Legislature(2005 - 2006)Anch LIO Conf Rm
08/29/2005 01:30 PM House HEALTH, EDUCATION & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| Status of Personal Care Attendant Regulations | |
| HB303 | |
| HB271 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 271 | TELECONFERENCED | |
| += | TELECONFERENCED | ||
| *+ | HB 303 | TELECONFERENCED | |
| + | TELECONFERENCED |
HB 303-ADULT COMPANION SERVICES WAIVER 1:50:16 PM CHAIR WILSON announced that the next order of business would be HOUSE BILL NO. 303, "An Act expanding reimbursable waiver services under Medicaid waivers for older Alaskans and adults with physical disabilities to include adult companion services; and relating to legislative intent concerning eligibility and coverage for personal care attendant services." 1:51:12 PM JON SHERWOOD, Medical Assistant Administrator IV, Department of Health and Social Services (DHSS), per the chair's request, explained that a Medicaid waiver is a device allowed by federal law to bypass the normal limits that federal regulations would impose on a state in operating a Medicaid program. Under normal federal law certain services can and cannot be provided. Therefore, a waiver allows those services not normally allowed under federal law to be provided with some conditions. In Alaska, waivers are usually home- and community-based service waivers. Under the home- and community-based services waiver, the state is allowed to provide certain services as an alternative to nursing home care and institutions for the mentally retarded and developmentally disabled. Mr. Sherwood explained that under a waiver, the state has to define the services it will offer, which have to be reasonably related to meeting the needs of the target population. MR. SHERWOOD, in response to Chair Wilson, specified that Alaska has stayed with standard definitions, with some modifications. It's simpler to use the federal government's definition because there is less review of it, he noted. As part of the process of submitting a waiver, the state has to specify the number of people to be served. He highlighted that waivers are different from the rest of Medicaid because under the rest of Medicaid if a state meets the basic eligibility criteria, the service is provided. However, under waivers, once the state specifies the number of people it will serve, no more people can be served even if the eligibility criteria is met because the state wouldn't have the authority to add more people to the waiver. 1:55:11 PM MR. SHERWOOD, in further response to Chair Wilson, said that people [beyond the specified amount in the waiver] can be added any time during the year as long as the department has received authority from the federal government to serve additional persons. He explained that part of what the department does to get a waiver approved is to show that the waiver will be cost neutral in that the department won't spend more on individuals in a community setting than it would for those in an institution. A complicated formula is offered as proof of the aforementioned. Therefore, any time the number of people served is changed, that formula has to be resubmitted. MR. SHERWOOD specified that Alaska has four waivers. There is a waiver that serves older Alaskans, those 65 years and older who meet nursing home level care. Another waiver serves adults with physical disabilities, those between the age of 21 and 64 who meet nursing home level care. Yet another waiver serves children with complex medical conditions, those children up through the age of 21 who would be served by a nursing home or long-term hospitalization. Finally, there is a waiver that serves people of all ages with mental retardation or developmental disabilities which meet the institutional standard for the Intermediate Care Facility for the Mentally Retarded (ICFMR). Mr. Sherwood informed the committee that at any given time, about 2,800 people on waivers are served. He recalled that in 2005, a little under 3,600 people on waivers were served. These waivers have been available since late 1993, he noted. Alaska obtained waivers to serve people of all ages for both nursing home and ICFMR levels of care. Furthermore, Alaska's breadth of services is fairly wide, he related. For instance, Alaska's waivers offer care coordination, payment for services in assisted living facilities, adult day care, private duty nursing, respite, chores, meals, social transportation, environmental modification, specialized equipment and supplies, and a wide range of habilitative services for those with developmental disabilities. Mr. Sherwood related that the companion service is probably the only service not offered under a waiver. 2:00:12 PM MR. SHERWOOD informed the committee that each waiver requires filling out a document that is 60-80 pages with backup materials. The initial approval period is three years, and the waivers are renewed every five years. In fact, this fiscal year the department is preparing for renewal for all four of the waivers. He explained that before the waivers are renewed, they must undergo federal review, which occurred about a year ago. Based on that review, Mr. Sherwood said he expected that the department will have to provide additional documentation regarding the department's quality assurance methods. He related that over $100 million was spent on the waivers in fiscal year (FY) 05. In conclusion, Mr. Sherwood opined that Alaska has been very successful in using waivers to avoid institutionalization. 2:02:04 PM CHAIR WILSON requested a list detailing the services provided under each waiver. MR. SHERWOOD agreed to do so. 2:03:08 PM JANET CLARKE, Assistant Commissioner, Finance and Management Services, Department of Health and Social Services, began by reviewing HB 303. Section 1 is legislative intent, which basically addresses the personal care attendant program. She then turned attention to subsection (b) on page 2, line 28, which lays out the intent to restore the nonmedical care supervision and socialization services through companion services. Section 2 outlines the direction from the legislature to seek assistance for an additional waiver, referred to as companion care for services for older Alaskans and adults with physical disabilities. She opined that the committee probably saw this language in legislation such as HB 125 and HB 193. 2:04:55 PM MS. CLARKE related that the department believes that it's premature to pass this type of legislation at this point. Currently, the department is performing a long-term care study, which will help determine what services are necessary in the continuum of care. To pass this legislation before the study is complete is a bit premature, she reiterated. Ms. Clarke explained that merely adding this additional service on top of the existing service system without reviewing all of the other components, some inefficiencies and costs will occur. The department has been taking steps to look forward at the Medicaid program, specifically a contractor has been acquired to help the department develop a better long-term forecast for Medicaid. As part of that, the contractor is reviewing the state's demographics and outlining the services being used. Based on those demographics, the contractor is relating what the service array will look like in the future. Furthermore, the department is embarking on the long-term care study. She opined that both studies are trying to help the department get a handle on the Medicaid budget as well as the program itself. The hope, she further opined, is to obtain advice on how to best structure the state's Medicaid program for the future. 2:08:48 PM MS. CLARK turned attention to the draft fiscal note for HB 303. 2:09:34 PM REPRESENTATIVE GARDNER inquired as to when the information from the two contractors will be available. MS. CLARKE answered that there should definitely be information regarding the long-term forecast for Medicaid available by January, but perhaps as early as November. In response to Chair Wilson, Ms. Clarke agreed to provide the chair with a summary of the information when available. MR. SHERWOOD informed the committee that the notice of intent to award the long-term care study has been issued. He estimated that a contractor will probably be officially on board about September 15th. According to the terms of the request for proposals (RFP), the final report should be available by February 10 although there may be some interim information prior to that. 2:11:42 PM MS. CLARKE referred to page 1 of the draft fiscal note. The fiscal note projects that if HB 303 were to pass and the department implemented regulations to add the service halfway through the fiscal year, in FY 07 the cost would be $759,600. In FY 08, there would be a full year of costs for the program and the cost escalates forward such that in 2011 adding the service would cost over $31 million. In response to Chair Wilson, Ms. Clarke referred to page 2 of the fiscal note that attempts to cost out companion services. Part of the cost model was that companion services wouldn't replace any other services, but would be in addition to existing services. Furthermore, [the cost model] would allow the primary caregiver to sleep during normal night-time hours when the care recipient may not be left safely alone. The aforementioned is a significant part of the cost. Page 2 of the fiscal note relates that currently there are 1,915 older Alaskans and adults with disabilities receiving waiver services, of those about 570 reside in an assisted living home and thus wouldn't be eligible. Therefore, the 1,345 is used and it's estimated that approximately 10 percent of those would have caregivers who would utilize companion services for 10 hours a day to allow them to work full-time. The median cost used for unskilled respite care workers was $19.72 per hour. For overnight supervision, the assumption was that 10 percent of the 1,345 recipients would be in need of overnight companion services. If those were limited to nine hours per evening and three nights per week, the cost is $3,737.70 for 135 recipients per year. Of the approximately 1,200 recipients who don't qualify for work-related or overnight companion services, the department estimates that 90 percent would utilize basic companion services, limited to 10 hours per week. Ms. Clarke acknowledged that the costs are startling, but she opined that it does all add up. 2:16:25 PM REPRESENTATIVE McGUIRE expressed interest in the study reviewing whether there is a population currently living in an institution-like setting who could live in a home environment with the assistance of a personal care attendant and the adult companion services. She questioned whether any of the aforementioned population would save the state money or create a neutral fiscal impact. 2:17:55 PM MS. CLARKE clarified that the department didn't calculate any offsetting costs. To qualify to be in a nursing home one has to meet the nursing home level of care. She highlighted that the growth of nursing homes in Alaska has really been constrained for the last 10-15 years. Prior to the availability of home- and community-based services, the state's only source of services for seniors were nursing homes. Ms. Clarke related the department's belief that there will always be those who have the need for the high level of nursing home care. She reiterated that the state has been lucky in maintaining a fairly static number of nursing home beds, which the department believes will continue in the future. 2:19:42 PM MR. SHERWOOD addressed the question regarding keeping people out of an assisted living home, which companion services would probably allow. However, when the individual needs extensive overnight or daytime supervision while someone is out of the house working, the wages for the companion would probably be comparable to personal care/respite care provider, which is around $20.00 per hour. When providing companion services on a large scale, there isn't as much of an economy of scale as would be achieved in an assisted living home. Therefore, the department doesn't expect to save money by keeping those with more intensive needs out of assisted living homes and placing them in companion services. Although there might be individual cases in which money would be saved, there will also be cases in which more money would be spent. Under the waiver, there would be an overall cost neutrality because once a service is offered there isn't a lot of ability to restrict the service as long as it's cheaper than an institution. 2:22:13 PM REPRESENTATIVE CISSNA informed the committee that companion services are listed in the regulations, although such services haven't been implemented. The aforementioned would make a difference in terms of the timing, she opined. She related that she has recently been involved in workshops regarding senior services from which she has surmised that Alaska is going through some of the same things other states have experienced in the past. Other states and the Legislative Legal and Research Services 2004 study have found that the average for [companion care services] is $50 or so a day, which is significantly less than nursing home care. She inquired as to the department's comments on that. 2:24:43 PM MR. SHERWOOD opined that the department would agree that home- and community-based services are significantly less expensive than institutional care. However, the department doesn't believe companion services would significantly reduce the amount of institutional care for which the [department] pays. Already, the [department] does an impressive job with regard to serving people through the home and the community and have a relatively small percentage of folks served in institutional care. At any given time, of the 3,300 people [being served], only about 500 are in nursing homes. Mr. Sherwood related that the home- and community-based system, including companion services, would increase overall expenditures on waivers that wouldn't be offset by a decline in nursing home units. 2:26:34 PM REPRESENTATIVE CISSNA related that she has received the sentiment of confusion with regard to the changes being put in place. Therefore, she was pleased to hear Ms. Clarke's desire not to include more changes before a study has been done. Representative Cissna then expressed interest in how the state will increase its efforts to make decisions regarding Medicaid. She opined that the changes [from last summer and these proposed today] are "incredibly brutal." 2:28:55 PM MR. SHERWOOD, in response to Representative Seaton, said that the large effect of companion services is that it would allow people to remain in their own home versus an assisted living facility [or] a nursing home. 2:30:04 PM CHAIR WILSON surmised that there are many questions, and therefore it would serve the committee to wait until it receives the reports before deciding what to do next. [HB 303 was held over.]
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