03/26/2019 03:00 PM House HEALTH & SOCIAL SERVICES

            HB 29-INSURANCE COVERAGE FOR TELEHEALTH                                                                         
                                                                                                                                
3:57:51 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  ZULKOSKY  announced that  the  next  order of  business                                                               
would  be  HOUSE BILL  NO.  29,  "An  Act relating  to  insurance                                                               
coverage for benefits provided  through telehealth; and providing                                                               
for an effective date."                                                                                                         
                                                                                                                                
3:58:30 PM                                                                                                                    
                                                                                                                                
The committee took an at-ease from 3:58 p.m. to 4:00 p.m.                                                                       
                                                                                                                                
4:00:11 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ introduced  HB 29 as the  sponsor of the                                                               
bill, stating that this bill  increased access to and reduced the                                                               
cost of health care by  requiring insurers to reimburse providers                                                               
for delivering  health care services  via telehealth.   She added                                                               
that telehealth was already covered  and provided for by Medicaid                                                               
and the Indian  Health Services.  She pointed out  that it was so                                                               
effective  in these  markets that  it  should be  covered in  its                                                               
entirety in the  private market as it increased  access to health                                                               
care  in Rural  Alaska.   She shared  a PowerPoint  titled "House                                                               
Bill  29  Insurance  Coverage  for  Telehealth."    She  directed                                                               
attention to  slide 2, "Telehealth:  Why is this  important?" and                                                               
pointed  out that  it would  reduce the  cost of  health care  by                                                               
reducing travel  expenses.  She  said that  it could be  used for                                                               
primary, specialty, and  behavioral health care.   She noted that                                                               
this also supported necessary  innovations and transformations in                                                               
health care.   She pointed  out that this could  reduce emergency                                                               
room visits.   She added that the state plan  did not provide for                                                               
tele-health.                                                                                                                    
                                                                                                                                
4:03:37 PM                                                                                                                    
                                                                                                                                
BERNICE   NISBETT,    Staff,   Representative    Ivy   Spohnholz,                                                               
paraphrased from  the Sectional  Analysis to  HB 29  [Included in                                                               
members' packets], which read:                                                                                                  
                                                                                                                                
     Section 1.                                                                                                             
     AS  21.42.422 has  been  amended  to require  insurance                                                                    
     coverage   for   health   benefits   provided   through                                                                    
     telehealth technology.                                                                                                     
                                                                                                                                
     Section 2.                                                                                                             
     AS 21.42.422  is a new  subsection that  defines health                                                                    
     care insurer  as a person  transacting the  business of                                                                    
     health   care  insurance   except   for  a   nonfederal                                                                    
     governmental  plan.  It  also adds  the  definition  of                                                                    
     telehealth  under  47.05.270(e)   as  the  practice  of                                                                    
     health    care    delivery,   evaluation,    diagnosis,                                                                    
     consultation,  or  treatment,  using  the  transfer  of                                                                    
     health  care  data  through   audio,  visual,  or  data                                                                    
     communications,  performed over  two or  more locations                                                                    
     between  providers who  are  physically separated  from                                                                    
     the recipient or from each  other or between a provider                                                                    
     and a recipient who  are physically separated from each                                                                    
     other.                                                                                                                     
                                                                                                                                
     Section 3                                                                                                              
     The  changes  to Section  1  of  this bill  applies  to                                                                    
     health care  insurance plans that are  offered, issued,                                                                    
     delivered, or renewed on or after the effective date.                                                                      
                                                                                                                                
     Section 4                                                                                                              
     The effective date is July 1, 2020.                                                                                        
                                                                                                                                
4:05:21 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE CLAMAN asked if  Department of Commerce, Community                                                               
& Economic Development and the  administration were in support of                                                               
the proposed bill.                                                                                                              
                                                                                                                                
4:05:43 PM                                                                                                                    
                                                                                                                                
LORI WING-HEIER, Director, Juneau  Office, Division of Insurance,                                                               
Department  of Commerce,  Community  &  Economic Development,  in                                                               
response  to  Representative  Claman,  said  that  Department  of                                                               
Commerce,  Community  & Economic  Development  was  very much  in                                                               
support of anything that would  provide access to health care yet                                                               
lower  the cost  at the  same time.   She  acknowledged that  the                                                               
department was in support of the proposed bill.                                                                                 
                                                                                                                                
4:06:05 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE PRUITT asked if it was possible to mandate this.                                                                 
                                                                                                                                
MS. WING-HEIER reported that the  Division of Insurance estimated                                                               
that insured  plans, which the division  regulated, covered about                                                               
15 percent of Alaskans.                                                                                                         
                                                                                                                                
REPRESENTATIVE PRUITT asked why there  was a need to mandate this                                                               
to the insurance companies, as it offered a cost savings.                                                                       
                                                                                                                                
MS. WING-HEIER replied  that this would increase  access to Rural                                                               
Alaska, especially  for specialties and would  reduce the overall                                                               
costs if  it could address  common things and eliminate  the need                                                               
to  visit  the provider.    She  reported  that there  were  data                                                               
projections   for   virtual   hospitals  in   the   future   with                                                               
recuperation  at home,  although there  were not  any numbers  to                                                               
support  this.   In  response  to the  need  for  a mandate,  she                                                               
reported  that   any  conversation  for  new   services  prompted                                                               
discussions  and  sometimes it  was  necessary  to push  for  the                                                               
offering of newer products or services.                                                                                         
                                                                                                                                
REPRESENTATIVE PRUITT  asked about the options.   He acknowledged                                                               
that, although  Moda Health  had submitted  a letter  of support,                                                               
they would  not be required to  provide this with their  plan for                                                               
the state.   He  questioned whether there  would be  support from                                                               
the  providers who  would be  required to  offer telehealth.   He                                                               
shared  his  difficulty  for  understanding  why  a  cost  saving                                                               
measure would need to be mandated.                                                                                              
                                                                                                                                
MS.  WING-HEIER  explained  that  previous  attempts  to  deliver                                                               
telehealth had not  been provided by all  insurance providers and                                                               
that this mandate would ensure parity.                                                                                          
                                                                                                                                
REPRESENTATIVE  PRUITT  asked  how to  prevent  individuals  from                                                               
recruiting the  use of telehealth  services without  allowing for                                                               
the  best  interests  of  the   patient.    He  opined  that  the                                                               
introduction of  money through  a mandate  brought with  it those                                                               
who would take advantage.                                                                                                       
                                                                                                                                
4:10:51 PM                                                                                                                    
                                                                                                                                
MS.  WING-HEIER expressed  agreement that  there were  bad actors                                                               
making  "big dollars  out of  it" and  this included  doctors and                                                               
insurance agents.   She stated that  it was necessary to  use due                                                               
diligence  and  take  the necessary  actions  against  those  bad                                                               
players.                                                                                                                        
                                                                                                                                
REPRESENTATIVE PRUITT asked  how to ensure that  her division had                                                               
the  tools to  "take  action as  needed if  there  are those  bad                                                               
players that  come up."   He asked if  it would be  necessary for                                                               
statute changes  to allow the  authority to pursue  these people,                                                               
some of whom may not even be in the state.                                                                                      
                                                                                                                                
MS. WING-HEIER  reported that the  agency had  four investigators                                                               
and she declared  they were "a critical part of  us being able to                                                               
look at people that  are the bad actors in the  state.  When they                                                               
cross  state lines,  we end  up  working with  the U.S.  Attorney                                                               
General or with the FBI, and  that's not uncommon."  She declared                                                               
that these federal agencies "actually have the jurisdiction."                                                                   
                                                                                                                                
4:13:29 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE JACKSON asked if this  would cover all Alaskans or                                                               
just  those through  certain health  care  facilities or  certain                                                               
insurance companies.                                                                                                            
                                                                                                                                
REPRESENTATIVE SPOHNHOLZ replied that  the intent of the proposed                                                               
bill was to ensure that  insurers operating in the private market                                                               
be  required to  cover telehealth  services.   She reported  that                                                               
telehealth services  were already  authorized and paid  for under                                                               
Medicaid, as  well as  tribal health.   This proposed  bill would                                                               
expand  the market  for  access to  telehealth  into the  private                                                               
market.  She  stated that self-insured plans  which were governed                                                               
by  federal law,  including the  insurance plan  by the  State of                                                               
Alaska, could not be included in state law.                                                                                     
                                                                                                                                
MS. WING-HEIER said that the State  of Alaska had adopted a tele-                                                               
doc option in its retirement and benefit plan.                                                                                  
                                                                                                                                
REPRESENTATIVE  JACKSON declared  that  this  was beneficial  and                                                               
saved a lot of  time, travel, and money.  She  asked that this be                                                               
shared with our federal delegation.                                                                                             
                                                                                                                                
REPRESENTATIVE  SPOHNHOLZ expressed  her intention  to coordinate                                                               
with the  federal delegation.   She expressed agreement  that the                                                               
state  plan  now allowed  tele-doc,  which  she described  as  "a                                                               
virtual form of an urgent care,"  although this was not quite the                                                               
complete service that she supported for lasting relationships.                                                                  
                                                                                                                                
4:17:28 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE CLAMAN asked about the tele-doc coverage.                                                                        
                                                                                                                                
REPRESENTATIVE   SPOHNHOLZ,  in   response,  explained   that  it                                                               
depended on the provider.  She  said that Aetna had a requirement                                                               
that providers  go through a  process to  determine participation                                                               
in telehealth.                                                                                                                  
                                                                                                                                
REPRESENTATIVE  CLAMAN  said  that   it  was  available  if  they                                                               
followed the steps.   He noted that there was  a zero fiscal note                                                               
and asked if  there would be additional costs  due to enforcement                                                               
authority.                                                                                                                      
                                                                                                                                
MS. WING-HEIER  replied that  it was not  expected to  change the                                                               
workload.                                                                                                                       
                                                                                                                                
4:19:54 PM                                                                                                                    
                                                                                                                                
VICTORIA   KNAPP,  Chief   Operations   Officer,  Mat-Su   Health                                                               
Services, Inc., stated that they  relied on telehealth to provide                                                               
specialty  psychiatric  services   for  individuals  with  mental                                                               
health  issues.   She noted  that there  were "huge  shortages of                                                               
psychiatric  providers in  the State  of Alaska."   She  reported                                                               
that they had  providers both in-state and  out-of-state who were                                                               
licensed in the  State of Alaska.  She declared  that they were a                                                               
safety net provider  and had gone to  telehealth services several                                                               
years prior due to a  shortage of available in-person psychiatric                                                               
providers.  She added  that, as they did not want  to have a wait                                                               
list  for   psychiatric  services,   they  moved   to  telehealth                                                               
services.   She  noted that,  on those  occasions when  a private                                                               
health  plan did  not cover  these services,  the patient  had to                                                               
decide whether to  make out of pocket payment or  not receive the                                                               
services.  She expressed a desire  for everyone to be covered for                                                               
telehealth.                                                                                                                     
                                                                                                                                
4:21:54 PM                                                                                                                    
                                                                                                                                
AROM EVANS,  MD, Orion Behavioral  Health Network, said  that his                                                               
organization  primarily   provided  services  for   children  and                                                               
adolescents.   He  said  there  was a  need  for medical  service                                                               
providers for children,  and that many of them were  out of state                                                               
and could  only be  accessed through telehealth.   He  stated his                                                               
support for  HB 29.  He  said that tele-doc was  an important and                                                               
useful  service but  that it  was a  very different  service than                                                               
telehealth.   With tele-doc, as  it was an on-demand  service and                                                               
you could not schedule a  follow-up appointment, you may not have                                                               
the same provider.                                                                                                              
                                                                                                                                
4:23:48 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  asked whether,  since with  telehealth there                                                               
were no in-person meetings, there was  a potential to not build a                                                               
strong relationship that would make the care as effective.                                                                      
                                                                                                                                
DR. EVANS said  they used a hybrid model as  they maintained four                                                               
physical clinics  around the  state.   He acknowledged  that many                                                               
patients  and family  members needed  that  reassurance and  they                                                               
treated this on a case by case basis.                                                                                           
                                                                                                                                
4:26:02 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JACKSON  asked  about  genetic  work-ups  through                                                               
telehealth.                                                                                                                     
                                                                                                                                
DR.  EVANS   explained  that  genetic  work-ups   were  conducted                                                               
primarily  in  the  laboratory,  as  they  reviewed  symptoms  to                                                               
determine  the necessary  tests,  and these  work-ups included  a                                                               
physical exam that could be provided by a local doctor.                                                                         
                                                                                                                                
4:27:09 PM                                                                                                                    
                                                                                                                                
ROBERT BARATTA,  National Consultant, Teladoc  Health, referenced                                                               
the earlier discussion for fraud  and abuse, and pointed out that                                                               
prior  to  access  of  the  service, there  had  to  be  a  valid                                                               
physician  - patient  relationship established.   He  pointed out                                                               
that Alaska  had such a  statute as  well as guidelines  from the                                                               
State Board  of Medicine, for  the way this relationship  must be                                                               
established.  For  reimbursement, the service had  to be provided                                                               
in accordance with that valid  relationship.  He pointed out that                                                               
most insurance plans  had the authority to make sure  that it was                                                               
medically necessary.                                                                                                            
                                                                                                                                
REPRESENTATIVE  JACKSON   asked  about  the   difference  between                                                               
charges from a tele-doc and an office visit.                                                                                    
                                                                                                                                
MR.  BARATTA explained  that there  was a  tele-medicine platform                                                               
which  a  patient  could  access through  their  computer  for  a                                                               
virtual  visit  with  a  physician.   He  said  it  mimicked  the                                                               
experience  of a  visit to  an Urgent  Care center  with a  board                                                               
certified and Alaska licensed physician.                                                                                        
                                                                                                                                
4:30:02 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY opened public testimony.                                                                                      
                                                                                                                                
4:30:24 PM                                                                                                                    
                                                                                                                                
CYNTHIA MARK, Teladoc Health, emphasized  that it was possible to                                                               
establish  an  on-going  relationship  with  an  Alaska  provider                                                               
through telehealth and  to see that same provider  on an on-going                                                               
basis.   She stated support for  HB 29, pointing out  that it was                                                               
good policy and good legislation.                                                                                               
                                                                                                                                
4:32:02 PM                                                                                                                    
                                                                                                                                
CHRISTOPHER   DIETRICH,   Assistant   Medical   Director,   Orion                                                               
Behavioral  Health Network,  stated his  support for  HB 29.   He                                                               
offered  an  example  of  a patient  released  from  API  (Alaska                                                               
Psychiatric Institute) who moved to  Rural Alaska, and the option                                                               
for telehealth.                                                                                                                 
                                                                                                                                
4:33:44 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY closed public testimony.                                                                                      
                                                                                                                                
[HB 29 was held over.]