Legislature(2015 - 2016)HOUSE FINANCE 519
03/28/2016 01:30 PM House FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| SB74 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 74 | TELECONFERENCED | |
| + | TELECONFERENCED |
HOUSE FINANCE COMMITTEE
March 28, 2016
1:31 p.m.
1:31:12 PM
CALL TO ORDER
Co-Chair Thompson called the House Finance Committee
meeting to order at 1:31 p.m.
MEMBERS PRESENT
Representative Mark Neuman, Co-Chair
Representative Steve Thompson, Co-Chair
Representative Dan Saddler, Vice-Chair
Representative Bryce Edgmon
Representative Les Gara
Representative Lynn Gattis
Representative David Guttenberg
Representative Scott Kawasaki
Representative Cathy Munoz
Representative Lance Pruitt
Representative Tammie Wilson
MEMBERS ABSENT
None
ALSO PRESENT
Heather Shadduck, Staff, Senator Pete Kelly; Jeff Jessee,
Chief Executive Officer, Alaska Mental Health Trust
Authority; Karen Forrest, Deputy Commissioner, Department
of Health and Social Services; Randall Burns, Director,
Division of Behavioral Health, Department of Health and
Social Services; Kate Burkhart, Executive Director, Alaska
Mental Health Board and Advisory Board on Alcoholism and
Drug Abuse, Division of Behavioral Health, Department of
Health and Social Services; Jon Sherwood, Deputy
Commissioner, Medicaid and Health Care Policy, Department
of Health and Social Services; Valerie Davidson,
Commissioner, Department of Health and Social Services;
Duane Mayes, Director, Division of Senior and Disabilities
Services, Department of Health and Social Services.
PRESENT VIA TELECONFERENCE
Charlie Curie, CEO, The Curie Group LLC, Maryland; Shane
Spotts, Contractor, Senior Disability Services, Health
Management Associates.
SUMMARY
CSSB 74(FIN) am
MEDICAID REFORM;TELEMEDICINE;DRUG DATABASE
CSSB 74(FIN) am was HEARD and HELD in committee
for further consideration.
Co-Chair Thompson discussed housekeeping.
CS FOR SENATE BILL NO. 74(FIN) am
"An Act relating to diagnosis, treatment, and
prescription of drugs without a physical examination
by a physician; relating to the delivery of services
by a licensed professional counselor, marriage and
family therapist, psychologist, psychological
associate, and social worker by audio, video, or data
communications; relating to the duties of the State
Medical Board; relating to limitations of actions;
establishing the Alaska Medical Assistance False Claim
and Reporting Act; relating to medical assistance
programs administered by the Department of Health and
Social Services; relating to the controlled substance
prescription database; relating to the duties of the
Board of Pharmacy; relating to the duties of the
Department of Commerce, Community, and Economic
Development; relating to accounting for program
receipts; relating to public record status of records
related to the Alaska Medical Assistance False Claim
and Reporting Act; establishing a telemedicine
business registry; relating to competitive bidding for
medical assistance products and services; relating to
verification of eligibility for public assistance
programs administered by the Department of Health and
Social Services; relating to annual audits of state
medical assistance providers; relating to reporting
overpayments of medical assistance payments;
establishing authority to assess civil penalties for
violations of medical assistance program requirements;
relating to seizure and forfeiture of property for
medical assistance fraud; relating to the duties of
the Department of Health and Social Services;
establishing medical assistance demonstration
projects; relating to Alaska Pioneers' Homes and
Alaska Veterans' Homes; relating to the duties of the
Department of Administration; relating to the Alaska
Mental Health Trust Authority; relating to feasibility
studies for the provision of specified state services;
amending Rules 4, 5, 7, 12, 24, 26, 27, 41, 77, 79,
82, and 89, Alaska Rules of Civil Procedure, and Rule
37, Alaska Rules of Criminal Procedure; and providing
for an effective date."
1:32:09 PM
HEATHER SHADDUCK, STAFF, SENATOR PETE KELLY, referred to
the document, "Medicaid Reform Topic and Section
Reference", which detailed which section and page number
specific Medicaid topics could be found in the legislation.
She said that the hope was that behavioral health would be
integrated into the reformed Medicaid system. She said that
the sections that referred to behavioral health were as
follows:
Sec. 28 - Medicaid Reform Program (b) - Comprehensive
Behavioral Health Program
Ms. Shadduck read from the section:
(b) The department shall, in coordination with the
Alaska Mental Health Trust Authority, efficiently
manage a comprehensive and integrated behavioral
health
program that uses evidence-based, data-driven
practices to achieve positive outcomes for people
with mental health or substance abuse disorders
and children with severe emotional disturbances.
The goal of the program is to assist recipients of
services under the program to recover by achieving the
highest level of autonomy with the least dependence on
state-funded services possible for each person. The
program must include
(1) a plan for providing a continuum of
community-based services to address housing,
employment, criminal justice, and other relevant
issues;
(2) services from a wide array of providers
and disciplines, including licensed or
certified mental health and primary care
professionals; and
(3) efforts to reduce operational barriers
that fragment services, minimize
administrative burdens, and reduce the
effectiveness and efficiency of the program.
Sec. 30 - (f) 1115 Waiver for behavioral health
Ms. Shadduck explained that Section 30 pertained
specifically to waivers and would be discussed further by
the departments.
Sec. 31 - ER Project - (a)(4)
Ms. Shadduck relayed that the section called for a process
for assisting users of emergency departments in making
appointments with primary care or behavioral health
providers within 96 hours after an emergency department
visit.
Sec. 31 - Coordinated Care Project (a)(1)
Ms. Shadduck relayed that behavioral health would be an
option under the program.
Sec. 33 - Removal of Grantee Requirement for Community
Mental Health Clinics
Sec. 34 - Removal of Grantee Requirement for Drug &
Alcohol treatment centers & Community Mental Health
Clinics
Ms. Shadduck explained that Sections 33 and 34 would remove
the requirement for a clinic, or rehabilitative service, to
receive a grant from the Division of Behavioral Health in
order to bill Medicaid.
1:35:30 PM
Ms. Shadduck spoke to Section, "Waivers (1915 i & k
options, 1945 Health Homes, 1115 Waivers". She cited a
document from the department that delineated basic waiver
information (copy on file).
Ms. Shadduck continued to Section 41, "Medicaid State Plan;
Waivers; Instructions; Notice to Revisor of Statutes". She
said that Section 38, "Implementing the Federal Policy on
Tribal Medicaid Reimbursement" would conclude the
discussion.
Co-Chair Thompson asked Ms. Shadduck for a list of the
sections under discussion.
Ms. Shadduck referred back to the document that had been
previously distributed, "Medicaid Reform Topic and Section
Reference". She reiterated that the sections pertaining to
behavioral health were: 28, 30, 31, 33, 34; for waivers: 30
and 41; for the federal rule change: 38.
1:37:48 PM
JEFF JESSEE, CHIEF EXECUTIVE OFFICER, ALASKA MENTAL HEALTH
TRUST AUTHORITY, provided context for the presentation. He
asserted that beneficiaries of the mental health trust
included more than people with behavioral health problems.
He avowed that behavioral health would be a key element for
successful Medicaid reform. He believed in moving away from
a fee-for-services, to a value based system: paying for
outcomes, rather than activities. He shared that the trust
had made a substantial investment in assisting the state
with Medicaid reform, and had retained the services of
experts on the matter. He introduced Charlie Curie and
provided information about his employment background, which
involved time spent in Alaska.
1:40:04 PM
CHARLIE CURIE, CEO, THE CURIE GROUP LLC, MARYLAND (via
teleconference), provided additional history of his time in
Alaska. He said that he had visited every corner of the
state and had met with Alaska Native Corporations during
his research into healthcare in Alaska. He had formerly
been Deputy Secretary for Mental Health and Substance Abuse
Services for the State of Pennsylvania, where he had
implemented a behavioral health Medicaid program. He said
he would be drawing on all of his past experiences in the
field to bring his expertise to our unique, frontier state.
He credited the legislature and the administration for
prioritizing the topic. He provided a PowerPoint
presentation, "Behavioral Health System Transformation"
dated March 28, 2016 (copy on file). He spoke to Slide 2,
"Trends in Public Behavioral Health":
· States Facing "Intractable" Challenges
· Opioid Epidemic identified by Public Officials
o Governors and Legislatures Have Prioritized
Issue
o Congress Has Identified Issue and Funded
o Issues with MAT Diversion
(Methadone/Suboxone)
Mr. Curie informed the committee that the opioid epidemic
had been identified by public officials in nearly every
state. He asserted that the problem needed to be dealt with
in a multi-faceted manner, both in terms of prescription
pain medication, which had contributed to the heroin
crisis, and the assurance of access to treatment and
healthcare. He urged the employment of evidence based
solutions and access to the latest science.
1:44:21 PM
Mr. Curie addressed Slide 3, "Trends in Public BH
continued..."
· High Profile Mental Health Related Violent
Incidents-Crisis Stabilization Access
· Prevention & Wellness
o Look at what is preventing cost savings
ƒObesity, diabetes, risk for heart
disease
ƒEven more expensive when combined with
BH disorders
o Focus shifting to health behavior change
He proclaimed that there was a need in communities to
examine pathways to the appropriate assessment of patients,
and crisis stabilization with the training of frontline
workers and members of the police force. He explained that
people with serious mental illnesses and addictive
disorders had a higher rate of illness, and the illnesses
were more likely to be detrimental and life threatening.
He directed attention to Slide 4, "Tends in Public BH
continued…":
ƒTechnological Advances
ƒAddress Provider EHR Capacity
ƒClinically Driven
ƒFacilitate Integrated Care
ƒEfficient Data Collection
ƒRequired by ACA
Mr. Curie pointed out to the committee that these
priorities had been established as far back as the Bush
administration in the 1990s. He urged that, regardless of
the Affordable Care Act, these were priorities that needed
to be in place for a transformed system of care with
greater accountability.
1:47:17 PM
Mr. Curie spoke to Slide 5, "Why Integrated Care?":
ƒBurden of behavioral health disorders is great.
ƒBehavioral and physical health issues are
"interwoven".
ƒTreatment Gap behavioral health disorders is
large.
ƒPrimary care in Behavioral Health settings
enhance access
ƒProviding MH & SA services in primary care
settings reduces stigma.
Mr. Curie said that data had reflected that costs were
reduced when behavioral and physical healthcare were
address simultaneously; emergency room and inpatient care
were utilized less if the right treatment was given, the
right way, and at the right time. He stated that people
with serious mental illness were more at-risk for diabetes
and other life-threatening disorders, due in-part to
medications, and also due to the challenges they faced in
attempting to lead a healthy lifestyle. He relayed that
there were over 22 million Americans afflicted with an
addictive disorder at any given time, and less than 2
million per year received treatment.
1:49:27 PM
Mr. Curie continued to address integrated care on Slide 6:
ƒTreating "common" behavioral health disorders in
primary care settings is cost effective.
ƒMajority of people with behavioral health
disorders treated in collaborative/integrated
primary care settings have good outcomes.
Mr. Curie stated that screening was available for
depression and substance use.
Mr. Curie spoke Slide 7, "Barriers to Integrated Care":
ƒBH and PH providers operate in "silos"
ƒRare sharing of information
ƒConfidentiality Laws and Regulations
ƒPayment and parity issues still persist
Mr. Curie shared that, historically, mental health and
addiction services had not been easily treated in
mainstream healthcare settings. He shared that mental
health systems had evolved out of state mental health
hospitals and community based agencies, as well as drug and
alcohol centers, and were not part of mainstream
healthcare. He added that there had been challenges in
information sharing between behavioral physical health
systems. He said that there were confidentiality laws that
addressed mental health and drug and alcohol issues. He
relayed that there had been parity laws that required that
mental illnesses and addiction disorders should be treated
on par with physical health disorders, but that these laws
had not been implemented across the entire county.
1:52:35 PM
Mr. Curie addressed Slide 8, "What does this mean for
Alaska?":
ƒStreamlining
ƒUtilization Control
ƒGrant Reformation
ƒMedicaid Redesign
Mr. Curie stressed that the services should be streamlined
and not unduly bureaucratic. He said that control and
utilization management criteria should be in place to
assure the people were reviewed and were receiving the
right treatment, at the right time. He related that
structures of accountability and management needed to be
put into place. He continued to Slide 9, "How to Achieve
the Vision?":
ƒLook at models from other States-MCO, ASO, ACO,
Fee-for-Service, PCCM, PIHP, PAHP, health homes,
etc.
ƒMake policy decisions (e.g., populations, system
management, geographic area, benefit package,
risk arrangements)
ƒDevelop/improve capacity-at DBH and provider
levels
ƒImplement the systems changes
Mr. Curie said that there were a range of models that could
show what worked and what did not work. He believed that
Alaska could learn from both the successes and failures of
other states. He hoped that the state could build toward a
system that had a value based payment system where there
could be risk or shared savings arrangements.
1:55:30 PM
Mr. Curie turned to Slide 10, "Assessing Organizational
Readiness":
ƒLeadership
ƒCapacity for Change
ƒAccess, Services and Outcomes
ƒBusiness, IT, and Performance
ƒClinical Infrastructure, CQI, and Sustainability
ƒAt the State level, most important is Contract
Management (role of state government)
Mr. Curie recommended that at the state level, the most
important aspect would be in contract management and
holding contractors accountable.
Mr. Curie moved to Slide 11, "What States have learned
about Contract Management":
•Identify people with SMI and Kids with SED
-Mine the data in states
-Require plans to identify people with SMI & Kids
with SED
•Implement ways to incent enrollment of people with
SMI and Kids with SED
-Higher rates for people with more complex and/or
chronic conditions
-Mitigation of risk approaches
Mr. Curie said that a range of other states had found that
it was necessary to identify people with serious mental
illness, and kids with serious emotional disturbances, by
requiring plans to identify people with particular needs.
He asserted that this most vulnerable population was the
population for which the state was most responsible.
He continued to speak to contract management on Slide 12:
-Require acceptance in a plan regardless of
severity of conditions
•Include the comprehensive array of services needed
for People with SMI and SED
-Recovery oriented services psycho social rehab
(psycho social necessity)
•Linkage to: prevention wellness, peer supports
Mr. Curie related that if people were able to build a life
in their communities, relapses were less likely to occur.
He believed that it was important for any managed system of
behavioral health services to address a holistic approach
to recovery. He relayed that peer support had become an
important part of both treating mental illness and
addictive disorders.
1:58:35 PM
Mr. Curie spoke to Slide 13. "Behavioral Health Managed
Care Contract Standards":
•Incentives to avoid cost shifting to other systems
•Consumer Choice & Protection
•Assertive outreach and access standards
•Network and providers should include those with
demonstrated expertise with people with SMI and kids
with SED (CMHC's)
Mr. Curie said that it would be important to have
incentives for systems to assume responsibility for the
population for which they were responsible. He highlighted
that providers in Alaska had demonstrated expertise with
severe mental illness and children with severe emotional
disturbances, and had been providing services to those
populations for years.
1:59:59 PM
Mr. Curie continued with contract standards on Slide 14:
•Clear standards for treatment planning and
coordination consumer driven
•Integrated BH/PH care standards
•Consumer involvement
•Use of Peers
•Reinvestment of cost savings as an expectation
Mr. Curie spoke to reinvestment of cost savings in the
Pennsylvania program. He continued to Slide 15:
•Performance measures
-Access (timeliness, geography, MH, SU & PC)
-Service utilization (in lieu of ER, IP, more
community based)
-Quality (readmission rates, timely follow up,
level of independent living, school
participation)
-Physical health metrics (hbp, cholesterol,
diabetes, med compliance)
-BH metrics
Mr. Curie spoke to a white paper from the Pennsylvania
program ["Long-Term Performance of the Pennsylvania
Medicaid Behavioral Health Program" by Compass Health
Analytics, Inc., dated December 2010 (copy on file)]. He
said that after the first 10 years of implementation of a
capitated system in Pennsylvania there was $4 billion in
realized cost savings, increased alcohol and drug
providers, increased access to care by all populations, and
successful quality of care. He recapped that the key was to
evolve a managed system in a way that helped the system
grow and maintain the capacity to be successful, while
preserving a structure of transparent accountability for
all parties involved.
2:02:07 PM
Representative Wilson queried the savings by the State of
Pennsylvania.
Mr. Curie explained that Pennsylvania had realized savings
by moving from a fee-for-service system to a managed care
system: $4 billion of savings realized over 10 years. He
furthered that experts in behavioral health and managed
care had been consulted during Pennsylvania's process, and
Philadelphia had developed their own managed entity. He
said that contracting with an entity that had expertise in
the field was an essential element to a successful program.
Vice-Chair Saddler asked how much of the bill accomplished
the transformation described by the presentation.
Mr. Curie believed the bill gave the foundational basis
that the state would need to pursue a managed care system.
He added that the 1115 waivers would be a great pathway to
success.
Vice-Chair Saddler pointed to Slide 10. He wondered how
ready the Department of Health and Social Services Division
of Behavioral Health was for the system evolution.
Mr. Curie responded that some reorganization would be
necessary and contractual management capacities would need
to be assessed. He said that the key would be to have the
management oversight, and ongoing implementation of
contract management and accountability.
Vice-Chair Saddler queried the top five behavioral
disorders in Alaska.
Mr. Curie replied that depression, substance abuse and
addiction, and mental illnesses that resulted in psychosis
were they key essentials that needed to be addressed.
2:07:15 PM
Representative Guttenberg whether Mr. Curie had experienced
resistance to change.
Mr. Curie believed that resistance to change was based in
fear. He relayed a personal story about systemic change in
Philadelphia. He said that providers often resisted change
because they feared that they lacked the capacity to
address the standards.
2:09:25 PM
Representative Guttenberg spoke about clients with mental
and behavioral health disorders. He explored the idea that
change could be difficult for people with mental health
disorders. He asked whether Mr. Curie had received feedback
from clients.
Mr. Curie replied in the affirmative. He said that consumer
satisfaction had been high in Pennsylvania; consumers had
felt like they had more and better choices. He said that
consumers in other states had rated the reform measures
highly and had felt like they were working with a better
system.
Representative Guttenberg asked how long it took for the
issues to settle out related to confidences in the system.
Mr. Curie replied that stakeholders had to be engaged
upfront; the concerns of providers and consumers should be
discussed, and the system being set up should be
demonstrated. He stated that improvements were typically
seen within the first year of system implementation. He
felt that the waivers that the bill highlighted would give
the state the opportunity to address longstanding issues
and that people would be attracted to those new
opportunities. He stated that once the system was
implemented and people became engaged, positive outcomes
were witnessed within 2 years.
2:13:43 PM
Co-Chair Thompson referred to the white paper related to
Pennsylvania, which was dated 2010. He asked if there
continued to be success in the program after 2010.
Mr. Curie answered in the affirmative. He elaborated that
the Office of Mental Health and Substance Abuse Services,
within their Department of Health and Social Services,
executed evaluations each year. He noted that the system
had been phased in in Pennsylvania, which was something to
consider for Alaska. He added that the maturing of the
actuarial rate setting process had continued to keep cost
contained.
2:15:11 PM
Mr. Jessee testified that he did not have prepared
testimony and relayed that he would speak to the committee
the following day.
2:15:41 PM
KAREN FORREST, DEPUTY COMMISSIONER, DEPARTMENT OF HEALTH
AND SOCIAL SERVICES, explained that she would walk through
the significant reforms in the behavioral health system
that were outlined in SB 74. She mentioned that the Alaska
Behavioral Health System Assessment, completed in 2015,
confirmed that the state had a fragmented behavioral health
system with significant gaps, especially in the area of
substance abuse services. She said that there were a number
of barriers impeding access and impacting quality and cost.
She relayed that the behavioral health reform projects
found in the bill would help to build out the continuum of
care, which would lead to improved access; additionally,
quality of care would be improved through integration with
primary care, and barriers and administrative burdens would
be reduced. She stated that the reforms would reduce
general fund costs to other state agencies, such as the
Department of Corrections, the Court System, and the Office
of Children's Services. She related that Sections 1, 2, 6,
and 7 of the bill would expand, and encourage, the use of
telehealth for behavioral health by listened professional
counselors, marital and family therapists, psychologists
and psychological associates, and social workers.
Representative Wilson asked which document the testifier
was speaking to.
Ms. Forrest explained that she would highlight the sections
of the bill that were connected to the articulated vision
for the changes in the behavioral health system highlighted
by Mr. Curie.
Co-Chair Thompson asked Ms. Forrest to repeat the bill
sections that she was speaking to.
Ms. Forrest repeated the sections that she was referring
to.
2:19:54 PM
Ms. Forrest spoke to Sections 3, 4, and 5, which related to
telehealth for physicians. She anticipated that the changes
would help expand psychiatric coverage. She said that the
provisions dovetailed with the provisions in Section 30 of
the bill, which allowed the department to provide
incentives for telehealth. She stated that the first step
in implementing that provision would be to convene a
workgroup in order to identify legal technological and
financial barriers to increasing telehealth. She relayed
that Section 28 would create the Medical Assistance Reform
Program; subsection B, page 26, line 18, would require the
department, in coordination with AMHTA to efficiently
manage a comprehensive and integrated behavioral health
program that used evidence based and data driven practices
to achieve positive outcomes. She said that gaps would be
addressed in the continuum, particularly in the lower
levels of care, but also in higher levels of care. She said
that the program required under Section 28 must include a
plan for providing a continuum of community based services.
She related that the section also required that services
should be provided from a wide array of providers and
disciplines. Regulations and practices already in place
would be examined to determine which providers could
provide which services, in which settings, and under which
conditions. She concluded that the intent of the section
was to address the fragmented system. She said that the
program must also include efforts to reduce operational
barriers and administrative burdens that impeded access for
consumers.
2:23:16 PM
Ms. Forrest addressed Section 30 of the bill, beginning on
page 29. She said that the waivers section was the key to
reform in the area of behavioral health. She spoke to Page
30, line 9, which required the department to apply for the
1115 Behavioral Health Medicaid Waiver from the Centers for
Medicare and Medicaid Services (CMS) in order to establish
a demonstration project focused on improving the behavioral
health system for Medicaid recipients. The department would
be required to engage the stakeholder in the community. She
relayed that the purpose of the 1115 waiver was to create
and evaluate an innovative service delivery system that
improved care, increased efficiency, and managed cost. She
said that the general criteria that CMS used to review
waiver applications included questions pertaining to
increased access and the stabilization of providers and
provider networks. She stated that the application would
need to reflect that health outcomes would be improved, and
would be budget neutral. She relayed that during the course
of the waiver federal Medicaid expenditures could not
exceed federal spending without the waiver. The array of
services proposed would have to be offset by reductions
elsewhere; such as reducing emergency department
expenditures by providing lower cost crisis stabilization.
She articulated that the waivers generally had a five-year
lifespan, with the option of a three-year extension. She
verbalized that an administrative services organization
would be used to help move the system from program
management to quality management; a system based on
outcomes as opposed to fee-for-service.
2:26:12 PM
RANDALL BURNS, DIRECTOR, DIVISION OF BEHAVIORAL HEALTH,
DEPARTMENT OF HEALTH AND SOCIAL SERVICES, focused on what
it would take to apply for an 1115 waiver. He reiterated
that the waiver was for five years, and was a research
demonstration, required to have a foundational hypothesis
that could be tested throughout the process of the
demonstration. He imparted that the process had to have a
strong, ongoing evaluation component that measured the
effects of the redesign on the system of care. He
reiterated that it could not cost the federal government
more than without the waiver; however, the cost neutrality
could be shown at the end of the demonstration, without
extending additional Medicaid. He said that the various
involved parties would draft a concept paper within the
next six months that would be introduced to CMS, which
would mark the beginning of intense communication with all
of the stakeholders. He highlighted two other things: there
would be a readiness assessment of current Division of
Behavioral Health (DBH) staff, and a review of providers.
He elaborated on what the assessments would entail. He said
that once the concept paper was filed with CMS, the
department would begin drafting the application. He
detailed the application particulars.
2:31:12 PM
Mr. Burns relayed that the application could take from a
few months to 3 years. He stated that as the application
was being written, the request for information concerning
the Administrative Services Organization (ASO) would be
drafted simultaneously. He explained that an ASO was a
third party with whom the department would contract to
manage Alaska's redesigned behavioral health system. The
ASO would provide the department with national expertise
around a managed Medicaid system of care, and help the
transition of the division to a program management model.
He relayed that the contract with the ASO could include
significant incentives within the payment structure, with
flexibility for the ASO to pass on incentives to providers
for achievement of quality in the network targets. He
shared that a request for information (RFI) was often use
in the solicitation of a request for proposal (RFP). The
department intended to release the RFI for the ASO in
February 2017. He stated that the information that was
received during the RFI process about the interest of any
ASO in working in Alaska, and under what conditions, would
help inform the drafting of the waiver application. He
warned that some of the ASO could take issue with the
limitations that were due to the geography of Alaska. He
elucidated that based on the quality and the nature of the
responses, and assuming negotiations with CMS were
promising, the department would release an RFP for the
services during the first quarter of FY18. He conveyed that
if the RFP was successful the ASO would be contracted and
working to create the networks and have services in place
by the time the 1115 waiver was granted. He communicated
that the integration and primary case management health
home models were key to the redesign effort.
2:35:37 PM
Mr. Burns relayed that after 1 to 2 years under the waiver,
the state would apply for a substance use disorder (SUD)
waiver, with the hope to eliminate the Medicaid
Institutions for Mental Diseases (IMD) exclusion for
substance use disorder treatment.
Ms. Forrest spoke to Section 31, pages 30 and 31:
Section 31 (page 30-34)
AS 47.07.038. Collaborative, hospital-based project to
reduce use of emergency department services.
Requires the department to partner with a statewide
professional hospital organization to design and
implement a demonstration project to reduce non-urgent
use of emergency departments by Medicaid recipients.
AS 47.07.039. Coordinated care demonstration
projects
AS 47.07.039 (a)
Requires DHSS to solicit and contract with one or
more third-party entities for coordinated care
demonstration projects for individuals who
qualify for Medicaid benefits on or before
December 31, 2016. DHSS may use an innovative
procurement process as described under AS
36.30.308. A proposal for consideration must
include three or more of the following:
(1) Comprehensive primary-care-based
management, including behavioral health
services and coordination of long-term
services and support;
(2) Care coordination, including the
assignment of a primary care provider
located in the local geographic area of the
recipient;
(3) Health promotion;
(4) Comprehensive transitional care and
follow-up care after inpatient treatment;
(5) Referral to community and social support
services, including career and education
training services;
(6) Sustainability and the ability to
replicate in other regions of the state;
(7) Integration and coordination of
benefits, services, and utilization
management;
(8) Local accountability for health and
resource allocation.
Ms. Forrest mentioned Section 33, page 35:
Section 33 (page 35) Removal of Grantee Requirement
47.07.900(4)
Amends Medicaid Administration definitions, by
removing the grantee status requirement for
outpatient community mental health clinics
serving Medicaid patients.
Ms. Forrest read from Section 34:
Section 34 (page 35) Removal of Grantee Requirement
AS 47.07.900(17)
Amends by removing the grantee/contractor status
requirement from drug and alcohol treatment
centers and outpatient community mental health
clinics. This change, and the one in the previous
section, allows mental health and drug treatment
service providers who do not receive grants from
the department to become enrolled Medicaid
providers and deliver services to Medicaid
recipients.
Ms. Forrest informed the committee that the changes were
required by CMS. She stated that in the last on-site
evaluation, CMS had told the department that the
requirements had to be removed. She furthered that there
was a general provision that Medicaid allow any willing and
qualified provider to participate in Medicaid, as directed
by the Freedom of Choice provision, the requirements had
restricted Medicaid recipients in their freedom of choice.
She relayed that, as the state Medicaid agency, the
department had the ability to set reasonable standards
related to the qualifications of the provider; CMS
generally questioned state established qualification that
limited services only to the providers of the states
choosing. She said that the sections of the bill needed to
remain in order for the state to be able to bill Medicaid.
2:38:42 PM
Ms. Forrest referred to Section 39:
Section 39 (page 37-38)
Uncodified: Health Information Infrastructure
Plan.
Requires DHSS to develop a plan to strengthen the
health information infrastructure, including
health data analytics capability, to support
transformation of the health system in Alaska.
Ms. Forrest attested that there was a need to connect
behavioral health providers to the Alaska Statewide Health
Information Exchange, to improve care coordination. She
spoke to Section 40:
Section 40 (page 38-39)
Uncodified: Feasibility Studies for the Provision
of Specified State Services.
(a) Requires DHSS to conduct a study analyzing
the feasibility of privatizing the Alaska
Pioneers' Homes and select facilities of the
division of juvenile justice.
(b) Requires DHSS in conjunction with the Alaska
Mental Health Trust Authority to conduct a study
analyzing the feasibility of privatizing the
Alaska Psychiatric Institute.
(c) Requires the Department of Administration to
conduct a study analyzing the feasibility of
creating a health care Authority to coordinate
health care plans and consolidate purchasing
effectiveness for all state employees, retired
state employees, retired teachers, Medicaid
Assistance recipients, University of Alaska
employees, employees of state corporations, and
school district employees.
(d) Provides a definition for "school district"
Section 40 (page 38-39)
Uncodified: Feasibility Studies for the Provision
of Specified State Services.
(a) Requires DHSS to conduct a study analyzing
the feasibility of privatizing the Alaska
Pioneers' Homes and select facilities of the
division of juvenile justice.
(b) Requires DHSS in conjunction with the Alaska
Mental Health Trust Authority to conduct a study
analyzing the feasibility of privatizing the
Alaska Psychiatric Institute.
(c) Requires the Department of Administration to
conduct a study analyzing the feasibility of
creating a health care Authority to coordinate
health care plans and consolidate purchasing
effectiveness for all state employees, retired
state employees, retired teachers, Medicaid
Assistance recipients, University of Alaska
employees, employees of state corporations, and
school district employees.
(d) Provides a definition for "school district"
Ms. Forrest believed that all sections of the bill set the
stage for a comprehensive vision of behavioral health
reform that would result in improved access and quality of
healthcare, while reducing overall costs.
2:40:21 PM
KATE BURKHART, EXECUTIVE DIRECTOR, ALASKA MENTAL HEALTH
BOARD AND ADVISORY BOARD ON ALCOHOLISM AND DRUG ABUSE,
DIVISION OF BEHAVIORAL HEALTH, DEPARTMENT OF HEALTH AND
SOCIAL SERVICES, testified that the boards had been
involved in healthcare and Medicaid reform efforts for many
years, the process over the past 18 to 24 months being the
most inclusive. She relayed that the board had participated
in conversations with stakeholders and providers, and had
offered to engage with Medicaid recipients, which the
department had granted. She stated that the board engaged
in 8 separate community conversations in fall of 2015, and
had reviewed public input from community town hall
meetings, other public meetings, and the streamlining
initiative, to compile consumer input to inform the
process. She shared that recipients and experts had many
of the same ideas and concerns for reform. She imparted
that access to high quality services, at appropriate levels
of care, made up the bulk of the comments. She said that
the community groups spoke of the need to have increased
access to medication management and psychiatry services.
She explained that the telehealth and coordinated care
provisions in the bill spoke to the issue by encouraging
increased access to private mental health professionals
that were not practicing within community behavioral health
centers. She furthered that the ability to receive care
when it was needed, and not later, was essential to
addressing many of the relevant social problem that stemmed
from unaddressed behavioral health disorders. She
communicated that the consumers had talked about the need
to address the quality of primary and behavioral health
care services that were currently available. She said that
the quality of the actual medical services provided had not
been an issue, but that the context for which that care was
provided had been mentioned; the issues of stigma and
discrimination, as well as a lack of understanding of how
to serve someone with a serious mental illness who also
had some kind of co-morbidity. Families, especially those
of children with serious emotional and behavioral disorders
talked about how they had to aggressively advocate for
their children's primary care needs as well as their mental
health needs. She said that SB 74 would provide a framework
through which the primary case care management project, and
the 1115 waiver, would foster patient advocacy and
navigation through complex healthcare systems. She noted
that the complicated nature of insurance was lamented by
testifiers from all areas of usage. She felt that the bill
would implement reforms that would make it easier for
people to get to the services that they needed, rather than
accessing acute care services. She disclosed that
coordination of care was a reoccurring issue during
conversations with community members. She revealed that
parents and care providers often found themselves without
time and resources for self-care, prompting the need for
family-based care. She spoke to primary case management,
and gave the example of a young man with significant mental
health and primary care needs who did not want to go to all
of his necessary appointments; family members had suggested
that someone could be employed who would make sure that the
young man received the care he needed, which would take the
burden off of the family. She spoke to the need for
administrative efficiencies. Providers and the board had
testified to the need to streamline the administrative
burden in order to reduce costs and make it easier to
access care. She said that when paperwork drove care,
rather than the person's needs, patients did not receive
the care needed to help them get better. She spoke to the
need for supportive services, which SB 74 would provide by
reforming the Medicaid system in a way that correlated the
reforms to the healthcare services with the needed
community support. She asserted that open conversation with
all involved parties should continue throughout the
development of the 1115 waivers as well as the
implementation of many of the provisions in the
legislation. She said that the boards were committed to
supporting the implementation of the efforts. She said the
inclusive nature of the reform efforts so far had been
greatly appreciated.
2:50:48 PM
Vice-Chair Saddler asked whether there were two different
1115 waivers.
Ms. Forrest answered in the affirmative.
Vice-Chair Saddler asked whether all of the same conditions
and timelines would apply for both waivers.
MS. Forrest deferred the question to Jon Sherwood, Deputy
Commissioner, Medicaid and Health Care Policy, Department
of Health and Social Services.
Vice-Chair Saddler asked whether the Division of Behavioral
Health was ready for the transformation described in the
legislation.
Mr. Burns replied in the affirmative. He said that people
were aware of the systemic problems and that most of the
staff were program managers who dealt with services issues
on a daily basis. He said that his employees were committed
to improving the system.
Vice-Chair Saddler queried the effectiveness of the
Division of Behavioral Health.
Mr. Burns replied that the division was very effective and
had successfully served many individuals in the state. He
admitted that there were gaps in the system, but that most
recently the system had been focused on treating the
seriously mentally ill and severely emotionally disturbed
children, who were the most difficult population to serve
because their needs changed quickly and medication
management could be difficult. He believed that the
division had done the best work possible given the range of
services that were available to their clientele. He
maintained that the division was highly effective in
providing the services that it was capable of providing.
Vice-Chair Saddler referred Page 30, line 1, which spoke to
the 1915(i) waiver. He asked how "area" would be defined,
and which area would most likely receive the demonstration
project.
Ms. Forrest replied that the geographic area had yet to be
defined. She said that utilization, and needs within
communities, would be considered. She added that the area
could be as large as Anchorage, or an entire region of the
state, she reiterated that it was yet undefined.
2:55:32 PM
Mr. Burns interjected that the hope was that the ASO would
be interested in a statewide system, and subcontract if
there were entities that were interested in providing the
services on a regional basis. He stated that there could be
a statewide system with subcontractors for specific
regions.
Vice-Chair Saddler worried that the bill had too wide a
scope. He said that he supported the legislation.
Mr. Burns replied that the goal was to improve the system
while keeping costs under control.
Co-Chair Neuman echoed concerns made by Vice-Chair Saddler.
He elaborated that there were many new requirements,
commitments, regulation changes, and requests for changes
that the legislature could not predict because regulations
had yet to be written. He spoke to the collaborative
hospital based project on Page 30. He wondered how many
statewide professional hospital associations existed in the
state.
Co-Chair Thompson replied that the answer was one.
Co-Chair Neuman understood there were many professional
organizations that communicated with each other, but noted
that the consumer had not been involved in the
conversations. He hoped that the effectiveness of the
regulation changes could be measured before they were
implemented. He expressed distain for federal regulations
being tied to federal funds. He asked for a list of federal
requirements that were tied to federal funds.
2:59:54 PM
Representative Kawasaki asked whether federal statute
required going through a managed care or accountable care
organization for the 1115 waiver.
Mr. Burns answered in the negative. He added that
management of the waiver would be entirely up to the state.
Representative Kawasaki surmised that an accountable care
model was being considered by the department because it had
worked in other states.
Mr. Burns replied that it was part of the reason. He
elaborated that accountable care organizations brought a
depth of expertise to the table. He said that the state
would perform the RFP to see what kind of interest there
was in assisting the state in moving forward with a managed
Medicaid system.
Representative Kawasaki asked whether the state could run
its own managed care organization under the 1115 waiver.
Mr. Burns answered in the affirmative. He explained that
the state could decide not to contract with an ASO, and run
it through the department.
Representative Kawasaki spoke about the Behavioral Access
Imitative that was expected to produce net cost to Medicaid
because of the expected accessibility of service to
enrollees. He asked about the five-year term requirement
for the waiver to prove net-neutrality, and whether general
fund savings would be off-set elsewhere.
Mr. Burns answered that other savings to the system would
be measured, like possible savings from the demonstration
projects for emergency rooms, which was partially
associated with behavioral health treatment.
Representative Kawasaki relayed that he had a list of the
current optional and mandatory waivers and services under
Medicaid. He said that 19 were mandatory for adults, and 26
that the state had applied to optionally, some of which
were waivered. He asked what the overall cost would be for
the 1115 waivers.
Co-Chair Thompson thought that the question was in-depth
and may require more time.
Ms. Forrest deferred the question to a later time when
discussing the fiscal notes.
3:04:20 PM
Representative Guttenberg referred to the final report from
Agnew::Beck Consulting, LCC: "Recommended Medicaid Redesign
Expansion Strategies for Alaska, which cited the goals of
improved health, optimizing access, increasing value, and
containing costs. He hoped that within the process that the
department would illustrate how those goals might be
accomplished. He argued that there were significant
barriers for delivering telemedicine in Alaska. He hoped
that the state current broadband capabilities would be
considered before performing RFPs.
Ms. Forrest agreed that broadband capability was a concern.
She added that an organized and structured conversation
should take place about the capabilities of systems already
in place, and the broadband capabilities of the state. She
added that there had been success using telemedicine in the
Tribal Health System.
Representative Guttenberg referred to a question from
Representative Kawasaki related to ASOs. He asked about the
administrative overburden of too many program managers.
3:08:42 PM
Mr. Burns replied that other states had managed their
projects individually by region and had not tried
implementing an overarching ASO. He added that the state
could make its own choices about the delivery of care
within the state.
Representative Guttenberg understood that the pilot program
would include regional delivery of services. He worried
about the ability to translate from region to region. He
expressed concern that a program that worked in one region
would not be appropriate for a different region.
Mr. Burns responded that one of the advantages of the
system was that the RFP would specifically address the
unique needs of different regions. He stressed that generic
RFPs would not be written.
3:11:10 PM
Representative Wilson wondered whether the department
already had the authority to do some of the things
stipulated in the bill.
Mr. Burns replied that the division could probably still
pursue an 1115 waiver, but thought that there might be
Medicaid provisions that would require the authorization
extended by the legislation.
Representative Wilson was disturbed that the Medicaid
system was not more efficient. She expressed interest in
the managed care model. She understood that the department
had not before had the authority to address the problems
through managed care.
Mr. Burns responded that one of the reasons for the gap in
service was that until recently Medicaid had not covered a
large portion of the population. He said that the expansion
had exposed the system on a holistic level, which had
revealed the systemic limitations.
3:14:16 PM
Representative Wilson opined that Medicaid had already been
funded with billions of state dollars. She said that she
could not understand what the bill would do without first
understanding all of the issues with the system. She
expressed apprehension that the system could function
successfully solely online.
Ms. Burkhart stated that one of the most critical issues
was workforce capacity. She shared that one of the goals of
the system redesign was alleviate the workforce capacity
issues in the community behavioral health system by
allowing private practitioners to bill Medicaid services.
Currently, private licensed marriage and family therapists
were not able to provide therapy to Medicaid recipients.
Medicaid recipients with mild to moderate behavioral health
disorders often went without care until they developed an
acute mental illness, and then the community behavioral
health center will serve them because they become part of
the priority population. She pointed out that SB 74 would
allow for private licensed mental health professional to
provide reimbursable services to Medicaid, which opens up
workforce capacity for the mild to moderate needs that were
currently going unaddressed. The hope was that this would
relieve some of the pressure on community mental health
centers.
3:17:33 PM
Representative Wilson shared that her problem with the bill
was that she did not understand what was already required
by statute. She wanted to know what the department could
currently do, without the bill. She requested a chart
comparing the department's current authority, versus what
was proposed in the bill.
Representative Gara surmised that the bill addressed some
reform issues by relieving workforce shortages and
leveraging federal funding. He understood that the 1115
waiver was projected to save the state over $200 million in
general funds over the next 5 years.
Ms. Forrest clarified that Representative Gara had spoken
to savings attached to the Tribal Policy portion of the
bill, which did not require a waiver.
Representative Gara asked whether the non-tribal part of
the 1115 waiver leveraged additional federal funds.
Ms. Forrest answered that the 1115 Behavioral Health
Medicaid waiver gave the department the opportunity to
provide additional services in an effective manner.
Representative Gara asked whether it would qualify services
that could be paid for by Medicaid.
Ms. Forrest answered in the affirmative.
Representative Gara understood that those services would
otherwise be paid for with general funds.
Ms. Forrest replied in the affirmative.
Representative Gara probed the dividing line between the
1115 waiver and behavioral health. He understood that
current law limited behavioral health treatment to
federally qualified medical centers, or with a psychiatrist
present.
Ms. Forrest answered in the affirmative.
Representative Gara recognized that the number of
qualifying psychiatrists in the state was limited.
Ms. Forrest illuminated that federal law required that
services in a physician's clinic had to be provided under
the general direction of a physician. She said that
regulation had been established for both physician clinics
and community mental health clinics. She expressed that
regulations could be changed, and that the 1115 waiver
would be examined for expanding access while maintaining
budget neutrality.
3:21:40 PM
Representative Gara surmised that if the 1115 waiver was
pursued and successful, the state would be able to provide
behavioral health services without the supervision of a
physician, a phycologist, and without being inside a
federally qualified medical health center.
Ms. Forrest answered that that 1115 waiver would allow the
department to examine its utilization patterns across the
state and provide the opportunity to refine regulations.
Representative Gara asked whether the behavioral health
treatment under the waiver included substance abuse
treatment.
Ms. Forrest replied that it referred to clinic services,
which could be applied to substance abuse treatment.
Representative Gattis wanted to have a broad conversation
about the 26 optional services Representative Kawasaki
spoke of, particularly the fiscal aspects of the options.
Vice-Chair Saddler understood that the currently system did
not allow for marital or family therapists to bill Medicaid
because they did not provide services under contract. He
spoke to the provision on Page 35, line 12 and 13 that
removed the requirement for rehabilitative services to be
provided by someone at a community mental health
establishment that was under contract. He asked whether
changing that requirement would expand capacity.
Ms. Forrest answered in the affirmative.
Vice-Chair Saddler asked whether there was enough capacity
to maintain the existing mental behavioral health services
until the bill was implemented.
Ms. Forrest answered in the affirmative. She added that it
would be a challenge to reform the system, while
simultaneously providing services, and that it would take
coordinated and concentrated effort and good communication.
3:26:15 PM
Ms. Burkhart elaborated that providers had been working in
anticipation of the change contemplated in SB 74. She said
that community mental health centers and behavioral health
centers had added primary care capacity around the
integration of primary care and behavioral health and
coordination of care and case management. She relayed that
the Juneau Alliance for Mental Health had added a primary
care clinic to their establishment and the Anchorage
Community Mental Health Services had had primary care
capacity for several years. She explained that providers
would inform through their experiences and help to bring
their peers along in the process. She stated that the
department had received a planning grant for certified
community behavioral health clinics, which was a federally
supported model for integrated and coordinated healthcare.
She related that the funds had been applied for with the
support of the behavioral health provider community;
provider organizations had a greater capacity for change
because they had been engaged in preparing for change.
Vice-Chair Saddler referred to a 2009 report on health
clinics throughout Alaska. He was interested in a report on
behavioral services. He asked how well the department was
staffed to handle the transformation.
Ms. Forrest answered that the department could do it, but
that it would be a large amount of work. She voiced that
resources were limited, but the change was needed. She
shared that staff and providers were enthusiastic to make
the change.
Vice-Chair Saddler asked whether the Indian Health Service
(IHS) provided behavioral health services.
Mr. Burns replied in the affirmative. He added that all
Tribal Health organizations provided behavioral health
divisions and provided significant behavioral health
services.
3:30:12 PM
Representative Munoz asked whether family and marriage
counselors had to be associated with a drug and alcohol
treatment center, or an out-patient mental health clinic,
in order to bill Medicaid for services.
Mr. Burns answered that currently the person did have to be
associated with a clinic that was managed by a physician.
Representative Munoz restated the question.
Ms. Burkhart clarified that she was referring to language
in SB 74 that removed language in statute requiring that a
facility be a grantee. She said that if SB 74 passed with
the aforementioned language, a licensed mental health
professional would be able to bill Medicaid for behavioral
health clinic services, both mental health and substance
abuse.
Representative Munoz asked for clarification concerning
marital counselors.
Ms. Burkhart answered that if the bill passed individual
marital counselors would be able to bill directly to
Medicaid.
3:32:30 PM
JON SHERWOOD, DEPUTY COMMISSIONER, MEDICAID AND HEALTH CARE
POLICY, DEPARTMENT OF HEALTH AND SOCIAL SERVICES, clarified
that Section 33 addressed clinic services, which by federal
definition must be supervised by a physician;
rehabilitative services did not have the requirement.
Representative Munoz asked for verification that a
rehabilitative service would include marriage counseling.
Mr. Sherwood answered in the affirmative.
3:33:48 PM
AT EASE
3:43:16 PM
RECONVENED
Co-Chair Thompson discussed housekeeping.
VALERIE DAVIDSON, COMMISSIONER, DEPARTMENT OF HEALTH AND
SOCIAL SERVICES, spoke to Section 38, page 37 of the bill,
which dealt with the federal policy on tribal Medicaid
reimbursement. She introduced her support staff. She
reminded the committee of previous conversations concerning
the 100 percent federal match policy, and stated that she
would be giving an update on recent developments.
Historically, CMS had allowed states to claim 100 percent
federal match for Medicaid services provided to IHS
beneficiaries under certain circumstances. In order to
qualify the person had to be an IHS beneficiary, enrolled
in Medicaid, and the care must be provided through an IHS
facility. She said that CMS had construed the words "Indian
Health Services" narrowly in the past; an IHS facility was
construed as within the four walls of the facility. She
opined that what that had meant was that medically
necessary travel and accommodation services, as well as
care referred outside of the IHS facility (or tribally
operated facility) would not be able to claim 100 percent
federal match. She said that the 1115 waiver would allow
for 100 percent federal match for medically necessary
travel and accommodation services, and care that was
provided in a non IHS or tribally operated facility, but
had been a referral from one of those entities. She shared
that the Secretary of the Department of Health and Human
Services, Sylvia Burwell, had indicated that national
policy could be changed, rather than require an 1115
waiver. She said that CMS had issued a request for comment
and had recently issued a health official letter, providing
additional guidance to states regarding reimbursement
services on February 26, 2016. She relayed that CMS had
changed national policy to accommodate Alaska, and would
provide 100 percent federal match for medically necessary
travel and accommodation services, and full referrals from
IHS to non-IHS facilities, as long as certain conditions
were met. She said that the department had anticipated that
approximately $12.5 million in savings would be realized in
FY17, which had increased to $32 million, and would
increase to $92 million by 2022. She said that Section 38,
lines 2 through 19, required the department to collaborate
with Tribal Health and the federal government to implement
the policy, and required the department to report the
estimated savings and to fully implement the policy within
6 months.
3:49:33 PM
Co-Chair Thompson understood that there would be 100
percent federal match for IHS travel, which meant 50
percent state, 50 percent federal.
Commissioner Davidson clarified that under the Medicaid
program the federal government paid the Federal Medical
Assistance Percentage (FMAP). For regular Medicaid it was a
50 percent match, 50 percent federal and 50 percent state.
However, for the services described through the tribal
policy change, the match would be 100 percent federal,
meaning that zero state dollars would be used. She
referenced a letter from CMS dated February 26, 2016 (copy
on file). She discussed page 3:
Permitting a Wider Scope of Services
In this letter, we are re-interpreting the scope of
services considered to be "received through" an
IHS/Tribal facility. Under our previous
interpretation, in order to be "received through" an
IHS/Tribal facility, and therefore, qualify for 100
percent FMAP, the service had to be a "facility
service." By that, we meant that it had to be within
the scope of services that a Medicaid facility of the
same type (e.g., inpatient hospital, outpatient
hospital, clinic, Federally Qualified Health
Center/Rural Health Clinic, nursing facility) can
provide under Medicaid law and regulation. Under our
new interpretation, as described more fully below, the
scope of services that can be considered to be
"received through" an IHS/Tribal facility for purposes
of 100 percent FMAP includes any services that the
IHS/Tribal facility is authorized to provide according
to IHS rules, that are also covered under the approved
Medicaid state plan, including long-term services and
supports (LTSS). Medicaid coverable benefit categories
include all 1905(a), 1915(i), 1915(j), 1915(k), 1945,
and 1915(c) services set forth in the state plan, as
well as any other authority established in the future
as a state plan benefit.
This scope of service change also applies to
transportation that is covered as a service under the
state Medicaid plan. Under regulations at 42 CFR
440.170(a), a state can elect to cover transportation
and other related travel expenses determined necessary
to secure medical examinations and treatment for a
beneficiary. Related travel expenses include the cost
of meals and lodging en route to and from medical
care, and while receiving medical care, as well as the
cost for an attendant to accompany the beneficiary, if
necessary. Covered transportation services can include
both emergency medical transportation and non-
emergency medical transportation.
Medicaid Beneficiary and IHS/Tribal Facility
Participation is Voluntary
This new interpretation does not provide authority for
states to require any AI/AN Medicaid beneficiary to
receive services through an IHS/Tribal facility.
Nothing in this letter affects the entitlement of
AI/AN Medicaid beneficiaries to freedom of choice of
provider under section 1902(a)(23) of the Social
Security Act. State Medicaid agencies may not,
directly or indirectly, require AI/ANs who are
eligible for Medicaid to receive covered services from
IHS/Tribal facilities for the purpose of qualifying
the cost of their services for 100 percent FMAP.
Similarly, neither state Medicaid agencies nor
IHS/Tribal facilities may require an AI/AN Medicaid
beneficiary to receive services from a non-IHS/Tribal
provider to whom the facility has referred the
beneficiary for care. Nor can a state delay the
provision of medical assistance by requiring that
beneficiaries initiate or continue a patient
relationship with the IHS/Tribal facility. Finally,
federal Medicaid law does not require either
IHS/Tribal facilities or non-IHS/Tribal providers to
enter into the written care coordination agreements
described in this SHO.
Commissioner Davidson continued to Page 4 of the letter:
Request for Services In Accordance With a Written Care
Coordination Agreement
In this letter, CMS also revises its interpretation to
provide that a service may be considered "received
through" an IHS/Tribal facility when an IHS/Tribal
facility practitioner requests the service, for his or
her patient, from a non-IHS/Tribal provider (outside
of the IHS/Tribal facility), who is also a Medicaid
provider, in accordance with a care coordination
agreement meeting the criteria described below. The
purpose of this revised policy interpretation is to
enable IHS/Tribal facilities to expand the scope of
services they are able to offer to their AI/AN
patients while ensuring coordination of care in
accordance with best medical practice standards.
A covered service will be considered to be "received
through" an IHS/Tribal facility not only when the
service is furnished directly by the facility to a
Medicaid-eligible AI/AN patient, but also when the
service is furnished by a non-IHS/Tribal provider at
the request of an IHS/Tribal facility practitioner on
behalf of his or her patient and the patient remains
in the Tribal facility practitioner's care in
accordance with a written care coordination agreement
meeting the requirements described below. Under this
policy, both the IHS/Tribal facility and the non-
IHS/Tribal provider must be enrolled in the state's
Medicaid program as rendering providers. Second, there
must be an established relationship between the
patient and a qualified practitioner at an IHS/Tribal
facility. Third, care must be provided pursuant to a
written care coordination agreement between the
IHS/Tribal facility and the non-IHS/Tribal provider,
under which the IHS/Tribal facility practitioner
remains responsible for overseeing his or her
patient's care and the IHS/Tribal facility retains
control of the patient's medical record.
A non-IHS/Tribal provider from which an IHS/Tribal
facility practitioner could request services could
include an Urban Indian Health Organization that
participates in Medicaid, or any other Medicaid-
participating provider. Furthermore, the relationship
between the IHS/Tribal facility practitioner and the
patient could be based on visits, including the
initial visit, through telehealth procedures that meet
state and/or IHS standards for such procedures, if the
IHS/Tribal facility has that capacity.
A self-request by the beneficiary, or a request from a
non-IHS/Tribal provider, does not suffice for purposes
of 100 percent FMAP; in such circumstances, the non-
IHS/Tribal provider could furnish the service and bill
the state Medicaid program, but the state expenditure
for the service would not qualify for 100 percent
FMAP. Similarly, the non-IHS/Tribal provider may refer
the facility patient to another non-IHS/Tribal
provider; however, if the patient receives a covered
service from that other provider without a request
from the IHS/Tribal facility practitioner, or the
IHS/Tribal facility practitioner does not remain
responsible for the patient's care, the state
expenditure for the service would not qualify for 100
percent FMAP.
At a minimum, care coordination will involve:
(1)The IHS/Tribal facility practitioner providing
a request for specific services (by electronic or
other verifiable means) and relevant information
about his or her patient to the non-IHS/Tribal
provider;
(2)The non-IHS/Tribal provider sending
information about the care it provides to the
patient, including the results of any screening,
diagnostic or treatment procedures, to the
IHS/Tribal facility practitioner;
(3)The IHS/Tribal facility practitioner
continuing to assume responsibility for the
patient's care by assessing the information and
taking appropriate action, including, when
necessary, furnishing or requesting additional
services; and
(4)The IHS/Tribal facility incorporating the
patient's information in the medical record
through the Health Information Exchange or other
agreed-upon means.
Written care coordination agreements under this policy
could take various forms, including but not limited to
a formal contract, a provider agreement, or a
memorandum of understanding and, to the extent it is
consistent with IHS authority, would not be governed
by federal procurement rules. The IHS/Tribal facility
may decide the form of the written agreement that is
executed with the non-IHS/Tribal provider.
Commissioner Davidson spoke to Page 5:
Medicaid Billing and Payments to Non-IHS/Tribal
Providers
For services provided to Medicaid-eligible AI/AN
beneficiaries that are rendered by a non-IHS/Tribal
provider in accordance with a written care
coordination arrangement, there are several options
regarding how those services may be billed to
Medicaid.
The first option is for the non-IHS/Tribal provider to
bill the Medicaid agency directly. If the non-
IHS/Tribal provider bills the state Medicaid program
directly, the provider would be reimbursed at the rate
authorized under the Medicaid state plan applicable to
the provider type and service rendered. To support the
application of the 100 percent FMAP, the state should
ensure that claims include fields that document that
the item or service was "received through" an
IHS/Tribal facility. When a non-IHS provider bills a
state directly, the state's payment rate for a covered
service furnished by a non-IHS/Tribal provider to an
AI/AN Medicaid beneficiary under a written care
coordination agreement must be the same as the rate
for that service furnished by that provider to a non-
AI/AN beneficiary or to an AI/AN beneficiary who self-
refers to the provider. Similarly, a state agency
cannot establish one rate for services furnished by
the facility to AI/AN beneficiaries and another for
the same services provided by that facility to non-
AI/AN Medicaid beneficiaries.
A second option is for the IHS or Tribal facility to
handle all billing. In that case, the IHS/Tribal
facility would have to separately identify services
provided by non-IHS/Tribal providers under agreement
that can be claimed as services of the IHS/Tribal
facility ("IHS/Tribal facility services") from those
that cannot. Inpatient services that are furnished by
non-IHS providers outside of IHS/Tribal facilities
could never be claimed as IHS/Tribal facility
services. For IHS, other services provided by non-
IHS providers outside of an IHS facility generally
cannot be claimed as IHS facility services. Tribal
facilities generally may have more flexibility than
IHS and should consult with their state to determine
the circumstances in which other services provided by
non-Tribal providers can be claimed as Tribal facility
services. The circumstances under which Tribal
facilities may claim services as their own are the
same as those that apply for other similar facilities
in the state (e.g., inpatient or outpatient hospitals,
nursing facilities, Federally Qualified Health
Centers, etc.). Services that can properly be claimed
as IHS/Tribal facility services may be billed directly
by the IHS/Tribal facility and are paid at the
applicable Medicaid state plan IHS/Tribal facility
rate. For all other services provided by non-
IHS/Tribal providers, IHS or the Tribe could bill for
these services as an assigned claim by that provider
and the payment rate would be the state plan rate
applicable to the furnishing provider and the service,
not the applicable Medicaid state plan IHS/Tribal
facility rate. These services are still eligible for
the 100 percent FMAP, provided other requirements have
been met.
The billing arrangement should be reflected in the
written agreement between the IHS/Tribal facility and
the non-
IHS/Tribal provider. Payment methodologies for
facility services furnished by both the IHS/Tribal
facility and rate methodologies paid to non-IHS/Tribal
providers must be set forth in an approved state
Medicaid plan. Payment rates can reflect the unique
access concerns in particular geographic areas, or
with respect to certain types of providers. However,
rates may not vary based on the applicable FMAP.
States should review existing state plans to ensure
compliance with the policy articulated in this letter.
3:55:25 PM
Commissioner Davidson continued with Page 6:
Managed Care
The discussion above assumes that the Medicaid-
eligible AI/AN has "received [services] through" the
IHS/Tribal facility on a fee-for-service basis. In
some cases, however, Medicaid-eligible AI/ANs may be
enrolled in a risk-based Medicaid managed care
organization (MCO), prepaid inpatient health plan
(PIHP), or prepaid ambulatory health plan (PAHP), in
which case the state Medicaid agency is making monthly
capitation payments on behalf of the AI/AN enrollee to
the MCO, PIHP, or PAHP. The state may claim 100
percent FMAP for the portion of the capitation payment
attributable to the cost of services "received
through" an IHS/Tribal facility if the following
conditions are met:
(1)The service is furnished to an AI/AN Medicaid
beneficiary who is enrolled in the managed care
plan;
(2)The service meets the same requirements to be
considered "received through" an IHS/Tribal
facility as would apply in a fee-for-service
delivery system and the managed care plan
maintains auditable documentation to demonstrate
that those requirements are met;
(3)The non-IHS/Tribal provider is a network
provider of the enrollee's managed care plan;
(4)The non-IHS/Tribal provider is paid by the
managed care plan consistent with the network
provider's contractual agreement with the managed
care plan; and
(5)The state has complied with section
1932(h)(2)(C)(ii) of the Act consistent with CMS
guidance.
States would be permitted to claim the 100 percent
FMAP for a portion of the capitation payment for
AI/ANs who are enrolled in managed care, even though
the state itself has made no direct payment for
services "received through" an
IHS/Tribal facility. The portion of the managed care
payment eligible to be claimed at 100 percent FMAP
must be based on the cost of services attributable to
IHS/Tribal services or encounters received through an
IHS/Tribal provider meeting the requirements outlined
in this section.
Commissioner Davidson concluded with Page 7:
Compliance and Documentation
To ensure accountability for program expenditures, in
states where IHS/Tribal facilities elect to implement
the policy described in this letter, the Medicaid
agency will need to establish a process for
documenting claims for expenditures for items or
services "received through" an IHS/Tribal facility.
The documentation must be sufficient to establish that
(1) the item or service was furnished to an AI/AN
patient of an
IHS/Tribal facility practitioner pursuant to a request
for services from the practitioner; (2) the requested
service was within the scope of a written care
coordination agreement under which the IHS/Tribal
facility practitioner maintains responsibility for the
patient's care; (3) the rate of payment is authorized
under the state plan and is consistent with the
requirements set forth in nthis letter; and (4) there
is no duplicate billing by both the facility and the
provider for the same service to the same beneficiary.
Applicability to Section 1115 Demonstrations
State expenditures for services covered under section
1115 demonstration authority are eligible for 100
percent FMAP as long as all of the elements of being
"received through" an IHS or Tribal facility that are
described in this SHO are present.
Relationship Between 100 Percent FMAP for Tribal
Services and Other Federal Matching Rates
The 100 percent FMAP for services "received through"
an IHS/Tribal facility is available for services
provided to AI/ANs as described in this SHO instead of
the regular F
MAP rate described in section 1905(b) of the Act, the
newly eligible FMAP rate described in section 1905(y)
of the Act, the enhanced FMAP rate for breast and
cervical cancer, or the enhanced rate for Community
First Choice services.
3:57:08 PM
Mr. Sherwood addressed a document titled "Federal Medicaid
Authorities for Restructuring Medicaid Health Care Delivery
or Payment" dated March 25, 2016 (copy on file), which
explained each demonstration waiver by the authority it
extended, a brief description of the waiver, key
flexibilities and /or limitations, and where it could be
located in the bill. He explained that waiver authority
under the federal Medicaid program meant that the federal
government had the ability to waive certain federal
provisions that would normally apply to Medicaid. He said
that the three main provisions were: a service must be
available statewide (statewideness), comparability of
service, and freedom of choice. He said that the different
waiver authorities allowed the waiving of one or more of
the requirements. The 1115 demonstration waiver was the
broadest waiver authority that extended beyond Medicaid. He
said that the waiver allowed states to test policy
innovations that were likely to further the objectives of
the Medicaid program. The waiver would be granted for up to
5 years, and could be renewed, although not in perpetuity.
He shared that the state of Arizona operated its entire
Medicaid program under an 1115 waiver and had always been a
managed care program. He relayed that a key feature of the
waiver was that a demonstration hypothesis containing
evaluation assessments had to be present, and it must be
budget neutral to the federal government. He added that
Section 30 of the bill contained the 2 demonstration
waivers; one for behavioral health, and another for an
innovative payment model. He continued to the Health Homes
Option, which examined care management, primary care, and
acute behavioral health long-term services and supports for
individuals with chronic illnesses. He stated that to
qualify individuals had to have 2 chronic conditions, 1
chronic condition with the risk of another, or a serious
and persistent mental health condition. States had the
choice to select the chronic condition that would be
addressed and participation had to be voluntary and allow a
choice of providers. He said that there was an incentive
for states to start the waiver; because savings might not
be immediately realized the federal government would
provide 90 percent federal funds for the Health Home
payments for the first 8 quarters. States implementing the
waiver must take part in an impact assessment involving
survey and independent evaluation of the program.
4:02:26 PM
Mr. Sherwood spoke to Home & Community-Based Services
Waivers and Options on page 2 of the document. He explained
that, historically, long-term care had meant
institutionalization and over the years different
alternatives had been provided under the Medicaid program.
The oldest alternative was the 1915(c) Home and Community
Based Waiver Program, which was the program the state
currently operated; 4 waivers were currently offered for
different populations. The waivers required the
demonstration of the necessity for an institutional level
of care and had to be offered the choice of institutional
services. He furthered that there were waivers renewable
for 5 year periods that had to demonstrate cost neutrality
to the Medicaid program as a whole and not to the federal
government. The maximum number of participants for each
waiver had to be specified and the criteria for entrance
selection. He said that 2 options that were offered in the
bill similar to the waiver were the Section 1915(i) and
Section 1915(k). He said that the 1915(k) option required
individuals to meet an institutional level of care to
receive services. As an incentive to states to use the
option, states were provided a 6 percentage point increase
in the federal matching payments for services. He said that
the state was already making services available to people
in the program without issues of cost neutrality or
limitations on the number of individuals served. He noted
that the remainder of the document discussed managed care
authorities, both waivers and options in federal statute
that were not specifically cited in the bill. He said that
some ways of doing managed care were voluntary and some
could mandate participation.
4:07:42 PM
DUANE MAYES, DIRECTOR, DIVISION OF SENIOR AND DISABILITIES
SERVICES, DEPARTMENT OF HEALTH AND SOCIAL SERVICES,
introduced the presentation "1915(i) and 1915(k) Options
for the State of Alaska" dated March 28, 2016 (copy on
file).
4:08:37 PM
SHANE SPOTTS, CONTRACTOR, SENIOR DISABILITY SERVICES,
HEALTH MANAGEMENT ASSOCIATES (via teleconference),
introduced himself and spoke to the presentation. He read
from Slide 3:
· In 2012, 1915(k) became a new option to provide
consumer-directed, home and community-based
attendant services and supports
· Eligibility
o Must meet functional eligibility equal to an
institutional level of care
o Medicaid eligible
· As long as eligibility criteria are met, benefits
are available to all Alaskans statewide regardless
of age or diagnosis
· Federal government contributes more money (56%
instead of typical 50% Medicaid match to state
dollars in Alaska)
· Agency model and consumer-directed model at state's
discretion
4:10:51 PM
Mr. Spotts turned to Slide 4 and addressed the PCA state
plan.
PCA total spend is $85,200,043.36
· 49% ($41,786,777.39) of expenditures by
individuals currently on a waiver
· 1,603 individuals currently on a waiver receiving
PCA services
· 3,308 individuals receiving PCA services not on a
waiver
4:12:27 PM
Mr. Spotts moved to Slides 5 and 6 related to 1915(i)
background. He addressed Slide 6:
· State plan option to provide consumer-directed,
home- and community-based attendant services and
supports
· Individuals do NOT need to be eligible for an
institutional level of care currently required under
1915(c) HCBS waivers or 1915(k) (Community First
Choice)
o Medicaid eligible
o Targeted populations
· Federal government contributes (50% match to state
dollars in Alaska)
4:13:33 PM
Mr. Spotts continued on Slide 7 related to 1915(i) SDS
general fund refinancing:
· GR Program: Estimated 349 of 545 recipients eligible
for 1915i program.
· Adult Day Grants: Estimated 114 of 423 recipients
eligible for 1915i program.
· Senior In-home Grants: Estimated 123 of 1,371
recipients eligible for 1915i program.
· Community Developmental Disability Grants: Estimated
all recipients eligible for 1915i program.
· Estimated savings of shift to 1915i is $8,530,000.
4:14:40 PM
Mr. Spotts addressed target dates on Slide 8:
· Implementation Plan Due- 7/31/2016
· Submit to CMS
· CMS Approval
· Begin Implementation
4:15:30 PM
Vice-Chair Saddler requested and estimated timeline for CMS
to approve the 1915(i) waiver. He understood that the wait
time could be as short as 3 months and as long as 3 years.
Mr. Spotts replied that the 1115 waivers were more complex
and required significant negotiation with the federal
government. He believed that the (i) option would require 3
to 6 months of negotiation with the federal government.
Vice-Chair Saddler understood that the 1915(k) offered the
inventive of an extra 6 percent on the FMAP, but wondered
whether the Medicaid expansion population would receive the
higher FMAP under the 1915(k).
Mr. Sherwood replied that it was a 6 percent enhanced FMAP,
50 percent would be the default for most cases. He said
that existing higher match rates should expect the enhanced
6 percent, up to 100 percent.
Vice-Chair Saddler clarified that a beneficiary under the
expanded population would receive the FMAP in effect, plus
an enhanced 6 percent, up to 100 percent.
Mr. Sherwood replied in the affirmative.
Mr. Spotts concurred.
4:17:52 PM
Representative Gara pointed to the estimated savings bullet
on Slide 7. He asked whether the shift would be from a
different waiver program, or a shift on to a Medicaid
waiver altogether.
Mr. Spotts answered that it was a shift to the Medicaid
program from a state funded only program. He explained that
100 percent state dollars were currently being paid for
services, and the savings would occur from receiving the
federal matching percentage of shifting individuals to the
Medicaid program.
Representative Gara asked about the level of care
requirements to receive the 1915(i) waiver.
Mr. Spotts answered that the waiver was still a Home and
Community Based option, which meant that the services had
to be provided in-home or out in the community. He relayed
that the waiver lowered the institutional level of care
threshold in order to give the states more flexibility to
fill any gaps in underserved populations.
4:20:14 PM
Representative Gara asked how long the 1915(i) and 1115
waivers had been available.
Commissioner Davidson responded that the 1115 waiver
authority had been around for a long time; however, the
1915(i) and (k) options had only been around for a few
years.
Vice-Chair Saddler asked about possible difficulties for
waiver renewal after 5 years.
Mr. Sherwood replied that some states had operated 1115
waivers for a long time but typically made program
adjustments when up for renewal. He said that if a state
wanted to execute the exact same program over and over
again, CMS could take issue. He asserted that if programs
were run as intended, with adjustments being made as states
learned what worked and what didn't, waiver renewal should
not be a problem. He stated that waivers that were not
demonstration waivers had no barriers to repeat renewals.
Vice-Chair Saddler understood that if the state went
through the 1915 demonstration then the program would be
implemented permanently.
Mr. Sherwood answered that it would have to be renewed
after a five year period and there must be justification
for renewal. He relayed that most managed care waivers and
options had evolved out of 1115 demonstration projects.
4:24:23 PM
Vice-Chair Saddler expressed concern that the state would
enter into the demonstration waiver application and then
not be allowed to renew, leaving a segment of the
population without care.
Mr. Sherwood believed the concern was legitimate. He
elaborated that the state would be required under 1115
demonstration waivers to create a transition plan in case
of termination of the waiver.
Vice-Chair Saddler wondered whether a new CMS director or
Secretary of Health and Human Services could withdraw
approval for a waiver.
Mr. Sherwood replied that the waiver could not be withdrawn
prior to the end of the five-year period.
Representative Wilson asked if the state would be forced to
keep supporting a program that was shown to be working and
whether the state would have to pay for the working
program.
4:26:46 PM
Mr. Sherwood clarified that the only waiver that could not
be renewed automatically was the 1115 demonstration waiver.
If the federal government determined that it was not going
to renew the 1115 demonstration waiver, the state would not
be obligated to spend state money or provide services
otherwise covered by Medicaid. He reiterated that a
transition plan would be considered which would ensure that
people were informed of the changes that were happening and
be made aware of other alternatives within the regular
Medicaid program or within other programs that might be
appropriate for their situation.
Representative Wilson maintained concern for the future
funding of the waivers.
Mr. Sherwood replied that 1115 demonstration waiver was the
only waiver where there could be a renewal issue. He
reiterated that the 1915 (i) and (k) options did not have
the same demonstration requirement and in those cases, if
the state decided not to continue and option, the state
would revert back to the original match of 50/50, or the
legislature to return to funding the grant programs that
had previously provided services. He stressed that the
state would have no obligation to continue to pay for
services in the 1115 demonstration waivers that would not
otherwise be covered under the regular Medicaid program.
Representative Gara asked whether managed care was barred
in the private sector in Alaska.
Mr. Sherwood replied no; managed care was regulated through
the Division of Insurance and the state had provisions for
managed care written in statute.
4:30:33 PM
Mr. Mayes provided the Slides, "Community Developmental
Disabilities Grants 1915(i) Impact" dated March 4, 2016. He
shared that there were 19 stated that had implemented the
1915(i) option. He said that 5 states had implemented the
1915(k) option. He relayed that it could take the state 3
to 6 months to get approval for the option. He explained
that with the 1915(k) option CMS required a developmental
council, which was composed of 11 voting members who were
actual recipients of services, or family members of
recipients of services. He continued that there were 8
advisory associations who were called upon after voting
members voiced their opinions. He shared that the contract
would end on July 30, 2016, at which time the contractor
would provide a development plan for the state to carry
forward.
4:34:32 PM
Representative Wilson where the programs that the waivers
supported generated from.
Mr. Mayes replied that the department was refinancing all
of its general fund programs with the 1915(i) option so
that it could draw down 50 percent federal match. The
department was taking existing people receiving services
within the 1915(c) waiver and moving them to receive
personal care attendant services with an additional federal
match. He clarified that the program was not growing, the
department was working to actualize deductions and not
increases.
Representative Wilson queried how the state managed to
spend nearly $11.6 million in general funds for Community
Developmental Disabilities Grants.
Mr. Mayes replied that the line item for the funding had
existed in the Division of Senior Disabilities Services for
several years.
Representative Wilson understood that the program was in
the budget but wanted to know the genesis of the program.
Mr. Mayes deferred to Mr. Sherwood.
Mr. Sherwood replied that the programs were in statute and
existed going back to the 1980s, prior to the development
of the Home and Community Based waiver system. He said that
there had been grant programs that provided home and
community based services for people with developmental
disabilities for at least the past 25 years.
4:37:51 PM
Representative Wilson understood that the programs had been
established in statute and were not connected to Medicaid,
and that this new waiver option under Medicaid expansion
would continue the program, while providing federal
matching funds.
Mr. Sherwood responded that the one of the duties that
Alaska assumed with statehood was taking over the role of
providing for people with developmental disabilities, which
the state had done by building a facility in Valdez and by
funding grant programs. Prior to statehood people with
developmental disabilities had been sent to Oregon for
care.
CSSB 74(FIN) am was HEARD and HELD in committee for further
consideration.
Co-Chair Thompson addressed housekeeping.
ADJOURNMENT
4:40:24 PM
The meeting was adjourned at 4:40 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| Federal Medicaid Authorities Table 3-25-16.pdf |
HFIN 3/28/2016 1:30:00 PM |
SB 74 |
| SB74 Behavioral Health HFIN 032816 - AK BH Systems Assesment.pdf |
HFIN 3/28/2016 1:30:00 PM |
SB 74 |
| SB74 Behavioral Health HFIN 032816 - Agnew_Beck Exec Sum and BH Access Init.pdf |
HFIN 3/28/2016 1:30:00 PM |
SB 74 |
| SB74 Fed Waivers Options HFIN 032816 - CMS Tribal Facility Rule Change Letter.pdf |
HFIN 3/28/2016 1:30:00 PM |
SB 74 |
| SB74 Fed Waivers Options HFIN 032816- DHSS SDS Waivers Options Graphics.pdf |
HFIN 3/28/2016 1:30:00 PM |
SB 74 |
| SB 74 Federal Medicaid Authorities Table 3-25-16.pdf |
HFIN 3/28/2016 1:30:00 PM |
SB 74 |
| SB 74 Behaiviorial Health The Curie Group AK Presentation March 2016.pdf |
HFIN 3/28/2016 1:30:00 PM |
SB 74 |
| SB 74 BH HealthChoices Performance Evaluation Whitepaper December 2010.pdf |
HFIN 3/28/2016 1:30:00 PM |
SB 74 |
| SB 74 Fed. Overviews Shane Spotts slide 1915ik.pdf |
HFIN 3/28/2016 1:30:00 PM |
SB 74 |