§ 17b-341 — (Formerly Sec. 17-314a). Self-pay rates regulated. Provider agreement. Rate adjustments. Appeals.

Connecticut § 17b-341

• Jurisdiction: Connecticut
• Title 17b: Social Services
• Ch. 319y: Long-Term Care

Text

(a)(1) As used in this section, “self-pay patient” means a patient who is not receiving state or municipal assistance to pay for the cost of care. (2) The Commissioner of Social Services shall determine annually, after a public hearing, the rates to be charged to self-pay patients in any of the following licensed facilities if the facility does not have a provider agreement with the state to provide services to recipients of benefits obtained through Title XIX of the Social Security Amendments of 1965, except a facility that did not have a provider agreement in effect as of January 1, 1991, or had entered into a limited provider agreement before January 1, 1991: Chronic and convalescent nursing homes, chronic disease hospitals associated with chronic and convalescent nursing homes and rest homes with nursing supervision. Each such facility that does have such a provider agreement, each such facility that did not have a provider agreement in effect as of January 1, 1991, or had entered into a limited provider agreement before January 1, 1991, and each residential care home shall determine its own self-pay rates. Rates determined pursuant to this section shall be effective July 1, 1991, and on July first of each year thereafter through June 30, 1993, and shall be determined for each facility individually, on the basis of payment for the reasonable costs of providing all services. All self-pay patients shall be given notice of a rate increase at least thirty days prior to the effective date of such rate increase. In determining rates to be charged to self-pay patients the commissioner shall: (A) Consider the quality of care provided by each facility, based on information which the Department of Public Health shall provide to the commissioner, and any testimony or information received from other interested parties; and (B) take into account the relevant cost considerations set forth in section 17b-340 and in the regulations adopted in accordance with subsection (a) of section 17b-238 . Such regulations shall include, but not be limited to, the establishment of a formula for allowing profit or an operating surplus, and a fair rate of return on invested capital or equity. Nothing in this section shall authorize the commissioner to set a rate lower than the rate set under section 17b-340 for comparable services. Each facility determining its own self-pay rates shall report such rates to the commissioner upon determination and upon any modification. The commissioner shall document each rate so reported and each rate determined for a facility by the commissioner pursuant to this section. Each facility shall charge any self-pay patient who is insured under a long-term care insurance policy which is precertified pursuant to section 38a-475 a rate which is at least five per cent less than the rate charged other self-pay patients. On and after April 1, 2008, each facility shall charge self-pay patients a per diem rate and not a monthly rate. (b) Any hospital, home or any self-pay patient or his guardian or conservator aggrieved by said commissioner's decision regarding the rates to be charged to self-pay patients may obtain, by written request to said commissioner, a hearing on all items of aggrievement in accordance with sections 4-176e to 4-181a , inclusive, if the request is made not later than ten days after written notice of the decision is provided by said commissioner to such home or hospital. Upon receipt of such notice concerning the rate decision, the home or hospital shall immediately give written notice of said commissioner's decision to any patient affected or his guardian or conservator. (c) In the event of an unforeseen or material change in circumstances such hospital or home may submit an application for a rate increase at any time in a form and manner prescribed by the commissioner by regulations adopted in accordance with subsection (a) of section 17b-238 . All self-pay patients shall be given notice of an application for a rate increase as soon as possible after receipt of such application by the commissioner, but in no case shall such notice be provided less than ten days prior to the effective date of such increase. The commissioner may approve, modify, or deny such rate increase request with or without a public hearing thereon not less than ten nor more than thirty days after receipt of such request. Notice of such decision shall be given immediately to the hospital or home by certified mail and to the public by publication in a newspaper having a circulation in the area affected. If such rate increase request is denied, modified or approved without a public hearing the applicant or any member of the public may request such a hearing not later than thirty days after the date of such decision, in which case the commissioner shall hold a public hearing. Any public hearing provided by this section shall be held not less than ten nor more than thirty days after receipt of the request for a rate increase or the request for a hearing by the applicant or a member of the public. Notice of the hearing shall be given to the hospital or home by certified mail and to the public, by publication in a newspaper having a circulation in the area affected, at least one week prior to such hearing. Such hearing shall be held, at the discretion of the commissioner, in Hartford or in the area served by such hospital or home. The commissioner shall require from such hospital or home such information, data, records, studies and evaluations as he considers necessary to determine the need for such increases in accordance with the regulations adopted pursuant to section 17b-238 . Such proposed increases shall take effect thirty days after such hearing or thirty days after the receipt of any data requested by the commissioner, whichever is later, unless within such period the commissioner denies the requested increase or approves such percentage of the increase as he feels is justified. If no hearing is held or requested the commissioner's decision shall take effect thirty days after the date of such decision. The applicant shall have the burden of proof that an increase is warranted. (d) Any party aggrieved by said commissioner's decision after a hearing conducted pursuant to subsection (b) or (c), may appeal therefrom in accordance with the provisions of section 4-183 , except venue shall be in the judicial district in which the home or hospital is located. Such appeal shall have precedence in respect to order of trial over all other cases except writs of habeas corpus, actions brought by or on behalf of the state, including informations on the relation of private individuals, and appeals from awards or decisions of administrative law judges. (e) The Superior Court, on application of the Commissioner of Social Services or the Attorney General, may enforce any determination made by the commissioner, pursuant to subsection (a), (b), or (c) of this section, by appropriate decree or process, including but not limited to the following: (1) An order requiring a hospital or home to cease and desist from charging a self-pay patient a rate in excess of the allowable rate set pursuant to this section; and (2) an order that the hospital or home refund to a self-pay patient any amount paid in excess of the allowable rate set pursuant to this section. The decree or process shall issue upon proof of the allowable rate established pursuant to this section and proof that a self-pay patient has paid any amount in excess of the allowable rate established pursuant to this section, as required by the hospital or home.

Legislative History

(P.A. 79-182, S. 1, 4; P.A. 80-141; 80-203; 80-483, S. 77, 186; P.A. 88-156, S. 21; 88-317, S. 75, 107; June Sp. Sess. P.A. 91-8, S. 23, 63; P.A. 92-231, S. 1, 10; P.A. 93-262, S. 1, 87; 93-381, S. 9, 39; P.A. 95-257, S. 12, 21, 58; P.A. 97-112, S. 2; P.A. 03-268, S. 9; P.A. 08-30, S. 1; P.A. 10-32, S. 67; P.A. 21-18, S. 1.) History: P.A. 80-141 required consideration of quality of care based on health services department information or on other information or testimony in determination of rates; P.A. 80-203 required thirty-day notice of impending increase to self-pay patients in Subsec. (a), required notification of application for increase to self-pay patients in Subsec. (c) and placed burden of proof that increase is necessary on applicant and added Subsec. (e) re enforcement of orders by court; P.A. 80-483 deleted reference to counties in Subsec. (d) and replaced “workmen's compensation” with “workers' compensation”; P.A. 88-156 substituted chronic and convalescent nursing homes for chronic and convalescent hospitals and added chronic disease hospitals associated with chronic and convalescent nursing homes to list of establishments for which the commissioner sets the rates to be charged to self-pay patients in Subsec. (a); P.A. 88-317 amended reference to Secs. 4-177 to 4-181 in Subsec. (b) to include new sections added to Ch. 54, effective July 1, 1989, and applicable to all agency proceedings commencing on or after that date; June Sp. Sess. P.A. 91-8 amended Subsec. (a) re rate determination and the rate of payment for nursing homes, chronic disease hospitals associated with chronic and convalescent nursing homes, chronic and convalescent hospitals, rest homes, homes for the aged and residential facilities for the care of the mentally retarded added provisions requiring facilities with provider agreements and homes for aged to determine their own self pay rates and to report rates to the commissioner and required commissioner to report rates to the human service committee on December 31, 1992; P.A. 92-231 amended Subsec. (a) by requiring facilities to charge self-pay patients insured under long-term care policies precertified pursuant to Sec. 38a-475 a rate at least 5% less than the rate charged other self-pay patients; P.A. 93-262 authorized substitution of commissioner and department of social services for commissioner and department of income maintenance, effective July 1, 1993; P.A. 93-381 replaced department of health services with department of public health and addiction services, effective July 1, 1993; Sec. 17-314a transferred to Sec. 17b-341 in 1995; P.A. 95-257 replaced Commissioner and Department of Public Health and Addiction Services with Commissioner and Department of Public Health, effective July 1, 1995; P.A. 97-112 replaced “home for the aged” with “residential care home”; P.A. 03-268 amended Subsec. (a) by deleting provision which required commissioner to report facility self-pay rates to human services committee by December 31, 1992; P.A. 08-30 amended Subsec. (a) by moving existing definition of “self-pay patient” to new Subdiv. (1), designating existing provisions as Subdiv. (2) and adding requirement that on and after April 1, 2008, each facility charge self-pay patients a per diem rate and not a monthly rate, effective April 30, 2008; P.A. 10-32 made technical changes in Subsec. (a)(2), effective May 10, 2010; pursuant to P.A. 21-18, “workers' compensation commissioners” was changed editorially by the Revisors to “administrative law judges” in Subsec. (d), effective October 1, 2021.