Legislature(2009 - 2010)BUTROVICH 205
01/25/2010 01:30 PM Senate HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| SB199 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| *+ | SB 199 | TELECONFERENCED | |
SB 199-MEDICAID COVERAGE FOR DENTURES
1:30:41 PM
CHAIR DAVIS announced consideration of SB199 and asked Senator
Ellis to present the bill.
[Indisc. audio for much of Senator Ellis's introduction.]
1:31:15 PM
SENATOR ELLIS, sponsor of SB 199, thanked the committee for
hearing the bill and introduced his aid, Max Hensley. He
directed the committee's attention to an opinion piece he
authored that was published in The Senior Voice. In it he
related the striking story of an elderly man who walked into his
office about a year ago and threatened to commit suicide after
his interaction with the Medicaid adult dental office. The man
had qualified for dentures under the program but was told he had
to choose between his upper or lower denture at that time and
have the other denture installed the following year. He felt
frustrated and humiliated and didn't know where to turn.
SENATOR ELLIS reminded the committee that he supported a bill
last year to improve Medicaid coverage for dental health. When
the bill came before the committee, he agreed not to include
this provision for a two-year funding cycle in order to move it
through more quickly, but vowed to pursue the matter this
session.
1:34:15 PM
Allowing people to receive a full set of dentures at one time
will improve patients' oral health and reduce the impact on
Alaska's dentists. He introduced members of Alaska's dental
community, Dr. Dave Logan representing the Alaska Dental
Society, and Dr. Dirk Menard calling in from Fairbanks on
teleconference, and noted that the member's packets contain
letters of support from a wide variety of providers. Senator
Ellis was gratified by the number of people who came forward to
offer their support including AARP Alaska, the Alaska Primary
Care Association, Alaska Public Health Association, The State's
Joint Advocacy Board's Commission on Aging, Mental Health Trust
Authority, Governor's Council on Disabilities and Special
Education, The Advisory Board on Alcoholism and Drug Abuse, and
the Brain Injury Network.
SENATOR ELLIS continued; this bill allows patients who are
eligible for dentures under the Medicaid Adult Dental Program to
fund a complete set of dentures. Current law limits patients up
to $1150 in preventative or restorative services per year, a cap
that was designed to cover one half of a set of dentures. In
testimony before this committee in 2006, the designers of the
program stated their intention that patients would receive their
uppers on June 30th and their lowers on the first day of July in
the new fiscal year. That has not proved to be practical for the
state, for the dentists, or for the patients. Dental emergencies
cannot be scheduled around the state's fiscal calendar; patients
are suffering and dentists are being inconvenienced by this
rule. This is the kind of frustrating situation that gives
government and state agencies a bad name.
SB 199 does not increase the total amount of benefit a patient
is eligible for, but allows patients to access two years'
benefit in a single fiscal year to complete a relatively
expensive procedure in the most medically effective and cost
effective way, so everyone benefits. He asked for the
committee's support in passing the bill.
1:37:45 PM
MARIE DARLIN, Coordinator, Capital City Task Force, AARP, Juneau
Alaska added their support for this very important bill; it
makes sense for clients and providers.
1:38:43 PM
BRADLEY WHISTLER, Dental Officer, Department of Health and
Social Services (DHSS), said the department likes SB 199
conceptually. For adults needing an upper and lower denture, the
services would typically be done at the same time in dental
offices. The department noted that, with implementation of adult
preventive and restorative services in the Medicaid program,
recipients might time either an upper or lower denture at the
end of one fiscal year and have the other denture done at the
beginning of the next fiscal year. He is aware of circumstances
in which the timing did not work and patients had to wait an
extended period of time to get the opposing denture.
MR. WHISTLER continued; if the bill is passed, recipients and
dental providers will no longer be required to provide the upper
and lower dentures over a two-year period; they will be allowed
to utilize the annual limit for two years to complete the
procedure. The department has heard examples of patients
delaying extractions when they can't get the opposing denture
within the short time period [that would allow them to obtain a
full set in one procedure], which often leads to complications
requiring oral surgery, sometimes with sedation or general
anesthesia costs. However, the department is noting the
likelihood of increased expenditures for accelerating the annual
limit in proving these services and is concerned about the
administrative costs to implement the program. Dental services
and the prior authorization process by which they track the
annual limit are both based on the state fiscal year; so
implementing these services is going to require manually
tracking recipients who have received the services and
accounting for the annual limit over the two-year period to
ensure they are not getting additional services in the following
state fiscal year.
Because of these concerns, the department is not taking a
position of support or opposition to SB 199. Administrative
costs for implementing the changes reflected in the bill could
be reduced by eliminating partial dentures from the exception of
the $1150 annual limit. The department will continue to look at
the cost of the services and try to find ways to reduce the
administrative burden for implementation, but at this time the
estimates are as outlined in the fiscal note for this bill.
1:41:27 PM
SENATOR DYSON asked how the state got into this situation.
MR. WHISTLER replied that when this bill was first proposed,
they looked at a variety of levels in the annual limit. What
drove the process was the expenditure estimates for the bill and
the decision to keep enough in the limit to cover an upper or
lower denture within one fiscal year. In terms of timing,
especially in the first year of the program, some clients didn't
get services in time to get one denture done and found
themselves at the beginning of the state fiscal year having
spent the entire benefit and having to wait a year before
getting the other denture.
1:42:41 PM
SENATOR DYSON said he suspected that all dental experts,
including Mr. Whistler, would agree that having the option to
get both dentures done at the same time serves the clients'
interests best. He did not understand how they ended up with a
program that is suboptimal for the patient/clients just because
of administrative costs.
MR. WHISTLER answered that part of the decision was based on
expenditures for the program, and there was nothing that
precluded a person from getting both sets of dentures; the
Medicaid program just would not pay for it.
1:43:44 PM
SENATOR DYSON asked if he was saying that the way the federal
program is administered is what drove the decision.
MR. WHISTLER answered no, that all of the services in these
programs are optional services for the state to provide, so it
had nothing to do with federal law. It was an effort to expand
services while controlling expenditures. If they had been trying
to address this situation at the outset, they would have been
looking at an annual limit of $2300 or $2400.
1:44:35 PM
SENATOR DYSON prompted that they might have looked at the plan
Senator Ellis has suggested, $2300 over two years, a brilliant
solution that should net out. The senator disclosed that he
himself is undergoing some reconstructive dental work, which
piqued his interest in this issue. He discovered that dental
implants, which can sometimes prevent the need for partial
plates, are not covered even if the medical provider thinks that
is the best solution. He also wondered whether the program would
allow a patient to get the maximum annual benefit available and
make up the difference himself in order to receive optimal
treatment on any dental services.
1:47:18 PM
MR. WHISTLER responded that in terms of the program and
balancing costs, they looked at several possible approaches:
make a specific appropriation for these services so they are
monitored more carefully, set an annual limit, and look at what
services they will cover. They decided not to cover some
services including implants. They cover periodontal maintenance
in terms of scaling teeth but do not cover periodontal surgery.
They will do a root canal but do not pay for surgery to cap the
end of the tooth. It was a balancing act, deciding what the
program would cover and what it would not.
1:46:45 PM
SENATOR DYSON persisted, the program will pay for a bridge,
which would not be required for an implant; why not provide the
money a bridge would have cost and let the patient pay the
balance for the more optimal service?
MR. WHISTLER answered that most of the Medicaid program is
managed by services provided, so to provide just an open annual
limit was not an approach that was considered. He pointed out
that the current annual limit would not cover a three-unit
(complete) bridge. The plan was to expand the services
available, which were fairly limited in the adult Medicaid
program, and move toward better prevention and routine
restoration. They anticipated that there would be a co-pay by
recipients once they had exhausted their annual limit.
1:48:09 PM
SENATOR DYSON said his question was, why not let patients get
the benefit of what the state has agreed to pay and then allow
them to pay any balance required to get a superior service.
MR. WHISTLER replied that he doesn't have a better answer for
that. It is not an approach that was considered in implementing
these services. That would be basically just making a fixed
dollar amount available to any client for dental services.
1:48:53 PM
JON SHERWOOD, Medical Assistant Administrator, Department of
Health and Social Services, explained that the approach Senator
Dyson described wouldn't be allowed under federal law without
some kind of waiver, and when they looked at adding a dental
option, they didn't consider that. Under the Medicaid program
they have to define the procedures they will cover and pay the
cost of those procedures only. They were allowed to set a dollar
limit on what they would pay for dental services, but even that
required clarification from the federal government. They would
have to include all of the services they want to cover and just
set a dollar limit, and the belief at the time was that would
create a greater demand for dental services than was within the
target budget for the initial legislation.
1:50:45 PM
SENATOR THOMAS asked why the fiscal note shows no offset in
2012.
1:51:10 PM
MR. WHISTLER said denture expenditure has increased for each
fiscal year the program has been in place and there would be an
acceleration of expenditures in the first year as people got
both upper and lower dentures. With new individuals coming into
the program every year, they did not believe one year would be
adequate to fully meet the unmet demand for denture services.
Also, complete dentures generally require follow-up work.
Partial dentures are often an alternative to doing crown and
bridge work and can be less expensive, so he felt they would
continue to see more partial dentures in the program. The
department expects to see some offset in the third fiscal year,
at which time the fiscal note will drop down to zero in terms of
the denture expenditures in the program.
1:52:17 PM
SENATOR THOMAS said he is also concerned about the second fiscal
note. He questioned whether they had looked at the possibility
of modifying the existing computer program to assist in tracking
the amount of annual benefit used and patients' previous dental
history, or whether they are in some way constrained by the
federal government.
1:52:56 PM
MR. WHISTLER responded that there is no federal issue. The
entire claims processing and tracking system is based on the
state fiscal year. Reprogramming the system for a set of dental
services that works differently from the rest of the program
would probably be expensive. He deferred to John Sherwood
regarding whether they had considered reprogramming costs, and
said that, at least at the outset, tracking would be a manual
process.
1:53:47 PM
MR. SHERWOOD interjected that the claims processing system was
purchased in 1987 and was first used in 1989. They are looking
at ways to modify it but haven't found any yet. It is old and is
not a relational database, so changes are complicated and
expensive, though they may be possible. He said he will let them
know if they find solution, but so far it appears this will have
to be done manually.
1:55:12 PM
SENATOR THOMAS referred to previous discussions about electronic
versus manual claims and problems providers have experienced
with the filing of claims. He opined that, if this is yet
another issue with the system in place, and electronic records
are the way of the future, it may be wise to invest in a new
system now. The legislature would like to see it be as efficient
and accurate a system as possible. He suggested that Dr. Logan
might be willing to comment on that.
1:56:20 PM
SENATOR PASKVAN asked if the numbers in the fiscal note are
solely for dentures.
MR. WHISTLER answered yes.
SENATOR PASKVAN noted that the expected savings in travel
expense was not included.
MR. WHISTLER referred to his earlier testimony that there are
areas of potential savings to other parts of the Medicaid
program; one would be transportation expenses. If a second oral
surgery is required, that would be another source of potential
savings for the program as a whole. Since it is a separate
appropriation however, those transportation savings would be to
a different funding source in the Medicaid program.
1:57:28 PM
SENATOR PASKVAN asked if it is likely that transportation
services and emergency room expenses would overwhelm the numbers
in the fiscal note.
MR.WHISTLER could not speak to that level of detail regarding
what is going on in the program.
1:57:58 PM
DAVID LOGAN DDS, The Alaska Dental Society, Juneau Alaska,
thanked Senator Ellis and those on the committee who co-
sponsored this bill. He said his only regret is that the Alaska
Dental Society didn't think of it themselves; it is an elegant
solution to a long-standing problem, one that is fair to the
state, fair to the dental providers and especially great for the
recipients. Dental Medicaid providers are frequently placed in
the uncomfortable position of helping a patient decide which
arch they are going to do, upper or lower teeth. It is a
decision he hates to make. The patients turn to him for
guidance, but often the patient has either no teeth or two
hopeless sets of dentition. It is not an easy decision to make.
2:00:05 PM
DR. LOGAN said, as a provider in Southeast he also sees patients
from other communities, and the travel costs are not small. This
is a multi-step procedure that generally requires several
follow-up visits; by time a person flies in from another
community and stays at a hotel, the travel costs dwarf the cost
of the procedure.
He recounted a situation that illustrates the problem this
presents for patients and providers. A man was flown to Juneau
from Sitka; he actually lived in a community in the interior
that did not have access to dental care. Dr. Logan wrote to the
Medicaid division asking for authorization to cover both sets in
one visit and explained that travel costs would ultimately be
more than the cost of the dentures. He got a response from
Medicaid saying that their hands were tied under statute and
they could pay for only one. He asked his lab to provide a break
on the second arch and absorbed the additional cost to provide
his patient with a full set of dentures.
Addressing Senator Thomas's comments about electronic claims,
Dr. Logan asserted that they are not the wave of the future;
they are here now. He asked whether the department could
incorporate this into the new computer system they are
developing. He also agreed with Senator Paskvan regarding the
hidden costs they see with dentures: travel, the cost of
retaining hopeless teeth, and ER visits. Dental care is not
inexpensive, but a single ER visit can cover the cost of a
denture. Taking all of that into consideration, he thinks they
could see cost savings in the first fiscal year.
2:03:48 PM
SENATOR ELLIS thanked Dr. Logan and stated that, based on this
and other testimony today, he is going to ask the department to
reflect the cost savings even if it is not to the same portion
of the budget. It is clear that the state will realize
significant savings if this becomes law, so there has got to be
some way to reflect that in the fiscal note.
2:05:07 PM
DIRK MENARD, DDS, said he simply called to add his support. It
makes sense from a clinical and a fiscal standpoint to do both
sets of dentures at one time. Many times his office will make an
upper set only to find out next year it's in the wrong position
to the lower set and they have to re-do the whole process.
2:05:59 PM
SENATOR ELLIS asked if a person can chew food with one set of
dentures.
2:06:46 PM
MR. MENARD said not very effectively. When people lose their
teeth, the second set of dentures ends up holding the first set
in. It also helps in articulating.
2:07:59 PM
DENISE DANIELLO, Executive Director, Alaska Commission on Aging,
Department of Health and Social Services, said she believes this
bill will help to improve the health and wellness of older
Alaskans. The Commission on Aging has supported the Medicaid
dental program since it began in 2006. The Medicaid Adult Dental
Program helps many low income seniors who live with a variety of
painful and destructive dental problems and could not otherwise
afford routine visits or dentures.
Studies have shown the link between oral health and chronic
disease. Older adults are at high risk for dental decay, which
has been associated with periodontal disease, diabetes,
pneumonia, and cardiovascular disease. The inability to chew
food properly can lead to chronic malnutrition and associated
problems. Furthermore, seniors with ill-fitting dentures or
missing teeth may avoid opportunities for social engagement,
which is important to maintaining their physical and mental
health.
MS. DANIELLO provided some data based on Medicaid claims
information on seniors 65 years of age and older. It indicates
that a total of 3104 seniors used the Medicaid Adult Dental
Program between April 1, 2007 and December 31, 2009. Of this
number, 1200 seniors or 39 percent received dentures. (She
pointed out that this was an unduplicated count.) The Cost for
an upper denture was quoted as $1085, a lower as $1125, and
approximately $2225 for a complete set of dentures, which falls
just under the two-year cap of $2300.
She stressed that the Alaska Commission on Aging supports the
bill and asked that the legislature consider their
recommendations for future improvements to the Adult Medicaid
Program. They recommend allowing eligible patients access to two
years' total funding if they receive partial dentures and need
additional denture services in the same year. Pending approval
of SB 199 and its successful implementation, they believe the
legislature should begin working with the department to expand
the two-year access to cover other services that are included
under the Medicaid Adult Dental Program such as root canals,
crowns and even dental exams. They also believe the legislature
should consider adjusting the current cap, as it has not been
changed for at least three years.
2:13:20 PM
CHAIR DAVIS closed testimony on SB199. She said this is a good
piece of legislation and it is her intention to move it out of
committee. She asked if there are any other comments at this
time.
2:14:19 PM
SENATOR PASKVAN said, as he sees it, the two issues before the
committee come down to 1) the offset, which he believes will
equal out and 2) the savings. When he looks at the savings in
travel, lodging and other medical costs, he believes this is the
right answer at the right time. He likes the bill.
2:15:06 PM
SENATOR DYSON pointed out that the committee has the authority
to alter the fiscal note and there are excellent points in favor
of doing that. He suggested that the committee do that while it
is in their purview and make it easier for the Finance
Committee. He does not want Finance to have the easy excuse of
what may be an over-stated fiscal note to deny this. Part of the
fiscal note anticipates an increased number of people signing
up, which has nothing to do with the bill, so the fiscal note is
misleading in at least one and possibly more than one point.
2:16:18 PM
CHAIR DAVIS thanked Senator Dyson for his statement. She thinks
some adjustments will be made, perhaps in Finance, but said they
should let the Finance Committee do their job.
2:16:46 PM
SENATOR ELLIS added, with respect for Senator Dyson's comments,
he wished he were comfortable making that change in a way that
would not offend the people at Health and Social Services and
would move them further along. He is also uncomfortable with
some of the numbers the department put forward, but is sure this
is their best effort and they are still working on it. He said
he has made a request to the department to find some way in the
fiscal note to accommodate the savings that common sense tells
them will be there, but he does not feel qualified to make that
adjustment here. He does not believe Finance would use this note
as an excuse not to hear the bill and consider it and hopes they
can work together on it at that level.
2:18:28 PM
VICE-CHAIR PASKVAN moved to report SB 199 from committee with
individual recommendations and attached fiscal note(s). There
being no objection, the motion carried and SB 199 passed from
committee.
2:19:19 PM
There being no further business to come before the committee,
Chair Davis adjourned the meeting at 2:19 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| Scanned Bill 199.pdf |
SHSS 1/25/2010 1:30:00 PM |