Rep. Jillian Gilchrest, D-West Hartford Credit: Hugh McQuaid / CTNewsJunkie

A key state lawmaker said Thursday she opposes the idea of reverting back to a controversial managed care plan for nearly one million Medicaid recipients, setting up a potential showdown between Gov. Ned Lamont and a legislature controlled by his party.

State Rep. Jillian Gilchrest, D-West Hartford, said a move back to so-called “capitated” managed care would limit quality healthcare for the state’s most vulnerable residents.

“It’s not a direction we want to go,” said Gilchrest, who also co-chairs the state’s Council on Medical Assistance Program Oversights, which advises the state on issues related to its Medicaid HUSKY plan.

Then-Gov. Dannel P. Malloy moved the state’s HUSKY and Charter Oak health plans out of so-called “capitated” managed care in 2011 after a variety of concerns, including costs, access to care and control over the programs. It’s a system used by many states to manage healthcare for Medicaid beneficiaries through private managed-care companies.

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Gov. Dannel P. Malloy responds to a question on May 25, 2018. Credit: File photo / CTNewsJunkie

Previously, the state paid the companies to set fees for each beneficiary. Malloy moved Connecticut into a self-insured system in which the state pays medical claims.

CTNewsJunkie reported Wednesday that Lamont is considering moving the state back to capitated managed care.

Lamont spokesperson David Bednarz said the administration owes it to patients and taxpayers to consider changes to the Medicaid program. He said Lamont would seek input from lawmakers and stakeholders before any changes were made.

“In order to continue providing expansive services, it is our obligation to members, providers, and other taxpayers to periodically review the Medicaid program to identify potential efficiencies,” Bednarz said. “We are in the very early stages of conversations about what that review looks like, and in keeping with the governor’s general approach to governing, will seek out the involvement of legislators and stakeholders as we work through this.”

Capitated managed care provides private health insurers an up-front flat fee. The state  contracted with companies before 2012 to manage care for hundreds of thousands of beneficiaries. It now has nearly one million residents in the multi-billion-dollar HUSKY program.

Among the criticisms was that the old system gave managed-care companies an incentive to deny care since they could keep money not spent on patients’ medical needs. Advocates also said there were concerns over a lack of accountability since private insurers and other companies controlled the program, as opposed to the state.

Gilchrest said an example of how a lack of state control has harmed patients is the program that provides non-emergency medical transportation to Medicaid patients. Run by a private company, she said there are on-going problems with patients not being picked up and payments not being made.

“We don’t want the entire (Medicaid) program run this way,” she said.

The current fee-for-service system has reduced denials for service and increased accountability while reducing complexities, patient advocates say. It is administered through the state Department of Social Services.

The question of whether Lamont can unilaterally revert to the previous system could be a matter of debate. Gilchrest said she believes the General Assembly has more than an advisory role in making the decision and that it can pass legislation blocking a change.

Additionally, the oversight council will discuss the issue at its next meeting, she said.

The state is currently undertaking a two-year study of Medicaid rates and needs to find a way to increase its investment in Medicaid, not cut it, Gilchrest said.

Susan Halpin, executive director of the Connecticut Association of Health Plans, said her industry is open to the direction Lamont appears to be considering if there is adequate funding and the complexities of the previous plan were addressed.

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Gov. Ned Lamont and his now former communications director, Adam Joseph, on May 25, 2023. Credit: Hugh McQuaid / File Photo / CTNewsjunkie

Bednarz noted that Lamont “strongly supports the important role that Medicaid plays in providing affordable, quality healthcare to nearly a million people in Connecticut.”

He provided a litany of examples of what he described as initiatives that over the past several years have increased access and improved quality of healthcare, including expanded healthcare for undocumented children and postpartum women and the use of administrative service organizations to focus on care management for high-needs populations.

The administration, Bednarz said, has “maintained higher primary care rates, increased investments in substance use disorder services to address the opioid epidemic, expanded the number of pediatric inpatient psychiatric beds, including a specialized unit for children with autism to address critical needs and expanded the breadth and depth of behavioral health services for children.”

“In addition, efforts are under way to improve transition services for justice-involved individuals, establish a maternity bundle that will include coverage of doulas and lactation consultants, and review of utilization management changes with respect to pharmacy,” Bednarz said.

Lamont’s interest in capitated managed care stems from his experience using the system when he owned a company that provided cable television service to colleges, patient advocates contend. They argue that his employees, for the most part, did not face the medical and financial challenges that Medicaid beneficiaries face.