Health center advocacy group launches legal action over ‘inadequate’ Medicaid reimbursement

NORTH CANAAN — The new federally qualified health center in North Canaan has treated more than 1,000 patients since opening its doors last summer to strong demand in the Northwest Corner. However, operators of that facility, and others like it in Connecticut, said they are facing a “serious financial crisis” because Medicaid reimbursements have failed for decades to cover the actual costs of providing essential services.

In response to the longstanding problem, the not-for-profit Community Health Center Association of Connecticut has filed a Declaratory Ruling Request with the state Department of Social Services regarding that agency’s legal obligations for setting and revising Medicaid reimbursement rates for the state’s federally qualified health centers, also referred to as FQHC’s.

The legal action follows more than 18 months of administrative rate requests and unsuccessful negotiations with DSS, according to a statement issued by the association on March 11, which noted:

“After great effort made by the FQHC’s to work with DSS and reach resolution, the offer made by DSS offers inadequate rate adjustments, failing to address the FQHCs’ financial concerns, and requires them to surrender their due process rights under the law.”

Joanne Borduas, who chairs the association’s board of directors, said DSS’s offer was for “less than reasonable costs and came with unacceptable policy stipulations that we would be made to agree to in order to get the grossly inadequate proposed rate rebasing, which would be paid over a four-year schedule.”

“Our request to DSS was clear,” said Borduas, who also serves as CEO of Community Health and Wellness Center of Greater Torrington which also has centers in North Canaan and Winsted.

“We want DSS to follow the Federal law and compensate us accordingly so we can continue to care for our most vulnerable populations, and we need that to happen now because our 440,000 patients, 264,000 of whom are enrolled in Medicaid across our FQHC network, need us.”

Borduas noted that the decision to move forward comes after years of CHC/ACT and health centers making “good faith efforts” to get this important process changed to comply with federal law.

She said the financial strain on the state’s health centers has reached a point where vital services are at severe risk, including those under the umbrella of Community Health and Wellness Center.

“As of now we continue to operate without additional cuts or layoffs, however, it is difficult to fill vacant positions. It is difficult to recruit in this environment. We need to stay competitive with workforce wages in order to recruit providers, and that is difficult to do.”

She added that “We cannot provide raises for our staff who are extremely valuable, care about our mission and the people we serve and who work hard every day, and we cannot think of expanding services to meet community needs because there is an associated cost.”

In response to Declaratory Ruling Request filed with the state Department of Social services, that agency’s spokesperson, Christine Stuart reported on March 13 that the department acknowledges receipt of the request and “shall be analyzing and responding in due course and in compliance with statutes pertaining to petitions of state agencies for a declaratory ruling.”

DSS 2024 report: state’s method cost effective

In 2024, the Department of Social Services issued a “final report” into the state’s Medicaid program which found the state’s operating methods to be “cost-effective and high-performing, while identifying some areas where further improvements can be made.”

The analysis, which was conducted by Accenture and Manatt at the request of the state, evaluated the current program’s cost efficiency, quality and access, “while also exploring whether other models of operations could be an improvement over the current system, which operates through an administrative services organization model.”

The report found that Connecticut’s program “stands out as a model of cost-efficiency, with per capita spending 14% lower than the average of most northeastern states, and administrative costs significantly lower than managed care states (3.8% vs. 9.4%).”

The DSS “final report” further noted: “It also shows that the state is meeting national benchmarks to provide reliable service delivery while maintaining fiscal responsibility and is performing above the median on approximately 70% of national adult and child quality measures,” and suggests other states “could benefit from reviewing Connecticut’s program as a blueprint to achieve similar results.”

The Community Health Center Association of Connecticut is not convinced.

It maintains that as the state’s health centers begin to “suspend vital services, freeze hiring and deplete their cash reserves,” they have been left with no choice other than to pursue legal remedies. “They are not seeking special treatment, but simply asking DSS to follow the law as written.”

CHWC’s dental services ‘not sustainable’

Speaking to her experience as CEO of Community Health and Wellness Center of Greater Torrington, Borduas explained that adjusted rates for medical and mental health were received by the state Department of Social Services for adding the North Canaan Health Center.

“Medical rates per our 2024 cost per Medicaid patient leaves a $122.48 gap between reimbursement and cost per patient. This difference,” she noted, “is what we lose for every patient enrolled in Medicaid that we care for.”

Behavior health is better compensated, said Borduas, but dental, which was offered at Community Health and Wellness Center’s Torrington and Winsted locations, is compensated $137.15 below 2024 costs and as a result, “CHWC has had to unfortunately suspend our dental services having incurred $350,000 in losses for restorative care in 2024.”

That included services like dentures, bridges, crowns and root canals, and an analysis of full services is in process and will likely yield greater losses, said Borduas. “The low Medicaid reimbursement that applies to 60% of our patients, the large gaps in payments are simply not sustainable.”

440,000 patients served by FQHC’s

Connecticut’s federally qualified health centers provide critical medical, dental and behavioral healthcare to more than 440,000 of the state’s neediest and most marginalized residents.

On average, 60% of patients at the statewide centers have Medicaid coverage, where their care cannot be denied, according to the association.

“The FQHC’s need a rate-setting process that makes sense and follows the law, to ensure that all Connecticut residents, regardless of their income or background, can continue to access the care they need,” added Borduas.

Shawn K. Frick, CEO of the Community Health Care Association of Connecticut, noted that “The Connecticut legislature has been consistently supportive of our work, but our attempts to address this issue through the legislative process have been consistently opposed by the administration.”