Legislature(2013 - 2014)HOUSE FINANCE 519
02/25/2014 01:30 PM House FINANCE
| Audio | Topic |
|---|---|
| Start | |
| SB49 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| += | SB 49 | TELECONFERENCED | |
HOUSE FINANCE COMMITTEE
February 25, 2014
1:33 p.m.
1:33:16 PM
CALL TO ORDER
Co-Chair Stoltze called the House Finance Committee meeting
to order at 1:33 p.m.
MEMBERS PRESENT
Representative Alan Austerman, Co-Chair
Representative Bill Stoltze, Co-Chair
Representative Mark Neuman, Vice-Chair
Representative Mia Costello
Representative Bryce Edgmon
Representative Les Gara
Representative David Guttenberg
Representative Lindsey Holmes
Representative Cathy Munoz
Representative Steve Thompson
Representative Tammie Wilson
MEMBERS ABSENT
None
ALSO PRESENT
Michael Barnhill, Deputy Commissioner, Department of
Administration; William Streur, Commissioner, Department of
Health and Social Services; Stacie Kraly, Assistant
Attorney of Law, Department of Law; Senator John Coghill;
Representative Gabrielle Ledoux.
SUMMARY
SSSB 49 (FIN)
MEDICAID PAYMENT FOR ABORTIONS; TERMS
SSSB 49 (FIN) was HEARD and HELD in committee for
further consideration.
SPONSOR SUBSTITUTE FOR SENATE BILL NO. 49 am
"An Act relating to women's health services and
defining 'medically necessary abortion' for purposes
of making payments under the state Medicaid program."
1:33:30 PM
Co-Chair Stoltze continued deliberations on HB 49. He
invited the administration to testify and introduced
committee members.
Representative Wilson asked if the "medically necessary"
clause could be used for both state insurance and Medicaid.
MICHAEL BARNHILL, DEPUTY COMMISSIONER, DEPARTMENT OF
ADMINISTRATION, replied that the legislature had the
ability to clarify a definition applying to the state's
employee health plan. He offered to discuss the potential
to amend the state's health care plan.
Representative Wilson appreciated the effort. She wished to
clarify the definition of "medically necessary" for both
Medicaid and the state health plan.
1:37:00 PM
Mr. Barnhill discussed statistics related to the state's
employee health plan, AlaskaCare. He listed seven claims
for induced abortions in 2010, five were denied, one was
approved, reviewed and denied, and the seventh was
processed incorrectly. He stated that most insurance plans
required medical procedures to be deemed medically
necessary. He wished to identify a more concrete and
explicit definition of the term "medically necessary." He
added that all claims submitted for abortion in 2011 were
denied.
Mr. Barnhill stated that insurance plans preferred not to
pay for care that was not certified as medically necessary.
He pointed out other medical procedures that were not
deemed necessary. The state employee health plan required
analysis for the medical necessity of treatment. He noted
that the new state health care provider, AETNA had compiled
a list of procedures and treatments deemed medically
necessary. Elective abortion was not covered by the state
insurance clinical policy bulletins. If a procedure was
done for the convenience of a patient, it was not medically
necessary. He believed that the current administration of
the state plan was standard and appropriate.
1:41:34 PM
Representative Wilson appreciated the information. She
stated that the process used by the state seemed sound. She
wondered why a similar process was not used by Medicaid.
Co-Chair Stoltze asked if a preapproval period was similar
to a waiting period.
Mr. Barnhill replied that precertification was required for
some medical procedures; abortion was not included. The
list of procedures was compiled by AETNA with the view that
certain procedures required precertification for various
reasons.
Co-Chair Stoltze asked about the approval process time
required for an elective procedure.
1:44:27 PM
Mr. Barnhill replied that approval required longer than 24
hours.
Representative Wilson repeated her question.
WILLIAM STREUR, COMMISSIONER, DEPARTMENT OF HEALTH AND
SOCIAL SERVICES, replied that Medicaid was an entitlement
program. He stated that the program did observe allowable
medical procedures in a method similar to that of the
state's insurance. He mentioned the program's practice of
prior authorization and retrospective review for procedures
suspected to be elective rather than necessary.
1:47:25 PM
Representative Wilson understood that the regulations were
undergoing a change in process. She hoped to imitate the
successful state insurance practice of paying for
procedures that were thoughtfully deemed medically
necessary.
Commissioner Streur stated that the Medicaid process was
similar to the one used by the state healthcare system. He
explained that the fear of a lawsuit was present regarding
denial of payment for pregnancy terminations. He offered to
review the rigorous process offered to state employees by
AETNA.
Representative Wilson wished to remain consistent in her
position of supporting groups receiving insurance from
Medicaid and those receiving insurance from other sources.
She advocated for consistency among the approaches and
services offered in the state.
Co-Chair Stoltze discussed the potential for litigation in
many capital project proposals. He opined that a decision
for public policy should not be made with litigation in
mind.
1:51:05 PM
Representative Wilson argued that if one state plan was not
challenged, then why not incorporate a similar method for
Medicaid.
Representative Edgmon clarified that Medicaid patients were
in the lower income strata. He believed that the different
strata should be viewed differently.
1:52:52 PM
Commissioner Streur noted that SB 49 discussed a
definition, while Mr. Barhnill discussed a process. He
stated that that a published definition for abortion
coverage did not exist in the state employee health plan.
He agreed that comparisons of the two plans were difficult.
Mr. Barnhill agreed that abortion was not specifically
defined in the state employee health plan book.
1:54:55 PM
Representative Costello asked about the process regarding a
Medicaid recipient who had an abortion. She understood that
the paperwork was submitted to the Department of Health and
Social Services following completion of the procedure.
Commissioner Streur concurred. He noted that recipients
were sometimes flown to Anchorage without knowing whether
the appointment was for family planning counseling or an
abortion. If an abortion was performed, the provider
submitted a form stating that the pregnancy was either the
result of rape or incest or medically necessary. He noted
that all of the forms for the last three years were
identified as "medically necessary." In 2012, he
implemented strict use of the Medicaid form. In 2013, the
current form was drafted and included approximately 20
examples of potential medical necessity. He added that
Alaska had the highest rate of domestic violence and sexual
assault in the nation.
1:57:52 PM
Representative Costello asked if the bill would change the
course of events. She wondered if women on Medicaid would
wait for approval to move forward with a planned abortion
if the legislation were to pass.
Commissioner Streur stated that the statute would not
change the process significantly. He believed that the
stricter rules and parameters would be established for
abortions paid for by Medicaid under the statute.
Representative Costello asked if Medicaid recipients would
undergo the abortion procedure prior to the submission of
the insurance paperwork. She asked the price of a medical
abortion procedure.
1:59:21 PM
Commissioner Streur believed that there was no requirement
for a waiting period prior to the procedure; the
legislation did define which abortions would be eligible
for payment. The cost of the procedure was approximately
$600.
Representative Gara asked how long Mr. Barnhill was an
assistant Attorney General.
Mr. Barnhill replied 12 years.
Representative Gara asked if the greatest opportunity for
lawsuit was during a violation of a Supreme Court order. He
stated that a Supreme Court order defined abortions allowed
under state law. The state signed a consent decree in 2011
to define medically necessary.
Mr. Barnhill replied that people can sue any time about
anything. A complaint in the United States could be heard
before a court of law in any state in the country.
Representative Gara asked if it was very likely that
violating a Supreme Court order would result in litigation.
Mr. Barnhill refused to testify about whether an action was
very likely to result in litigation.
Representative Gara argued that a definition for medical
necessity already existed in state law. He asked if the
definition in SB 49 was different from that established in
the Supreme Court opinion and the settlement between the
state and the parties.
STACIE KRALY, ASSISTANT ATTORNEY OF LAW, DEPARTMENT OF LAW,
requested further information about the consent decree.
2:04:17 PM
Representative Gara replied that the consent decree defined
medically necessary shall be certified by a physician to
ameliorate a condition harmful to the woman's physical or
psychological health.
Co-Chair Stoltze asked for the consent decree in writing
for members and sponsors to refer to.
Representative Gara responded that the consent decree
included language related to harm to a woman's physical and
psychological health, while the definition in SB 49 omitted
the words "psychological health."
Ms. Kraly replied that the Supreme Court did articulate a
list of conditions with a reference to bipolar disorder.
The list was not identified as a definition of medical
necessity. She wished to see the consent decree to
determine whether it related to the 2001 Planned Parenthood
decision.
2:06:13 PM
Representative Gara asked for an estimate for the potential
litigation cost.
Commissioner Streur replied that he did not have an
estimate of the cost of a potential litigation.
Representative Gara wished to review facts related to the
women's health program.
Co-Chair Stoltze replied that the issue was discussed
earlier.
Representative Gara wished to gain an understanding about
the elimination of the women's health program from the CS
earlier in the day.
Co-Chair Stoltze allowed the discussion.
Representative Gara asked the commissioner about the
differences between coverage of family planning under the
women's health program, which was deleted from the
legislation. He asked if the women's health program covered
women without children, while Medicaid extended family
planning services to women with children.
2:08:15 PM
Commissioner Streur concurred; the two options were
different. The "people" were not eligible for Medicaid.
Representative Gara asked if Medicaid did not cover family
planning coverage for women with children at a certain
income level.
Commissioner Streur replied that childless adults not
eligible for Medicaid coverage under 100 percent of poverty
level were few. Most adults with children had some level of
coverage within Medicaid and would be eligible for family
services.
Representative Gara asked about a pregnant woman without
children.
Commissioner Streur replied that once a woman became
pregnant, she was eligible for an array of Medicaid service
upon application.
Co-Chair Stoltze requested that committee members request
answers instead of validation.
Representative Gara asked if the family planning services
were the same ones available under the women's health
program.
Commissioner Streur believed so.
Representative Gara asked about the income limit for
participation in the program for family planning services.
Commissioner Streur stated 100 percent of federal poverty
level was the requirement for Medicaid; the family planning
amendment removed in the morning meeting was 175 percent. A
pregnant woman who qualified for Denali Kid Care (DKC)
would be eligible up to 175 percent of poverty level.
2:11:14 PM
Representative Gara asked which pregnant women would not be
covered by DKC.
Commissioner Streur replied that most pregnant women at or
below 175 percent of poverty level would be covered by DKC.
He noted that the women must apply for DKC.
Representative Gara asked which women would not be covered.
Commissioner Streur stated that exceptions existed, but he
believed that most women in the mentioned parameters were
covered.
Representative Gara asked if all pregnant women seeking
family planning services were covered under the women's
health program.
Commissioner Streur concurred.
Representative Gara understood that DKC covered
approximately 65 percent of federal funding. He asked if
the family planning services under the women's health
program would be covered at 90 percent of federal funding.
Commissioner Streur replied yes.
2:12:42 PM
Representative Holmes asked about the regulations proposed
that were similar to the legislation. She wondered about
the different elements. She requested further explanation
about the differences.
Commissioner Streur commented on the differences between
the regulations and the bill. He assumed that the requested
difference was related to the psychiatric disorder
component. He stated that the decision to include the issue
was difficult, but he wished to include a portion that
would survive challenge for the continued movement toward a
meaningful program. The language was related to a
psychiatric disorder that placed a woman in imminent danger
of medical impairment of major bodily function if abortion
is not performed.
Representative Holmes noted earlier questions regarding the
omission of mental health in the bill language.
Co-Chair Stoltze stated that Senator Coghill would share
information received by the Alaska Mental Health Trust
during recent discussions.
Representative Holmes wished to provide the commissioner
the opportunity to address the issue.
Co-Chair Stoltze believed that the commissioner was present
during the mentioned conversations.
Representative Holmes requested additional information
related to a nonviable fetus and abortion.
Co-Chair Stoltze relayed that a fetus could be referred to
as a baby.
Representative Holmes understood. She wished to understand
the coverage available for women encountering this very
difficult and rare situation.
2:16:32 PM
Commissioner Streur replied that that he believed that the
procedure was covered in the unlikely event of a woman
carrying a nonviable fetus.
Representative Holmes requested further confirmation from
the department.
Representative Munoz asked about abortions that were not
funded for reasons that were not deemed medically
necessary.
Commissioner Streur expressed confidence that abortion
procedures were delivered, but not paid for by insurance.
He had no knowledge of the denial of abortion payments from
Medicaid during the last calendar year.
Representative Munoz asked if all medically funded
abortions were approved by Medicaid regardless of medical
necessity.
Commissioner Streur disagreed. He stated that the form
required for reimbursement required certification of
medical necessity by the physician performing the
procedure.
Representative Munoz asked if the commissioner was aware of
any procedures rejected for Medicaid reimbursement.
Commissioner Streur replied that a request filed without
the certification was denied, however, requests without
certification were not received in the last year.
2:19:14 PM
Representative Edgmon discussed data related to pregnancies
in Alaska. He read from literature provided by the
Guttmacher Institute that approximately 50 percent of
pregnancies were unwanted at a huge cost absorbed by state
agencies. The majorities of unwanted pregnancies were
unintended and could have been prevented with additional
family planning services.
Commissioner Streur was familiar with the source. He stated
that he read the article and noted that the assumptions
made by the large research institute could not be
corroborated or denied.
2:22:10 PM
Representative Edgmon wondered if more family planning
services could reduce the number of unwanted pregnancies.
He wondered if increased family planning services might
save the state money.
Co-Chair Stoltze asked about the parameters of family
planning.
2:23:13 PM
SENATOR JOHN COGHILL stated that the Guttmacher Institute
was credible and pro-abortion. He was unsure of related
statistics in Alaska. He found it difficult to believe that
50 percent of pregnancies in Alaska were unintended and
unwanted. He noted that the discussion of family planning
begged the question "are our families deeply involved the
way they should be." He wondered if Planned Parenthood was
the optimal location for family planning resources, as
their main goal was family planning for contraception and
abortion, which he considered a method of population
control rather than family planning.
Senator Coghill stated that Planned Parenthood was the
aggressive litigant in every abortion case in Alaska
proposing that abortion be performed with the lowest
possible threshold to entrants. He understood that the goal
of Planned Parenthood was to protect women's right to
choose. He agreed that women deserved the right to choose,
but that right was not a financial responsibility of
government. He opined that the cost of an elective abortion
was the responsibility of the woman. The state would
provide funds for preventative services and education
related to pregnancy. He agreed that unintended pregnancies
should be prevented by wise choices
2:26:41 PM
REPRESENTATIVE GABRIELLE LEDOUX, explained that the bill's
attempt was to define the term "medically necessary" as
related to an abortion procedure. She argued that a
discussion about family planning was better suited to a
budget discussion for the Department of Health and Social
Services. She stated that the proposed legislation was
simple and ought not to be decorated with family planning
amendments.
Representative Edgmon pointed out the economic perspective
of his argument. He wondered if state savings could be
realized with a reduction of unwanted pregnancies. He
believed that a correlation existed between state savings
and family planning.
Commissioner Streur spoke to family planning aspect of the
bill. He noted that his response to Representative Gara
related to family planning was relevant to Medicaid and
DKC. He stated that family planning services were offered
in most public health centers. The services covered at 90
percent/10 percent were available to any woman presenting
for diagnosis of general reproductive health conditions,
diagnosis of sexually transmitted diseases and infections
and for contraception. All other family planning services
were covered at 50 percent. He stated that the public
health center staff distributed contraception and had for
many years at a cost of $800 per participant.
2:30:30 PM
Representative Guttenberg asked if the commissioner
participated in the creation of the list of acceptable
reasons for an abortion.
Commissioner Streur responded in the negative.
Representative Guttenberg asked if there was another
medical procedure that required a similar list of
prerequisites.
Commissioner Streur answered that most medical procedures
were approved with prior authorization or retrospective
review utilizing specific criteria. He noted that the
manner of publishing the requirements was different for the
abortion procedure.
Representative Guttenberg asked if another procedure was
described or delineated similarly in statute.
Commissioner Streur replied that there was limited scope in
regulation, but he could not speak to statutorily
requirements.
Senator Coghill surmised that since Row vs Wade there had
not been another similarly litigated health topic. He noted
that the definition of medically necessary emanated from a
consent decree through a Supreme Court Case. He pointed out
language protecting the doctor's opinion. The goal was to
protect the life of the mother to the extent possible.
2:32:54 PM
Representative Guttenberg asked about Tay-Sachs disease.
Senator Coghill did not know about Tay-Sachs disease.
Representative Guttenberg read from a dictionary, that Tay-
Sachs disease was a "hereditary disorder caused by the
absence of an enzyme needed to break down fatty material
leading to death in childhood." He wondered why the disease
was not included in the list of approved medically
necessary reasons for compensated abortion.
Representative Ledoux replied that the item related to the
death of a child and not the mother. The list of medically
necessary diseases included those related to the death of
the mother, not the death of the child.
Representative Guttenberg asked how that was different from
sickle cell.
Senator Coghill relayed that the sickle cell anemia listed
was a concern to the mother.
Representative Holmes MOVED friendly AMENDMENT related to
Senator Coghill's testimony. She corrected that he had
meant the responsibility of the woman and man when he
discussed payment for an elective abortion.
Senator Coghill appreciated the correction.
2:35:35 PM
Representative Wilson asked about the process between the
patient, her doctor and the state.
Commissioner Streur replied that the procedure was first
performed. The provider then submitted a form attesting to
the medical necessity of the procedure. Without the form,
the physician would not be paid for the procedure.
Representative Wilson expressed confusion about the process
and how the bill would change it.
Commissioner Streur replied that the determination of
medical necessity could be conducted at any time. He stated
that the medical review of a chart could occur at any time.
2:38:10 PM
Representative Wilson opined that the bill addressed the
medical necessity of one procedure alone. She wondered if a
doctor would deny services to a woman if the procedure was
not deemed medically necessary.
Commissioner Streur replied that the doctor would make the
decision to either perform the procedure or submit the form
certifying medical necessity or receive other means of
payment. The choice would be left to the woman to go
forward with the procedure or to remain pregnant.
Representative Wilson posed a scenario in which the
abortion procedure requested was not medically necessary.
She asked about additional means of payment for abortion
services. She wondered what would happen to the woman who
chose to have an abortion despite the doctor's denial of
medical necessity.
2:40:42 PM
Commissioner Streur replied that other funding sources
existed to help women in need. He could not speak about the
safety of procedures offered at discount rates; he could
only speak to Medicaid.
Representative Wilson commented that the Alaska Bureau of
Vital Statistics provided a form related to abortion
procedures. She wondered about the "other" category listed
on the form in which 766 abortions were documented in 2012.
2:42:40 PM
Commissioner Streur offered to visit the Alaska Bureau of
Vital Statistics to obtain and provide the requested
information.
Representative Gara stressed the goal of limiting the
number of unwanted pregnancies and abortions. He asked
about the difference in coverage between DKC and the
women's health program. He understood that DKC allowed
coverage during pregnancy up to 175 percent of the poverty
level with the option for family planning services. He
expressed interest in the family planning options available
for women who were not pregnant and wished to avoid
pregnancy. He noted that an adult woman was not eligible
for DKC unless she was pregnant.
Commissioner Streur agreed.
Representative Gara pointed out that a non-pregnant adult
without children was not eligible for family planning
services under DKC.
Commissioner Streur concurred.
Representative Gara asked if the women's health program
allowed a non-pregnant childless woman contraceptive and
other family planning services.
2:45:44 PM
AT EASE
2:46:03 PM
RECONVENED
Commissioner Streur replied that a non-pregnant woman who
was not receiving Medicaid could receive services through a
public health center.
Representative Gara asked specifically about the women's
health program.
Commissioner Streur stated that an expansion of the program
was necessary for the inclusion of women who were not
eligible for Medicaid; the expansion would be similar to
that discussed for Medicaid.
Representative Gara asked if Alaska applied to the federal
government for the amount eligible through the American
Affordable Care Act, would a non-pregnant adult woman
receive contraceptive services under the women's health
program, but not under DKC.
2:48:58 PM
Representative Gara asked again if the state applied to
obtain the women's health coverage program up to 175
percent of the poverty level as was allowed under the
American Affordable Care Act would family planning services
including contraception be covered for non-pregnant women
in the state.
Commissioner Streur replied yes.
Representative Gara asked if the option available under an
expansion of the women's health program to non-pregnant
adult women were unavailable in the state through DKC.
Commissioner Streur agreed.
2:50:47 PM
Representative Munoz asked about Medicaid and the 90/10
split available for three categories of service. She
wondered if the population would be eligible for other
services at the 50/50 split.
Commissioner Streur responded that the three categories for
the 90/10 split included the diagnosis of general
reproductive health conditions, the diagnosis of sexually
transmitted infections and contraception. He noted that
family planning related services such as the treatment of
the diagnosed conditions were eligible for the normal
federal participation rate of 50 percent.
Representative Munoz asked if the legislation's fiscal note
included the 50/50 cost to the state.
Commissioner Streur stated that he was unsure, but would
provide the answer to the committee.
2:52:40 PM
Senator Coghill appreciated the time spent on the issue. He
appreciated the issue's complexity. He explained the
state's agreement with the federal government to care for
people under certain economic conditions. He noted that a
process was defined regarding medical necessity. The narrow
legislation was highly litigated and required fine
attention to the definition of medical necessity. He added
that peripheral issues of philosophy and practice added to
the complexity. The goal of the sponsor was to allow for
state funded abortions that benefited the health and life
of the mother.
Representative Ledoux thanked the committee. She opined
that the discussion assumed that care provided in a public
health clinic was substandard. She stressed that the
clinics provided family planning services and she herself
had taken advantage of services from the Kodiak public
health clinic.
Co-Chair Stoltze stated that he did not want to rush the
committee through the process. He opined that proper public
process would require additional debate and consideration
of the legislation. He noted the submission of an amendment
that would be discussed in a future meeting.
2:57:06 PM
Co-Chair Stoltze believed that the fiscal note was
accurately expressed.
Co-Chair Stoltze discussed the next day's schedule.
SSSB 49 (FIN) was HEARD and HELD in committee for further
consideration.
ADJOURNMENT
2:59:30 PM
The meeting was adjourned at 2:59 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 49 Testimony HFIN.pdf |
HFIN 2/25/2014 1:30:00 PM |
SB 49 |
| SB 49 Amendment #1 Gara-Guttenberg.pdf |
HFIN 2/25/2014 1:30:00 PM |
SB 49 |