Legislature(2019 - 2020)CAPITOL 106

04/25/2019 03:00 PM HEALTH & SOCIAL SERVICES

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Audio Topic
03:03:28 PM Start
03:04:00 PM HB133
03:09:00 PM HB84
03:18:41 PM Presentation(s): Sb 74 Implementation Update
05:38:31 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+= HB 133 JUVENILES: JUSTICE,FACILITES,TREATMENT TELECONFERENCED
Moved HB 133 Out of Committee
+= HB 84 WORKERS' COMP: POLICE, FIRE, EMT, PARAMED TELECONFERENCED
Moved HB 84 Out of Committee
+ Presentation: SB 74 (2016) Medicaid Reform Update TELECONFERENCED
+ Bills Previously Heard/Scheduled TELECONFERENCED
+= HB 89 OPIOID PRESCRIPTION INFORMATION TELECONFERENCED
Scheduled but Not Heard
                    ALASKA STATE LEGISLATURE                                                                                  
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
                         April 25, 2019                                                                                         
                           3:03 p.m.                                                                                            
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Representative Ivy Spohnholz, Co-Chair                                                                                          
Representative Tiffany Zulkosky, Co-Chair                                                                                       
Representative Matt Claman                                                                                                      
Representative Harriet Drummond                                                                                                 
Representative Geran Tarr                                                                                                       
Representative Lance Pruitt                                                                                                     
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Representative Sharon Jackson                                                                                                   
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
HOUSE BILL NO. 133                                                                                                              
"An Act  relating to care  of juveniles and to  juvenile justice;                                                               
relating  to employment  of juvenile  probation  officers by  the                                                               
Department of Health and Social  Services; relating to terms used                                                               
in  juvenile justice;  relating to  mandatory reporters  of child                                                               
abuse  or  neglect;  relating  to sexual  assault  in  the  third                                                               
degree;  relating  to  sexual  assault   in  the  fourth  degree;                                                               
repealing  a  requirement  for  administrative  revocation  of  a                                                               
minor's  driver's   license,  permit,  privilege  to   drive,  or                                                               
privilege to  obtain a license  for consumption or  possession of                                                               
alcohol or drugs; and providing for an effective date."                                                                         
                                                                                                                                
     - MOVED HB 133 OUT OF COMMITTEE                                                                                            
                                                                                                                                
HOUSE BILL NO. 84                                                                                                               
"An  Act relating  to  the presumption  of  compensability for  a                                                               
disability  resulting  from  certain diseases  for  firefighters,                                                               
emergency medical technicians, paramedics, and peace officers."                                                                 
                                                                                                                                
     - MOVED HB 84 OUT OF COMMITTEE                                                                                             
                                                                                                                                
PRESENTATION(S): SB 74 IMPLEMENTATION UPDATE                                                                                    
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
HOUSE BILL NO. 89                                                                                                               
"An Act relating to the  prescription of opioids; relating to the                                                               
practice  of dentistry;  relating  to the  practice of  medicine;                                                               
relating to  the practice of  podiatry; relating to  the practice                                                               
of osteopathy; relating  to the practice of  nursing; relating to                                                               
the  practice  of optometry;  and  relating  to the  practice  of                                                               
pharmacy."                                                                                                                      
                                                                                                                                
     - SCHEDULED BUT NOT HEARD                                                                                                  
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: HB 133                                                                                                                  
SHORT TITLE: JUVENILES: JUSTICE,FACILITES,TREATMENT                                                                             
SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ                                                                                         
                                                                                                                                
04/15/19       (H)       READ THE FIRST TIME - REFERRALS                                                                        
04/15/19       (H)       HSS, JUD                                                                                               
04/23/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
04/23/19       (H)       Heard & Held                                                                                           
04/23/19       (H)       MINUTE(HSS)                                                                                            
04/25/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
BILL: HB  84                                                                                                                  
SHORT TITLE: WORKERS' COMP: POLICE, FIRE, EMT, PARAMED                                                                          
SPONSOR(s): REPRESENTATIVE(s) JOSEPHSON                                                                                         
                                                                                                                                
03/06/19       (H)       READ THE FIRST TIME - REFERRALS                                                                        
03/06/19       (H)       HSS, L&C                                                                                               
04/04/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
04/04/19       (H)       Heard & Held                                                                                           
04/04/19       (H)       MINUTE(HSS)                                                                                            
04/25/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
MEGAN HOLLAND, Staff                                                                                                            
Representative Ivy Spohnholz                                                                                                    
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:   Reviewed  HB  133 on  behalf  of the  bill                                                             
sponsor, Representative Spohnholz.                                                                                              
                                                                                                                                
REPRESENTATIVE ANDY JOSEPHSON                                                                                                   
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT:   Speaking as  the sponsor,  testified during                                                             
the hearing of HB 84.                                                                                                           
                                                                                                                                
ELISE SORUM-BIRK, Staff                                                                                                         
Representative Andy Josephson                                                                                                   
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:   Reviewed  HB  84  on  behalf of  the  bill                                                             
sponsor, Representative Josephson.                                                                                              
                                                                                                                                
HEATHER CARPENTER, Health Care Policy Advisor                                                                                   
Office of the Commissioner                                                                                                      
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:   Introduced  and  co-provided a  PowerPoint                                                             
presentation  entitled,  "SB  74 (2016)  Implementation  Update,"                                                               
dated 4/25/19.                                                                                                                  
                                                                                                                                
GENNIFER MOREAU-JOHNSON, Acting Director                                                                                        
Division of Behavioral Health                                                                                                   
Department of Health and Social Services                                                                                        
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT:     Co-provided  a  PowerPoint  presentation                                                             
entitled, "SB 74 (2016) Implementation Update," dated 4/25/19.                                                                  
                                                                                                                                
DEB ETHERIDGE, Acting Director                                                                                                  
Juneau Office                                                                                                                   
Division of Senior and Disabilities Services                                                                                    
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:     Co-provided  a  PowerPoint  presentation                                                             
entitled, "SB 74 Implementation Update," dated 4/25/19.                                                                         
                                                                                                                                
BECKY HULTBERG, President/CEO                                                                                                   
Alaska State Hospital and Nursing Home Association                                                                              
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT:     Co-provided  a  PowerPoint  presentation                                                             
entitled, "SB 74 Implementation Update," dated 4/25/19.                                                                         
                                                                                                                                
SARA CHAMBERS, Acting Director                                                                                                  
Division of Corporations, Business, and Professional Licensing                                                                  
Department of Commerce, Community & Economic Development                                                                        
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:     Co-provided  a  PowerPoint  presentation                                                             
entitled, "SB 74 Implementation Update," dated 4/25/19.                                                                         
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
3:03:28 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  IVY  SPOHNHOLZ  called  the  House  Health  and  Social                                                             
Services  Standing  Committee  meeting  to  order  at  3:03  p.m.                                                               
Representatives  Zulkosky,  Tarr,  Drummond, and  Spohnholz  were                                                               
present at the call to  order.  Representatives Pruitt and Claman                                                               
arrived as the meeting was in progress.                                                                                         
                                                                                                                                
         HB 133-JUVENILES: JUSTICE,FACILITES,TREATMENT                                                                      
                                                                                                                                
3:04:00 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ  announced the  first order of  business would                                                               
be HOUSE BILL NO. 133, "An  Act relating to care of juveniles and                                                               
to  juvenile   justice;  relating   to  employment   of  juvenile                                                               
probation  officers  by  the  Department  of  Health  and  Social                                                               
Services; relating  to terms used  in juvenile  justice; relating                                                               
to mandatory  reporters of  child abuse  or neglect;  relating to                                                               
sexual assault  in the third  degree; relating to  sexual assault                                                               
in the fourth degree; repealing  a requirement for administrative                                                               
revocation of  a minor's driver's  license, permit,  privilege to                                                               
drive,  or  privilege to  obtain  a  license for  consumption  or                                                               
possession of  alcohol or drugs;  and providing for  an effective                                                               
date."                                                                                                                          
                                                                                                                                
3:04:44 PM                                                                                                                    
                                                                                                                                
MEGAN HOLLAND, Staff, Representative  Ivy Spohnholz, Alaska State                                                               
Legislature, on  behalf of  Representative Spohnholz,  sponsor of                                                               
HB 133, reminded  the committee HB 133 is a  Division of Juvenile                                                               
Justice (DJJ),  Department of Health and  Social Services (DHSS),                                                               
"clean-up"  bill which  updates  the language  used  to refer  to                                                               
facilities that are  operated by DJJ and to  the authorities held                                                               
by  the  division.    The   bill  also  contains  several  policy                                                               
clarifications to  ensure DJJ can  complete its mission  and also                                                               
to  ensure   relevant  state  statutes  accurately   reflect  DJJ                                                               
authorities.   She referred  to a previous  hearing in  which the                                                               
committee discussed section  6 of the bill - which  would close a                                                               
loophole in  statutes related to  sexual abuse  of a minor  - and                                                               
offered to provide invited testimony in this regard.                                                                            
                                                                                                                                
3:07:17 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY  moved to report  HB 133 out of  committee with                                                               
individual  recommendations  and  the  accompanying  zero  fiscal                                                               
notes.  There being no objection,  HB 133 was reported out of the                                                               
House Health and Social Services Standing Committee.                                                                            
                                                                                                                                
3:07:35 PM                                                                                                                    
                                                                                                                                
The committee took an at-ease from 3:07 p.m. to 3:09 p.m.                                                                       
                                                                                                                                
        HB 84-WORKERS' COMP: POLICE, FIRE, EMT, PARAMED                                                                     
                                                                                                                                
3:09:00 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ announced the next  order of business would be                                                               
HOUSE  BILL  NO. 84,  "An  Act  relating  to the  presumption  of                                                               
compensability for  a disability resulting from  certain diseases                                                               
for firefighters, emergency  medical technicians, paramedics, and                                                               
peace officers."                                                                                                                
                                                                                                                                
3:09:10 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE ANDY JOSEPHSON,  Alaska State Legislature, sponsor                                                               
of  HB 84,  informed the  committee  the bill  would broaden  and                                                               
further explain  the intent of  the original  presumptive illness                                                               
bill.                                                                                                                           
                                                                                                                                
3:09:36 PM                                                                                                                    
                                                                                                                                
ELISE  SORUM-BIRK, Staff,  Representative Andy  Josephson, Alaska                                                               
State  Legislature,   on  behalf  of   Representative  Josephson,                                                               
sponsor of HB  84, stated HB 84 adds new  categories of emergency                                                               
worker  to the  existing  presumptive  legislation that  provides                                                               
presumptive  coverage for  certain diseases;  the new  categories                                                               
are   emergency  medical   technicians,  paramedics,   and  peace                                                               
officers.   Further, the bill adds  breast cancer to the  list of                                                               
diseases  covered  by  presumptive   coverage  and  also  extends                                                               
coverage  to professionals  who entered  service prior  to August                                                               
2008, who  have gone through  all official  medical examinations,                                                               
and who  did not show  evidence of  disease in their  first seven                                                               
years of service.                                                                                                               
                                                                                                                                
REPRESENTATIVE JOSEPHSON  related the  case of a  firefighter who                                                               
developed  prostate cancer  and who  had difficulty  establishing                                                               
"presumption"; he  pointed out -  if HB 84  had been in  effect -                                                               
the  firefighter's presumptive  coverage  would  have been  clear                                                               
because he was  working before 2008, and thus he  could have been                                                               
exposed  to  a  toxic  substance  that  later  gave  him  cancer.                                                               
Further, this example clarified  that compliance with the medical                                                               
examination requirements  [within existing statute]  was adequate                                                               
even  though there  was  not an  established  system for  medical                                                               
examinations.   Representative Josephson  restated the  bill also                                                               
expands the  categories to  other first  responders.   He further                                                               
explained:                                                                                                                      
                                                                                                                                
     [HB 84] is still a very  limited benefit in that it can                                                                    
     only last  for 60 months  total following the  last day                                                                    
     of employment.  ... It can  only be earned, or  one can                                                                    
     only  qualify if  they fought  fires, for  example, for                                                                    
     seven  years,  and then  there's  also  some burden  of                                                                    
     proof to  say, "This is  the thing  that I think  I was                                                                    
     exposed to."   So,  this doesn't  just come  flowing in                                                                    
     just at one's  beck and call.  It has,  it has some ...                                                                    
     sideboards, and those would still exist.                                                                                   
                                                                                                                                
CO-CHAIR SPOHNHOLZ  has heard  testimony reporting  breast cancer                                                               
rates  are   approximately  six   times  higher   amongst  female                                                               
firefighters; she questioned whether  breast cancer victims would                                                               
still have  to demonstrate exposure  to a chemical  documented to                                                               
increase the  incidence of  breast cancer  in order  to establish                                                               
presumptive coverage for breast cancer.                                                                                         
                                                                                                                                
REPRESENTATIVE   JOSEPHSON  indicated   yes.      He  noted   the                                                               
aforementioned  testimony was  reported from  a study  limited to                                                               
the San Francisco [California] Fire Department.                                                                                 
                                                                                                                                
3:13:49 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY  moved to  report HB 84  out of  committee with                                                               
individual  recommendations  and  the  accompanying  zero  fiscal                                                               
note.   There being no objection,  HB 84 was reported  out of the                                                               
House Health and Social Services Standing Committee.                                                                            
                                                                                                                                
3:14:07 PM                                                                                                                    
                                                                                                                                
The committee took an at-ease from 3:14 p.m. to 3:18 p.m.                                                                       
                                                                                                                                
^PRESENTATION(S): SB 74 IMPLEMENTATION UPDATE                                                                                 
          PRESENTATION(S): SB 74 IMPLEMENTATION UPDATE                                                                      
                                                                                                                              
3:18:41 PM                                                                                                                    
                                                                                                                                
CO-CHAIR SPOHNHOLZ  announced the  final order of  business would                                                               
be a presentation updating the  implementation of Senate Bill 74,                                                               
[passed in the Twenty-ninth Alaska State Legislature].                                                                          
                                                                                                                                
3:19:03 PM                                                                                                                    
                                                                                                                                
HEATHER  CARPENTER, Health  Care  Policy Advisor,  Office of  the                                                               
Commissioner, Department  of Health  and Social  Services (DHSS),                                                               
introduced  a PowerPoint  presentation  entitled,  "SB 74  (2016)                                                               
Implementation  Update."    Ms. Carpenter  said  Medicaid  reform                                                               
covers the many  topics shown on slide 2,  and directed attention                                                               
to slide 3, noting the  first topic for discussion, [section 1115                                                               
of  the  Social  Security  Act  Behavioral  Health  Waiver  (1115                                                               
waiver)],  would  be  presented  by the  Division  of  Behavioral                                                               
Health, DHSS.                                                                                                                   
                                                                                                                                
3:20:11 PM                                                                                                                    
                                                                                                                                
GENNIFER MOREAU-JOHNSON, Acting  Director, Division of Behavioral                                                               
Health  (DBH), DHSS,  informed the  committee  DBH submitted  its                                                               
1115 waiver  demonstration project  application in  January 2018,                                                               
which  was  followed by  a  federal  public comment  period,  and                                                               
approval was received from the  Centers for Medicare and Medicaid                                                               
Services  (CMS).   In  March 2018,  negotiations  with CMS  began                                                               
during which  CMS offered  to "fast  track" the  Substance Misuse                                                               
Disorder (SUD)  treatment component.  In  November 2018, approval                                                               
for the SUD  component was received, followed by  approval of the                                                               
DBH  implementation   plan,  which  requires  DBH   to  meet  six                                                               
milestones, including:   access  to critical  levels of  care for                                                               
SUD   treatment;  use   of   evidence-based   criteria;  use   of                                                               
nationally-recognized    program   standards    for   residential                                                               
treatment provider qualifications;  sufficient provider capacity.                                                               
Further, DBH will  use a phased-in approach  focused initially on                                                               
Anchorage,  the   Matanuska-Susitna  (Mat-Su)   area,  Southeast,                                                               
Fairbanks, Nome, and Kodiak (slide 4).                                                                                          
                                                                                                                                
REPRESENTATIVE  TARR asked  what  Nome and  Kodiak  have done  to                                                               
prepare so they can participate  in the initial implementation of                                                               
the plan.                                                                                                                       
                                                                                                                                
MS. MOREAU-JOHNSON  was unsure.  She  said DBH has made  the plan                                                               
available to  any area that  is ready to implement  the services,                                                               
and  Kodiak and  Nome "voiced  their interest."   She  offered to                                                               
provide  additional  information  in  this regard.    In  further                                                               
response to  Representative Tarr,  she agreed the  regions across                                                               
the state are very different.                                                                                                   
                                                                                                                                
3:25:51 PM                                                                                                                    
                                                                                                                                
MS. MOREAU-JOHNSON directed attention  to slide 5 which described                                                               
the population [affected by SUD].   She clarified the 1115 waiver                                                               
is not  a "level of care"  waiver; however, DBH's data  has shown                                                               
SUD  [patients] are  typically served  at  the acute  end of  the                                                               
behavioral  health  continuum  of  care, and  thus  the  division                                                               
identified  certain   populations  in  order  to   provide  early                                                               
prevention and  intervention services.  The  division is approved                                                               
through  the  1115  waiver to  provide  the  following  services:                                                               
residential  treatment  for  those  with  SUD;  opioid  treatment                                                               
services for persons experiencing  opioid use disorder; intensive                                                               
outpatient services; partial  hospitalization services; medically                                                               
monitored  intensive inpatient  services in  a hospital  setting;                                                               
medically  managed intensive  inpatient  services  in a  hospital                                                               
setting;   ambulatory  withdrawal   management  services   in  an                                                               
outpatient  setting;  clinically managed  residential  withdrawal                                                               
management; medically monitored  inpatient withdrawal management;                                                               
medically  managed  intensive  inpatient  withdrawal  management;                                                               
recovery peer  support services.  Ms.  Moreau-Johnson pointed out                                                               
DBH  has an  exemption  from the  Institute  for Mental  Diseases                                                               
(IMD)  exclusion  and  thereby  is allowed  to  provide  Medicaid                                                               
coverage in  certain facilities for  individuals over the  age of                                                               
21, or under the of age 64.   Continuing to the present status of                                                               
implementation, she noted DBH has  drafted regulations to support                                                               
the  implementation  of  SUD treatment  services  and  will  have                                                               
Medicaid  coverage  for services  beginning  July  1, [2019];  in                                                               
addition,  DBH   is  working  with  providers   to  complete  the                                                               
statewide gap  analysis, is holding  roundtables, and  is working                                                               
to ensure providers  will be ready to access  services.  Further,                                                               
DBH noticed its  intent to award a contract  to an administrative                                                               
services  organization and  targets  July 1,  [2019] for  service                                                               
delivery.  Also, DBH continues  to negotiate with CMS for federal                                                               
approval of  the remaining components  of the 1115  waiver (slide                                                               
6).                                                                                                                             
                                                                                                                                
3:30:27 PM                                                                                                                    
                                                                                                                                
MS.  MOREAU-JOHNSON restated  DBH  identified the  aforementioned                                                               
component of the  1115 waiver by the population  of those needing                                                               
acute care;  the remaining populations that  are pending approval                                                               
are at-risk  families and youth,  and individuals  who experience                                                               
serious  mental illness.   Those  identified  needing acute  care                                                               
require a  diagnosis from the  Diagnostic and  Statistical Manual                                                               
(DSM)  of  mental  disorders;  at-risk  families  and  youth  are                                                               
identified  by the  Alaska Longitudinal  Child Abuse  and Neglect                                                               
study social determinants.  She  advised CMS has indicated DBH is                                                               
very  close to  receiving  approval for  the components  awaiting                                                               
approval  (slide 7).   Ms.  Moreau-Johnson returned  attention to                                                               
the  notice  of  intent  to   award  an  administrative  services                                                               
organization  contract and  recalled  the Senate  Bill 74  fiscal                                                               
note  directed DBH  to contract  with an  administrative services                                                               
organization  (ASO).    Therefore,   DBH  issued  a  request  for                                                               
proposal  and is  approaching contract  negotiations which  could                                                               
take  two  months.   Functions  of  the  administrative  services                                                               
organization  include utilization  management, clinical  reviews,                                                               
provider  development and  support,  recipient outreach,  quality                                                               
management,  data management,  and potentially  claims processing                                                               
(slide  8).   In response  to  Co-Chair Spohnholz,  she said  the                                                               
proposal  evaluation   committee  intends   to  award   [the  ASO                                                               
contract] to Optum.                                                                                                             
                                                                                                                                
CO-CHAIR ZULKOSKY  referred to  slide 3 and  asked for  a further                                                               
description of the  intent and functionality of  the 1115 waiver.                                                               
For  example,  whether  the 1115  waiver  intends  to  streamline                                                               
access to integrated care services,  so Alaskans who are affected                                                               
by SUD, do not suffer significant impacts to their health.                                                                      
                                                                                                                                
3:36:22 PM                                                                                                                    
                                                                                                                                
MS.  MOREAU-JOHNSON agreed  with Co-Chair  Zulkosky's description                                                               
of the  1115 waiver; she added  the 1115 waiver allows  the state                                                               
"to  fund, through  the 1115  authority,  the acute  end of  care                                                               
also."     Further,  the  1115   waiver  allows  the   state  the                                                               
opportunity  to innovate  and provide  Medicaid services  in ways                                                               
that go beyond  the constraints of the Medicaid state  plan.  She                                                               
noted  the  state's  application achieved  budget  neutrality  by                                                               
identifying populations  that have been  served at the  acute end                                                               
of  care,  thus  the  state  will  show  a  savings  in  Medicaid                                                               
expenditures  by  increasing  the   availability  and  access  to                                                               
community-based care, prevention, and  early intervention, and at                                                               
the same time meet the needs  of the acute end of care [patients]                                                               
by "waiving  some of the  rules that  appear in the  state plan."                                                               
For example, in the state plan,  Medicaid cannot pay a daily rate                                                               
outside of  a medical facility thus  providers are "piece-mealing                                                               
together" charges that the 1115 waiver will allow.                                                                              
                                                                                                                                
REPRESENTATIVE  TARR returned  attention to  DBH's award  for ASO                                                               
services  as  described  on  slide  8.   She  asked  whether  all                                                               
providers will  be required to  participate in the  ASO structure                                                               
for behavioral  health management, or whether  participation will                                                               
be limited to Medicaid patients.                                                                                                
                                                                                                                                
MS. MOREAU-JOHNSON  explained the  ASO will  be assisting  DBH in                                                               
administering  all  publicly  funded behavioral  health  services                                                               
administered by  DHSS.   She stressed the  ASO will  not contract                                                               
with providers -  as would a managed care entity  - and the state                                                               
will not delegate  authority to the ASO;  therefore, providers of                                                               
Medicaid  services will  enroll with  Medicaid and  the ASO  will                                                               
provide support and expertise to DBH.                                                                                           
                                                                                                                                
3:40:47 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE CLAMAN remarked:                                                                                                 
                                                                                                                                
     As I  understand, the  substance use  disorder approval                                                                    
     had come under the 1115  waiver, and we were waiting, I                                                                    
     think, for  the behavioral health waiver  and it sounds                                                                    
     like what we've  now got is this, is  the procedure for                                                                    
     the administrative  services which will  essentially be                                                                    
     administering  the   behavioral  health  part   of  the                                                                    
     waiver.  ...  Is  there   another  waiver  we're  still                                                                    
     waiting to receive?                                                                                                        
                                                                                                                                
MS.  MOREAU-JOHNSON   clarified  the  ASO  will   assist  DBH  in                                                               
administering all  behavioral health  services that  are publicly                                                               
funded,  including SUD  services.   In fact,  the section  of the                                                               
1115 waiver  that was  approved was  the SUD  treatment services;                                                               
the  remainder  of  the  services,  such  as  mental  health  and                                                               
behavioral health  support, are  due to be  approved and  the ASO                                                               
will assist DBH in administering all of the [Medicaid] services.                                                                
                                                                                                                                
REPRESENTATIVE  CLAMAN surmised  the behavioral  health component                                                               
waiver is pending, and after  approval is received, ASO will help                                                               
administer all the waivers.                                                                                                     
                                                                                                                                
MS. MOREAU-JOHNSON said correct.                                                                                                
                                                                                                                                
REPRESENTATIVE CLAMAN  asked when the behavioral  health approval                                                               
is expected and whether there are other outstanding waivers.                                                                    
                                                                                                                                
MS. MOREAU-JOHNSON  related a representative of  CMS reported CMS                                                               
is drafting the approval document  for behavioral health services                                                               
and  thus  she is  confident  the  approval will  be  forthcoming                                                               
within  one month.    Speaking  from her  knowledge  of the  1115                                                               
waiver  demonstration project,  she said  she knows  of no  other                                                               
waivers.                                                                                                                        
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  clarified  the   1115  waiver  is  the  only                                                               
application  currently in  process, although  there are  multiple                                                               
parts to the  1115 waiver.  She pointed out  elements of the 1115                                                               
waiver include  intervention and  prevention work, which  are new                                                               
to Medicaid services.   She discussed how the  collection of data                                                               
could be used  to identify families that are at  risk for serious                                                               
problems and  then respond  by using the  1115 waiver  to provide                                                               
outreach and  support to families.   Co-Chair  Spohnholz returned                                                               
attention  to  the  selection of  Optum,  noting  Optum's  sister                                                               
company   is  UnitedHealthcare,   which   is  administering   the                                                               
[Medicare    Coordinated   Care    Demonstration   Project]    in                                                               
Southcentral, and asked about the  possibility of integrating the                                                               
coordination of care through the structure of the ASO.                                                                          
                                                                                                                                
3:46:10 PM                                                                                                                    
                                                                                                                                
MS.  MOREAU-JOHNSON said  the proposal  evaluation committee  did                                                               
not include  a reference  to the  relationship between  Optum and                                                               
UnitedHealthcare  in  its  recommendation; however,  one  of  the                                                               
performance measures of  the ASO is to  help integrate behavioral                                                               
health care,  and it  is important  to identify  at-risk families                                                               
outside of behavioral health settings.                                                                                          
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  urged for  any  method  to identify  at-risk                                                               
populations and connect individuals to care.                                                                                    
                                                                                                                                
MS.  MOREAU-JOHNSON   advised  DBH  works  with   the  Office  of                                                               
Children's  Services (OCS),  DHSS, staff  to "loop-in  the social                                                               
services  agencies  that  work with  the  child  welfare  systems                                                               
because we're really trying to cast the net wide."                                                                              
                                                                                                                                
MS. CARPENTER directed attention  to slide 9, DBH's Comprehensive                                                               
Integrated  Mental  Health  Program Plan  (Comp  Plan)  entitled,                                                               
"Strengthening  the  System,"  which  was developed  by  DHSS  in                                                               
collaboration  with  the  Alaska Mental  Health  Trust  Authority                                                               
(AMHTA)  and their  advisory  boards.   The  Comp  Plan seeks  to                                                               
coordinate services across target  recipients' lifespans; by law,                                                               
recipients, also  known as trust beneficiaries,  are Alaskans who                                                               
experience mental illness or  a developmental disability, chronic                                                               
alcoholism,  Alzheimer's Disease  or  related  dementia, or  have                                                               
experienced  a   traumatic  brain  injury  (TMI).     The  target                                                               
population also includes  persons of all ages  who are vulnerable                                                               
to developing beneficiary  conditions.  The Comp  Plan also seeks                                                               
to  prevent the  aforementioned conditions,  when possible.   She                                                               
advised the  plan's public comment  period closed  [4/12/19]; the                                                               
previous Comp  Plan was  completed in 2006  and expired  in 2011,                                                               
thus the  Comp Plan  should be  updated now  along with  the 1115                                                               
waiver  and other  Medicaid reforms  (slide 10).   Ms.  Carpenter                                                               
said the  next topic, State  Plan Options, would be  presented by                                                               
the Division of Senior and Disabilities Services, DHSS.                                                                         
                                                                                                                                
3:50:08 PM                                                                                                                    
                                                                                                                                
DEB  ETHERIDGE,  Acting  Director,  Juneau  Office,  Division  of                                                               
Senior  and  Disabilities  Services (DSDS),  DHSS,  informed  the                                                               
committee  Senate  Bill  74  engaged  DSDS  in  two  initiatives:                                                               
refinance  general fund  (GF) dollars,  and maintain  services to                                                               
individuals  with  disabilities.     In  response  to  the  first                                                               
initiative,  DSDS utilized  the [federal  section 1915(c)  of the                                                               
Social  Security  Act   Individualized  Supports  Waiver  (ISW)].                                                               
Prior to 2016, DSDS administered  the Community and Developmental                                                               
Disabilities   Grant    for   individuals    with   developmental                                                               
disabilities who were  waiting on the DSDS registry  - also known                                                               
as  the   waitlist  -  for  an   Individuals  with  Developmental                                                               
Disabilities Waiver,  which is  a 100  percent GF  grant program.                                                               
After a  review of the  program and  its services, DSDS  chose to                                                               
refinance the  GF grant program with  a new ISW that  would serve                                                               
over  600  individuals, and  she  described  the history  of  the                                                               
change.  The new program was  implemented in October 2018 and can                                                               
serve  up to  620 individuals  to a  cap amount  of $17,500;  she                                                               
stressed DSDS  determined the cap  amount of $17,500  would serve                                                               
most  individuals.   The  ISW cap  is  lower because  residential                                                               
services are not provided.                                                                                                      
                                                                                                                                
CO-CHAIR  SPOHNHOLZ asked  about services  for those  whose needs                                                               
are not addressed within the cap amount of $17,500.                                                                             
                                                                                                                                
MS.  ETHERIDGE  said DSDS  identified  eight  individuals on  the                                                               
Community  and  Developmental  Disabilities Grant  who  would  be                                                               
better served by the  Individuals with Developmental Disabilities                                                               
Waiver which allows payment for residential services.                                                                           
                                                                                                                                
MS.  ETHERIDGE explained  the implementation  of the  program was                                                               
delayed for some  individuals, so DSDS used  $450,000 to continue                                                               
their services.                                                                                                                 
                                                                                                                                
MS.  CARPENTER  recalled  DHSS   purposefully  used  language  in                                                               
[Senate  Bill  74]  that  ensures   the  state  receives  maximum                                                               
benefits from the legislation.                                                                                                  
                                                                                                                                
3:55:03 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR asked for clarification of "the waitlist."                                                                  
                                                                                                                                
MS.  ETHERIDGE  said  there  are  over  700  individuals  on  the                                                               
Developmental Disability  Registry and  Review (DDRR);  DSDS drew                                                               
from  the  registry to  create  the  ISW waitlist;  however,  all                                                               
individuals  remain  on the  waitlist  for  the Individuals  with                                                               
Developmental Disabilities  Waiver.  Currently, DSDS  is updating                                                               
the waitlist;  of the 700  individuals, 425 have  been identified                                                               
for the  ISW and more  have opted not  to remain on  the waitlist                                                               
for the Individuals with Developmental  Disabilities Waiver.  She                                                               
said she expected  that next year, there will be  a difference in                                                               
the number  of individuals  on the DDRR  who receive  1115 waiver                                                               
services.  In  further response to Representative  Tarr, she said                                                               
625  individuals  were  identified  for the  ISW,  and  425  have                                                               
decided  to  remain on  the  waitlist  for the  Individuals  with                                                               
Developmental Disabilities Waiver.                                                                                              
                                                                                                                                
REPRESENTATIVE TARR  surmised a  different level  of need  is met                                                               
for individuals through the new ISW  and there remains a group of                                                               
people who  need to receive  more extensive services  through the                                                               
Individuals with Developmental Disabilities Waiver.                                                                             
                                                                                                                                
MS. ETHERIDGE said  the ISW provides services  for individuals at                                                               
service  levels  that were  received  through  the Community  and                                                               
Developmental  Disabilities Grant  program.   In response  to Co-                                                               
Chair  Spohnholz,  she  clarified  the  "larger"  waiver  is  the                                                               
Individuals   with  Developmental   Disabilities  (IDD)   Waiver,                                                               
formerly known as the People  with Intellectual and Developmental                                                               
Disabilities Waiver.                                                                                                            
                                                                                                                                
3:59:24 PM                                                                                                                    
                                                                                                                                
MS. ETHERIDGE  returned attention  to the second  DSDS initiative                                                               
within  Senate Bill  74, which  directed  DSDS to  apply for  the                                                               
Community  First  Choice program,  section  1915(k),  which is  a                                                               
different type of state plan option through CMS.  She remarked:                                                                 
                                                                                                                                
     The reason I  point that out is because  once a service                                                                    
     becomes   a  state   plan   service,   it  becomes   an                                                                    
     entitlement.  And  that is really important  for you to                                                                    
     know because  we are very careful  with implementing an                                                                    
     entitlement  program in  Alaska.   The Community  First                                                                    
     Choice program ... offers services  very similar to our                                                                    
     state plan personal care services  for people with, who                                                                    
     require nursing, or nursing facility  level of care, or                                                                    
     an institutional  level of  care.   It also  offers the                                                                    
     state  an  opportunity to  draw  down  an additional  6                                                                    
     percent enhanced match.                                                                                                    
                                                                                                                                
MS.  ETHERIDGE further  explained,  through  the Community  First                                                               
Choice state  plan option, DSDS provides  personal care services,                                                               
education  and  training  on  how  to hire,  fire,  and  train  a                                                               
personal  care   attendant,  personal  emergency   response,  and                                                               
training  to  do a  task;  for  all  these services  the  state's                                                               
enhanced   federal    medical   assistance    percentage   (FMAP)                                                               
reimbursement  is 56  percent.   Further, DSDS  auto-enrolled 826                                                               
individuals  in  the  Community First  Choice  program  who  were                                                               
receiving  state  plan  personal  care services,  and  Home-  and                                                               
Community-Based  Services, for  an estimated  savings in  2019 of                                                               
over $2 million (slide 12).                                                                                                     
                                                                                                                                
REPRESENTATIVE  CLAMAN  asked  if   enrollees  are  primarily  an                                                               
elderly population or others with significant disabilities.                                                                     
                                                                                                                                
MS. ETHERIDGE said the population  consists of any individual who                                                               
meets requirements  for an  institutional level  of care,  and so                                                               
may  be a  person with  disabilities, intellectual  developmental                                                               
disabilities, physical disabilities, or a senior.                                                                               
                                                                                                                                
4:02:38 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR  asked for clarification of  how services are                                                               
being reorganized through existing and new waivers.                                                                             
                                                                                                                                
MS.  ETHERIDGE explained  the  existing  1915(c) waivers  remain;                                                               
however,  if  a   service  currently  offered  by   a  Home-  and                                                               
Community-Based  Waiver  is  now offered  through  the  Community                                                               
First  Choice program,  DBH will  transition  to Community  First                                                               
Choice and save  an additional 6 percent.   She further explained                                                               
DBH did not  initially transition all services  because there are                                                               
two  institutional levels  of care:   under  21 in  a residential                                                               
treatment  facility  or over  65  in  an institution  for  mental                                                               
disease,  and  DBH  was  unsure  of  the  number  of  individuals                                                               
receiving  these two  levels of  care  who may  transition.   She                                                               
cautioned DBH  expects the number  of individuals  identified for                                                               
personal care,  personal emergency  response, and  chore services                                                               
to be  low, but  the population  of individuals  entering respite                                                               
care is not  well understood and therefore creates  a higher risk                                                               
to DBH.                                                                                                                         
                                                                                                                                
CO-CHAIR  SPOHNHOLZ questioned  how  respite care  could carry  a                                                               
higher risk.                                                                                                                    
                                                                                                                                
MS. ETHERIDGE advised respite care  could be expensive because it                                                               
could be expanded to a population not currently served by DBH.                                                                  
                                                                                                                                
4:04:54 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY  asked for  a "high  level perspective"  on the                                                               
mission  of  the  aforementioned  programs and  how  the  waivers                                                               
reform the Medicaid system.                                                                                                     
                                                                                                                                
MS.  ETHERIDGE  explained  Home-  and  Community-Based  Services,                                                               
including personal  care, provide people with  assistance so they                                                               
can remain  in their home and  community - without risk  to their                                                               
health  - and  avoid  transitioning  into a  nursing  home.   The                                                               
mission of DSDS is to  provide services so individuals can remain                                                               
safe and  secure, and federal waivers  allow DSDS to do  so.  For                                                               
example,  the state  plan is  a  contract with  CMS; the  waivers                                                               
provide permission to waive some of  the rules of the contract so                                                               
that DSDS  can provide services at  lesser levels of care  and at                                                               
lower cost.   Another  example is that  DSDS currently  serves 14                                                               
individuals out  of state  at an  intermediate care  facility for                                                               
Individuals with Intellectual  and Developmental Disabilities; if                                                               
they  could  be served  in  a  Home-and Community-Based  setting,                                                               
their care would be less expensive.                                                                                             
                                                                                                                                
CO-CHAIR SPOHNHOLZ recalled  at one time the  state funded grants                                                               
to organizations that were then  obligated to provide services to                                                               
a  specific  group   of  people;  however,  the   system  is  now                                                               
facilitated through the waiver structure.   She asked whether the                                                               
new system  comes with tools  to help the community  develop "the                                                               
right kinds of services to support  ... the population we need to                                                               
care for?"                                                                                                                      
                                                                                                                                
MS.  ETHERIDGE acknowledged  there  is a  tremendous change  from                                                               
providers having the  flexibility of a grant to  instead having a                                                               
reimbursement  system  such  as  the  Home-  and  Community-Based                                                               
Waiver, which is  more of a medical model and  a more restrictive                                                               
system.   She  said  DSDS seeks  a balance  in  order to  provide                                                               
services  the state  can afford;  for  example, DSDS  administers                                                               
services to  seniors and as  seniors reach more  expensive levels                                                               
of  care, services  cannot  be managed  in a  grant  but must  be                                                               
leveraged  with  federal  funds.    Further,  as  DSDS  increases                                                               
Medicaid services  through the ISW,  it seeks to ensure  there is                                                               
the workforce needed to deliver services.                                                                                       
                                                                                                                                
CO-CHAIR SPOHNHOLZ  asked about challenges faced  by the provider                                                               
community  as the  system moves  from  a grant-based  model to  a                                                               
medical billing-based model.                                                                                                    
                                                                                                                                
MS.  ETHERIDGE advised  many providers  served the  Community and                                                               
Developmental  Disability   Grant  program  and  the   Home-  and                                                               
Community-Based Waiver  thus some  issues, such  as conflict-free                                                               
case management,  have arisen.   In further response  to Co-Chair                                                               
Spohnholz,  she  acknowledged  the  change  from  a  grant  to  a                                                               
reimbursement  system   for  expenditures  is  difficult.     She                                                               
remarked:                                                                                                                       
                                                                                                                                
     Because  you  do  have  to have  the  money  up  front.                                                                    
     Medicaid pays  you back  for incurred  expenditures, so                                                                    
     you  do  have to  have  the  capacity to  provide  that                                                                    
     service up  front, where the  grants are  the opposite.                                                                    
     And so, we've ...  definitely gotten feedback about how                                                                    
     that's structured ....                                                                                                     
                                                                                                                                
4:12:44 PM                                                                                                                    
                                                                                                                                
MS. CARPENTER pointed out DHSS is  moving forward with the ASO to                                                               
address  this  issue;  the  ASO  will  assist  behavioral  health                                                               
providers  - who  have not  participated in  Medicaid billings  -                                                               
through the transition.                                                                                                         
                                                                                                                                
REPRESENTATIVE TARR related an example  of personal services that                                                               
were cut  back for an  individual who receives 24-hour  care, and                                                               
an  example   of  an  individual   whose  services   through  the                                                               
Developmental Disabilities  (DD) Waiver  were cut back,  both due                                                               
to  budget pressure.   She  expressed  her concern  there may  be                                                               
unmet needs due  to cost adjustments in  personal care assistance                                                               
(PCA) services.                                                                                                                 
                                                                                                                                
MS. ETHERIDGE  recalled last legislative session  DSDS was tasked                                                               
with completing a  data analysis of 2017-2018  data; the division                                                               
found a  significant decrease in  spending for personal  care and                                                               
Home- and Community-Based [care],  and increased expenditures for                                                               
long-term care.  She said DSDS seeks to "re-balance that."                                                                      
                                                                                                                                
REPRESENTATIVE TARR  observed PCA  services are much  less costly                                                               
than institutional-level care.                                                                                                  
                                                                                                                                
4:18:24 PM                                                                                                                    
                                                                                                                                
MS. CARPENTER redirected  attention to slide 13  and noted Senate                                                               
Bill  74   also  focused  on  "superutilizer"   reduction.    She                                                               
explained  superutilizers  are  individuals  comprising  about  5                                                               
percent  of  the Medicaid  population  who  use approximately  95                                                               
percent  of the  services; Senate  Bill 74  identified two  areas                                                               
with  which  to  reduce  the percentage  of  superutilizers,  the                                                               
Alaska Emergency Department  Coordination Project, facilitated by                                                               
the Alaska State Hospital and  Nursing Home Association (ASHNHA),                                                               
and Primary Care  Case Management.  Primary  Care Case Management                                                               
has  two  components:    the  Alaska  Medicaid  Coordinated  Care                                                               
Initiative and the Care Management  Program.  The Care Management                                                               
Program  identifies  superutilizers   by  reviewing  claims  that                                                               
indicate   high   emergency   room  (ER)   usage   and   abnormal                                                               
prescription  usage behaviors  and  refers those  claims to  case                                                               
management.   The Care  Management Program is  also known  as the                                                               
Locked-In  Program,  which  covers  about  300  participants  per                                                               
month,  who  are  assigned  one primary  care  provider  and  one                                                               
pharmacy.  She said participants  are "locked in" with a provider                                                               
with whom  they have a relationship,  or one is assigned  by DBH.                                                               
The Alaska  Medicaid Coordinated Care Initiative  is available to                                                               
all Medicaid recipients who are  not otherwise enrolled in a case                                                               
management program;  approximately 30,000-50,000  individuals per                                                               
month have  access to the program,  mostly telephonically through                                                               
MedExpert,  and  another  55 individuals  are  served  by  Qualis                                                               
Health.   She discussed further  coordination of care  with other                                                               
agencies  such as  the Department  of Corrections,  OCS, and  the                                                               
Division  of  Public  Health, DHSS.    Ms.  Carpenter  concluded,                                                               
estimating the  savings from fewer  ER visits,  fewer duplicative                                                               
services, and  fewer prescriptions, are approximately  $8 million                                                               
per  year.     She  turned  attention  to  the   second  area  of                                                               
superutilizer reduction and said  the Alaska Emergency Department                                                               
Coordination Project would be presented by ASHNHA.                                                                              
                                                                                                                                
4:21:22 PM                                                                                                                    
                                                                                                                                
BECKY HULTBERG, President/CEO, Alaska  State Hospital and Nursing                                                               
Home Association (ASHNHA), informed  the committee ASHNHA brought                                                               
the Alaska Emergency Department  (ED) Coordination Project to the                                                               
legislature with the goals to improve  care in EDs and reduce the                                                               
inappropriate utilization of  ED services (slide 14).   The model                                                               
ASHNHA  implemented  was  the Seven  Best  Practices  Model  from                                                               
Washington  State;  she said  the  key  elements of  the  project                                                               
include implementation  of an ED electronic  information exchange                                                               
system  that   "pushes"  complete   critical  information   to  a                                                               
clinician at  the point of  care, without further research.   She                                                               
said  the model  was implemented  at eleven  hospitals in  Alaska                                                               
beginning  in  February 2017.    Ms.  Hultberg noted  the  system                                                               
provides regional  and nationwide records  of care; a  second key                                                               
element of the model is  the Prescription Drug Monitoring Program                                                               
(PDMP)  which  reports  patient use  of  narcotic  prescriptions.                                                               
Other  elements  of  the  model   are  statewide  guidelines  for                                                               
prescribing narcotics  and care  coordination (slide 15).   Slide                                                               
17 further  described the electronic ED  information system which                                                               
provides "flags"  in a  patient's record that  will alert  the ED                                                               
physician  of pertinent  information.   Ms.  Hultberg related  ED                                                               
physicians support the system because it improves patient care.                                                                 
                                                                                                                                
4:25:24 PM                                                                                                                    
                                                                                                                                
CO-CHAIR   SPOHNHOLZ  asked   whether   the  Alaska   Psychiatric                                                               
Institute (API) is part of the electronic information system.                                                                   
                                                                                                                                
MS. HULTBERG  advised API  is "technically not  at a  point where                                                               
they are able ... to join."                                                                                                     
                                                                                                                                
REPRESENTATIVE   TARR  noted   the   system   only  provides   ER                                                               
information  and asked  if this  information  is only  a part  of                                                               
electronic hospital records or is a separate system.                                                                            
                                                                                                                                
MS. HULTBERG explained one problem  with medical records is there                                                               
is  a  huge  volume  of   electronic  information  that  must  be                                                               
searched;  even if  records are  interoperable, patients  may not                                                               
volunteer information about their  visits to other hospitals, and                                                               
the  system "pulls  the information  they need  to know,  at that                                                               
point in time, and it pushes it  to them so they don't have to go                                                               
hunt for it ...."                                                                                                               
                                                                                                                                
REPRESENTATIVE  TARR asked  whether  the  system would  integrate                                                               
health records beyond the ER.                                                                                                   
                                                                                                                                
MS. HULTBERG  advised the system is  a separate piece to  help in                                                               
the ER care setting and  is not a substitute for interoperability                                                               
[of medical records].                                                                                                           
                                                                                                                                
REPRESENTATIVE CLAMAN questioned whether  the system will provide                                                               
information  to the  Mat-Su Regional  Medical Center  ER about  a                                                               
patient's recent visits to "Providence  family practice," or only                                                               
about visits to the Providence Alaska Medical Center ER.                                                                        
                                                                                                                                
MS. HULTBERG  said the system  does not provide full  records but                                                               
uses "flags" to  alert an ER physician  of pertinent information.                                                               
However,  if Providence  family  practice were  connected to  the                                                               
system,  and  a  patient  has  a  care  plan,  Providence  family                                                               
practice can upload the care  plan, which would then be available                                                               
to the ER physician.                                                                                                            
                                                                                                                                
4:29:41 PM                                                                                                                    
                                                                                                                                
MS. HULTBERG returned  attention to slide 17 and  said the system                                                               
is operational  at eleven  hospitals and  at six  other entities.                                                               
Slide  18  listed  participating  organizations;  she  noted  the                                                               
system will  be expanded to  additional hospitals and  to include                                                               
primary care providers.                                                                                                         
                                                                                                                                
CO-CHAIR SPOHNHOLZ  opined communication between EDs  and primary                                                               
care providers is critical to  reducing healthcare costs, and she                                                               
elaborated.                                                                                                                     
                                                                                                                                
MS. HULTBERG agreed.  She said  another element of the project is                                                               
the  ED narcotic  prescribing  guidelines  that were  voluntarily                                                               
developed by ED  physicians.  The guidelines  allow physicians to                                                               
inform  patients  that  every  ED  in  Alaska  is  following  the                                                               
guidelines and  thus avoid having patients  visiting multiple EDs                                                               
seeking narcotics.   Further, the  guidelines have  been endorsed                                                               
by  every  provider  and  hospital,  have  reduced  prescriptions                                                               
issued  by  EDs,  and  have connected  PDMP  information  to  the                                                               
exchange system (slides 19 and 20).   Slide 21 illustrated a case                                                               
study  conducted   by  CollectiveMedical  with   Mat-Su  Regional                                                               
Medical Center to  identify the impact of the  combination of the                                                               
narcotics  guidelines,  the  ED information  exchange,  and  case                                                               
management work.   The study  reported a 79 percent  reduction in                                                               
opioid scripts written in EDs  while maintaining positive patient                                                               
satisfaction  rates.     Ms.   Hultberg  closed,   reviewing  the                                                               
project's goals of improving patient  care and, thereby, reducing                                                               
ED costs; although not accompanied  by a major data study, ASHNHA                                                               
believes both goals have been accomplished (slide 23).                                                                          
                                                                                                                                
4:34:40 PM                                                                                                                    
                                                                                                                                
MS. CARPENTER  recalled during  the drafting  of Senate  Bill 74,                                                               
DHSS  sought language  that would  allow  the state  to test  for                                                               
projects and determine value over  volume; in fact, discussion of                                                               
the  bill covered  managed care  organizations, accountable  care                                                               
organizations, and provider-based models.   However, DHSS decided                                                               
upon  coordinated  care  demonstration  projects  that  would  be                                                               
proposed  by providers  on a  regional  basis.   For example,  on                                                               
9/1/18,  Providence  Family  Medicine   Center  began  testing  a                                                               
patient-centered  medical  home   model  project  which  provides                                                               
participating    Medicaid   patients    the   services    of   an                                                               
interdisciplinary  care team:    primary  care, case  management,                                                               
care   coordination,   social   work,   health   education,   and                                                               
transitional and follow-up  care.  The state is  paying a partial                                                               
capitation rate  for additional services.   She said  the project                                                               
is voluntary,  involves approximately  5,000 patients  per month,                                                               
and  the state  is  currently assessing  the project's  outcomes.                                                               
The  other  project is  a  contract  with UnitedHealthcare  on  a                                                               
Managed  Care Organization  that is  expected to  begin operation                                                               
[10/1/19];  discussions regarding  the project  are underway  and                                                               
are related to rates.  In  addition, provisions of House Bill 176                                                               
[passed in the Thirtieth Alaska  State Legislature], known as the                                                               
ground  emergency  medical  transport (GEMT)  bill,  allow  local                                                               
governments  to  receive  cost-based   payments  outside  of  the                                                               
managed  care organization  structure,    and  this provision  is                                                               
also being reviewed by DHSS (slide 24).                                                                                         
                                                                                                                                
REPRESENTATIVE TARR  asked whether  already existing  models were                                                               
considered.                                                                                                                     
                                                                                                                                
4:39:01 PM                                                                                                                    
                                                                                                                                
MS. CARPENTER explained  the state issued a  request for proposal                                                               
(RFP)  and  responded to  proposals  that  were submitted.    She                                                               
turned attention  to section 43  of Senate  Bill 74 which  is the                                                               
Medicaid Reform  Program statute  that requires  several specific                                                               
reports.    One  of  the   reports  required  is  the  Electronic                                                               
Explanation  of  Medical  Benefits   (EOMBs),  which  intends  to                                                               
encourage  Medicaid recipients  to  review  their explanation  of                                                               
benefit  (EOB),  so  that  mistakes,  fraud,  and  abuse  may  be                                                               
reported, and she  described the procedure.   Currently, 2,500 of                                                               
100,000 adult  recipients have registered for  the service, which                                                               
will be  expanded to  include children  (slides 25  and 26).   In                                                               
response  to Co-Chair  Spohnholz,  Ms. Carpenter  said she  would                                                               
provide examples of the type  of problems that have been reported                                                               
by recipients.                                                                                                                  
                                                                                                                                
MS. CARPENTER said another aspect  of the Medicaid Reform Program                                                               
is redesigning  the payment process;  although DHSS  received one                                                               
proposal to  bundle payments, DHSS determined  the proposal would                                                               
not be cost-neutral, and she  elaborated.  No proposal for global                                                               
payments was received.                                                                                                          
                                                                                                                                
CO-CHAIR SPOHNHOLZ  asked for descriptions of  health maintenance                                                               
organization  (HMO)  capitation,  bundled  payments,  and  global                                                               
payments.                                                                                                                       
                                                                                                                                
MS.  CARPENTER  explained bundled  payments  are  charged from  a                                                               
variety of  providers related  to one  service, for  example, all                                                               
the  charges  related  to  a   surgery,  with  the  exception  of                                                               
diagnoses.    A capitated  rate  is  charged  by a  managed  care                                                               
organization  with which  DHSS  has an  agreement  for a  certain                                                               
cost.   She said she  would provide a comparison  between bundled                                                               
and global payments.                                                                                                            
                                                                                                                                
4:44:36 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR asked whether  the aforementioned reforms are                                                               
intended to  reduce the administrative  costs of the  delivery of                                                               
services.                                                                                                                       
                                                                                                                                
MS.  CARPENTER said  DHSS always  seeks to  reduce administrative                                                               
costs;  for  example,  through   regulation,  DHSS  was  able  to                                                               
eliminate   "the   72-hour  rule"   in   order   to  remove   "an                                                               
administrative  nightmare" for  physicians,  and she  elaborated.                                                               
She restated DHSS seeks to  redesign the payment process in order                                                               
to  pay for  value  over volume;  Alaska Medicaid  is  a fee  for                                                               
service  system,  which  encourages   providers  to  charge  "for                                                               
everything, so  if [we] change the  system in how we're  paying -                                                               
we want to pay for outcomes - we  don't want to just pay for sick                                                               
care ...."                                                                                                                      
                                                                                                                                
REPRESENTATIVE  TARR returned  to the  topic of  bundled payments                                                               
and questioned  how DHSS determined  bundled payments were  not a                                                               
good option.                                                                                                                    
                                                                                                                                
MS.  CARPENTER said  she  would  provide copies  of  a report  to                                                               
explain why  bundled payments  would not  save costs  for smaller                                                               
communities at this time.                                                                                                       
                                                                                                                                
CO-CHAIR SPOHNHOLZ  observed there  is less opportunity  for cost                                                               
savings  "the narrower  the range  of  services you're  providing                                                               
..."   Capitated rates are  an incentive for providers  to change                                                               
the way  they provide care because  they wish to raise  the level                                                               
of health  for recipients; however, [in  small communities] there                                                               
is  less  opportunity to  find  costs  savings in  administrative                                                               
reforms such as billing.                                                                                                        
                                                                                                                                
MS. CARPENTER  returned to  the topic  of Medicaid  reform within                                                               
Senate  Bill 74  and said  in  2016, DHSS  engaged a  stakeholder                                                               
group that  developed 18 quality and  cost effectiveness measures                                                               
to monitor  the Medicaid program  throughout the  reform process.                                                               
A report  released "year 1"  results in December [2018]  and DHSS                                                               
will  continue to  report results  in  this regard.   The  annual                                                               
Medicaid reform  report to the  legislature is  transmitted every                                                               
November and  includes information related to  policy and finance                                                               
related  to Medicaid.   In  addition, Senate  Bill 74  required a                                                               
biannual  report on  the Alaska  Medicaid Management  Information                                                               
System  (MMIS),  which  was  certified by  CMS  on  9/28/18;  CMS                                                               
certification  allows  Alaska to  receive  federal  funds for  75                                                               
percent of operations and maintenance (slide 27).                                                                               
                                                                                                                                
4:51:10 PM                                                                                                                    
                                                                                                                                
MS.  CARPENTER continued  to slide  30 which  indicated DHSS  has                                                               
achieved  three-quarters  of  claims  for  FY  19,  totaling  $65                                                               
million, and  is on  track to  meet or exceed  its target  of $84                                                               
million in savings through efforts such as Tribal reclaiming.                                                                   
                                                                                                                                
CO-CHAIR  ZULKOSKY  disclosed she  works  for  the Alaska  Native                                                               
Tribal Health  Consortium during interim and  acknowledged DHSS's                                                               
work to  ensure Tribal  reclaiming is  audit-proof and  free from                                                               
abuse or fraud.                                                                                                                 
                                                                                                                                
MS. CARPENTER continued  to the topic of fraud,  waste, and abuse                                                               
and  pointed  out another  annual  legislative  report is  issued                                                               
jointly by DHSS  and the Department of Law  every November (slide                                                               
31).  Also,  Senate Bill 74 requires  an eligibility verification                                                               
system  conducted by  a third  party, and  CMS requires  an Asset                                                               
Verification   System  and   an   Independent  Verification   and                                                               
Validation System.  There have  been three responses to a request                                                               
of interest  issued by the  Division of Public  Assistance, DHSS,                                                               
and the systems will be implemented.                                                                                            
                                                                                                                                
4:54:44 PM                                                                                                                    
                                                                                                                                
The committee took an at-ease from 4:54 p.m. to 4:56 p.m.                                                                       
                                                                                                                                
MS.   CARPENTER  added   the  aforementioned   systems  will   be                                                               
implemented  this  fiscal  year  upon   approval  by  CMS.    The                                                               
Eligibility  Verification   System  will  also   satisfy  federal                                                               
requirements  under   the  Food   and  Nutrition   Service,  U.S.                                                               
Department  of Agriculture  (slide  32).   She  continued to  the                                                               
topic of Pioneer Homes, noting  Senate Bill 74 required residents                                                               
to show proof  of Medicaid when applying  for payment assistance;                                                               
the goal  of this  provision is  to have  elders first  apply for                                                               
federal  [assistance].    She  pointed out  the  provision  is  a                                                               
successful  strategy to  increase  Medicaid  receipts and  reduce                                                               
cost for  elders residing  in Pioneer Homes.   Although  it takes                                                               
about six  months to obtain  proof of a Medicaid  application due                                                               
to staffing issues, the strategy  has increased the federal match                                                               
to 50 percent and reduced  GF payment assistance to elders living                                                               
in Pioneer Homes (slide 33).                                                                                                    
                                                                                                                                
4:59:20 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE TARR asked  whether there is a  Medicaid waiver to                                                               
address the  issues that arise when  an elder, who needs  to move                                                               
to a Pioneer Home, has assets.                                                                                                  
                                                                                                                                
MS.  CARPENTER advised  elders can  place assets  into a  [Miller                                                               
Trust,  also known  as a  Qualified  Income Trust]  and said  she                                                               
would provide more information in this regard.                                                                                  
                                                                                                                                
CO-CHAIR ZULKOSKY,  in response  to Representative  Tarr, advised                                                               
Alaska is not unique in  its requirement that elders divest their                                                               
assets to qualify for Pioneer Home payment assistance.                                                                          
                                                                                                                                
MS. CARPENTER said  the topic of Telehealth would  be provided by                                                               
the  Department of  Commerce,  Community  & Economic  Development                                                               
(DCCED).                                                                                                                        
                                                                                                                                
5:01:40 PM                                                                                                                    
                                                                                                                                
SARA  CHAMBERS,   Acting  Director,  Division   of  Corporations,                                                               
Business,  and   Professional  Licensing,  DCCED,   informed  the                                                               
committee Senate Bill 74 expanded  telehealth services - in which                                                               
physicians provide services while not  in the room with a patient                                                               
-  to audiologists,  speech  language  pathologists, marital  and                                                               
family therapists,  occupational therapists,  and others  who may                                                               
reasonably provide telehealth  services through videoconferencing                                                               
and  audioconferencing.    In  this  provision,  Senate  Bill  74                                                               
required  the  state  to  create   a  registry  for  telemedicine                                                               
businesses and thus 245 individual  and corporate businesses have                                                               
registered  with  the  Division of  Corporations,  Business,  and                                                               
Professional Licensing  (slide 34).   She  pointed out  the PDMP,                                                               
under  the  purview  of  the   Board  of  Pharmacy,  Division  of                                                               
Corporations,  Business and  Professional  Licensing, DCCED,  was                                                               
changed by  Senate Bill  74 from an  optional report  to mandated                                                               
registration  and reporting  for  pharmacists, physicians,  nurse                                                               
practitioners,   optometrists,  and   dentists.     This  ensures                                                               
providers  check  the  PDMP  prior to  dispensing  or  issuing  a                                                               
prescription to  a patient;  mandated registration  has increased                                                               
the  number of  users; however,  a number  of affected  providers                                                               
have not  yet registered  and await further  action by  the board                                                               
(slide 35).                                                                                                                     
                                                                                                                                
CO-CHAIR  SPOHNHOLZ asked  for the  difference in  number between                                                               
providers  who are  registered with  the U.  S. Drug  Enforcement                                                               
Administration  (DEA),  U.S.  Department of  Justice,  and  those                                                               
registered with the PDMP.                                                                                                       
                                                                                                                                
MS.  CARPENTER  explained  about  25 percent  of  each  licensing                                                               
category is not registered.                                                                                                     
                                                                                                                                
REPRESENTATIVE  PRUITT  questioned  whether  there  is  a  sunset                                                               
related to the PDMP.                                                                                                            
                                                                                                                                
MS. CARPENTER  recalled Senate Bill  74 included a sunset  on the                                                               
PDMP provision  which was  removed in House  Bill 159  [passed in                                                               
the Thirtieth Alaska State Legislature].                                                                                        
                                                                                                                                
5:06:48 PM                                                                                                                    
                                                                                                                                
CO-CHAIR  SPOHNHOLZ shared  other uses  for the  PDMP such  as to                                                               
notify providers of a drug overdose.                                                                                            
                                                                                                                                
MS.  CHAMBERS directed  attention to  slide 36  which illustrated                                                               
increased use of the PDMP by providers.                                                                                         
                                                                                                                                
REPRESENTATIVE  PRUITT   questioned  whether  the   division  has                                                               
options if a provider refuses to register or use the PDMP.                                                                      
                                                                                                                                
MS. CHAMBERS said  at this time the division can  review the rate                                                               
of  a  provider's  use  of  the PDMP  and  she  discussed  future                                                               
options.                                                                                                                        
                                                                                                                                
REPRESENTATIVE  PRUITT  urged  for   a  legislative  solution  to                                                               
[address providers who do not register or use the PDMP].                                                                        
                                                                                                                                
MS. CHAMBERS  advised Senate Bill  74 was also designed  to allow                                                               
subordinates to access and check the  PDMP so as not to overwhelm                                                               
providers.                                                                                                                      
                                                                                                                                
CO-CHAIR SPOHNHOLZ added [House Bill  159] expanded the number of                                                               
people who are allowed to perform data entry [into the PDMP].                                                                   
                                                                                                                                
MS.  CHAMBERS directed  attention to  slide 37  which illustrated                                                               
the number of prescriptions reported  in 2016 and 2017; there was                                                               
about a 10 percent decrease  in opioid prescriptions in the first                                                               
year of the PDMP.                                                                                                               
                                                                                                                                
5:12:47 PM                                                                                                                    
                                                                                                                                
CO-CHAIR ZULKOSKY  observed some  hospitals have  strengthened or                                                               
instituted  pain management  plans  in response  to  the rise  in                                                               
opioid use and  asked whether the division  considered the effect                                                               
of  programs,  such as  pill  counts  and  drug testing,  on  the                                                               
decreased availability of opioids.                                                                                              
                                                                                                                                
MS. CHAMBERS acknowledged there  may be other elements [affecting                                                               
drug use] that are  outside of the scope of the  PDMP.  She noted                                                               
the  related   boards  are  encouraging  more   collaboration  to                                                               
consider  how DCCED  can  help  facilitate conversations  between                                                               
pharmacists  and prescribers;  pharmacies need  to be  in contact                                                               
with all licensed  providers so they can  efficiently question or                                                               
confirm appropriate  drug use.  In  fact, this is a  recent issue                                                               
that has led to crises for some patients.                                                                                       
                                                                                                                                
CO-CHAIR  SPOHNHOLZ related  concerns  about the  PDMP for  those                                                               
with   issues  of   chronic  pain   who  may   suffer  unintended                                                               
consequences.                                                                                                                   
                                                                                                                                
5:18:11 PM                                                                                                                    
                                                                                                                                
MS. CHAMBERS opined the aforementioned  crises are not a negative                                                               
consequence  of Senate  Bill 74  but  are "growing  pains."   She                                                               
directed attention  to slide 38  which illustrated the  number of                                                               
patients receiving opioid prescriptions  has decreased except for                                                               
prescriptions   greater   than   100  milligram   (mg)   morphine                                                               
equivalent  per  day (MME).    She  pointed  out Senate  Bill  74                                                               
required  prescriber  boards   to  submit  recommendations  about                                                               
prescriptive  guidelines  to  the  legislature;  guidelines  were                                                               
completed in  2016 and  were primarily based  on the  Centers for                                                               
Disease  Control  (CDC),  U.S.  Department of  Health  and  Human                                                               
Services, guidelines.  She cautioned  there are no "hard and fast                                                               
rules"  in   this  regard,  thus   education  for   patients  and                                                               
prescribers   is  warranted.      Slide   39  provided   detailed                                                               
information  about  the  PDMP  annual  report  delivered  to  the                                                               
legislature   in   March   2019,   and   available   online   at:                                                               
pdmp.alaska.gov.                                                                                                                
                                                                                                                                
MS.  CARPENTER directed  attention to  slide 40  which identified                                                               
savings from  Medicaid reform and  other adjustments.   She noted                                                               
DHSS has already incorporated the shown savings into its budget.                                                                
                                                                                                                                
CO-CHAIR SPOHNHOLZ pointed  out DHSS has saved  over $139 million                                                               
by finding ways to better achieve its mission.                                                                                  
                                                                                                                                
CO-CHAIR   ZULKOSKY   observed   many   of   the   reforms   were                                                               
administrative but have also improved access to programs.                                                                       
                                                                                                                                
MS.  CARPENTER said  the section  1115  Behavioral Health  Waiver                                                               
will have  the most impact  to access because some  services that                                                               
were previously not Medicaid billable now are.                                                                                  
                                                                                                                                
CO-CHAIR ZULKOSKY  returned attention to  slide 40 and  asked Ms.                                                               
Carpenter   to  differentiate   between  GF   savings  and   cost                                                               
avoidance.                                                                                                                      
                                                                                                                                
5:24:39 PM                                                                                                                    
                                                                                                                                
MS. CARPENTER said she would provide  details in this regard.  In                                                               
further  response to  Co-Chair Zulkosky,  she  explained an  area                                                               
that may turn out  to be an offset - and not  cost avoidance - is                                                               
telehealth because DHSS  did not estimate a  specific money value                                                               
of  the savings  in telehealth;  telehealth savings  include DSDS                                                               
services and have the most potential for offset savings.                                                                        
                                                                                                                                
CO-CHAIR  ZULKOSKY  suggested  savings  and  realized  investment                                                               
under Medicaid reform and expansion may approach $250 million.                                                                  
                                                                                                                                
CO-CHAIR SPOHNHOLZ  questioned why savings related  to telehealth                                                               
are not measured.                                                                                                               
                                                                                                                                
MS. CARPENTER  advised major savings from  telehealth fall within                                                               
DCCED licensing  and would not  be reflected in  Medicaid reform;                                                               
for example, most telehealth savings  are part of "Tribal health"                                                               
and thus are  100 percent GF.  She offered  to conduct additional                                                               
research.                                                                                                                       
                                                                                                                                
CO-CHAIR  SPOHNHOLZ  recalled  telehealth  was  identified  as  a                                                               
"strategy"  as a  part  of Senate  Bill 74;  however,  no one  is                                                               
tracking how  much money  the state  is saving  - or  spending on                                                               
travel  that   could  be  avoided   -  by  expanding   access  to                                                               
telehealth.   She characterized telehealth  as a  future redesign                                                               
opportunity.                                                                                                                    
                                                                                                                                
5:29:49 PM                                                                                                                    
                                                                                                                                
MS.  CARPENTER  agreed the  cost  of  travel is  significant  for                                                               
Alaska.  She continued to slide  41 which was a graph that showed                                                               
enrollment  has  grown  over  the  past four  years  due  to  the                                                               
economic recession and Medicaid  expansion; however, reforms have                                                               
allowed  DHSS to  hold state  GF  spending per  enrollee flat  as                                                               
Medicaid  spending has  increased.   Slide 42  indicated the  per                                                               
enrollee  cost   curve  was  held  well   below  DHSS's  original                                                               
forecast.   She concluded Medicaid  reforms are effective  and an                                                               
accomplishment by DHSS.                                                                                                         
                                                                                                                                
CO-CHAIR ZULKOSKY urged DHSS to  provide more general information                                                               
on the  focus and mission  of its  programs and services,  and to                                                               
provide additional information on what  percent of Senate Bill 74                                                               
has been  fully realized and  the timeline required to  reach 100                                                               
percent of implementation.                                                                                                      
                                                                                                                                
MS. CARPENTER  agreed there are outstanding  provisions of Senate                                                               
Bill  74; for  example, one  state  plan option  is the  [section                                                               
2703/1945 of  the Social  Security Act]  Health Home  State Plan,                                                               
which  has  been delayed  until  the  results of  the  Providence                                                               
Family Medicine  Center medical home model  project become known,                                                               
because the state  would only receive eight  quarters of enhanced                                                               
90 percent  federal match.   Other provisions  of Senate  Bill 74                                                               
have been delayed due to "the right timing as well as just the,                                                                 
the mass amount of work for the department ... [that] would fall                                                                
on the same, you know, handful of individuals."                                                                                 
                                                                                                                                
CO-CHAIR ZULKOSKY restated her question.                                                                                        
                                                                                                                                
MS. CARPENTER said she would provide a percentage of the reforms                                                                
within the purview of DHSS that have been implemented.                                                                          
                                                                                                                                
CO-CHAIR SPOHNHOLZ acknowledged the amount of time and work                                                                     
needed to implement Senate Bill 74 and other reforms.                                                                           
                                                                                                                                
5:38:31 PM                                                                                                                    
                                                                                                                                
ADJOURNMENT                                                                                                                   
                                                                                                                                
There being no further business before the committee, the House                                                                 
Health and Social Services Standing Committee meeting was                                                                       
adjourned at [5:38] p.m.                                                                                                        

Document Name Date/Time Subjects
HB133 Supporting Document-Carey Case 4.22.19.pdf HHSS 4/23/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 133
HB133 Sectional Analysis ver M 4.24.19.pdf HHSS 4/25/2019 3:00:00 PM
HB 133
HB133 Supporting Document-Reference by Definition 4.22.19.pdf HHSS 4/23/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 133
HB133 Sponsor Statement 4.22.19.pdf HHSS 4/23/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 133
HB133 Fiscal Note DHSS DJJ 4.21.2019.pdf HHSS 4/23/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 133
HB084 Sectional Analysis 4.3.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HL&C 2/26/2020 3:15:00 PM
HB 84
HB084 Sponsor Statement 3.28.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HL&C 2/26/2020 3:15:00 PM
HB 84
HB084 Supporting Document- Breast Cancer in Women Firefighters.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HL&C 2/26/2020 3:15:00 PM
HB 84
HB084 Supporting Document- Asbestos 03.28.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HL&C 2/26/2020 3:15:00 PM
HB 84
HB084 Supporting Document- Letter of Support ACAT 4.3.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HL&C 2/26/2020 3:15:00 PM
HB 84
HB084 Supporting Document- RADS in Police from Chemical Spill 3.28.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HL&C 2/26/2020 3:15:00 PM
HB 84
HB084 Fiscal Note DLWD WC 04.03.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HL&C 2/26/2020 3:15:00 PM
HB 84
HB084 Letter of Support- APOA 3.28.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HL&C 2/26/2020 3:15:00 PM
HB 84
HB084 Opposition Document- AML Joint Insurance Association 3.29.2019.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HL&C 2/26/2020 3:15:00 PM
HB 84
HB084 Presentation 4.3.19.pdf HHSS 4/4/2019 3:00:00 PM
HHSS 4/25/2019 3:00:00 PM
HB 84
Medicaid Reform Update Presentation for HHSS April 25 2019.pdf HHSS 4/25/2019 3:00:00 PM
Medicaid Reform Update