNet,
which builds on work already under way with
HUSKY’s Primary Care Case Management (PCCM)
Program as well as a multi-payer pilot project led by
the Comptroller. Our Committees and Task Forces
recommended that PCMHs should eventually be
required to meet nationally promulgated accreditation
or certification standards. However, clinicians who
serve as medical homes should not be required to
provide all services directly in the office, according
to our committees. In particular, small practices could
share support services to meet PCMH standards. For
example, the ACA authorizes funding for community
health teams to perform functions that might not be
undertaken within a one- or two-physician office. Our
PCMH Advisory Committee further recommended
that SustiNet create a “learning collaborative” through
which practices could support each other in becoming
medical homes—a strategy that also may be supported
by the ACA. Federal legislation further permits states,
beginning in 2011, to provide chronically ill Medicaid
beneficiaries with PCMH services, with a 90 percent
federal match rate applying to the first 8 calendar
quarters. The ACA appropriated $25 million in state
planning grants for such an initiative, starting in 2011.
We also learned that efforts to develop coordinated,
multi-payer reforms can be hindered by anti-trust
law. To overcome those barriers, a regulatory
program supervised by the State of Connecticut can
be established to permit and encourage cooperative
agreements between health care purchasers, hospitals,
and other health care providers. Such a program is
allowed when its benefits outweigh the disadvantages
caused by potential adverse effects on competition.
We likewise found that a significant federal and
state effort is under way to coordinate and finance
implementation of electronic medical records (EMRs)
and interoperable electronic health records (EHRs).
Connecticut has created the Health Information
Technology Exchange of Connecticut (HITECT)
to oversee efforts to meet federal requirements and
maximize federal support. In addition, Connecticut has
received a grant to support a regional extension center
that will provide support and training to practices
implementing EMRs. Our HIT Advisory Committee
recommended that SustiNet leverage these efforts,
rather than undertake unrelated efforts to encourage
HIT diffusion. Our Committee further recommended
formal representation of SustiNet on the HITECT
Board. It also proposed that SustiNet seek to influence
the requirements established for EMRs in Connecticut
to assure that systems meet basic analytic needs and
capture race and ethnicity data that will allow for
ongoing measurement of health disparities.
The Provider and Quality Advisory Committee
supported the use of evidence-based standards of
care in practices serving SustiNet members, applying
in Connecticut guidelines that have already been
promulgated by national and international authorities.
The committee also supported payment reform that
promotes provider accountability for costs, reduces
unnecessary care, and provides incentives for improving
quality and safety while reducing disparities.
The Workforce Task Force highlighted a shortage of
primary care providers in Connecticut, which might
undermine efforts to implement delivery system reform.
The Task Force made recommendations for increasing
the supply of primary care clinicians through targeted
efforts such as debt relief and broadening scope of
practice of some non-physician primary care providers.
The Task Force also recommended specific efforts to
train clinicians in working within the patient-centered
medical home model, including changes to nursing
curricula to reflect the needs of the PCMH. The Task
Force recommended that the state develop its capacity
to assess the demand for and supply of primary care
providers through an overall state strategic plan for its
health care workforce.
We found that our recommended interventions
(PCMH, HIT, evidence-based care guidelines, and
payment reform) have limited use in Connecticut at
present, and SustiNet could play a key role helping
to expand these efforts. The State Employees Health
Benefits Plan’s (SEHP) large-scale pilot program for
PCMH, noted above, exemplifies the leadership that
SustiNet could provide on a much wider scale.
15
 BOARD RECOMMENDATION:
We recommend that SustiNet:
• Strongly encourage and provide incentives
and technical and other assistance for SustiNet
providers to implement patient-centered medical
homes.
• In appropriate areas, implement alternatives to
fee-for-service provider payment that encourage
the provision of care that improves health
and safety. Such payment mechanisms could
include pay-for-performance, bundled payments,
global payments, or other innovations that are
supported by emerging research.
• Provide incentives for evidence-based care that
encourage providers to follow evidence-based
clinical guidelines. Such encouragement should
be carefully structured to preserve clinicians’
ability to provide patients with care that
meets their individual needs, even when such
personalized care goes outside approved clinical
guidelines.
• Establish a Pay-for-Performance system to
reward providers for improving health care
quality and safety and reducing racial and ethnic
disparities in health access, utilization, quality of
care, and health outcomes.
• Encourage, support, and eventually require
SustiNet providers to use interoperable EHRs to
document and manage care.
• Integrate into every component of the SustiNet
plan strategies for reducing and eliminating
racial and ethnic disparities.
• Take all steps necessary to collect and publish
provider price information that will help
consumers make informed choices.
In addition, we recommend that the Legislature
establish convener authority, consistent with state and
federal anti-trust law, that will allow collaboration
among multiple payers and providers in developing
and applying payment and delivery system
innovations. The legislature also should examine the
method recommended by the Workforce Task Force
16
for assessing and enhancing both the overall supply
of primary care clinicians in the state and available
training in the PCMH model.
Governance and
administration
The Board considered questions related to SustiNet’s
governance and administration, including the
following:
• How should SustiNet relate to existing state
agencies?
• What governance structure is most appropriate
for SustiNet?
• What powers and duties should the SustiNet
governing body have?
• What administrative structures and capacities are
necessary to implement SustiNet?
We considered three basic options for governance, as
follows:
1 SustiNet as quasi-governmental agency
administering a health plan. Under this option,
a SustiNet governing board would oversee a quasi-
governmental agency that administers the SustiNet
health plan. SustiNet would contract with the
Comptroller’s Office and the Department of Social
Services (DSS) to provide health insurance coverage
to state employees and enrollees in Medicaid and
HUSKY.
2
SustiNet as overseer and health plan. Under
this option, the SustiNet governing body would,
in addition to administering the SustiNet health
plan, oversee the Comptroller’s Office and DSS
with respect to all rules, regulations, and procedures
related to SEHP, Medicaid, and HUSKY.
3 SustiNet as superagency and health plan.
Under this option, SustiNet would be a new state
agency going beyond health plan administration to
oversee SEHP, Medicaid, and HUSKY.
Each option assumes that SustiNet would develop and reduction, health care quality and payment,
the capacity by 2014 to offer coverage to groups and health care safety, preventive health care, and
individuals both within and outside the state’s Health health disparities and equity.
Insurance Exchange.
BOARD RECOMMENDATION:
The Board was provided with examples of each The Board recommends the establishment of the
governance model and considered their advantages SustiNet Authority as a quasi-governmental agency
and disadvantages. The Board was particularly (option #1 described above), as soon as possible.
concerned with minimizing disruption to current We recommend that the authority be governed by a
coverage arrangements, maximizing coordination board of directors, which could include members of
across programs and plans, and minimizing (in the the current Board, and that the SustiNet governing
short term, while Connecticut is faced with serious board should have overall responsibility for SustiNet.
budget shortfalls) the need for new, state-funded staff We further recommend including as board members
and administrative infrastructure. both consumer representatives and individuals with
specific expertise needed to oversee the operation of
We also examined the administrative capacities
the SustiNet health plan. We believe that the SustiNet
that would be necessary in SustiNet, regardless of
governing board will be more effective if it is as small
its governance model. These include enrollment;
as possible.
premium billing and collection; marketing; provider
contracting, management, and payment; customer We recommend that staffing and other administrative
relations; and data collection and analysis. In addition, support for SustiNet should be provided initially
a system for determining eligibility and calculating by the Office of the Comptroller and that such staff
subsidies will be needed for SustiNet to accomplish should help the SustiNet governing board obtain
its coverage goals. We observed that existing state resources (including federal and philanthropic funds)
agencies possess many of these capacities, which to support meeting its administrative needs, in both
could be leveraged for SustiNet. the short and long term. We believe that a strong and
adequately funded administrative infrastructure will be
Lastly, the Board reviewed the recommendations of
essential to SustiNet’s success.
our Advisory Committees and Task Forces related to
governance and administration. These included the Table 3 summarizes our concept of how SustiNet
following: governance and administration could evolve from
2011 through 2014.
• SustiNet should have strong links with all
state-run health agencies, including DSS, the
Department of Public Health, the Department of
Mental Health and Addiction Services, and the
Department of Children and Families;
• SustiNet should have a strong link to HITECT,
as discussed above;
• The SustiNet governing board should include
representation of SustiNet enrollees and
individuals with experience in reducing health
disparities; and
• The SustiNet governing board should establish
standing advisory committees on the Patient-
Centered Medical Home, obesity prevention
17
 Table 3.
Possible timeline for evolution of SustiNet governance and administration, Calendar Years
2011-2014

2011 2012 2013 2014

SustiNet Board Appointed and take Transition to Independent

office by 9/1/2011. independence from from Comptroller
Housed within the Comptroller’s no later than
the Office of the Office. 1/1/2013.
Comptroller.

SustiNet Authority begins no

Authority later than 3/1/2012.

SustiNet staff Existing state After sufficient Staff fully

agencies provide resources are independent
staff. identified outside no later than
the General Fund, 1/1/2013.
Executive Director
begins work no
later than 3/1/2012.
Transition to
independent staff.

Responsibilities Begin advising Move forward, Assume direct Beginning

Comptroller and DSS as feasible, with responsibility for 1/1/2014, offer
about delivery system offering SustiNet to administering SustiNet to all
and payment reforms small firms and non- SustiNet plan employers and
for SEHP and profit corporations. no later than individuals,
Medicaid/HUSKY. Begin preparing 1/1/2013. inside and
ASAP, give to meet 1/1/14 Contract with outside the
municipalities deadline for offering Comptroller exchange.
the option to buy SustiNet to firms and DSS to
SustiNet. and individuals. serve SEHP
Analyze feasibility of and Medicaid/
offering SustiNet to HUSKY.
small firms and non-
profit corporations.

18
Coverage and access
One of SustiNet’s central goals is to ensure that as many
Connecticut residents as possible obtain affordable,
high-quality, comprehensive health coverage. After
devoting significant time to understanding the impact
of federal legislation, we learned that the ACA provides
significantly increased federal support for subsidized
coverage along with a mandate for individuals to obtain
coverage and incentives for employers to offer it; the
latter incentives include tax credits for small firms that
provide insurance and penalties for larger companies
that do not.
However, we were troubled by the limits on ACA
subsidies for adults with incomes above 138 percent
FPL, who fall outside the legislation’s increase in
required Medicaid eligibility. Subsidies for coverage in
the exchange will leave these adults facing significant
costs, as illustrated by Table 4.
Considerable evidence suggests that cost-sharing
imposed on low-income households can deter
enrollment into coverage and prevent utilization of
essential services, with potentially significant adverse
effects on patient health.11 We were thus concerned
about the impact of cost-sharing on two groups: 16,000
HUSKY parents with incomes between 138 and 185
percent FPL, who today receive comprehensive benefits
and are not charged premiums or copayments; and
41,000 other low-income adults with incomes between
138 and 200 FPL, many of whom will be unable to
afford what they will be charged in the exchange.12
To prevent today’s HUSKY parents from encountering
new barriers to accessing care as well as to improve
coverage and access for other low-income adults, we
believe that, beginning on January 1, 2014, Connecticut
should implement the Basic Health Program (BH)
option provided under federal law. With BH, Medicaid-
ineligible adults with incomes at or below 200 percent
of FPL are covered through state contracts with

Table 4. Premium and out-of-pocket costs for a single, uninsured adult receiving
subsidies in the exchange under the ACA, at various income levels

FPL Monthly pre-tax Monthly premium Average out-

income of-pocket cost-
sharing

150 $1,354 $54.15 6%

175 $1,579 $81.34 13%

200 $1,805 $113.72 13%

225 $2,031 $145.70 27%

250 staff $2,256 $181.63 27%

Source: Urban Institute, 2010. Notes: Dollar amounts assume 2010 FPL levels and enrollment into the second-lowest cost “silver” plan under
the ACA, which is the plan on which ACA subsidies are based. Out-of-pocket cost-sharing represents the average percentage of covered
services paid by the consumer, taking into account deductibles, copayments, and co-insurance. These costs would apply under the ACA
anywhere in the country, so they are not limited to Connecticut.

19
 health plans or providers. Such adults either (a) have
incomes too high to qualify for federally-matched
Medicaid or (b) are lawfully resident immigrants
whose immigration status makes them ineligible for
federally-matched Medicaid (most often because their
status was granted within the last 5 years). To fund the
state’s BH contracts, the federal government provides
95 percent of what it would have spent on subsidies
if BH members had received coverage through the
exchange. State contracts must have “attributes of
managed care,” which can involve primary care case
management systems, such as patient-centered medical
homes, rather than risk-bearing, fully capitated, private
insurance. Federal BH dollars must be placed in a trust
fund and spent only to benefit BH members. Covered
benefits and cost-sharing protections may not fall
below federally-specified minimums. However, states
may provide more comprehensive benefits with lower
cost-sharing (such as the benefits and cost-sharing
protections that states furnish through federally-
reimbursed Medicaid).
To be clear, we would not recommend implementing
the Basic Health option if the state provided no more
than the minimum level of coverage required by
federal law. Rather, the purpose of our proposed BH
implementation is two-fold: to preserve, for populations
covered by current law, HUSKY’s existing affordability
and comprehensiveness of coverage, so that, from the
member’s perspective, benefits would be exactly what
Medicaid now provides; and to extend that same level
of assistance to other low-income, uninsured adults.
One disadvantage of providing HUSKY rather than
subsidies in the exchange is that provider payment
rates are now much lower in HUSKY than in the kind
of commercial coverage likely to be offered in the
exchange. While we believe that, for this particular
population, access to care is typically impaired more by
cost-sharing than by HUSKY’s provider participation
limits, the BH option allows a modest improvement
of provider payment rates at no cost to the General
Fund. According to Dr. Gruber’s modeling, federal
BH payments will exceed HUSKY costs for low-
income adults by at least 7 to 13 percent. Accordingly,
20
as the state uses BH to extend HUSKY, in its current
configuration of covered benefits, cost-sharing rules,
and consumer safeguards, to adults with incomes up to
200 percent FPL, the excess of federal BH payments
over baseline HUSKY costs should be used to raise
payment rates for adults with incomes above 138
percent FPL.
Not only would this approach make coverage and care
more affordable for low-income adults, it would also
save money for the state General Fund. By moving
HUSKY parents above 138 percent FPL from Medicaid,
for which the state pays 50 percent of all costs, into BH,
where the federal government will pay all expenses,
Connecticut taxpayers will save approximately $50
million a year in net General Fund costs, according to
Dr. Gruber’s modeling.
Under the approach we recommend, a single, integrated
HUSKY program will provide subsidized coverage
to all otherwise uninsured adults with incomes up to
200 percent FPL and children up to 300 percent FPL.
Not only will this make coverage more affordable, our
recommended strategy will also improve continuity
of care. Income levels fluctuate greatly for many low-
income households. Under the recommended policy,
income fluctuations that move families above or below
138 percent of FPL will not force a change between
HUSKY and the very different systems of coverage
and care that will be available in the exchange. Rather,
coverage and care will be continuous, so long as
household income does not exceed 200 percent of FPL.
We also considered two other policy options that,
unlike BH, would increase state General Fund costs.
First, HUSKY eligibility could expand before enhanced
federal funding is first available in 2014. If HUSKY
served all adults up to 185 percent FPL, rather than
just parents, approximately 60,000 uninsured residents
would gain coverage, according to Dr. Gruber’s
estimates. However, because federal matching funds
would pay only 50 percent of Medicaid costs before
2014, the resulting net expense to the state General
Fund would be approximately $100 million to $150
million a year.
Second, as noted above, HUSKY reimbursement, as a
general matter, now falls far below private levels. As
a result, many providers are unwilling to see HUSKY
patients. Access to care could improve considerably if
HUSKY payment rates increased.
To address this longstanding problem, we considered
a policy option that would have increased HUSKY
payment rates to the point that per capita costs would
equal those paid by large employers—in effect, raising
HUSKY payment to private levels. According to Dr.
Gruber’s estimates, this would cost the state General
Fund approximately $180 million to $190 million a year.
We also considered the less expensive approach of
using Medicare rather than private levels as the goal
for increased Medicaid payment. We learned that, with
some populations (children and pregnant women, for
example), Medicare levels are problematic, so a different
benchmark would be needed in such cases. We further
learned that, with some services, current Medicaid
reimbursement is sufficient or even excessive, suggesting
the need for a broader analysis and realignment of
payment practices.
One final issue involves maximizing the number of
eligible uninsured who sign up for coverage. According
to Dr. Gruber’s estimates, nearly half (47 percent)
of Connecticut residents who would remain without
coverage under our recommendations will qualify for
subsidies, either through HUSKY or the exchange. To
reach this group of uninsured, the state will need to go
beyond the minimum requirements of federal law.
BOARD RECOMMENDATION:
As part of SustiNet, we recommend that, beginning on
January 1, 2014, HUSKY eligibility for adults should
increase to 200 percent of FPL, continuing the same
benefits, cost-sharing limits, and consumer protections
that apply under current law. Federal funding for this
coverage should be maximized by implementing the
Basic Health Program (BH) option for individuals who
are ineligible for federally-matched Medicaid. To the
extent federal BH dollars exceed baseline HUSKY
costs, payment rates should increase for the BH-eligible
population with incomes above 138 percent of FPL.
We further recommend that the state begin down a
path of increasing Medicaid and HUSKY provider
payments to at least Medicare levels (except for discrete
populations and services where a different benchmark
than Medicare is needed). The first step down this path
would occur in fiscal year 2012, when the Department
of Social Services would undertake a comprehensive
analysis of current reimbursement practices. Based on
that review, a budget-neutral realignment of provider
payments would take place in fiscal year 2013. After
that point, further payment increases would require a
net increase in state General Fund spending. We believe
that such higher payments will be essential for HUSKY
to provide adequate access to essential care, particularly
with the expanded population the program will serve in
the future. We also believe that, as this increase goes into
effect, SustiNet should embrace the goal that Medicaid
and HUSKY coverage should not impair members’
access to SustiNet providers; and that Medicaid and
HUSKY members should receive the same access to care
that is enjoyed by the privately insured, based on specific
standards adopted by the SustiNet Authority.
We urge the General Assembly and state agencies to
work together to find the resources necessary both for
this increase in HUSKY payment and, before 2014, to
expand HUSKY eligibility for childless adults to the
highest possible income level—if possible, to the same
185 percent FPL threshold that now applies to parents.
We also urge the Legislature to examine ways in
which Connecticut can increase its supply of primary
care clinicians through methods other than increasing
payment levels, consistent with the recommendations of
the Workforce Task Force.
Finally, we recommend that SustiNet, the Department
of Social Services, other state agencies, and
Connecticut’s health insurance exchange should work
together to maximize identification of the uninsured,
determine their eligibility for assistance, and enroll
them into coverage.
21
 Prevention and public health
investments
The SustiNet law placed a strong emphasis on health
insurance coverage for preventive care and increased
investment in public health. The Board considered
several issues related to preventive care and public
health investments. These included:
• The extent to which current coverage for
potential SustiNet populations includes
appropriate preventive care;
• The extent to which coverage offered in
the future to privately-insured groups and
individuals should include preventive care;
• The appropriate role of the SustiNet plan in
promoting public health; and
• The highest priorities for state investments in
public health outside SustiNet’s membership,
with coordination between the Department of
Public Health and the SustiNet plan to maximize
opportunities for success.
We also considered the recommendations of our
Preventive Health Care Advisory Committee. That
committee broadly defined its charge to improve health
for SustiNet members, addressing the needs of the
whole person, including physical health, mental health,
addictive behaviors, and oral health. The Committee
recommended that SustiNet cover a comprehensive
package of preventive services, without requiring cost
sharing. These services included:
• A basic set of preventive services (including
items receiving an “A” or “B” rating on the
U.S. Preventive Services Task Force list)
addressing physiological, emotional, mental,
and developmental conditions for members from
birth to the end of life;
• All Early and Periodic Screening, Diagnosis,
and Treatment (EPSDT) services for Medicaid
children13
• Regularly scheduled screenings and other
preventive services, such as mammograms,
22
immunizations, assessments of behavioral health
needs, and other evidence-based care;
• Dental services;
• An annual Individual Preventive Care Plan;
• Chronic care planning and support, including
promoting healthy nutrition, sleep, exercise, and
tobacco and substance abuse cessation; and
• Counseling and education about sexually-
transmitted disease, infectious disease control,
domestic violence, and environmental toxins.
The Obesity Task Force and the Tobacco Use and
Cessation Task Force also offered guidance about
preventive benefits and public health investments.
On benefits, they recommended coverage for nutrition
counseling and smoking cessation treatment.
Those task forces also recommended statewide efforts to:
• Enhance surveillance related to key health
indicators;
• Provide more tobacco cessation services;
• Include in K-12 education tobacco, drug, and
alcohol use prevention, as well as nutrition, stress
management, and exercise; and
• Improve the nutrition environment in schools
while reducing unhealthy marketing to children.
In addition, the PCMH Advisory Committee recognized
that public education would be necessary to maximize
the use of preventive services through the medical home
model, and the Workforce Task Force recommended
investment in the public health workforce to support
broader public health efforts.
BOARD RECOMMENDATION:
The Board recommends that SustiNet continue
to emphasize preventive health and public health
promotion by:
• Incorporating the best available knowledge about
the return on investment from preventive care in
benefit designs for both current state-sponsored

groups and populations that might purchase
the SustiNet plan as a competitive option in the
marketplace; and
• Appropriately investing in the health of its
covered population through education and support
services that might go beyond traditional health
insurance but could have a clear, positive impact
on health.
In addition, the Board recommends that the General
Assembly, in collaboration with state agencies, the
SustiNet Board, and other appropriate stakeholders,
identify necessary resources and enact legislation to
invest in statewide primary prevention efforts that
promote healthy nutrition, sleep, physical exercise, and
the prevention and cessation of the use of tobacco and
other addictive substances. The Board also supports
investments in:
• Improving community infrastructure and
investing in workforce training to support
healthy lifestyles and furnish preventive care;
• Including public health workforce capacity
in state health care workforce assessment and
strategic planning;
• Reducing racial and ethnic disparities in access
to resources that improve health while increasing
support for healthy living by families from
multiple, diverse cultures; and
• Facilitating the receipt of funds for health care
workforce training and development, including
efforts to promote cultural and linguistic
competence in serving the state’s diverse
residents.
Coverage and Cost Estimates
Coverage
Based on Dr. Gruber’s projections, our proposal, along
with national legislation, would substantially increase
insurance coverage in Connecticut. Taking 2017 as a
representative year, the number of uninsured would fall
by at least 55 percent, compared to levels in the absence
of reform.14 More than 200,000 otherwise uninsured
residents would gain coverage.
The availability of subsidies would cause a minority
of firms with 100 or fewer employees to stop offering
insurance. These are companies that, today, cover
mostly low-wage workers who, beginning in 2014,
would be better off if their employers stopped offering
insurance so the employees could qualify for subsidies.
As a result, the number of people covered by small
employers would fall by 9 to 10 percent. More than 70
percent of affected workers would shift to subsidized
coverage in the exchange or other individual insurance,
and the overall proportion of small firm employees
without coverage would decline from 45 percent to
between 26 and 27 percent.
The overall impact on Connecticut coverage would
include a sizable reduction in the proportion of
residents without insurance, a significant increase in the
percentage of Connecticut citizens receiving subsidies,
and a small drop in employer-sponsored insurance
(ESI) (Figure 2).
23
 Figure 2.
Coverage of residents under age 65, with and without reform: 2017

6%
12% 3%

12% 17% Uninsured

4% Tax Credits
4%
Public
Individual
ESI
72% 70%

Without Reform With Reform

Source: Gruber Microsimulation Model. Notes: “ESI” means employer-sponsored insurance. Public coverage includes Medicaid
and HUSKY. With reform, “individual” coverage includes both subsidized and unsubsidized coverage in the exchange as well as
nongroup insurance outside the exchange. This figure assumes that SustiNet’s delivery system and payment reforms have no effect
slowing cost growth.

Cost HUSKY payment rates to at least Medicare

Our discussion of cost requires several preliminary
comments:
• Like the rest of Dr. Gruber’s estimates, the
analysis is limited to effects involving residents
under age 65.
• Costs are stated in 2010 dollars.
• The combined policies under discussion do
not include either (a) an expansion of HUSKY
eligibility before 2014 or (b) an increase in
levels. As explained earlier, these two initiatives
will require the Legislature, SustiNet, and the
Administration to collaborate in finding new
resources to fund the resulting costs. The costs of
these proposals, to the extent they are known,15 are
set forth in the earlier discussion, rather than here.
State costs itemized below represent net charges to
the State General Fund. They do not include matching
federal dollars, even if those funds are subject to the
state’s spending cap.

24
An important question involves the extent to which On the other hand, reform will increase state costs in
SustiNet slows cost growth. To address this question, several areas:
Dr. Gruber produced estimates reflecting two different
scenarios: a pessimistic scenario, in which SustiNet has • Enrollment is likely to increase in existing
no effect on cost growth; and an optimistic scenario, categories of Medicaid and HUSKY eligibility,
in which SustiNet slows cost growth by 1 percentage for which the state pays 50 percent of all costs.
point per year. In neither case did Dr. Gruber assume • For newly eligible Medicaid adults with incomes
any “spillover” effects, through which a reduction in at or below 138 percent of FPL, the federal
uninsurance (and a consequent decrease in shifting government pays less than 100 percent of their
uncompensated care costs to private insurance) or costs after 2016. While the state’s share will be
a spread of SustiNet reforms to other health plans small, gradually rising to 10 percent in 2020 and
would slow cost growth outside the four corners of the remaining at that level thereafter, there will be
SustiNet plan. some state costs for these adults beginning in
Beginning in 2014, the proposal we recommend, 2017.
combined with national reform, would improve the • Enrollment into state employee coverage is
state’s fiscal situation, in several ways: likely to increase modestly because of the
individual mandate.
• Implementing the Medicaid expansion required
Altogether, state budget gains will outweigh new
by the ACA will greatly increase federal funding
costs by a substantial margin. Figure 3 illustrates the
for the population formerly covered by State
magnitude of the above factors under the pessimistic
Administered General Assistance (SAGA).
scenario, through which SustiNet has no effect in
By converting SAGA into a new category of
moderating health care cost growth. Under this
Medicaid eligibility (Medicaid for Low-Income
assumption, total state budget deficits would fall
Adults, or LIA), Governor Rell reduced the
by $224 million in 2017, compared to levels in the
proportion of costs paid by Connecticut from
absence of reform.
90 percent to 54 percent.16 Beginning in 2014,
the state share will fall to 9 percent, yielding
significant savings.
• By implementing the Basic Health Program
option, the state will shift the cost of covering
16,000 HUSKY parents from Medicaid, for
which the federal government pays 50 percent
of all expenses, into BH, where the federal
government pays all costs.
• The above-described small decline in ESI will
result in a modest increase in wages, based on
research showing that employers increase pay,
to some degree, when they achieve health care
cost savings. A slight wage increase will, in turn,
raise state income tax revenues.
• If SustiNet slows health care cost growth, state
Medicaid and HUSKY spending will decline,
compared to projected spending without reform.
The state will likewise achieve savings in
providing employees and retirees with health
coverage.
25
 Figure 3.
Effects on state spending and revenue for residents under age 65, pessimistic scenario:
2017 (millions)

Source: Gruber Microsimulation Model. Notes: Savings from shifting HUSKY parents into BH are included in the cost estimates for existing
Medicaid/HUSKY populations. Savings for the conversion of SAGA to Medicaid for low-income adults are shown against a baseline in
which SAGA was not converted into Medicaid coverage of low-income adults. Cost estimates do not include any savings for state-funded
immigrants with incomes at or below 138 percent of FPL, who will be shifted into federally-funded BH under our proposal.

Figure 4 shows state fiscal effects in 2017 if SustiNet succeeds in slowing cost growth by 1 percentage point per
year. Under this more optimistic scenario, the state budget will improve by $425 million.

26
Figure 4.
Effects on state spending and revenue for residents under age 65, optimistic scenario:
2017 (millions)

Source: Gruber Microsimulation Model. Note: This figure assumes that, in SustiNet, delivery system and payment reforms slow cost growth
by 1 percentage point per year, beginning in 2012. See also notes to Figure 3.

The state’s net budget gains over time are displayed in Figure 5. Under the pessimistic scenario, savings gradually
decline as the federal government reduces its share of Medicaid costs for newly eligible adults. Under the
optimistic scenario, the impact of SustiNet on health care spending outweighs this modest decline in federal
support, so net state budget gains increase.

27
 Figure 5.
Net state budget savings for residents under age 65, optimistic and pessimistic scenarios:
2014-2019 (millions)

Source: Gruber Microsimulation Model. Notes: State budget effects include both outlays and revenues. The pessimistic scenario assumes that
SustiNet does not affect cost growth. Under the optimistic scenario, SustiNet slows cost growth by 1 percentage point per year. See also notes
to Figure 3.

Our proposal will also have implications for private sector costs. As noted earlier, small firm coverage will decline
by 9 to 10 percent in 2017. As a result, small firms will save approximately $380 to $400 million in premiums.
Ironically, these companies will save slightly less if SustiNet is more effective in slowing cost growth, because
fewer small firms will drop coverage.

Although premium savings will be the most significant cost effect for small employers, some firms with fewer than
50 workers will also receive tax credits created by the ACA. A few companies with between 50 and 100 employees
will pay penalties because they fail to offer ESI. In addition, any firms that drop coverage and increase wages will
see their payroll taxes rise. The net effect of all these factors is that companies with 100 or fewer workers will
realize gains of $399 to $415 million in 2017. Figure 6, below, shows how all these factors are projected to play
out under the scenario in which small employers’ costs are higher because SustiNet slows cost growth to the point
that a few additional firms offer coverage.

28
Figure 6.
Effects on health insurance costs and taxes for firms with 100 or fewer workers,
scenario in which SustiNet slows cost growth, allowing more such firms to offer
coverage: 2017 (millions)

Source: Gruber Microsimulation Model. Notes: This figure assumes that SustiNet is effective in slowing cost growth. Under a scenario in
which SustiNet has no effect slowing cost growth, premium savings will equal $403 million, tax credit amounts will total $52 million, payroll
taxes will increase by $34 rather than $32 million, and penalties for not offering coverage will remain at $6 million.

Among larger firms, the effects of reform are estimated to be negligible. In 2017, total costs for companies with
more than 100 employers are projected to decline by roughly $50 to $70 million, or less than one-half of 1 percent

Similarly, total household post-tax purchasing power will be essentially unchanged under the combination of
federal reform and our proposal, rising between $416 and $420 million a year, or less than one-half of 1 percent.
Wages will increase modestly when some firms stop offering coverage, as explained above. Connecticut residents
will receive more public-sector assistance in purchasing health coverage because of expanded Medicaid and
HUSKY as well as newly created subsidies in the exchange. On the other hand, taxes will rise, mainly because the
ACA increases Medicare payroll taxes for families earning more than $250,000 a year. Premium payments will go
up because more people enroll in coverage, but out-of-pocket costs will decline slightly. Figure 7 shows how these
effects balance out, under the pessimistic scenario in which SustiNet fails to slow cost growth.

29
 Figure 7.
Effects on household purchasing power for residents under age 65, scenario in which
SustiNet fails to slow cost growth: 2017 (millions)

Source: Gruber Microsimulation Model. Notes: Health insurance subsidies include Medicaid and HUSKY and premium and cost-sharing
subsidies in the exchange. This figure assumes that SustiNet does not slow cost growth. Under a different scenario in which SustiNet
slows cost growth by 1 percentage point per year beginning in 2012, wages will increase by $452 million, health insurance subsidies will
grow by $1.055 billion, premium payments will rise by $72 million, out-of-pocket costs will fall by $13 million, and taxes will increase
by $1.028 billion.

More broadly, SustiNet aims to spark broader reform
of health care delivery and payment in Connecticut,
using several strategies. First, SustiNet will lead
by example, rather than compulsion.17 It will
demonstrate the impact of nimbly implementing
cutting-edge reforms that seek to improve quality,
safety, and health outcomes while slowing cost
growth. If SustiNet proves effective, it will be easier
for others to move in similar directions.
Second, SustiNet will galvanize broader change by
harnessing the power of competition. If SustiNet’s
initiatives slow cost growth while maintaining or
improving quality and value, then private insurers
will need to implement similar reforms to preserve
market share.
Third, SustiNet’s continuity of coverage will strengthen
the business case for savings. Today, both commercial
insurers and Medicaid expect that a substantial fraction
of their members will soon be gone, which reduces
incentives to invest in long-term wellness. In the
commercial world, an employer may change carriers,
or a worker receiving ESI may move to a new job that
offers different insurance. In Medicaid, small changes
in income and failure to complete necessary paperwork

30
cause caseload “churning,” with members leaving the
program. Under our proposal, by contrast, regardless
of changes of income (and in some cases, even if
workers move from job to job), SustiNet’s members
will typically stay with the plan for the foreseeable
future, thus enhancing the return on investment from
efforts that increase preventive care, reduce obesity
and tobacco use, or successfully intervene in the early
development of other ongoing health problems.
Fourth, SustiNet will work with other payers to
implement coordinated efforts to help providers make
necessary changes to health care delivery. Already,
the Comptroller’s office is leading such a multi-payer
initiative to pilot-test patient-centered medical homes,
as noted above.
Fifth and, in some ways, most important, as SustiNet
enrollment increases, SustiNet’s leverage to bring about
delivery system and payment reforms will likewise
increase. The number of commercial enrollees who join
SustiNet depends, in part, on whether SustiNet achieves
cost savings. But Dr. Gruber found that, under both
pessimistic and optimistic scenarios, SustiNet is likely
to gain a significant share of the state’s small group and
individual markets, along with a modest share of the
large group market (Table 5).

Table 5. Estimated SustiNet enrollment, outside state-sponsored groups: 2017

Small firm Large firm Individual

enrollment enrollment enrollment

Covered Share of Covered Share of Covered Share of

lives small firm lives large firm lives individual
coverage coverage market

Pessimistic 136,000 24% 126,000 8% 32,000 14%

scenario

Optimistic 164,000 29% 165,000 10% 33,000 15%

scenario

Source: Urban Institute, 2010. Notes: Dollar amounts assume 2010 FPL levels and enrollment into the second-lowest cost “silver” plan under
the ACA, which is the plan on which ACA subsidies are based. Out-of-pocket cost-sharing represents the average percentage of covered
services paid by the consumer, taking into account deductibles, copayments, and co-insurance. These costs would apply under the ACA
anywhere in the country, so they are not limited to Connecticut.

31
 Detailed Recommendations to the
General Assembly
Our detailed recommendations address six core areas
related to SustiNet:
1 Governance and location within state government;
2 Policy-making duties and responsibilities of the
Authority Board;
3 Administrative duties and responsibilities of the
Authority;
4 Reforming health care delivery and payment;
5 Expanding coverage and access to care; and
6 State public health investments.
As detailed above, during our sixteen months of
deliberations we reviewed many of the challenges
that make it difficult to simply “flip the switch”
and begin SustiNet operations. These challenges
include different benefits, reimbursement levels,
and provider networks across state-funded groups;
constraints of collective bargaining agreements and
Medicaid law; and the need to obtain a state license
to offer SustiNet in Connecticut’s health insurance
exchange. In addition to securing licensure, SustiNet
will need to undertake considerable work developing
a new, publicly-administered, competitive health
insurance option that can succeed in the commercial
marketplace. Moreover, the lack of an adequate
primary care workforce and low Medicaid payment
levels must be overcome if SustiNet is to be fully
successful. We have attempted, in crafting the
following recommendations, to address these issues
and design a solid foundation for future success.
We believe strongly that the potential benefits of the
SustiNet plan warrant addressing the operational,
technical, and fiscal challenges inherent in start-up.
32
Governance and location
within state government
1 A quasi-governmental agency (the SustiNet
Authority) should be established to oversee and
operate the SustiNet plan. The Authority should
generally be modeled after the Connecticut Health
and Educational Facilities Authority and should
be bound by the highest legal standards of ethics,
transparency, and accountability. The Authority
should be structured to reflect governance principles
that embody the country’s best thinking about
effective and accountable administration (such
as those recommended by the Pew Center for the
States), including providing the public with regular
performance information.
2 The Authority should be established as soon as
possible and in no event later than March 1, 2012.
3 The Authority should be governed by a
reconstituted board of directors (the Authority
Board), which should be appointed and begin service
as soon as possible, no later than September 1, 2011.
The Authority Board should be responsible for setting
overall policy for the SustiNet health plan.
4 The Authority Board, which could include
members of the current Board, should be
appointed by a combination of elected officials in the
Executive and Legislative branches of Connecticut state
government and various stakeholder groups. Board
members should be required to have specified areas
of expertise. The Board should have the authority to
increase its membership to bring in additional expertise.
At the same time, the Board should be as small as
possible, to facilitate effective decision-making.
5
The Authority Board should establish a Consumer
Advisory Committee, with broad consumer
representation, and provide it with appropriate levels
of independent staffing. The Consumer Advisory
Committee should elect two representatives (one of
whom can be a professional consumer advocate) to
sit as voting members on the Authority Board and to
report the full breadth of advice from the Committee
to the Board. The Consumer Advisory Committee
should be responsible for preparing Consumer Impact
Statements describing the effects on consumers of the
Authority Board’s major policy decisions (identified
as such by the Committee). These statements would
be published to accompany the final version of the
Authority Board’s decisions when they are made
available to the public.
6 Until the SustiNet Authority obtains funding and
staffing, the Office of the Comptroller should
provide administrative support to the Authority Board
and help such Board maximize its access to resources
outside the General Fund, including federal funds and
philanthropic grants. This interim staffing arrangement
should terminate as soon as possible and in no event
later than January 1, 2013.
Policy-making duties and
responsibilities of the
Authority Board
1
The Authority Board should be responsible for
overseeing the SustiNet plan. This role includes
setting binding policy for delivery system and payment
reform affecting coverage received by SustiNet
members, except where such policy conflicts with state
or federal law or with collective bargaining agreements.
The Board should work with the Legislature and with
other state agencies to identify funding sources needed
to cover any necessary initial investments.
2 The Authority Board should be authorized to
convene committees and advisory groups as it deems
necessary to address such issues as implementation of the
patient-centered medical home, health care quality, health
care safety, incentives for evidence-based care, provider
payment, prevention, health disparities and equity, and
health information technology.
3 In addition to its policy-making authority described
above, the Authority Board should be authorized
to advise the State Comptroller and the Department
of Social Services on other matters related to health
insurance coverage for state employees and retirees
and individuals covered through Medicaid and
HUSKY. The Board should likewise be authorized
to make recommendations to the General Assembly,
state agencies, and non-governmental organizations
about changes in law, policy, practice, or procedure that
would slow health care cost growth, improve health care
quality or safety, increase access to health care, improve
population health, or reduce racial and ethnic disparities.
4 The Authority Board should take all necessary
actions (which may include conducting feasibility
and risk assessment studies, developing financial
projections, and obtaining a state insurance license) to
offer a SustiNet health insurance plan as an option for
employers and individuals to purchase, as follows:
a
Beginning as soon as possible in calendar year
2011, SustiNet should be an option for
purchase by municipalities, using the same benefits
and out-of-pocket costs that apply to state employees
and retirees. If requested by a particular municipality
and approved by the Authority Board, SustiNet may
provide the municipality’s enrollees with different
benefits or cost-sharing rules, including (but not
limited to) commercial benefits like those described
below. Coverage should be provided consistently with
small group rules, for municipal employers subject to
those rules. With larger municipal employers, SustiNet
should take necessary steps to avoid adverse selection,
including experience-rating premiums.
b To the extent feasible, taking into account other
duties of the Authority, SustiNet should be
available before 2014 to small firms and non-profit
corporations, with SustiNet offering commercial
benefits, as described below.
c Beginning on January 1, 2014, SustiNet should
be offered to all Connecticut employers and
individuals, both inside and outside the exchange.
5
In structuring insurance plans for the commercial
marketplace, the Authority Board should ensure
that plan designs:
aOffer a variety of benefits and out-of-
pocket costs, with each package providing
comprehensive, commercial-style benefits, including
dental care and parity of coverage for physical and
mental health conditions.
33
 b Include, to the maximum feasible extent
consistent with commercial viability, patient-
centered medical homes, integration of medical and
behavioral health care, an emphasis on prevention,
encouraging and supporting individual responsibility
for controllable health risks, and other design features
that make SustiNet stand out as a high-quality option
that is attractive in the marketplace.
and ethnic disparities involving health care and health
outcomes, and reducing the number of state residents
without insurance. The Authority should monitor the
accomplishment of such objectives and modify action
plans as necessary.
11 The Authority should be authorized to conduct
public education and outreach campaigns
to inform state residents about the SustiNet Plan

c Include cost-effective preventive services that

address physiological, emotional, mental, and
developmental conditions for members throughout
their life span from birth to the end of life. The
SustiNet Authority should periodically review and, if
necessary, revise its coverage of preventive care based
on the most current and reliable evidence available,
including results of SustiNet prevention initiatives.
and to encourage enrollment. In seeking to cover
the uninsured, such campaigns could partner with
community-based organizations and target populations
that are underserved by the health care delivery
system. The Authority Board should monitor the
effectiveness of such campaigns and modify strategies
as necessary.

6 The Comptroller, DSS, other appropriate

government agencies, and SustiNet should
encourage inclusion of cost-effective smoking
cessation services within covered benefits for all
SustiNet populations, at the earliest possible date.
12 The Authority should, within available
appropriations, develop and implement
systematic policies and practices to identify, qualify
for subsidies, enroll, and retain in coverage otherwise
uninsured individuals. Such policies and practices
may include collaboration with Connecticut’s health

7
insurance exchange, the Department of Revenue
When sold in the individual or group market,
Services, the Labor Department, and other local, state,
SustiNet should be subject to the same rules that
and federal agencies, as well as health care providers,
apply in that market, including rules for permitted
including hospitals and community health centers, and
premium variation. The Authority may use channels of
other nongovernmental organizations, as appropriate.
distribution and sale that apply to other plans in those
markets, including the use of brokers and agents.
Administrative duties and
8 The Authority should prevent harmful adverse
selection when commercial enrollees choose
SustiNet. This may include experience-rating
responsibilities of the
Authority
premiums when SustiNet is sold outside the exchange
to firms large enough to self-insure. The Authority, with approval from the Authority
Board, should be authorized and empowered to:

9 To cover unexpected differences between plan

expenditures and premiums, the Authority should
maintain prudent reserves and should be authorized to
take other appropriate steps, such as purchasing stop-
loss coverage or reinsurance.
1 Recruit and hire an Executive Director, who will
implement the administrative operations of the
SustiNet Authority. The Executive Director should
have the authority to hire staff and enter into contracts,
consistent with the Board’s overall direction and

10 The Authority should implement multi-

year action plans to achieve measurable
objectives in such areas as the effective prevention
and management of chronic illness, reducing racial
budget. After sufficient resources are identified outside
the state General Fund, the Executive Director should
be hired to begin work as soon as possible, not later
than March 1, 2012.

34
2 Adopt guidelines, policies, and regulations
necessary to carry out its duties.
its duties and the execution of its powers under
its enabling legislation, including contracts and
agreements for professional services, including but
3 Contract with one or more insurers or other
entities for administrative purposes, such as claims
processing, credentialing of providers, and establishing
not limited to financial consultants, actuaries, bond
counsel, underwriters, technical specialists, attorneys,
accountants, medical professionals, consultants, bio-
provider networks, provided that any such administrative ethicists, and such other independent professionals or
contract should pay per enrollee or on another basis that employees as the Authority shall deem necessary.
does not provide an incentive for administrators to delay
or deny coverage of necessary services.
9 Enter into interagency agreements for performance
of the Authority’s duties where such duties can be
4 Contract with the Comptroller and the Department
of Social Services to provide health insurance
coverage for the following populations:
implemented at lower cost or more cost-effectively by
contracting with a state agency.

a State employees and retirees; and

10 Establish policies and procedures:

b Individuals who receive Medicaid, HUSKY

(including with the eligibility expansions
a Governing the use of new and existing channels
of sale to employers, including public and
private purchasing pools, agents and brokers;
described below), and (if approved by the Authority
Board) other state-arranged or state-funded health
coverage. b Allowing the offering to employers of multi-
year contracts with predictable premiums; and

Enrolling these populations in SustiNet should not

be construed as authorization to modify premiums,
covered benefits, out-of-pocket cost-sharing, or
access to out-of-state providers for these membership
categories.
5 Solicit bids from individual providers and provider
organizations and arrange with insurers and others
for access to existing or new provider networks
and take such other steps as are needed to provide
c Ensuring that employers can easily and
conveniently purchase SustiNet Plan coverage for
their workers and dependents. Policies and procedures in
this area may include, but are not limited to, participation
requirements, timing of enrollment, open enrollment,
enrollment length, and other matters deemed appropriate
by the Authority Board.
11 Apply for and receive grant funding from
private and public sources to support functions
consistent with its mission.

12
all SustiNet Plan members with access to timely,
Make optimum use of opportunities created by
high-quality care throughout the state and medically
the federal government for securing new and
necessary care outside the state’s borders.
increased federal funding.

6 Commission surveys of consumers, employers,

and providers on issues related to health care and
health care coverage.
Reforming health care
delivery and payment

7 Negotiate on behalf of providers participating in

the SustiNet Plan to obtain discounted prices for
vaccines and other goods and services.
The Authority should be authorized to:

8 Make and enter into all contracts and agreements

necessary or incidental to the performance of
1 Implement changes in health care delivery and
payment for the populations covered in the
SustiNet plan, within the constraints of collective

35
 bargaining agreements and federal law (including
Medicaid). Such changes may include provider
contracting requirements and, to the extent consistent
with the above constraints as well as other state
statutes, benefit design modifications that do not
increase net state-funded costs. In reforming health
care delivery and payment, the Authority Board should
prioritize strategies that offer the greatest potential for
slowing cost growth.
2 Integrate strategies for reducing and eliminating
racial and ethnic disparities into every component
of the SustiNet plan, including outreach, enrollment,
benefit design, provider networks, financial incentives,
quality measurement, provider credentialing, enrollee
communications, and appeals.
3 Establish payment methods for licensed health
care providers that reflect evolving research
and experience both within the state and elsewhere,
promote access to care and patient health and safety,
prevent unnecessary spending, and ensure, to the
maximum extent feasible, sufficient compensation to
cover the reasonable cost of an efficient provider to
provide necessary care.
4 Strongly encourage and provide incentives
and technical and other assistance for SustiNet
providers to implement patient-centered medical
homes. The Authority should establish a timeline for
ensuring that all SustiNet members can receive care
from a patient-centered medical home.
5 In appropriate cases, implement alternatives to
fee-for-service provider payment. To encourage the
provision of care that is safe and improves health, such
alternatives may include pay-for-performance, bundled
payments, global payments, or other innovations.
To the extent warranted by available evidence, the
Authority Board should establish goals for increasing
the percentage of SustiNet expenditures made under
alternative payment methodologies over time. Based
on experience in Connecticut and elsewhere, the Board
should evaluate the effect of alternative payment
methodologies on quality, safety, and cost growth.
36
6 Provide incentives for evidence-based care
that encourage providers to follow evidence-
based clinical guidelines. Any system that rewards
providers for meeting such guidelines should provide
mechanisms for documenting reasons to depart from
guidelines because of, for example, an individual
patient’s clinical condition.
7 Establish a Pay-for-Performance system to reward
providers for improvements in health care quality
and safety and reductions in racial and ethnic disparities
in health access, utilization, quality of care, and health
outcomes. Such Pay-for-Performance systems could
reward providers for (a) making improvement as well
as for meeting benchmarks; (b) having an effective plan
in place for preventing illness and improving health
status; and (c) caring for patients with the most complex
and least well-controlled conditions.
8
Encourage, support, and eventually require
SustiNet providers to use interoperable electronic
health records to document and manage care. The
Authority Board should work with other organizations
within the state to maximize the usefulness and
minimize the cost to providers of this transformation,
taking advantage of available federal resources while
leveraging the combined purchasing power of the
state’s health care providers to obtain goods and
services of lower cost and higher value.
9
In all SustiNet systems for data intake and storage,
include fields that record members’ race, ethnicity,
and language in addition to age, gender, and other
demographic data, thereby creating the capacity
to track disparities in health outcomes and health
care services. Data systems should enable coding of
multiple races and ethnicities for a single individual.
10
Report provider performance in health care
quality, efficiency, safety, and racial and
ethnic disparities in health access, utilization, quality
of care, and health outcomes by geographic area
and by provider or organization, where feasible,
with outcomes risk-adjusted based on patient
characteristics, to the maximum extent possible.
The SustiNet Authority would:
a provide information to each provider
organization comparing its performance to
benchmarks and to other providers;
b provide guidance to providers on specific
actions that they can take to improve their
performance; and
c give providers an opportunity to review their
own data, suggest revisions, and take corrective
action before results are made public.
11 As soon as possible, create and maintain a data
warehouse tracking health care utilization by
SustiNet members and other state-sponsored populations.
12 Whether through such data warehouse or
otherwise, capture information necessary to
publish provider price comparisons that will help
consumers make informed choices.
13 Work with state agencies to develop a data
system that efficiently captures information
measuring cost and quality and that allows for
eventual integration of claims data and clinical
information from electronic medical records. In
doing so, the Board should coordinate with state
efforts to upgrade Medicaid and other information
systems to implement the Affordable Care Act, and
the state should maximize the use of available federal
funding for such purposes. Whenever possible, the
data development referenced in this provision should
be included within broader procurement efforts
undertaken by state government, whether to meet
requirements of the Affordable Care Act or otherwise.
14 Ensure that privacy and data security are
fully protected by the data systems described
above, including but not limited to compliance with
applicable federal requirements.
15 Work with other health plans and organizations
inside Connecticut to facilitate multi-payer
initiatives to reform health care delivery and payment.
16 Modify the above-described delivery and
payment reforms as warranted by evolving
evidence.
To maximize the effectiveness of the above-described
reforms, the General Assembly should make the
following statutory changes:
1 Where necessary, modify scope of practice laws
involving such provider groups as physician
assistants and advance practice nurses to help these
providers function effectively as part of a patient-
centered medical home.
2 Modify medical malpractice liability laws to (a)
provide a “safe harbor” that precludes liability
for patient injury caused by clinicians appropriately
following approved clinical guidelines; and (b)
ensure that patients, in such circumstances, receive
compensation for the harm they suffer.
3
Authorize SustiNet or another state agency,
with appropriate convener authority, to provide
direction, supervision, and control over approved
cooperative agreements and to give health care
providers, health provider networks, and purchasers
who participate in discussions or negotiations
authorized by this program immunity from civil
liability and criminal prosecution under federal and
state antitrust laws. The purpose of such actions
is to facilitate the exchange of information among
hospitals, other health care providers, and other
appropriate entities to encourage the development of
cooperative agreements, delivery arrangements, and
relationships intended to promote more cost-effective
health care delivery.
4 To the extent that delivery system and payment
reforms implemented by the SustiNet plan achieve
cost savings, the SustiNet Authority should be permitted
to retain most of the savings to invest in further
improvements in services provided to SustiNet members.
37
 Expanding Medicaid coverage
and access to care
As of January 1, 2014, HUSKY should expand to
cover uninsured adults with incomes at or below 200
percent FPL. Such expansion would receive federal
financial support as follows:
1 Federal Medicaid matching funds should be
claimed up to 138 percent FPL;18 and
2 Federal funding under the Basic Health Program
should be claimed for individuals up to 200
percent of FPL for whom federal Medicaid funds
are unavailable. Any excess in federal Basic Health
funding over baseline HUSKY costs should be paid
out in the form of increased payment rates to providers
serving HUSKY members with incomes above 138
percent FPL. For all HUSKY adults, benefits, cost-
sharing arrangements, and other consumer protections
(such as appeals) should equal what current law
provides to HUSKY parents.
The General Assembly, in collaboration with the
Department of Social Services (DSS), other state
agencies as appropriate, and the Authority Board, should
take the following steps, and identify revenue sources or
cost savings that are sufficient to pay for them:
1 Expand HUSKY eligibility to include childless
adults up to 185 percent FPL from July 1, 2012
through December 31, 2013.
2 Gradually increase HUSKY and Medicaid provider
payment to at least Medicare levels for clinical
services for which current rates are inadequate,
beginning on July 1, 2012. Such plan should include
payment increases to another appropriate benchmark
for services as to which Medicare fee schedules are
insufficient, such as services to pregnant women
and children. Such rate increases should be part of a
broader reform to Medicaid payment methodologies,
which should be developed by DSS during FY 2012.
Any Medicaid or HUSKY payment increases in
38
FY 2013 should be part of a cost-neutral, overall
realignment of payment levels and methods. In
subsequent years, payment should gradually increase
to the levels described above. As that increase takes
effect, SustiNet should commit to the goal that
Medicaid and HUSKY beneficiaries will not, by virtue
of that status, experience impaired access to providers
who serve other SustiNet members.
3 Adopt specific standards that define access of care.
Pursuant to those standards, HUSKY and Medicaid
beneficiaries would have access to care no less than
that received by the privately insured. For example,
such standards could define access in terms of the
number of providers within geographic areas that
include a specified number of members, travel times
required to reach participating providers (taking into
account different populations’ use of mass transit), etc.
State public health
investments
The General Assembly, in collaboration with state
agencies, the Authority Board, and other appropriate
stakeholders, should identify necessary resources and
enact legislation to accomplish the following goals:
1
Invest in primary prevention efforts to promote
healthy nutrition, sleep, physical exercise, and the
prevention and cessation of the use of tobacco and
other addictive substances.
2 Improve community infrastructure to support
healthy lifestyles and furnish preventive care. Such
investments could include, for example, creating safe
spaces for low-income children to play. They should
also include efforts to increase the availability of tests,
immunizations, and other preventive services at work,
at school, and in the community.
3 Implement and sustain a statewide, telephone
quit-line for smoking cessation that provides both
counseling and nicotine reduction products.
4 Increase the number and types of Tobacco Use
Cessation (TUC) services available in diverse
settings and develop and provide educational
13 Reduce racial and ethnic disparities in access
to resources that improve health and increase
health literacy and support for healthy living by
opportunities for training traditional and non- families from multiple, diverse cultures.
traditional TUC service providers.

5 Require age-appropriate life skill education in

grades K-12 that addresses anti-tobacco education,
prevention of drug and alcohol use, nutrition, stress
management, exercise, health literacy, the rights and
responsibilities of health insurance consumers, and
other appropriate topics.
14 Provide or otherwise facilitate the receipt of
funds for health care workforce training and
development, including efforts to promote cultural and
linguistic competence in serving the state’s diverse
residents.

6 Update, adopt, implement, fund, and sustain the

Connecticut Tobacco Use Prevention and Control
Plan.

7 Implement statewide surveillance of key health

indicators, using standard national surveys.

8 Improve the nutrition environment in schools and

day care facilities, including providing breakfast in
school and providing healthy school lunches.

9 Reduce unhealthy food marketing to children,

including making schools “ad-free” zones.

10 Provide or otherwise facilitate the receipt of funds

to expand the state’s public health workforce.

11 Include public health workforce capacity in

state health care workforce assessment and
strategic planning.

12 Develop and implement an overall strategic plan

for assessing and addressing shortages in the
state’s health workforce (including but not limited to
those involving primary care), potentially incorporating
such policies as targeted debt relief, broadening the
permitted scope of practice for non-physician providers,
training in new approaches to practice (such as those
involving patient-centered medical homes and health
information technology), and taking full advantage of
available federal resources.

39
 Timeline for Implementing SustiNet and the Affordable Care Act

2011 2012 2013 2014

SustiNet Board appointed Authority Independent from

Board and by 9/1/2011. operational no Comptroller no later than
Authority later than 3/1/2012 1/1/2013.
Housed within
the Office of the
Comptroller.

SustiNet Existing state Executive

agencies provide Director begins Staff fully independent no
staff later than 1/1/2013.
staff. work no later
than 3/1/2012,
as resources are
identified outside
General Fund.
SustiNet Includes current As soon as As soon as feasible, Offer SustiNet to
coverage Medicaid possible, offer offer SustiNet to small all individuals and
and HUSKY SustiNet to small businesses and non- employers through the
enrollees and businesses and profits. Exchange and other
state employee non-profits. channels, 1/1/2014.
Expand HUSKY to
and retiree health Expand HUSKY Expand HUSKY to
childless adults up to
benefit program to childless adults adults up to 200%
185% FPL, if funding
(SEHP). up to 185% FPL, using Medicaid
identified.
As soon as FPL, if funding and Basic Health to
feasible, identified. maximize federal
municipalities funds. Excess federal
can buy SustiNet. funds increase payment
rates for BH.

Delivery Begin advising Implement Assume direct

System Comptroller budget-neutral responsibility for
and DSS on re-alignment administering SustiNet
and
delivery system of Medicaid/ plan and implementing
Payment and payment HUSKY rates, delivery system and
Reform reforms for SEHP 7/1/12. payment reforms, no later
and Medicaid/ than 1/1/2013.
HUSKY. Begin multi-year initiative
Review Medicaid/ to increase Medicaid
HUSKY payment rates, 7/1/13, with goal of
methods and rates, reaching Medicare levels
starting 7/1/11. over time.
Contract with Comptroller
and DSS to serve SEHP
and Medicaid/HUSKY.
.

40 Continued >>
 2011 2012 2013 2014

Federal States may Medicaid payment

Reform: provide Medicaid rates for certain
to childless adults primary care
Coverage
(standard federal services increased
& Funding matching rate), to Medicare levels,
beginning 2010. with full federal
Federal planning funding (2013 and
grants and 2014).
enhanced federal
matching rates
for medical home
services available
in Medicaid,
1/1/2011.
Tax credits for
some small
businesses
to purchase
coverage,
beginning 2010.

Federal Minimum States must establish

Reform: medical loss ratio. an Exchange or the
Insurance Insurance market federal government
will.
Market reforms prohibit
rescissions, Insurance market
lifetime caps, pre- reforms establish
existing condition community rating,
exclusions eliminate pre-existing
for children, condition exclusions,
beginning 2010. limit waiting periods
to 90 days, etc.

41
 Conclusion
The state of Connecticut faces daunting budget
challenges. Those challenges make it more important
than ever to address serious problems involving limited
access to health coverage and care for thousands of
state residents; misdirected incentives that interfere
with the provision of high-quality, efficient care by
doctors, nurses, hospitals, and clinics; and health care
cost increases that are unsustainable for public and
private sectors alike. Our goal has been to develop
recommendations for the Connecticut General Assembly,
the Administration, and SustiNet’s future governing
entity that, while cognizant of today’s budget challenges,
will help Connecticut assume a leadership role in
addressing these pressing problems, which are national
in scope. We urge Connecticut’s policymakers to move
towards a more rational and fair system of health care
delivery and coverage, making wise choices in 2011 that
yield major gains for the state’s taxpayers, employers,
and families for years to come.
Endnotes
1
Implementing SustiNet Following Federal Enactment
of the Patient Protection and Affordable Care Act
of 2010: A Preliminary Report to the Connecticut
General Assembly, May 27, 2010. The report is
posted on the SustiNet website at http://www.ct.gov/
sustinet/lib/sustinet/board_of_directors_files/reports/
sustinet_60_day_report_05272010.pdf.
2
A more comprehensive description of Dr. Gruber’s
model is posted on the SustiNet website at http://www.
ct.gov/sustinet/lib/sustinet/board_of_directors_files/
resources/grubermodellongerdescription.pdf.
3
Medicaid will expand to individuals with incomes up
to 133 percent FPL. However, in calculating income,
5 FPL percentage points will be subtracted from
Modified Adjusted Gross Income. Accordingly, as a
practical matter, Medicaid coverage will reach 138
percent FPL.
42
4
Perhaps the most important reason to offer SustiNet
outside the exchange is that adverse selection by large
employers can be prevented more effectively than
inside the exchange.
5
In Federal Fiscal Year 2007, 530,000 Connecticut
residents received Medicaid and CHIP, of whom
52.7 percent were children, according to Urban
Institute and Kaiser Commission on Medicaid and
the Uninsured estimates based on 2010 data from
Medicaid Statistical Information System reports
from CMS. From June 2007 through June 2009,
total Medicaid and CHIP enrollment increased by
more than 14 percent in Connecticut, according to
data compiled in 2010 by the Health Management
Associates from state Medicaid enrollment reports
for the Kaiser Commission on Medicaid and the
Uninsured.
6
The Urban Institute and the Kaiser Commission
on Medicaid and the Uninsured, The Uninsured: A
Primer, December 2010 (state data for 2008-2009).
7
Section 1(2)(A) of the 2009 SustiNet law required
“coverage of medical home services; inpatient and
outpatient hospital care; generic and name-brand
prescription drugs; laboratory and x-ray services;
durable medical equipment; speech, physical and
occupational therapy; home health care; vision care;
family planning; emergency transportation; hospice;
prosthetics; podiatry; short-term rehabilitation; the
identification and treatment of developmental delays
from birth through age three; and wellness programs,
provided convincing scientific evidence demonstrates
that such programs are effective in reducing the
severity or incidence of chronic disease.”
8
These categories include ambulatory care, emergency
services, hospitalization, maternity and newborn
care, mental health and substance abuse services,
prescription drugs, rehabilitative and habilitative
services, laboratory services, preventive and wellness
services, chronic disease management, and pediatric
services (including oral and vision care). ACA
§1302(b)(1).
9
This means that, for the average enrollee, health
insurance will pay the listed percentage of all health
care costs included within the essential benefits
standard.
However, SEHP covers associated office visits,
10
prescription drugs, lab tests, and other services.
11
See, e.g., Julie Hudman and Molly O’Malley, Health
Insurance Premiums and Cost-Sharing: Findings
from the Research on Low-Income Populations,
Kaiser Commission on Medicaid and the Uninsured,
March 2003; Bill J. Wright, Matthew J. Carlson, Heidi
Allen, Alyssa L. Holmgren and D. Leif Rustvold,
“Raising Premiums And Other Costs For Oregon
Health Plan Enrollees Drove Many To Drop Out,”
Health Affairs, December 2010; 29(12): 2311-2316;
Dana P. Goldman; Geoffrey F. Joyce; Yuhui Zheng,
“Prescription Drug Cost Sharing: Associations With
Medication and Medical Utilization and Spending and
Health,” Journal of the American Medical Association,
July 4, 2007; 298(1):61-69; Becky A. Briesacher, Jerry
H. Gurwitz, and Stephen B. Soumerai, “Patients At-
Risk for Cost-Related Medication Nonadherence: A
Review of the Literature,” Journal of General Internal
Medicine, June 2007; 22(6): 864–871; Samantha
Artiga and Molly O’Malley, Increasing Premiums and
Cost-Sharing in Medicaid and SCHIP: Recent State
Experiences, Kaiser Commission on Medicaid and
the Uninsured, May 2005. Of course, this research
was done before enactment of an individual mandate,
which, all else equal, will increase enrollment.
These population estimates were developed by the
12
Gruber Microsimulation Model.
Under current federal law, these services are
13
provided to all Medicaid children, without cost-
sharing.
14
Dr. Gruber’s projections suggest that, under a
pessimistic scenario in which SustiNet does not slow
cost growth, the number of uninsured will fall by
38 percent in 2014, 48 percent in 2015, 53 percent
in 2016, and 55 percent in 2017 and later years. If
SustiNet slows cost growth by 1 percentage point per
year, that will increase the number of insured, because
fewer small firms will drop coverage. Under the latter,
more optimistic scenario, the number of uninsured will
fall by 56 percent in 2017 and later years—slightly
more than the level stated in the text.
15
The proposed increase in HUSKY payments cannot
currently be modeled, because it requires a thorough
analysis and revision of HUSKY and Medicaid
payment. The precise details of changed payment
rules will not be known until this analysis is complete.
After that, modeling cost effects should be much more
feasible.
In estimating savings, Dr. Gruber compared the
16
policy that will exist when federal and state reforms
are fully implemented, beginning in 2014, with the
policy that preceded this step by Governor Rell.
This general formulation was articulated by Howard
17
Kahn, the Chief Executive Officer of L.A. Care, at our
meeting on October 13, 2010.
18
Nominally, Medicaid will expand to individuals
with Modified Adjusted Gross Incomes (MAGI) up to
133 percent FPL. However, in determining income,
5 FPL percentage points are subtracted from MAGI.
Accordingly, the effective eligibility threshold is 138
percent FPL.
43
 APPENDIX
A. SustiNet Health Plan – Compiled Final Reports
a. Advisory Committees
i. Health Disparities & Equity
ii. Health Information & Technology
iii. Patient Centered Medical Home
iv. Preventive Healthcare
v. Healthcare Quality & Provider

b. Task Forces
i. Healthcare Work Force
ii. Tobacco & Smoking Cessation
iii. Childhood & Adult Obesity

B. Jonathan Gruber, Ph.D. – Microsimulation Model Summary

C. SustiNet Legislative Cross-Walk

 APPENDIX A

SustiNet Health Plan

Compiled Final Reports
Advisory Committees
Health Disparities & Equity
Health Information & Technology
Patient Centered Medical Home
Preventive Healthcare
Healthcare Quality & Provider

Task Forces
Healthcare Work Force
Tobacco & Smoking Cessation
Childhood & Adult Obesity
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 Source: “Health Insurance Technology Exchange of Connecticut Strategic Plan,
Draft, June 2010”http://www.ct.gov/dph/lib/dph/research_&_development/hite-
ct_strategic_plan_draft_v2.0.pdf

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)
)
)
i
Aiming Higher: Results from a State Scorecard on Health System Performance, The Commonwealth Fund,
October 2009
ii
Emergency Department Utilization in Connecticut, CT Hospital Association, April 2009.
iii
How, SK, et. al., “Public Views on US Health System Organization: A Call for New Directions”, Commonwealth
Fund Data Brief, August 2008.
iv
M. Friedberg, et. al., Primary Care: A Critical Review of the Evidence on Quality and Costs of Health Care,
Health Affairs 29:766-772, May 2010.
v
Yale University Library multi-database article search, 6/16/2010.
vi
E. Andrews and S. Toubman, Patient-Centered Medical Home: Improving Health Care by Shifting the Focus to
Patients, CT Medicine 73:479-480, September 2009.
vii
P. Grundy, et. al., The Multi-Stakeholder Movement for Primary Care Renewal and Reform, Health Affairs
29:791-797, May 2010.
viii
J DeVoe, et. al., Amer J Pub Hlth, 93:786, May 2003
ix
K. Grumbach et. al., The Outcomes of Implementing Patient-Centered Medical Home Interventions, Patient-
Centered Primary Care Collaborative, August 2009, A. Milstein and E. Gilbertson, American Medical Home Runs,
Health Affairs 28:1317-1326, September 2009, R. Reid, et. al., The Group Health Medical Home at Year Two,
Health Affairs 29:835-843, May 2010.
x
Christopher Atchison, presentation at Building a Medical Home: Issues and Decisions for State Policy Makers,
NASHP, 10/5/08, Tampa, FL
xi
C Hull, The Medical Home Model and Family Health Teams, Research and Education Services, Legislative
Assembly of Ontario, 5/11/09.
xii
Multi-payer Advanced Primary Care Practice Demonstration Solicitation, CMS, June 2010.
xiii
Patient Centered medical homes in the Patient Protection and Affordable Care Act, CT Health Policy Project,
April 2010.
xiv
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xv
Personal communication, Matt Katz, CT State Medical Society.
xvi
Primary Care Coalition of Connecticut, March 2010.
xvii
Supporting Small Practices, NCQA, June 2009.
xviii
P Nutting, et. al., Initial Lessons from the First National Demonstration Project on Practice Transformation to a
Patient-Centered Medical Home, Annals of Family Medicine, 7:254-260, May/June 2009.
xix
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CKLK"
xx
Physician Practice Connections – Patient Centered Medical Home, NCQA, www.ncqa.org
xxi
NCQA, September 2009.
xxii
Primary Care Case Management, CT Health Policy Project, http://www.cthealthpolicy.org/pccm/index.htm
xxiii
ACS HUSKY enrollment reports, June 2010.
xxiv
PA 10-166, An Act Concerning Expansion of the Primary Care Case Management Pilot Program, 2010 General
Assembly session.
xxv
Patient Centered Medical Home Initiative with ProHealth, presentation to committee, April 21, 2010.
xxvi
Ron Preston, presentation to committee, May 26, 2010, personal communications with VT state health
policymakers.
xxvii
CT’s population projections, US Census.
xxviii
CT State Data Center.
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S18*&4#S,>8B>&(.#$1)-=@#!)'>-&''#$1)-*>(4#6,-@,#$1)8=4#J,@#CKLK4#!"#$(&,8@4#&="#,("4#/MP,-.>-O#=%&#$,P,*>=@#1B#
R)8'>-O#/.)*,=>1-4#0&,(=%#ABB,>8'#CFE5TUHI5THV4#W)-&#LC4#CKKD"#
xxx
Unpublished survey, CT Health Policy Project.
xxxi
Addressing Racial and Ethnic Disparities in Health Care Fact Sheet. AHRQ, February 2000.
xxxii
Lessons for State Policymakers from Kaiser Permanente, Ann Torregrossa, PA GOHCR, Using Payment
Reform to Improve Health System Performance, NASHP State Health Policy Conference, Oct. 5, 2009.
xxxiii
Healthcare Effectiveness Data and Information Set 2011, NCQA.
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Recommendation #6: ""A8=%"($%";3,)+%,,"'8,%"&-7",4-=)+9"'%,,8()-+";%+%&)(,"&-7"

%4:1-<%%,5"

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Recommendation #7: O-N?)*-"+9-.+22*%2*)+&-",)6-"'7),,"-5?$+&)%3")3"9*+5-'"P.JD")3"

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(+3%45(+'!.&$)#4.#+)$6!/#.$!#+5!(+!-4/%(3!-%#3&$!#+5!&%(0(+#)&!#7#(%#/(%()8!*9!$0*1(+'!
.**0$!(+!2*.1-%#3&$:!!;%(0(+#)&!$0#%%!/4$(+&$$!&<&0-)(*+!#+5!$0*1(+'!.**0!*-)(*+:!

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$0*1&!(+,#%&5!/8!),&!$0*1&.!(+!),#)!()!($!#!3*0-%&<!0(<)4.&!3*+)#(+(+'!0#+8!
3,&0(3#%$!>(+3%45(+'!9*.0#%5&,85&6!38#+(5&6!3#./*+!0*+*<(5&6!#00*+(#6!#+5!
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Recommendation #9: K&1$!"#$,&/#$'($LCM.G&%#!!#,$&1>$'!"#%$1'1C!%&>.!.'1&/$1.<'!.1#$

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-%'>=<!,$-%.'%$!'$!"#.%$.1!%'>=<!.'1$&1>$&<<#-!&1<#$('%$,&/#$.1$M'11#<!.<=!6$

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Recommendation #11: ((9&:0$+&('%/""#(6$'.+$%.'(."(&'.,1#$'/(,)6(*,$).,$)()"(

."1,%%"(0'&(!"#$%$&'(")('%/""#(2+"0)6'(,)6('%/""#(&5&).'(;$)%#06$)2(6,87%,+&<(=7>?(,)6(
%"##&2&(@0)$5&+'$.8('&..$)2'A3(

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/,5&()"('*"E$)2(!"#$%$&'(-"+('.06&).'(F$./$)(./&('%/""#<('*"E$)2(")(./&(2+"0)6'(
5,+$&'(,)6(*,8()".(1&(F&##(&)-"+%&63((G,)8("-("0+(%"##&2&'(,)6(0)$5&+'$.$&'(,##"F(
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'!"+.'(&5&).'<(&.%3A3((H*"E$)2('/"0#6(1&(1,))&6(,.('0%/(&5&).'3(

4##(C"))&%.$%0.('%/""#'(*0'.(1&(%"**$..&6(."(!+"5$6$)2(,(/&,#./8(&)5$+")*&).(-"+(
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%+&,.&(!"#$%$&'(./,.(,+&('.+")2&+(./,)(./&(*$)$*0*('&.3(

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F$##()&&6(."(6+,-.('.,)6,+6$M&6(!"#$%&'3((H%/""#(&*!#"8&&'(,)6('%/""#(1",+6'(*,8(
"!!"'&(./&(!"#$%8(1&%,0'&($.($)5"#5&'()"(."1,%%"(0'&(,.(,##(.$*&'(")('%/""#(2+"0)6'<(
&5&)(,-.&+(*$)"+'(/,5&(#&-.('%/""#(-"+(./&(6,83((H"*&(&N!&%.&6("0.%"*&'("-(,6"!.$)2(,(
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FG,<D=,1=)<=&C,B'&,H?C="C=,-&=E=)<?'),")*,1')<&'AI,,
Recommendation #12: ((Q!6,.&<(,6"!.<($*!#&*&).<(-0)6(,)6('0'.,$)(./&(!"##$%&'%(&)
*"+,%%")-.$)/0$1$#&'"#),#2)!"#&0"3)/3,#3(

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 • !"#$%&'()*)+,%-'&(.*-&%-/(.#"(,-+%0+#1,22#(3'&%,(4"#/",33%-/(+5,+(
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Figure 1
!
An Ecological Model of Obesity
(NHLBI)

Influences Health
Behaviors
Outcomes
Biological & Demographic
Age, sex, race/ethnicity, SES, genes

Psychological Eating
Beliefs, preferences, emotions, self-efficacy, intentions,
Dietary patterns,
pros, cons, behavior change skills, body image, nutrient intake
motivation, knowledge

Social/Cultural
Social support, modeling, family factors, social norms,
cultural beliefs, acculturation
Sedentary
Behaviors Weight,
Balance
Energy

Organizational TV, computer use, Fat, &

driving Distribution
Practices, programs, norms, & policies in schools, worksite,
Health care settings, businesses, community orgs

Physical Environment
Access to & quality of foods, recreational facilities, cars, Physical Risk Factors,
sedentary entertainment; urban design, Activity CVD,
transportation infrastructure, information environment Recreation, Diabetes,
transportation, Cancers,
occupation, Costs
domestic
Policies/Incentives
Cost of foods, physical activities, & sedentary behaviors;
incentives for behaviors; regulation of environments

Developed for the NHLBI Workshop on Predictors of Obesity, Weight Gain, Diet, and Physical Activity; August 4-5, 2004, Bethesda MD

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 APPENDIX B

Jonathan Gruber, Ph.D.

Microsimulation Model Summary

 Short Description of Gruber Microsimulation Model

The model allows the user to input a set of policy parameters, and output the impact of
that policy on public sector costs and the distribution of insurance coverage. The modeling
approach used here is the type of “microsimulation” modeling used by the Treasury Department,
CBO, and other government entities. This approach consists of drawing on the best evidence
available in the health economics literature to model how individuals will respond to the changes
in the insurance environment induced by changes in government policy.

The model takes as its base the February and March Current Population Surveys. The
March survey contains information on family demographics, tax rates, and insurance coverage.
The February survey contains information on insurance offering by employers. I match to these
surveys information on:

• Group insurance costs and the distribution of premiums across employers and employees,
imputed by firm location and firm size;
• Nongroup insurance costs, which use a base cost estimated from existing nongroup insurance
pricing, adjusted by age, sex, and health status;
• Public insurance costs; and
• Underlying health care costs, which are imputed by age and health status.

This base set of data is then used to compute, for every possible policy change, the
impact of that policy change on the eligibility for, and price of, various types of insurance.
These price and eligibility changes are then run through a detailed and integrated set of
behavioral equations that relate them to behavioral responses by individuals, families, and firms.
These behavioral responses are modeled using the best available evidence from the health
economics literature, and include responses such as:

• The extent to which the currently uninsured will purchase newly subsidized insurance
coverage or take up newly available public coverage;
• The extent to which those with existing insurance coverage will take up subsidies to that type
of insurance coverage (e.g. to what extent will the nongroup insured take up subsidies to
nongroup insurance?);
• The extent to which those with one form of insurance coverage will switch to another form if
it is subsidized;
• The extent to which firms will react to the subsidies to non-employer insurance by dropping
their offering of insurance to their employees, or by cutting back on employer premium
contributions to insurance; and
• The extent to which those employees dropped from group coverage will then take up other
forms of insurance coverage.

It is very important to model potential firm responses to these policy changes. To capture
firm responses, I have created “synthetic” firms in the CPS by drawing for each worker other
“co-workers” in the CPS based on that worker’s wage, industry, firm size, and health insurance
offering status. These synthetic co-workers are grouped together to form firms, and I then model
firm responses based on the average effects of policies on their workforce.
 APPENDIX C

SustiNet Legislative Cross-Walk

 Substitute House Bill No. 6600 

Public Act No. 09‐148 

AN ACT CONCERNING THE ESTABLISHMENT OF THE SUSTINET PLAN 
 

Crosswalk To Report  Section  Statute 

    Be it enacted by the Senate and House of Representatives in General 
Assembly convened:  
  1  Section 1. (NEW) (Effective July 1, 2009) As used in sections 1 to 14, inclusive, 
Definitions:  of this act and section 17b‐297b of the general statutes, as amended by this 
  act:  
No action required 
(1) "SustiNet Plan" means a self‐insured health care delivery plan, that is 
designed to ensure that plan members receive high‐quality health care 
coverage without unnecessary costs;  
  1  (2) "Standard benefits package" means a set of covered benefits as 
  determined by the public authority, with out‐of‐pocket cost‐sharing limits 
Benefits   and provider network rules, subject to the same coverage mandates 
described in chapter 700c of the general statutes and the utilization 
review requirements described in chapter 698a of the general statutes 
that apply to group health insurance sold in this state. The standard 
benefits package includes, but is not limited to, the following:  
(A) Coverage of medical home services; inpatient and outpatient 
hospital care; generic and name‐brand prescription drugs; laboratory 
and x‐ray services; durable medical equipment; speech, physical and 
occupational therapy; home health care; vision care family planning; 
emergency transportation; hospice; prosthetics; podiatry; short‐term 
rehabilitation; the identification and treatment of developmental 
delays from birth through age three; and wellness programs, 
provided convincing scientific evidence demonstrates that such 
programs are effective in reducing the severity or incidence of 
chronic disease;  
(B) A per individual and per family deductible, provided preventive care 
or prescription drugs shall not be subject to any deductible;  
(C)  Preventive care requiring no copayment that includes well‐child 
visits, well‐baby care, prenatal care, annual physical examinations, 
immunizations and screenings;  
(D)  Office visits for matters other than preventive care for which there 
shall be a copayment;  
(E)   Prescription drug coverage with copayments for generic, name‐
brand preferred and name‐brand nonpreferred drugs;  
(F)  Coverage of mental and behavioral health services, including tobacco 
 

1 

 
 Crosswalk To Report  Section  Statute 
cessation services, substance abuse treatment services, and services 
that prevent and treat obesity with such services being at parity with 
the coverage for physical health services; and  
(G)  Dental care coverage that is comparable in scope to the median  
coverage provided to employees by large employers in the Northeast 
states; provided, in defining large employers, consideration shall be 
given to the capacity of available data to yield, without substantial 
expense, reliable estimates of median dental coverage offered by 
such employers;  
  1  (3)  "Electronic medical record" means a record of a person's medical 
Definitions:   treatment created by a licensed health care provider and stored in an 
  interoperable and accessible digital format;  
No action required 
(4)  "Electronic health record" means an electronic record of health‐related 
information on an individual that conforms to nationally recognized 
interoperability standards and that can be created, managed and 
consulted by authorized clinicians and staff across more than one health 
care organization;  
(5)   "Northeast states" means the Northeast states as defined by the United 
States Census Bureau;  
(6)  "Board of directors" means the SustiNet Health Partnership board of 
directors established pursuant to section 2 of this act;  
(7)  "Public authority" means a public authority or other entity recommended 
by the SustiNet Health Partnership board of directors in accordance with 
the provisions of subsection (b) of section 3 of this act;  
(8)  "Small employer" has the same meaning as provided in subparagraph (A) 
of subdivision (4) of section 38a‐564 of the general statutes; and  
(9)  "Nonstate public employer" means a municipality or other political 
subdivision of the state, including a board of education, quasi‐public 
agency or public library. 
  2  Sec. 2. (NEW) (Effective July 1, 2009)  
Establishes Board of 
Directors:  (a) There is established the SustiNet Health Partnership board of directors. 
  The board of directors shall consist of nine members, as follows: The 
No action required  Comptroller; the Healthcare Advocate; one appointed by the Governor, 
who shall be a representative of the nursing or allied health professions; 
one appointed by the president pro tempore of the Senate, who shall be 
a primary care physician; one appointed by the speaker of the House of 
Representatives, who shall be a representative of organized labor; one 
appointed by the majority leader of the Senate, who shall have expertise 
in the provision of employee health benefit plans for small businesses; 
one appointed by the majority leader of the House of Representatives, 
who shall have expertise in health care economics or health care policy; 
one appointed by the minority leader of the Senate, who shall have 
 

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 Crosswalk To Report  Section  Statute 
expertise in health information technology; and one appointed by the 
minority leader of the House of Representatives, who shall have expertise 
in the actuarial sciences or insurance underwriting. The Comptroller and 
the Healthcare Advocate shall serve as the chairpersons of the board of 
directors.  
(b)  Initial appointments to the board of directors shall be made on or before 
July 15, 2009.In the event that an appointing authority fails to appoint a 
board member by July 31, 2009, the president pro tempore of the Senate 
and the speaker of the House of Representatives shall jointly appoint a 
board member meeting the required specifications on behalf of such 
appointing authority and such board member shall serve a full term. The 
presence of not less than five members shall constitute a quorum for the 
transaction of business. The initial term for the board member appointed 
by the Governor shall be for two years. The initial term for board 
members appointed by the minority leader of the House of 
Representatives and the minority leader of the Senate shall be for three 
years. The initial term for board members appointed by the majority 
leader of the House of Representatives and the majority leader of the 
Senate shall be for four years. The initial term for the board members 
appointed by the speaker of the House of Representatives and the 
president pro tempore of the Senate shall be for five years. Terms 
pursuant to this subdivision shall expire on June thirtieth in accordance 
with the provisions of this subdivision. Any vacancy shall be filled by the 
appointing authority for the balance of the unexpired term. Not later 
than thirty days prior to the expiration of a term as provided for in this 
subsection, the appointing authority may reappoint the current board 
member or shall appoint a new member to the board. Other than an 
initial term, a board member shall serve for a term of five years and until 
a successor board member is appointed. A member of the board 
pursuant to this subdivision shall be eligible for reappointment. Any 
member of the board may be removed by the appropriate appointing 
authority for misfeasance, malfeasance or willful neglect of duty.  

(c)  The SustiNet Health Partnership board of directors shall not be construed 
to be a department, institution or agency of the state. The staff of the 
joint standing committee of the General Assembly having cognizance of 
matters relating to public health shall provide administrative support to 
the board of directors.  

  3  Sec. 3.  (NEW) (Effective July 1, 2009)  
Overall Design: 
  (a) The SustiNet Health Partnership board of directors shall design and 
Addressed in the Board’s,  establish implementation procedures to implement the SustiNet Plan. 
Advisory Committees’ and  The SustiNet Plan shall be designed to (1) improve the health of state 
Task Forces’  residents; (2) improve the quality of health care and access to health 
recommendations  care; (3) provide health insurance coverage to Connecticut residents who 
would otherwise be uninsured; (4) increase the range of health care 
insurance coverage options available to residents and employers; (5) 
slow the growth of per capita health care spending both in the short‐
 

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 Crosswalk To Report  Section  Statute 
term and in the long‐term; and (6) implement reforms to the health care 
delivery system that will apply to all SustiNet Plan members, provided 
any such reforms to health care coverage provided to state employees, 
retirees and their dependents shall be subject to applicable collective 
bargaining agreements.  
Governance and Location  3  (b) The SustiNet Health Partnership board of directors shall offer 
within State Government  recommendations to the General Assembly on the governance structure 
  of the entity that is best suited to provide oversight and implementation 
  of the SustiNet Plan. Such recommendations may include, but need not 
  be limited to, the establishment of a public authority authorized and 
  empowered:  
 
Administrative Duties and  (1)  To adopt guidelines, policies and regulations in accordance with 
Responsibilities of the  chapter 54 of the general statutes that are necessary to implement the 
Authority  provisions of sections 1 to 14, inclusive, of this act;  
 
Administrative Duties  (2)  To contract with insurers or other entities for administrative 
  purposes, such as claims processing and credentialing of providers. Such 
  contracts shall reimburse these entities using "per capita" fees or other 
  methods that do not create incentives to deny care. The selection of such 
  insurers or other entities may take into account their capacity and 
  willingness to (A) offer timely networks of participating providers both 
  within and outside the state, and (B) help finance the administrative 
  costs involved in the establishment and initial operation of the SustiNet 
  Plan;  
 
(3)  To solicit bids from individual providers and provider organizations 
Administrative Duties 
and to arrange with insurers and others for access to existing or new 
 
provider networks, and take such other steps to provide all SustiNet Plan 
 
members with access to timely, high‐quality care throughout the state 
 
and, in appropriate cases, care that is outside the state's borders;  
 
Administrative Duties  (4)  To establish appropriate deductibles, standard benefit packages and 
  out‐of‐pocket cost sharing levels for different providers, that may vary 
  based on quality, cost, provider agreement to refrain from balance billing 
  SustiNet Plan members, and other factors relevant to patient care and 
  financial sustainability;  
 
Administrative Duties  (5)  To commission surveys of consumers, employers and providers on 
  issues related to health care and health care coverage;  
 
Administrative Duties  (6)  To negotiate on behalf of providers participating in the SustiNet Plan 
  to obtain discounted prices for vaccines and other health care goods and 
  services;  
 
Administrative Duties  (7)  To make and enter into all contracts and agreements necessary or 
  incidental to the performance of its duties and the execution of its 
  powers under its enabling legislation, including contracts and agreements 
  for such professional services as financial consultants, actuaries, bond 

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 Crosswalk To Report  Section  Statute 
  counsel, underwriters, technical specialists, attorneys, accountants, 
  medical professionals, consultants, bio‐ethicists and such other 
  independent professionals or employees as the board of directors shall 
  deem necessary;  
 
Administrative Duties  (8)  To purchase reinsurance or stop loss coverage, to set aside reserves, 
  or to take other prudent steps that avoid excess exposure to risk in the 
  administration of a self‐insured plan;  
 
Administrative Duties  (9)  To enter into interagency agreements for performance of SustiNet 
  Plan duties that may  be implemented more efficiently or effectively by 
  an existing state agency;  
 
(10) To set payment methods for licensed health care providers that 
Reforming Health Care 
reflect evolving research and experience both within the state and 
Delivery and Payment 
elsewhere, promote access to care and patient health, prevent 
 
unnecessary spending, and ensure sufficient compensation to cover the 
 
reasonable cost of furnishing necessary care;  
 
Policy‐Making Duties and  (11) To appoint such advisory committees as may be deemed necessary 
Responsibilities of the  for the public authority to successfully implement the SustiNet Plan, 
Authority Board  further the objectives of the public authority and secure necessary input 
  from various experts and stakeholder groups;  
 
Established by current  (12) To establish and maintain an Internet web site that provides for 
board  timely posting of all public notices issued by the public authority or the 
  board of directors and such other information as the public authority or 
  board deems relevant in educating the public about the SustiNet Plan;  
 
Included in federal ACA  (13) To evaluate the implementation of an individual mandate in concert 
  with guaranteed issue, the elimination of preexisting condition 
  exclusions, and the implementation of auto‐enrollment;  
 
Administrative Duties  (14) To raise funds from private and public sources outside of the state 
  budget to contribute toward support of its mission and operations;  
 
(15) To make optimum use of opportunities created by the federal 
Administrative Duties 
government for securing new and increased federal funding, including, 
 
but not limited to, increased reimbursement revenues; 
 
  (16) In the event of the enactment of federal health care reform, to 
Submitted report  submit preliminary recommendations for the implementation of the 
  SustiNet Plan to the General Assembly not later than sixty days after the 
  date of enactment of such federal health care reform; and  
 
Included in federal ACA  (17) To study the feasibility of funding premium subsidies for individuals 
  with income that exceeds three hundred per cent of the federal poverty 
level but does not exceed four hundred per cent of the federal poverty 
level.  

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 Crosswalk To Report  Section  Statute 
  3  (c) Not later than January 1, 2011, the SustiNet Health Partnership board of 
Direction to submit this 
directors shall submit its design and implementation procedures in the 
report 
form of recommended legislation to the joint standing committees of the 
 
General Assembly having cognizance of matters relating to 
 
appropriations and the budgets of state agencies and finance, revenue 
 
and bonding.  
 
   
 
(d) All state and municipal agencies, departments, boards, commissions and 
In process 
councils shall fully cooperate with the board of directors in carrying out 
 
the purposes enumerated in this section.  
  4  Sec. 4.  (NEW) (Effective July 1, 2009)  
Overall Design: 
  (a) The board of directors shall develop the procedures and guidelines for 
Addressed in the Board’s,  the SustiNet Plan. Such procedures and guidelines shall be specific and 
Advisory Committees’ and  ensure that the SustiNet Plan is established in accordance with the five 
Task Forces’  following principles to guide health care reform as enumerated by the 
recommendations  Institute of Medicine: (1) Health care coverage should be universal; (2) 
  health care coverage should be continuous; (3) health care coverage 
  should be affordable to individuals and families; (4) the health insurance 
  strategy should be affordable and sustainable for society; and (5) health 
  care coverage should enhance health and well‐being by promoting access 
  to high‐quality care that is effective, efficient, safe, timely, patient‐
  centered and equitable.  
In process  (b) The board of directors shall identify all potential funding sources that 
  may be utilized to establish and administer the SustiNet Plan.  
 
Policy‐Making Duties and  (c) The board of directors shall recommend that the public authority adopt 
Responsibilities  periodic action plans to achieve measurable objectives in areas that 
  include, but are not limited to, effective management of chronic illness, 
  preventive care, reducing racial and ethnic disparities as related to health 
  care and health outcomes, and reducing the number of state residents 
  without insurance. The board of directors shall include in its 
recommendations that the public authority monitor the accomplishment 
of such objectives and modify action plans as necessary.  
  5  Sec. 5.  (NEW) (Effective July 1, 2009)  
Information Technology 
Advisory Committee    (a) For purposes of this section: (1) "Subscribing provider" means a licensed 
Recommendations  health care provider that: (A) Either is a participating provider in the 
  SustiNet Plan or provides services in this state; and (B) enters into a 
  binding agreement to pay a proportionate share of the cost of the goods 
and services described in this section, consistent with guidelines adopted 
  by the board; and (2) "approved software" means electronic medical 
  records software approved by the board, after receiving 
recommendations from the information technology committee, 
  established pursuant to this section.  
(b) The board of directors shall establish an information technology advisory 
 

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 Crosswalk To Report  Section  Statute 
5  committee that shall formulate a plan for developing, acquiring, 
financing, leasing or purchasing fully interoperable electronic medical 
  records software and hardware packages for subscribing providers. Such 
  plan shall include the development of a periodic payment system that 
allows subscribing providers to acquire approved software and hardware 
  while receiving the services described in this section. The committee shall 
  offer recommendations on matters that include, but are not limited to: 
(1) The furnishing of approved software to subscribing providers and to 
  participating providers, as the case may be, consistent with the capital 
acquisition, technical support, reduced‐cost digitization of records, 
 
software updating and software transition procedures described in this 
  section; and (2) the development and implementation of procedures to 
ensure that physicians, nurses, hospitals and other health care providers 
  gain access to hardware and approved software for interoperable 
  electronic medical records and the establishment of electronic health 
records for SustiNet Plan members.  
 
(c) The committee shall consult with health information technology 
  specialists, physicians, nurses, hospitals and other health care providers, 
as deemed appropriate by the committee, to identify potential software 
 
and hardware options that meet the needs of the full array of health care 
  practices in the state. Any electronic medical record package that the 
committee recommends for future possible purchase shall include, to the 
  maximum extent feasible: (1) A full set of functionalities for pertinent 
  provider categories, including practice management, patient scheduling, 
claims submission, billing, issuance and tracking of laboratory orders and 
  prescriptions; (2) automated patient reminders concerning upcoming 
appointments; (3) recommended preventive care services; (4) automated 
 
provision of test results to patients, when appropriate; (5) decision 
  support, including a notice of recommended services not yet received by 
a patient; (6) notice of potentially duplicative tests and other services; (7) 
  in the case of prescriptions, notice of potential interactions with other 
  drugs and past patient adverse reactions to similar medications; (8) 
notice of possible violation of patient wishes for end‐of‐life care; (9) 
  notice of services provided inconsistently with care guidelines adopted 
pursuant to section 8 of this act, along with options that permit the 
 
convenient recording of reasons why such guidelines are not being 
  followed; and (10) such additional functions as may be approved by the 
information technology committee.  
 
(d) The committee shall offer recommendations on the procurement and 
  development of approved software. Such recommendations may include 
  that any approved software have the capacity to: (1) Gather information 
pertinent to assessing health care outcomes, including activity 
  limitations, self‐reported health status and other quality of life indicators; 
and (2) allow the board of directors to track the accomplishment of 
 
clinical care objectives at all levels. The board of directors shall ensure 
  that SustiNet Plan providers who use approved software are able to 
electronically transmit to, and receive information from, all laboratories 
and pharmacies participating in the SustiNet Plan, without the need to 
 

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 Crosswalk To Report  Section  Statute 
5  construct interfaces, other than those constructed by the public 
authority.  
 
(e) The committee shall offer recommendations on the selection of vendors 
  to provide reduced‐cost, high‐quality digitization of paper medical 
  records for use with approved software. Such vendors shall be bonded, 
supervised and covered entities under the provisions of the Health 
  Insurance Portability and Accountability Act of 1996 (P. L. 104 191) 
(HIPAA), as amended from time to time, and in full compliance with other 
 
governing federal law.  
 
 
  (f) The committee shall offer recommendations on an integration system 
  through which electronic medical records used by subscribing providers 
are integrated into a single electronic health record for each SustiNet 
  Plan member, updated in real time whenever the member seeks or 
obtains care, and accessible to any participating or subscribing provider 
 
serving the member. Such electronic health record shall be designed to 
  automatically update approved software. Such updates may include 
incorporating newly approved clinical care guidelines, software patches 
  or other changes.  
  (g) All recommendations concerning electronic medical records and 
  electronic health records shall be developed and administered in a 
manner that is consistent with guidelines approved by the board of 
  directors for safeguarding privacy and data security and with state and 
federal law, including any recommendations of the United States 
 
Government Accountability Office. Such guidelines shall include the 
  remedies and sanctions that apply in the event of a provider's failure to 
comply with privacy or information security requirements. Remedies 
  shall include notice to affected members and may include, in appropriate 
  cases, termination of network privileges and denial or reduction of 
SustiNet Plan reimbursement. Remedies and sanctions recommended by 
  the board of directors shall be in addition to those otherwise available 
under state or federal law.  
 
(h) The committee shall develop recommended methods to eliminate or 
 
minimize transition costs for health care providers that, prior to January 
  1, 2011, have implemented comprehensive systems of electronic medical 
records or electronic health records. Such methods may include technical 
  assistance in transitioning to new software and development of modules 
  to help existing software connect to the integration system described in 
subsection (i) of this section.  
 
(i) The committee shall offer recommendations that permit subscribing 
  providers to receive a proportionate share of systemic cost savings that 
are specifically attributable to the implementation of electronic medical 
 
records and electronic health records. Such subscribing providers shall 
  include those that, throughout the period of their subscription, have 
been participating providers in the SustiNet Plan and that, but for the 
savings shared pursuant to this subsection, would incur net financial 
 

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 Crosswalk To Report  Section  Statute 
5  losses during their first five years of using approved software. The 
amount of savings shared by the board with a provider shall be limited to 
  the amount of net financial loss satisfactorily demonstrated by the 
  provider. A provider whose losses resulted from the provider's failure to 
take reasonable advantage of available technical support and other 
  services offered by the public authority shall not share in the systemic 
  cost savings.  
(j) The committee shall offer recommendations concerning the use of 
 
electronic health records to facilitate the provision of medical home 
  functions as described in section 6 of this act. The committee shall 
recommend methods for such electronic health records to generate 
  automatic notices to medical homes that: (1) Report when an enrolled 
  member receives services outside the medical home; (2) describe 
member compliance or noncompliance with provider instructions, as 
  relate to the filling of prescriptions, referral services, and recommended 
  tests, screenings or other services; and (3) identify the expiration of 
refillable prescriptions.  
 
(k) The committee shall offer recommendations requiring: (1) That each 
participating provider use either approved software or other electronic 
medical record software that is interoperable with approved software 
and the electronic health record integration system described in 
subsection (f) of this section; (2) the development and implementation of 
appropriate financial incentives for early subscriptions by participating 
providers, including discounted fees for providers who do not delay their 
subscriptions; (3) that no later than July 1, 2015, the board of directors 
require as a condition of participation in the SustiNet Plan that each 
participating provider use either approved software or other electronic 
medical record software that is interoperable with approved software 
and the electronic health record integration system described in 
subsection (f) of this section; (4) that after July 1, 2015, the board of 
directors have authority to provide additional support to a provider that 
demonstrates to the satisfaction of the board that such provider would 
experience special hardship due to the implementation of electronic 
medical records and electronic health records requirements within the 
specified time frame; and (5) that such provider be allowed to qualify for 
additional support and an exemption from compliance with the time 
frame specified in this subsection, but only if such an exemption is 
necessary to ensure that members in the geographic locality served by 
the provider continue to receive access to care.  
(l) The committee shall recommend methods to coordinate the 
development and implementation of electronic medical records and 
electronic health records in concert with the Department of Public Health 
and other state agencies to ensure efficiency and compatibility. The 
committee shall determine appropriate financing options, including, but 
not limited to, financing through the Connecticut Health and Educational 
Facilities Authority established pursuant to section 10a‐179 of the 
general statutes. 
 

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  6  Sec. 6.  (NEW) (Effective July 1, 2009)  

Medical Home Advisory    (a) The board of directors shall establish a medical home advisory committee 

Committee  that shall develop recommended internal procedures and proposed 
  regulations governing the administration of patient‐centered medical 
Recommendations  
  homes that provide health care services to SustiNet Plan members. The 
medical home advisory committee shall forward their recommended 
  internal procedures and proposed regulations to the board of directors in 
  accordance with such time and format requirements as may be 
prescribed by said board. The medical home advisory committee shall be 
  composed of physicians, nurses, consumer representatives and other 
qualified individuals chosen by said board.  
 
(b) Committee recommendations concerning patient‐centered medical 
  homes shall include that: (1) Medical home functions be defined by the 
  board of directors on an ongoing basis that incorporates evolving 
research concerning the delivery of health care services; and (2) if 
  limitations in provider infrastructure prevent all SustiNet Plan members 
from being enrolled in patient‐centered medical homes, enrollment in 
 
medical homes be implemented in phases with priority enrollment given 
  to members for whom cost savings appear most likely, including, in 
appropriate cases, members with chronic health conditions.  
 
(c) Subject to revision by the board of directors, the committee shall offer 
  recommendations that initial medical home functions include the 
  following:  

  (1)   Assisting members to safeguard and improve their own health by: (A) 
Advising members with chronic health conditions of methods to 
  monitor and manage their own conditions; (B) working with 
members to set and accomplish goals related to exercise, nutrition, 
 
use of tobacco and other addictive substances, sleep, and other 
  behaviors that directly affect such member's health; (C) 
implementing best practices to ensure that members understand 
  medical instructions and are able to follow such directions; and (D) 
  providing translation services and using culturally competent 
communication strategies in appropriate cases;  
 
(2)  Care coordination that includes: (A) Managing transitions between 
  home and the hospital;  (B) proactive monitoring to ensure that the 
  member receives all recommended primary and preventive care 
services; (C) the provision of basic mental health care, including 
  screening for depression, with referral relationships in place for 
those members who require additional assistance; (D) strategies to 
 
address stresses that arise in the workplace, home, school and the 
  community, including coordination with and referrals to available 
employee assistance programs; (E) referrals, in appropriate cases, to 
  nonmedical services such as housing and nutrition programs, 
6  domestic violence resources and other support groups; and (F) for a 
member with a complex health condition that involves care from 

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 Crosswalk To Report  Section  Statute 
multiple providers, ensuring that such providers share information 
about the member, as appropriate, and pursue a single, integrated 
treatment plan; and  

(3)  Providing readily accessible, twenty‐four‐hour consultative services 
by telephone, secure electronic mail or quickly scheduled office 
appointments for purposes that include reducing the need for 
hospital emergency room visits.  

(d) The committee shall offer recommendations on entities that may serve as 
a medical home, including that: (1) A licensed health care provider be 
allowed to serve as a medical home if such provider is authorized to 
provide all core medical home functions as prescribed by the board and 
operationally capable of providing such functions; and (2) a group 
practice or community health center serving as a medical home identify, 
for each member, a lead provider with primary responsibility for the 
member's care. In appropriate cases, as determined by the board of 
directors, a specialist may serve as a medical home and a patient's 
medical home may temporarily be with a health care provider who is 
overseeing the patient's care for the duration of a temporary medical 
condition, including pregnancy.  
(e) The committee shall offer recommendations concerning the 
responsibilities of a medical home provider. Such recommendations shall 
include that: (1) Each medical home provider be presented with a listing 
of all medical home functions, including patient education, care 
coordination and twenty‐four‐hour accessibility; and (2) if a provider does 
not wish to perform, within his or her office, certain functions outside 
core medical home functions, such provider shall make arrangements for 
other qualified entities or individuals to perform such functions, in a 
manner that integrates such functions into the medical home's clinical 
practice. Such qualified entities or individuals shall be certified by the 
board of directors based on factors that include the quality, safety and 
efficiency of the services provided. At the request of a core medical home 
provider, the board of directors shall make all necessary arrangements 
required for a qualified entity or individual to perform any medical home 
function not assumed by the core provider.  
(f) The medical home advisory committee may develop quality and safety 
standards for medical home functions that are not covered by existing 
professional standards, which may include care coordination and 
member education.  
(g) The committee shall recommend that the public authority assist in the 
development of community‐based resources to enhance medical home 
functions, including, but not limited to:  
(1)  The availability of loans on favorable terms that facilitate the 
development of necessary health care infrastructure, including 
community‐based providers of medical home services and 

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 Crosswalk To Report  Section  Statute 
community‐based preventive care service providers;  

(2)  The offering of reduced price consultants that shall assist physicians 
and other health care providers in restructuring their practices and 
offices so as to function more effectively and efficiently in response 
to changes in health care insurance coverage and the health care 
service delivery system that are attributable to the implementation 
of the SustiNet Plan; and  

(3)  The offering of continuing medical education courses that assist 
physicians, nurses and other clinicians in order to provide better 
care, consistent with the objectives of the SustiNet Plan, including 
training in the delivery of linguistically and culturally competent 
health care services.  

(h)  The committee shall offer recommendations concerning payment for 
medical home functions, including that: (1) All of the medical home 
functions set forth in this section be reimbursable and covered by the 
SustiNet Plan; (2) to the extent that such functions are generally not 
covered by commercial insurance, payment levels cover the full cost of 
performing such functions; and (3) in setting such payment levels, 
consideration be given to:   (A) Utilizing rate‐setting procedures based on 
those used to set physician payment levels for Medicare; (B) establishing 
monthly case management fees paid based on demonstrated 
performance of medical home functions; or (C) taking other steps, as 
deemed necessary by the board of directors, to make payments that 
cover the cost of performing each function.  

(i)  The committee shall offer recommendations that specialty referrals 
include, under circumstances set forth in the board's guidelines, prior 
consultation between the specialist and the medical home to ascertain 
whether such referral is medically necessary. If such referral is medically 
necessary, the consultation shall identify any tests or other procedures 
that shall be conducted or arranged by the medical home, prior to the 
specialty visit, so as to promote economic efficiencies. The SustiNet Plan 
shall reimburse the medical home and the specialist for time spent in any 
such consultation.  

  7  Sec. 7.  (NEW) (Effective July 1, 2009)  

Quality and Provider    (a) The board of directors shall establish a health care provider advisory 

Advisory Committee  committee that shall develop recommended clinical care and safety 
Recommendations    guidelines for use by participating health care providers. The committee 
  shall choose from nationally and internationally recognized guidelines for 
the provision of care, including guidelines for hospital safety and the 
  inpatient and outpatient treatment of particular conditions. The 
  committee shall continually assess the quality of evidence relevant to the 
costs, risks and benefits of treatments described in such guidelines. The 
  committee shall forward their recommended clinical care and safety 
guidelines to the board of directors in accordance with such time and 
 

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 Crosswalk To Report  Section  Statute 
7  format requirements as may be prescribed by said board. The committee 
shall include both health care consumers and health care providers.  
 
(b) The committee shall offer recommendations that health care providers 
  participating in the SustiNet Plan receive confidential reports comparing 
  their practice patterns with those of their peers. Such reports shall 
provide information about opportunities for appropriate continuing 
  medical education.  
  (c) The committee shall offer recommendations concerning quality of care 
standards for the care of particular medical conditions. Such standards 
may reflect outcomes over the entire care cycle for each health care 
condition, adjusted for patient risk and general consistency of care with 
approved guidelines as well as other factors. The committee shall offer 
recommendations that providers who meet or exceed quality of care 
standards for a particular medical condition be publicly recognized by the 
board of directors in such manner as said board determines appropriate. 
Such recognition shall be effectively communicated to SustiNet Plan 
members, including those who have been diagnosed with the particular 
medical condition for which recognition has been extended. Such 
communication to members shall be in multiple forms and reflect 
consideration of diversity in primary language, general and health literacy 
levels, past health‐information‐seeking behaviors, and computer and 
Internet use among members.  
(d) The committee shall recommend procedures that require hospitals and 
their medical staffs, physicians, nurse practitioners, and other 
participating health care providers to engage in periodic reviews of their 
quality of care. The purpose of such reviews shall be to develop plans for 
quality improvement. Such reviews shall include the identification of 
potential problems manifesting as adverse events or events that could 
have resulted in negative patient outcomes. As appropriate, such reviews 
shall incorporate confidential consultation with peers and colleagues, 
opportunities for continuing medical education, and other interventions 
and supports to improve performance. To the maximum extent 
permissible, such reviews shall incorporate existing peer review 
mechanisms. The committee's recommendations shall include that any 
review conducted in accordance with the provisions of this subsection be 
subject to the protections afforded by section 19a‐17b of the general 
statutes.  
(e) The board of directors, in consultation with the committee, shall develop 
hospital safety standards that shall be implemented in such hospitals. 
The board of directors shall establish monitoring procedures and 
sanctions that ensure compliance by each participating hospital with such 
safety standards and may establish performance incentives to encourage 
hospitals to exceed such safety standards.  
(f) The committee shall offer recommendations pertaining to information to 
be made available to participating providers concerning prescription 
drugs, medical devices, and other goods and services used in the delivery 
 

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 Crosswalk To Report  Section  Statute 
of health care. Such information may address emerging trends that 
involve utilization of goods and services that, in judgment of the public 
authority, are less than optimally cost effective. The committee shall 
offer recommendations concerning the provision of free samples of 
generic or other prescription drugs to participating providers.  
(g) The committee shall recommend policies and procedures that encourage 
participating providers to furnish and SustiNet Plan members to obtain 
appropriate evidenced‐based health care.  

Preventive Health Care  8  Sec. 8.  (NEW) (Effective July 1, 2009)  

Advisory Committee 
(a)  The board of directors shall establish a preventive health care advisory 
Recommendations 
committee that shall use evolving medical research to draft 
  recommendations to improve health outcomes for members in areas 
involving nutrition, sleep, physical exercise, and the prevention and 
cessation of the use of tobacco and other addictive substances. The 
committee shall include providers, consumers and other individuals 
chosen by said board. Such recommendations may be targeted to 
member populations where they are most likely to have a beneficial 
impact on the health of such members and may include behavioral 
components and financial incentives for participants. Such 
recommendations shall take into account existing preventive care 
programs administered by the state, including, but not limited to, state 
administered educational and awareness campaigns. Not later than July 
1, 2010, and annually thereafter, the preventive health care advisory 
committee shall submit such recommendations to the board of directors. 
(b) The board of directors shall recommend that the SustiNet Plan provide 
coverage for community‐based preventive care services and such services 
be required of all health insurance sold pursuant to the plan to individuals 
or employers. Community‐based preventive care services are those 
services identified by the board as capable of being safely administered in 
community settings. Such services shall include, but not be limited to, 
immunizations, simple tests and health care screenings. Such services 
shall be provided by individuals or entities who satisfy board of director 
approved standards for quality of care. The board of directors shall 
recommend that: (1) Prior to furnishing a community‐based preventive 
care service, a provider obtain information from a patient's electronic 
health record to verify that the service has not been provided in the past 
and that such services are not contraindicated for the patient; and (2) a 
provider promptly furnish relevant information about the service and the 
results of any test or screening to the patient's medical home or the 
patient's primary care provider if the patient does not have a medical 
home. The board of directors shall recommend that community‐based 
preventive services be allowed to be provided at job sites, schools or 
other community locations consistent with said board's guidelines.  
 

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 Crosswalk To Report  Section  Statute 
  9  Sec. 9.  (NEW) (Effective July 1, 2009)  

Policy‐Making Duties and  (a) The board of directors may develop recommendations that ensure that 

Responsibilities  on and after July 1, 2012, nonstate public employers are offered the 
benefits of the SustiNet Plan. The board of directors may develop 
  recommendations that permit the Comptroller to offer the benefits of the 
  SustiNet Plan to state employees, retirees and their dependents. No 
changes in health care benefits shall be implemented with regard to plans 
  administered under the provisions of subsection (a) of section 5‐259 of 
  the general statutes unless such changes are negotiated and agreed to by 
the state and the coalition committee established pursuant to subsection 
  (f) of section 5‐278 of the general statutes, through the collective 
bargaining process.  
 
(b) The board of directors shall develop recommendations that ensure that 
Policy‐Making Duties and  on and after July 1, 2012, employees of nonprofit organizations and small 
Responsibilities  businesses are offered the benefits of the SustiNet Plan. 
Expanding Medicaid  (c) The board of directors shall develop recommendations to ensure that the 
Coverage and Access to  HUSKY Plan Part A and Part B, Medicaid, and state‐administered general 
Care  assistance programs participate in the SustiNet Plan. Such 
  recommendations shall also ensure that HUSKY Plan Part A and Part B 
benefits are extended, to the extent permitted by federal law, to adults 
  with income at or below three hundred per cent of the federal poverty 
level. 
 
(d) The board of directors shall make recommendations to ensure that on 
Policy‐Making Duties and  and after July 1, 2012, state residents who are not offered employer‐
Responsibilities  sponsored insurance and who do not qualify for HUSKY Plan Part A and 
  Part B, Medicaid, or state‐administered general assistance are permitted 
to enroll in the SustiNet Plan. Such recommendations shall ensure that 
  premium variation based on member characteristics does not exceed in 
  total amount or in consideration of individual health risk, the variation 
permitted for a small employer carrier, as defined in subdivision (16) of 
  section 38a‐564 of the general statutes. 
Policy‐Making Duties and  (e) The board of directors shall make recommendations to provide an option 
Responsibilities  for enrollment into the SustiNet Plan, rather than employer‐sponsored 
insurance, for certain state residents who are offered employer‐
  sponsored insurance but who have a household income at or below four 
  hundred per cent of the federal poverty level. Said board may make 
recommendations for the establishment of (1) an enrollment procedure 
  for those individuals who demonstrate eligibility to enroll in the SustiNet 
Plan pursuant to this subsection; and (2) a method for the collection of 
 
payments from employers, whose employees would have received 
  employer‐sponsored insurance, but instead enroll in the SustiNet Plan in 
accordance with the provisions of this subsection. 
 
 

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 Crosswalk To Report  Section  Statute 
  10  Sec. 10.(NEW) (Effective July 1, 2009)  
 
Definition  (a) As used in this section "adverse selection" means purchase of SustiNet 
  Plan coverage by employers with unusually high‐cost employees and 
  dependents under circumstances where premium payments do not fully 
  cover the probable claims costs of the employer's members. 
  (b) The board of directors shall offer recommendations concerning:  
 
Administrative Duties  (1) The use of new and existing channels of sale to employers, including 
  public and private purchasing pools, agents and brokers;  
  (2) the offering of multi‐year contracts to employers with predictable 
Administrative Duties  premiums;   
 
  (3) policies and procedures to be established that ensure that employers 
Administrative Duties  can easily and conveniently purchase SustiNet Plan coverage for their 
  workers and dependents, including, but not limited to, participation 
  requirements, timing of enrollment, open enrollment, enrollment length 
  and other subject matters as deemed appropriate by said board;  
Policy‐Making Duties and  (4) policies and procedures to be established that prevent adverse 
Responsibilities  selection and achieve other goals specified by the board;  
 
Covered Populations;  (5) the availability of SustiNet Plan coverage for small employers on and 
Policy‐Making Duties and  after July 1, 2012, with premiums based on member characteristics as 
Responsibilities  permitted for small employer carriers, as defined in subdivision (16) of 
  section 38a‐564 of the general statutes;  
Covered Populations;  (6) the availability of SustiNet Plan coverage for employers who are not 
Policy‐Making Duties and  small employers with premiums charged to such employers to prevent 
Responsibilities  adverse selection, taking into account past claims experience, changes in 
  the characteristics of covered employees and dependents since the most 
  recent time period covered by claims data, and other factors approved by 
  the board of directors; and  
 
Benefits   (7) the availability of a standard benefits package to employers 
purchasing coverage under this section, provided no such benefit package 
provide less comprehensive coverage than that described in the model 
benefits packages adopted pursuant to section 12 of this act. 
  11  Sec. 11.(NEW) (Effective July 1, 2009)  
 
Responsibility of the Office  (a) As used in this section, "clearinghouse" means an independent 
of the Health Care  information clearinghouse recommended by the board of directors that 
Advocate  is: (1) Established and overseen by the Office of the Healthcare Advocate; 
  (2) operated by an independent research organization that contracts with 
  the Office of the Healthcare Advocate; and (3) responsible for providing 
  employers, individual purchasers of health coverage, and the general 
  public with comprehensive information about the care covered by the 
  SustiNet Plan and by private health plans licensed in the state of 
  Connecticut. 
 

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(b) The clearinghouse shall develop specifications for data that show for each 
 
health plan, quality of care, outcomes for particular health conditions, 
access to care, utilization of services, adequacy of provider networks, 
patient satisfaction, rates of disenrollment, grievances and complaints, 
and any other factors the Office of the Healthcare Advocate determines 
relevant to assessing health plan performance and value. In developing 
such specifications, the Office of the Healthcare Advocate shall consult 
with private insurers and with the board of directors. 
(c) The board of directors shall recommend that the following entities shall 
provide data to the clearinghouse in a time and manner as prescribed by 
the Office of the Healthcare Advocate: (1) The SustiNet Plan; (2) health 
insurers, as a condition of licensure; and (3) any self‐insured group plan 
that volunteers to provide data. Dissemination of any information 
provided by a self‐insured group plan shall be limited and in conformity 
with a written agreement governing such dissemination as developed and 
approved by the group plan and the Office of the Healthcare Advocate. 
(d) Except as provided for in subsection (c) of this section, the clearinghouse 
shall make public all information provided pursuant to subsection (b) of 
this section. The clearinghouse shall not disseminate any information that 
identifies individual patients or providers. The clearinghouse shall adjust 
outcomes based on patient risk levels, to the maximum extent possible. 
The clearinghouse shall make information available in multiple forms and 
languages, taking into account varying needs for the information and 
different methods of processing such information. 
(e) The clearinghouse shall collect data based on each plan's provision of 
services over continuous twelve‐month periods. Except as provided in 
subsection (c) of this section, the clearinghouse shall make public all 
information required by this section no later than August 1, 2013, with 
updated information provided each August first thereafter. 

  12  Sec. 12.(NEW) (Effective July 1, 2009)  

Responsibility of the Office  (a) Within available appropriations, the Office of the Healthcare Advocate 

of the Health Care  shall develop and update the model benefit packages, based on evolving 
Advocate  medical evidence and scientific literature, that make the greatest possible 
contribution to member health for a premium cost typical of private, 
  employer sponsored insurance in the Northeast states. Not later than 
December 1, 2010, and biennially thereafter, the Office of the Healthcare 
Advocate shall report to the board of directors on the updated model 
benefit packages. 
(b) After the promulgation of the model benefit packages, as provided in 
subsection (a) of this section, the board of directors may modify the 
standard benefits package if said board determines that: (1) Such 
modification would yield better outcomes for an equivalent expenditure 
of funds; or (2) providing additional coverage or reduced cost sharing for 
particular services as provided to particular member populations may 
 

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reduce net costs or provide sufficient improvements to health outcomes 
to warrant the resulting increase in net costs. Any such modification of 
the standard benefits package by the board shall ensure compliance with 
the coverage mandates described in chapter 700c of the general statutes 
and the utilization review requirements described in chapter 698a of the 
general statutes. 
(c) The Office of the Healthcare Advocate shall recommend guidelines for 
establishing an incentive system that recognizes employers who provide 
employees with health insurance benefits that are equal to or more 
comprehensive than the model benefit packages. Such incentives may 
include public recognition of employers who offer such comprehensive 
benefits. Not later than December 1, 2012, the Office of the Healthcare 
Advocate shall report, in accordance with section 11‐4a of the general 
statutes, on such guidelines and recommendations to the board of 
directors, the Governor and the joint standing committees of the General 
Assembly having cognizance of matters relating to public health, labor 
and public employees, and appropriations and the budgets of state 
agencies. 
 

  13  Sec. 13.(NEW) (Effective July 1, 2011)  

Policy‐Making Duties and  (a) The board of directors shall develop recommendations for public 

Responsibilities  education and outreach campaigns to ensure that state residents are 
informed about the SustiNet Plan and are encouraged to enroll in the 
plan. 
(b) The public education and outreach campaign shall utilize community‐
based organizations and shall include a focus on targeting populations 
that are underserved by the health care delivery system. 
(c) The public education and outreach campaign shall be based on evidence 
of the cost and effectiveness of similar efforts in this state and elsewhere. 
Such campaign shall incorporate an ongoing evaluation of its 
effectiveness, with corresponding changes in strategy, as needed. 

  14  Sec. 14.(NEW) (Effective July 1, 2011) The board of directors, in collaboration 
with state and municipal agencies, shall, within available appropriations, 
Policy‐Making Duties and  develop and implement systematic recommendations to identify uninsured 
Responsibilities  individuals in the state. Such recommendations may include that: 

(1) The Department of Revenue Services modify state income tax forms to 
request that a taxpayer identify existing health coverage for each 
member of the taxpayer's household. 
(2) The Labor Department modify application forms for initial and continuing 
claims for unemployment insurance to request information about health 
insurance status for the applicant and the applicant's dependents. 
(3) Hospitals, community health centers and other providers as determined 
by the board of directors shall: (A) Identify the health insurance status of 
 

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individuals who seek health care, and (B) convey such information, via 
secure electronic mail transmission, to said board to facilitate the 
potential enrollment of such individuals into health insurance coverage.  
 

  15  Sec. 15.Section 17b‐297b of the general statutes is repealed and the following 
is substituted in lieu thereof (Effective July 1, 2011):  
Responsibilities of 
Departments of Social  (a) To the extent permitted by federal law, the Commissioners of Social 
Services and Education  Services and Education, in consultation with the board of directors, shall 
jointly establish procedures for the sharing of information contained in 
applications for free and reduced price meals under the National School 
Lunch Program for the purpose of determining whether children 
participating in said program are eligible for coverage under the SustiNet 
Plan or the HUSKY Plan, Part A and Part B. The Commissioner of Social 
Services shall take all actions necessary to ensure that children identified 
as eligible for [either] the SustiNet Plan, or the HUSKY Plan, Part A or Part 
B, are enrolled in the appropriate plan. 
(b) The Commissioner of Education shall establish procedures whereby an 
individual may apply for the SustiNet Plan or the HUSKY Plan, Part A or 
Part B, at the same time such individual applies for the National School 
Lunch Program.  

  16  Sec. 16.(Effective from passage)  

Childhood and Adult  (a) There is established a task force to study childhood and adult obesity. 

Obesity Task Force  The task force shall examine evidence‐based strategies for preventing 
Recommendations  and reducing obesity in children and adults and develop a comprehensive 
plan that will effectuate a reduction in obesity among children and 
adults. 
(b) The task force shall consist of the following members: 
(1) One appointed by the speaker of the House of Representatives, who 
shall represent a consumer group with expertise in childhood and 
adult obesity;  
(2) One appointed by the president pro tempore of the Senate, who 
shall be an academic expert in childhood and adult obesity; 
(3) One appointed by the majority leader of the House of 
Representatives, who shall be a representative of the business 
community with expertise in childhood and adult obesity; 
(4) One appointed by the majority leader of the Senate, who shall be a 
health care practitioner with expertise in childhood and adult 
obesity; 
(5) One appointed by the minority leader of the House of 
Representatives, who shall be a representative of the business 
community with expertise in childhood and adult obesity;  

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(6) One appointed by the minority leader of the Senate, who shall be a 
health care practitioner with expertise in childhood and adult 
obesity;  
(7) One appointed by the Governor who shall be an academic expert in 
childhood and adult obesity; and 
(8) The Commissioners of Public Health, Social Services and Economic 
and Community Development and a representative of the SustiNet 
board of directors shall be ex‐officio nonvoting members of the task 
force. 
(c) Any member of the task force appointed under subdivision (1), (2), (3), 
(4), (5) or (6) of subsection (b) of this section may be a member of the 
General Assembly.  
(d) All appointments to the task force shall be made no later than thirty days 
after the effective date of this section. Any vacancy shall be filled by the 
appointing authority. 
(e) The members of the task force appointed by the speaker of the House of 
Representatives and the president pro tempore of the Senate shall serve 
as the chairpersons of the task force. Such chairpersons shall schedule 
the first meeting of the task force, which shall be held no later than thirty 
days after the effective date of this section. 
(f) The administrative staff of the joint standing committee of the General 
Assembly having cognizance of matters relating to public health shall 
serve as administrative staff of the task force.  
(g) Not later than July 1, 2010, the task force shall submit a report on its 
findings and recommendations to the board of directors and the joint 
standing committee of the General Assembly having cognizance of 
matters relating to public health, human services and appropriations and 
the budgets of state agencies in accordance with the provisions of 
section 11‐4a of the general statutes. The task force shall terminate on 
the date that it submits such report or January 1, 2011, whichever is 
later.  

  17  Sec. 17.(Effective from passage) 

Tobacco and Smoking  (a) There is established a task force to study tobacco use by children and 

Cessation Task Force  adults. The task force shall examine evidence‐based strategies for 
Recommendations  preventing and reducing tobacco use by children and adults, and then 
develop a comprehensive plan that will effectuate a reduction in tobacco 
use by children and adults.  
(b) The task force shall consist of the following members: 
(1) One appointed by the speaker of the House of Representatives, who 
shall represent a consumer group with expertise in tobacco use by 
children and adults;  
(2) One appointed by the president pro tempore of the Senate, who 

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 Crosswalk To Report  Section  Statute 
shall be an academic expert in tobacco use by children and adults;  
(3) One appointed by the majority leader of the House of 
Representatives, who shall be a representative of the business 
community with expertise in tobacco use by children and adults; 
(4) One appointed by the majority leader of the Senate, who shall be a 
health care practitioner with expertise in tobacco use by children and 
adults;  
(5) One appointed by the minority leader of the House of 
Representatives, who shall be representative of the business 
community with expertise in tobacco use by children and adults; 
(6) One appointed by the minority leader of the Senate, who shall be a 
health care practitioner with expertise in tobacco use by children and 
adults; 
(7) One appointed by the Governor who shall be an academic expert in 
tobacco use by children and adults; and 
(8) The Commissioners of Public Health, Social Services and Economic 
and Community Development and a representative of the SustiNet 
board of directors shall be ex‐officio, nonvoting members of the task 
force. 
(c) Any member of the task force appointed under subdivision (1), (2), (3), 
(4), (5) or (6) of subsection (b) of this section may be a member of the 
General Assembly.  
(d) All appointments to the task force shall be made no later than thirty days 
after the effective date of this section. Any vacancy shall be filled by the 
appointing authority. 
(e) The members of the task force appointed by the speaker of the House of 
Representatives and the president pro tempore of the Senate shall serve 
as the chairpersons of the task force. Such chairpersons shall schedule 
the first meeting of the task force, which shall be held no later than thirty 
days after the effective date of this section. 
(f) The administrative staff of the joint standing committee of the General 
Assembly having cognizance of matters relating to public health shall 
serve as administrative staff of the task force. 
(g) Not later than July 1, 2010, the task force shall submit a report on its 
findings and recommendations to the board of directors and the joint 
standing committee of the General Assembly having cognizance of 
matters relating to public health, human services and appropriations and 
the budgets of state agencies in accordance with the provisions of section 
11‐4a of the general statutes. The task force shall terminate on the date 
that it submits such report or January 1, 2011, whichever is later.  

  18  Sec. 18.(Effective from passage)  

Health Care Workforce  (a) There is established a task force to study the state's health care 

 

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Task Force  workforce. The task force shall develop a comprehensive plan for 
Recommendations  preventing and remedying state‐wide, regional and local shortage of 
necessary medical personnel, including, physicians, nurses and allied 
health professionals.  
(b) The task force shall consist of the following members: 
(1) One appointed by the speaker of the House of Representatives, who 
shall represent a consumer group with expertise in health care; 
(2) One appointed by the president pro tempore of the Senate, who 
shall be an academic expert on the health care workforce;  
(3) One appointed by the majority leader of the House of 
Representatives, who shall be a representative of the business 
community with expertise in health care;  
(4) One appointed by the majority leader of the Senate, who shall be a 
health care practitioner; 
(5) One appointed by the minority leader of the House of 
Representatives, who shall be a representative of the business 
community with expertise in health care; 
(6) One appointed by the minority leader of the Senate, who shall be a 
primary care physician; 
(7) One appointed by the Governor who shall be an academic expert in 
health care; and  
(8) The Commissioners of Public Health, Social Services and Economic 
and Community Development, the president of The University of 
Connecticut, the chancellor of the Connecticut State University 
System, the chancellor of the Regional Community‐Technical 
Colleges, and a representative of the SustiNet board of directors 
shall be ex‐officio, nonvoting members of the task force.  
(c) Any member of the task force appointed under subdivision (1), (2), (3), 
(4), (5) or (6) of subsection (b) of this section may be a member of the 
General Assembly. 
(d) All appointments to the task force shall be made no later than thirty days 
after the effective date of this section. Any vacancy shall be filled by the 
appointing authority. 
(e) The members of the task force appointed by the speaker of the House of 
Representatives and the president pro tempore of the Senate shall serve 
as the chairpersons of the task force.  Such chairpersons shall schedule 
the first meeting of the task force, which shall be held no later than thirty 
days after the effective date of this section.  
(f) The administrative staff of the joint standing committee of the General 
Assembly having cognizance of matters relating to public health shall 
serve as administrative staff of the task force. 
(g) Not later than July 1, 2010, the task force shall submit a report on its 
 

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findings and recommendations to the board of directors and the joint 
standing committee of the General Assembly having cognizance of 
matters relating to public health, human services and appropriations and 
the budgets of state agencies in accordance with the provisions of 
section 11‐4a of the general statutes. The task force shall terminate on 
the date that it submits such report or January 1, 2011, whichever is 
later.  

No reporting required  19  Sec. 19. (NEW) (Effective July 1, 2009) Any individual who serves on the 

SustiNet Health Partnership board of directors shall be subject to the 
provisions of section 1‐83 of the general statutes concerning the filing of 
a statement of financial interests.   

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