Legislature(1997 - 1998)
04/01/1998 09:08 AM Senate HES
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
SB 253 - MEDICAL ASS'T FOR CERTAIN DISABLED PERSON
CHAIRMAN WILKEN announced a committee substitute for SB 253 had
been prepared (version E). SENATOR ELLIS moved to adopt the
committee substitute as the working document of the committee.
There being no objection, the motion carried.
CHAIRMAN WILKEN asked whether CSSB 253(HES) was identical to the
House version of the bill.
PATTI SWENSON, legislative aide to Representative Con Bunde, stated
CSSB253(HES) is identical to the House version.
CHAIRMAN WILKEN noted the bill would be presented by Ms. Swenson,
on behalf of Representative Bunde, and Bob Briggs.
Number 045
ROBERT BRIGGS, an attorney with the Disability Law Center, gave the
following testimony on CSSB 253. The Disability Law Center is a
non-profit corporation that represents disabled clients, throughout
the state, on legal matters related to their disabilities. The
Disability Law Center has offices in Fairbanks, Bethel, Anchorage
and Juneau. His primary motivation for working on this subject was
prompted by a client, named Dawn, who was the recipient of a liver
transplant as the result of complications from having systemic
lupus. When Dawn went to work in January after recuperating from
the transplant, she lost all health benefits she received with
public assistance while not working. Because of pre-existing
condition rules, the health insurance she was provided through her
employer would not cover her condition until July of 1998. After
engaging in discussion and litigation with the State over whether
Dawn should be eligible for Medicaid under existing law, the
Disability Law Center decided that DHSS was correct that she was
not eligible. Last fall, the Disability Law Center began to
consider ways to change the law. Dawn no longer needs the benefits
of this bill, but asked Mr. Briggs to continue to work on this
subject to prevent the same problem from happening to other people
like her. Dawn earns $1700 per month gross income; her net income
is $1200 per month. Her regular medical expenses are $1200 per
month, including $900 for immunosuppressant medications. The
Disability Law Center suspects there is a small group of people in
Alaska in a situation similar to Dawn's. A constant refrain of
people within the disability community is that if one is medically
fragile, bridging the gap between being on public welfare roles and
receiving Medicaid and Medicare is difficult to do. Frequently a
disabling condition is life changing and causes one to enter a new
line of work that might be part-time or an entry level job with no
health benefits.
MR. BRIGGS informed committee members that Congress passed the
Balanced Budget Act of 1997 which gives states the option to
provide medicaid on a buy-in basis to low income, disabled workers.
The basic criteria is that the participant's income cannot be
greater than 250 percent of the poverty threshold, and the
participant has to contribute into the system on a sliding fee
scale, to be determined at the discretion of the State. Two bills
exercise this option. SB 253 is the Governor's bill on this
subject; the second bill is HB 459, which Mr. Briggs believes
contains slightly better provisions. CSSB 253 is identical to HB
459 as it passed the House Finance Committee just last week. The
fiscal impact of both bills is modest. In the first year, the
state will spend a total of $2,500 general fund dollars to put 17
people back to work. The expense is modest because of the
projected savings to the general fund from reducing reliance on the
Adult Public Assistance Program.
MR. BRIGGS handed out a document entitled, Summary of Fiscal Impact
of CSHB 459 (FIN) (Medicaid Buy-In Option), and noted page 2
contains a list of the numbers extracted from the four fiscal notes
for HB 459 that pertains to the impact on the general fund. He
explained the State will realize a $76,000 savings by the second
year of this program, a $200,000 savings in the third year, and
$300,000 in the fourth year. The general fund impact is quite
favorable.
Number 129
CHAIRMAN WILKEN asked what the numbers in FY 00 mean.
MR. BRIGGS explained for FY 00, the projected expense of HB 459 for
medicaid facilities is $59,000 of general fund monies. For
medicaid non-facilities, the general fund expense is projected to
be $54,700. For health purchasing group, the projected expense is
zero. The savings in Adult Public Assistance funds projected from
putting 17 people back to work in the first year, and 28 people
back to work in the second year, is $190,000. Mr. Briggs clarified
these numbers were based on the fiscal notes, and are not his own
projections.
CHAIRMAN WILKEN asked if the $190,000 is the result of taking 28
people off of the Adult Public Assistance Program.
MR. BRIGGS said yes, and the number will probably be higher than
28. He clarified that the fiscal notes expect 17 people to take
advantage of the program in the first year if it begins in the
middle of the fiscal year, and 28 will take advantage of it in the
second year.
CHAIRMAN WILKEN asked if that number will increase continually to
FY04 with additional people.
Number 152
MR. BRIGGS said a sloping line is projected, with 28 people in FY
00, 23 people in FY 01, 23 in FY 02, 22 in FY 03, and 21 in FY 04.
CHAIRMAN WILKEN questioned whether the Adult Public Assistance
amounts are cumulative.
MR. BRIGGS said he believes so but has not analyzed the document
that closely.
CHAIRMAN WILKEN noted the Medicaid Facilities amounts do not appear
to be cumulative but the Adult Public Assistance amounts do. He
asked Mr. Briggs to clarify those numbers for committee members at
a later date.
MR. BRIGGS stated Mr. Sherwood, from the Department of Health and
Social Services (DHSS) was available to answer questions.
Number 168
JON SHERWOOD, Division of Medical Assistance, DHSS, explained the
Adult Public Assistance amounts are cumulative. That category
applies to people who would otherwise be on Adult Public
Assistance, return to work, and no longer receive public
assistance. The medical assistance line is not cumulative. The
phenomenon that DHSS tried to capture is that the people who will
be most impacted by this bill are people who will receive medicaid
whether this legislation is enacted or not. For those people, the
issue is whether they can return to work and go off of Adult Public
Assistance. Because this provision is available, people who are
already transitioning off of Medicaid and returning to work may
stay on Medicaid a little longer as a result of these provisions.
What DHSS is trying to reflect in the fiscal notes is the fact that
there will be a small increase as some people who would otherwise
go off Medicaid a little sooner will stay on a little longer, but
overall, DHSS does not expect the people generally impacted by this
bill to be people who would stop receiving Medicaid because they
cannot afford to take the risk of returning to work without medical
coverage.
MR. BRIGGS concluded his testimony by urging committee members to
favorably consider CSSB 253(HES), or similar legislation, and to
take advantage of the opportunity provided by Congress for offering
Medicaid on a buy-in basis for disabled workers. In our society,
work is one of the most valuable attributes of being a citizen, and
people who are disabled want to be part of that community.
MR. SHERWOOD added that DHSS is very supportive of this
legislation. He commented the option became available through the
federal program this past summer, and DHSS is pleased to see
legislation before the Legislature this session.
Number 209
SENATOR GREEN asked for the definition of the phrase "disabled
persons" used in the bill.
MR. BRIGGS replied a disabled person is someone who has an
impairment that affects one or more life activities, such as
impairment of vision or hearing, and usually that impairment has to
be severe enough to prevent the person from being able to engage in
substantial gainful activity of $500 or more in a particular month,
according to the Social Security Administration.
SENATOR GREEN asked whether that definition is included in the
bill.
MR. BRIGGS said it is not.
SENATOR GREEN remarked the current challenge to the term "disabled"
is the inclusion of people with HIV. Her concern was that the
phrase is broad and not clearly defined, and it might have
unintended consequences.
MR. BRIGGS responded that a definition of "disability" is
referenced in the bill on page 2, lines 6-8. That language is a
reference to eligibility requirements based on disability. He
pointed out the federal rules pertaining to disability are
specific. The litigation referred to by Senator Green is before
the Supreme Court and relates to who is a disabled person under the
Americans with Disabilities Act. That is a separate question from
who is eligible for disability benefits. He believed there is a
higher threshold for eligibility for disability benefits under the
Social Security Act. Mr. Briggs said the federal program will be
paying 60 percent of the costs of this Medicaid program, and he
believes it will have stringent eligibility rules.
Number 254
SENATOR GREEN asked if there is any overlap with the Comprehensive
Health Insurance Association (CHIA) plan.
MR. BRIGGS replied it is possible for some people to take advantage
of the CHIA program if they have been denied insurance by two or
more insurance carriers. He noted his client, Dawn Pedersen, did
not take advantage of the CHIA program is because it has a six
month pre-existing rule and because the premiums are not always
affordable.
SENATOR GREEN noted the list in CSSB 253 contains a prioritization
of services but then changes to a list of individuals. She asked
what range of services those individuals, listed in numbers 28
through 32, are eligible for.
Number 283
MR. BRIGGS said he would interpret the section to follow the legal
doctrine of the specific controls the general, meaning that where
specific services are listed in priority, and the list later
contains specific categories of people, an individual in the 26th
category could not get social worker services if no funds are
available for those services.
SENATOR GREEN asked if the people who fall under category #26 would
be ineligible for any services except those on the list.
Number 302
SENATOR LEMAN clarified those people would not be eligible for any
service that has been excluded because of lack of funding.
MR. SHERWOOD clarified the services on the list are the services
which are optional: states have the option of including those
services in their medicaid programs. The mandatory services in the
program are available to anyone who is eligible for medicaid, if
he/she has a medical need for those services, i.e., inpatient
hospital stays or physician's visits. The mandatory services are
not listed in CSSB 253.
CHAIRMAN WILKEN noted Senators Leman and Ward joined the committee.
SENATOR LEMAN referred to Section 4, the Transitional Provision,
and asked if it would make more sense for DHSS to establish a
temporary sliding fee scale now, otherwise there is little
incentive for DHSS to get the sliding fee scale regulations
completed.
MR. BRIGGS replied the House HESS committee came up with that
section as a proposal for the transition. The Governor's bill, SB
253, is silent as to how the sliding fee scale is to be
implemented. He thought the addition of that section is an
improvement because it does require regulations, and by a specific
time. Mr. Briggs said he was formerly an assistant attorney
general, and is now involved in litigation with the State over
getting some regulations promulgated, and he knows how slow that
process is. He thought one year is the minimum amount of time
necessary to get regulations out. He did not believe this
particular provision would classify as a subject for emergency
regulations. He added the fiscal note projection is based on a
five percent contribution and the purpose of the program is to help
people get back to work. If the premiums are set too high, the
purpose will be frustrated.
Number 358
CHAIRMAN WILKEN asked Senator Leman if he was referring to page 4,
line 19.
SENATOR LEMAN stated he was referring to both Sections 4 and 5, and
the language on page 2, lines 7 through 11. He thought the bill
should have a different type of transitional provision. He
suggested using a sliding fee scale that ranges from zero to ten
percent from the poverty line to 250 percent of the poverty line.
CHAIRMAN WILKEN said he will follow up on that idea. He noted the
title was changed on the House bill so that it no longer pertains
only to disabled people, but also to midwives. He asked if Ms.
Swenson could share any information about that change.
MS. SWENSON explained the House Finance Committee members changed
the list that appears on page 2 of CSSB 253(HES) by moving midwife
services down to number 15 because they wanted to make those
services available. Representative Bunde offered the amendment to
the committee at the request of Senator Leman. Representative
Therriault asked to have the title tightened up so that those
services could not be moved again. She clarified the change only
had to do with where midwife services were placed on the list.
Number 390
MR. HOWARD HEDGES testified via teleconference from Homer on his
own behalf. He stated on April 1, 1993, he had a stroke that
attacked his left side. He continues physical therapy today, and
has regained some functions. In June of 1996, he felt strong
enough to return to work. When he did so, his medicaid benefits
would expire after one year. During that year, he tried to find a
way to get continued medicaid coverage because of the complications
caused by his stroke and diabetes. Coverage through the CHIA
program would have cost $705 per month with a $2500 deductible and
a six month waiting list before any payment would occur. He was
released from his job June 1, 1997 so that he could again receive
public assistance and medicaid. CSSB 253 will allow him to return
to work. He was earning $28,000 per year; now he draws social
security disability insurance and Adult Public Assistance.
Number 414
MILLIE RYAN, a planner with the Governor's Council on Disabilities
and Special Education, made the following remarks via
teleconference. The Council recently completed its three year
state plan planning process. The Council heard from many people
around the State about the different work disincentives that affect
them. The Council is working with a number of different agencies
and people to address those work disincentives. The Council
supports this bill because it will help disabled people return to
work.
PATRICK RINEHART, Executive Director of the State Independent
Living Council, testified in support of CSSB 253. He informed
committee members that Council members discussed this issue with
the Senate HESS committee earlier in the session. The Council is
very supportive of CSSB 253 and urges the committee to support the
bill as well.
Number 430
DENNIS MURRAY, testifying via teleconference from Kenai, made the
following comments about the provision in Section 3 that pertains
to personal care attendant services. Lutheran Health Systems
Heritage Place provides services to some 50 persons in the Kenai
Peninsula. He is a provider of those services in the Kenai
Peninsula area. CSSB 253 proposes to eliminate language in Alaska
statute regarding authorization and oversight for personal care
services. The personal care attendant (PCA) coordinator at
Heritage Place is a registered nurse, as required under current
statute. CSSB 253 changes that requirement and provides that the
oversight of personal care attendants must be consistent with a
care plan. The R.N. requirement was placed in statute as a
protection to the consumer and to the State, in terms of use of its
resources. Some believe the R.N. requirement is overkill and
creates unnecessary costs to the program, however he believes the
requirement is valid to provide standards of service, and its
elimination could have untold consequences. Mr. Murray explained
the personal care attendant service is medical in nature and is
paid for by medicaid. He urged the committee to look at recent
audits of services and some of the problems that occur when clear
standards of practice are not established. He did not think an
individual care plan will address the issues identified. He urged
caution with respect to who can provide the service. The federal
government has redefined a recipient's family to only include a
spouse and/or parent. With all of the legislation that has
recently been passed in the last two or three years to protect
frail and vulnerable individuals, he is concerned that the state
will be paying for services on a routine basis provided by family
members. He felt that situation should be the exception and not
the rule.
Number 469
SENATOR GREEN asked Mr. Murray which version of the bill he was
referring to.
MR. MURRAY said he was referring to page 4 of CSSB 253, subsection
15.
MR. BRIGGS commented that with regard to personal care attendant
services, to a certain extent it is unrelated to the question of
whether the state should exercise the option to provide medicaid on
a buy-in basis. The issues are connected in the sense that the
definition that would be changed does relate to medicaid. The
current definition of personal care services under state law is
more restrictive than the definition used for medicaid
reimbursements under federal law. The purpose of the change in
CSSB 253 is to make the state and federal definitions the same
which will allow more flexibility in how those services are
provided. He said regarding the provision that prevents family
members from receiving medicaid reimbursement for personal care
attendant services, he noted there are cases in which family
members are the only people able to care for the recipient because
no other services are available in the area. He stated he believes
that provision is a good idea, but the committee should not let the
inclusion of Section 3 prevent movement of the bill. Mr. Briggs
thought the change in definition of personal care services will
broaden the way those services can be delivered and help people get
to work who are unable to work now because of their severe
disabilities.
MR. MURRAY stated he is certainly not arguing against passage of
the bill, but payment to family members for personal care services
should be the exception, not the rule. He said his concern, after
25 years in the business, is that there are some dangers associated
with that provision. He cautioned that eliminating standards that
have validity is ill advised.
CHAIRMAN WILKEN asked Mr. Murray to describe Heritage Place.
MR. MURRAY answered Heritage Place is a nursing facility that also
provides home care services. He thought nursing facilities play an
integral role in the delivery of services.
Tape 98-29, Side B
SENATOR GREEN questioned whether Mr. Briggs found any inconsistency
in the definition of "disability" within the U.S. Code, because the
bill implies that the person, to be defined as disabled, could not
work.
MR. BRIGGS stated he was unprepared to answer Senator Green's
question and he would like to do some research and provide the
committee with a specific definition. He pointed out the
definition for social security benefits is an eligibility
definition. He clarified a person can be disabled, yet not be
eligible for social security benefits.
CHAIRMAN WILKEN referred to the summary of fiscal notes, and stated
if a cumulative amount is used for the Adult Public Assistance
Program, then a cumulative amount should be used for the other
categories. He noted the $553,000 will diminish substantially if
cumulative amounts are used throughout. He suggested that DHSS
prepare another fiscal note using all cumulative amounts, or none,
before the bill is heard in the Finance Committee. He asked if 20
to 25 different people will benefit each year by going off of Adult
Public Assistance with this legislation.
MR. SHERWOOD answered yes.
Number 504
SENATOR GREEN asked if the costs to the medicaid program in FY 00
will be about $110,000.
MR. BRIGGS said the cost would be about $114,000.
SENATOR GREEN questioned whether the subtotals will reflect the
impact on medicaid money no longer available to someone lower on
the list.
MR. BRIGGS said yes, that is the general fund expense.
SENATOR GREEN asked if the general fund expense covers 60 percent
of the cost of the program.
MR. BRIGGS explained the numbers on the page Senator Green was
looking at are general fund numbers. The numbers on the next page
are the overall numbers.
There being no further discussion on CSSB 253, CHAIRMAN WILKEN
announced the committee would hold the bill for further work.
MS. SWENSON added that the effect of the amendment would have been
to open the list up to any service that wanted to get around the
intent of the list. Instead of adopting the amending, the midwife
services were moved down on the list which had the same effect.
SENATOR LEMAN clarified that the amendment may have done that, but
not necessarily would have. He noted it was not his intent to open
the list, so to prevent that from happening, the other approach was
used which accomplished the desired result.
CHAIRMAN WILKEN thanked all participants for attending.
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