Legislature(2015 - 2016)CAPITOL 106
04/05/2016 03:00 PM HEALTH & SOCIAL SERVICES
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ALASKA STATE LEGISLATURE HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE April 5, 2016 3:05 p.m. MEMBERS PRESENT Representative Paul Seaton, Chair Representative Liz Vazquez, Vice Chair Representative Neal Foster Representative David Talerico Representative Geran Tarr Representative Adam Wool MEMBERS ABSENT Representative Louise Stutes COMMITTEE CALENDAR HOUSE BILL NO. 345 "An Act relating to insurance coverage for contraceptives and related services; relating to medical assistance coverage for contraceptives and related services; and providing for an effective date." - HEARD & HELD HOUSE BILL NO. 334 "An Act relating to visitation and child custody." - HEARD & HELD HOUSE BILL NO. 315 "An Act relating to an electronic visit verification system for providers of certain medical assistance services." - MOVED CSHB 315(HSS) OUT OF COMMITTEE PREVIOUS COMMITTEE ACTION BILL: HB 345 SHORT TITLE: INSURANCE COVERAGE FOR CONTRACEPTIVES SPONSOR(s): REPRESENTATIVE(s) CLAMAN 02/24/16 (H) READ THE FIRST TIME - REFERRALS 02/24/16 (H) HSS, FIN 04/05/16 (H) HSS AT 3:00 PM CAPITOL 106 BILL: HB 334 SHORT TITLE: CHILD CUSTODY;DOM. VIOLENCE;CHILD ABUSE SPONSOR(s): REPRESENTATIVE(s) MUNOZ 02/22/16 (H) READ THE FIRST TIME - REFERRALS 02/22/16 (H) HSS, JUD 03/22/16 (H) HSS AT 3:00 PM CAPITOL 106 03/22/16 (H) Heard & Held 03/22/16 (H) MINUTE(HSS) 03/24/16 (H) HSS AT 3:00 PM CAPITOL 106 03/24/16 (H) <Bill Hearing Rescheduled to 3/29/16> 03/29/16 (H) HSS AT 3:00 PM CAPITOL 106 03/29/16 (H) Heard & Held 03/29/16 (H) MINUTE(HSS) 04/05/16 (H) HSS AT 3:00 PM CAPITOL 106 BILL: HB 315 SHORT TITLE: ELECTRONIC VISIT VERIFICATION: MEDICAID SPONSOR(s): REPRESENTATIVE(s) VAZQUEZ 02/17/16 (H) READ THE FIRST TIME - REFERRALS 02/17/16 (H) HSS 03/22/16 (H) HSS AT 3:00 PM CAPITOL 106 03/22/16 (H) Heard & Held 03/22/16 (H) MINUTE(HSS) 03/24/16 (H) HSS AT 3:00 PM CAPITOL 106 03/24/16 (H) Heard & Held 03/24/16 (H) MINUTE(HSS) 04/05/16 (H) HSS AT 3:00 PM CAPITOL 106 WITNESS REGISTER MEGAN CAVANAUGH, Staff Representative Matt Claman Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Presented the changes to HB 345, on behalf of Representative Claman, prime sponsor. REPRESENTATIVE MATT CLAMAN Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Introduced HB 345, as prime sponsor. DIANA GREENE FOSTER, Researcher University of California, San Francisco San Francisco, California POSITION STATEMENT: Testified during discussion of HB 345. KENNI PSENAK LINDEN Palmer, Alaska POSITION STATEMENT: Testified in support of HB 345. ROBIN SMITH Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 345. CATRIONA REYNOLDS, Clinic Manager Kachemak Bay Family Planning Clinic Homer, Alaska POSITION STATEMENT: Testified in support of HB 345. STEVEN SAMUELSON Petersburg, Alaska POSITION STATEMENT: Testified in support of HB 345. ELIZABETH FIGUS Juneau, Alaska POSITION STATEMENT: Testified in support of HB 345. CHRISTINE NIEMI The League of Women Voters - Alaska Douglas, Alaska POSITION STATEMENT: Testified in support of HB 345. ALYSON CURREY Planned Parenthood of the Great Northwest and the Hawaiian Islands Juneau, Alaska POSITION STATEMENT: Testified in support of HB 345. SAMANTHA SAVAGE Fairbanks, Alaska POSITION STATEMENT: Testified in support of HB 345. CAITLIN HEDBERG Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 345. MAXINE DOOGAN Community United for Safety and Protection Fairbanks, Alaska POSITION STATEMENT: Testified in support for HB 345. MARGARET BRODIE, Director Division of Health Care Services Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Answered questions during discussion of HB 345. CRYSTAL KOENEMAN, Staff Representative Cathy Munoz Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Answered questions on HB 334, on behalf of the Representative Munoz, prime sponsor. KEELEY OLSON, Executive Director Standing Together Against Rape (STAR) Anchorage, Alaska POSITION STATEMENT: Testified during discussion of HB 334. CHRISTINE PATE, Legal Program Director Alaska Network on Domestic Violence & Sexual Assault (ANDVSA) Sitka, Alaska POSITION STATEMENT: Testified against proposed HB 334. LINDA BRUCE, Attorney Legislative Legal Services Legislative Affairs Agency Juneau, Alaska POSITION STATEMENT: Answered questions during discussion of HB 334. NANCY MEADE, General Counsel Administrative Staff Office of the Administrative Director Alaska Court System Anchorage, Alaska POSITION STATEMENT: Answered questions during discussion of HB 334. TANEEKA HANSEN, Staff Representative Paul Seaton Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Testified and answered questions during discussion of HB 315. DEB ETHERIDGE, Deputy Director Central Office Division of Senior and Disabilities Services Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: Answered questions during the discussion of HB 315. ACTION NARRATIVE 3:05:07 PM CHAIR PAUL SEATON called the House Health and Social Services Standing Committee meeting to order at 3:05 p.m. Representatives Seaton, Foster, Wool, and Talerico were present at the call to order. Representatives Vazquez and Tarr arrived as the meeting was in progress. HB 345-INSURANCE COVERAGE FOR CONTRACEPTIVES 3:05:49 PM CHAIR SEATON announced that the first order of business would be HOUSE BILL NO. 345, "An Act relating to insurance coverage for contraceptives and related services; relating to medical assistance coverage for contraceptives and related services; and providing for an effective date." 3:06:28 PM REPRESENTATIVE TALERICO moved to adopt the proposed committee substitute (CS) for HB 345, labeled 29-LS1503\H, Wallace, 3/22/16, as the working document. CHAIR SEATON objected for discussion. 3:07:24 PM MEGAN CAVANAUGH, Staff, Representative Matt Claman, Alaska State Legislature, shared the changes to the proposed committee substitute, Version H. She relayed that Version H removes the provisions that applied to over-the-counter contraceptives in the original bill on page 1, lines 11 - 12; page 2, lines 16 - 17; and page 3, lines 18 - 19. 3:08:15 PM REPRESENTATIVE MATT CLAMAN, Alaska State Legislature, as prime sponsor of HB 345, paraphrased from the sponsor statement [included in members' packets], which read as follows [original punctuation provided]: Unintended pregnancies have significant and negative consequences for individual women, their families, and society as a whole. Research links births resulting from unintended or closely spaced pregnancy to adverse maternal and child health outcomes and other social and economic challenges. With Alaska's fiscal challenges, we should look for ways to reduce costs in the shortterm and long-term. House Bill 345 will reduce costs associated with unintended pregnancies by making oral contraceptives more easily available to Alaskan women. In 2010, 48% of all pregnancies in Alaska were unintended. Alaska's unintended pregnancy rate in 2010 was 54 per 1,000 women aged 15-44. Of those unintended pregnancies, 60% resulted in births, 26% resulted in abortions, and the remainder resulted in miscarriages. Most unintended pregnancies are associated with significant public costs. In 2010, 64.3% of unplanned births in Alaska were publically funded, which resulted in a $42.9 million cost to the state. House Bill 345 seeks to reduce the costs of unintended pregnancies by making oral contraceptives more easily available to Alaskan women. A research study shows that women who were dispensed a 12-month supply of oral contraceptives were 30% less likely to have an unintended pregnancy than women who received a 1- or 3-month prescription. The study concluded that health insurance programs and public health programs may avert costly unintended pregnancies by increasing dispensing limits on oral contraceptives to a 1-year supply. HB 345 requires health care insurers, including Medicaid services, to cover 12 months of prescriptive oral contraceptives at a time. Alaskan women often face challenges while trying to access prescription contraceptives. Women living in rural Alaska have less access to healthcare services and therefore less reliable access to prescriptive contraceptives. Fisherwomen working on a boat for two or three months at a time need longer supplies of prescription oral contraceptives. This bill looks to reduce health care costs in Alaska by preventing unintended pregnancies and providing Alaskan women greater access to family planning options. 3:09:19 PM MS. CAVANAUGH clarified that the recently distributed fiscal note reflected the original version and not the proposed committee substitute, Version H. She explained that, additionally, a fiscal note was written for the Senate companion bill, SB 156, and reflected a $1.3 million cost savings for the state. CHAIR SEATON pointed out that the fiscal note for SB 156 was located in the committee packets. MS. CAVANAUGH reported that the proposed bill mandated that health care insurers provide coverage for a prescriptive contraceptive up to 12 months at one time. She defined prescriptive contraceptives as self-administered, hormonal contraceptives, namely oral contraceptives that do not require insertion or other types of administration by a medical professional. She said this was explained in Section 1 of the proposed bill, which contained a religious exemption as well as a definition for health care insurer, which included a self- insured employer, such as the State of Alaska. She moved on to explain that Section 2 of the proposed bill directed the Department of Health and Social Services to cover the 12 month supply of prescription contraceptives for eligible recipients of medical assistance. Section 3 of the proposed bill allowed for the 12 month supply of prescription contraceptives to be made available to Medicaid recipients, and Section 4 of the proposed bill related to the effective date. MS. CAVANAUGH stated that a major premise behind the proposed bill was that offering women greater access and availability to contraceptives reduced unintended pregnancies. This reduction in unintended pregnancies had a direct cost savings to the state, which was reflected in the provided fiscal note, which was drafted to the Senate version. She directed attention to the study [included in members' packets], which reported that, in 2010, 48 percent of pregnancies, about 8,000 pregnancies in Alaska, were unintended. She pointed out that the study had used the Centers for Disease Control and Prevention definition of an unintended pregnancy to mean either "mistimed, or the woman did not want to become pregnant at that time." She added that the study estimated that 3,000, or 64.3 percent of the unplanned pregnancies in 2010, were publicly funded. She reported that Alaska had spent almost $113 million on unintended pregnancies, that 70.8 percent was federally funded, while 42.9 percent was funded by the state. She relayed that these costs also had impacts on programs down the line, including foster care, and on the child's overall well-being. She shared that an additional study [included in members' packets] reviewed 84,000 women in California provided with varying amounts of oral contraceptives, and that those researchers observed a 30 percent reduction in the odds of pregnancy when given a year-long supply of oral contraceptives. Also reported in this study, the California family planning program paid $99 more annually for women who received three cycles of oral contraceptives and $44 more annually for women who received one cycle of oral contraceptives than it did for women who received the 12-month supply all at once. She shared that the additional costs were a result of pregnancy tests and associated visits. She noted that the proposed bill did not change who was eligible for coverage or what kind of prescriptions were being covered, the bill only allowed that women who currently received coverage for prescription contraceptives could receive the prescription for 12 months at one time, if they choose. She shared that there had been concerns expressed from the Small Business Association for whether the bill would apply to self-insured entities. She stated that the sponsor would continue to work with the group to address these concerns. She pointed out that an important inclusion to the proposed bill was for the definition of a health care insurer to include a self-insured entity, which did help to address some of the concerns. She declared that proposed HB 345 would offer "huge advantages for Alaskan women, from eliminating the inconvenience of refilling the prescription every one or three months at a time to the real inability for some Alaskan women to make it to the clinic, hospital, or pharmacy to refill that prescription at all." She listed the difficulties that many women faced in refilling prescriptions. 3:14:50 PM REPRESENTATIVE TARR pointed out that the fiscal note showed a $1.3 million savings annually. 3:15:11 PM CHAIR SEATON opened public testimony on HB 345. 3:15:24 PM DIANA GREENE FOSTER, Researcher, University of California, San Francisco, explained that she was working on research for the State of California to evaluate and analyze the impact of year- long supplies for oral contraceptives. She shared that her research indicated that the benefits included a cost savings of almost $100 annually per person. She reported that there were fewer clinic visits and fewer pregnancy tests. She relayed that a second study linked family planning dispensing to claims for pregnancies, births, and abortions. The findings were that women who received a one year supply were less likely to have either a birth or an abortion in the subsequent year. She stated that oral contraceptives were the most commonly used reversible method of contraception in the United States, and that most unintended pregnancies and most abortions occurred to women using contraceptives inconsistently. She reported that one in five women in abortion clinics reported that they had unprotected sex because they ran out of birth control. She allowed that this change would offer a higher potential for women to avert unintended pregnancies. 3:17:50 PM CHAIR SEATON noted that a synopsis of her research is included in members' packets. 3:18:27 PM KENNI PSENAK LINDEN shared that, as a college student, she had been diagnosed with Stage 4 endometriosis and had been prescribed hormonal birth control to allow for the future possibility to have children. She reported on the difficulty of maintaining consistent use of birth control while being only allowed a one-month prescription, and stated that having a 12- month supply readily available "would have been a huge relief and would have given me much needed peace of mind about my health and my ability to choose what was best for me in consultation with my doctor." She asked that the proposed bill address access to birth control by dependents. She relayed the health difficulties of endometriosis, and shared that the prescriptions for hormonal birth control allowed her to continue with and graduate from college. She declared support for the proposed bill. 3:20:23 PM ROBIN SMITH stated that this was a good bill, and there was no reason not to pass it as it offered cost savings. She declared that this was a preventative care bill, as it prevented unintended and unwanted births and abortions. She listed 10 reasons why a doctor might prescribe birth control pills, other than to prevent pregnancy: protection against ovarian and endometrial cancer; prevention of ovarian cysts; prevent and treat endometriosis; prevent anemia; avoid migraines associated with menstrual periods; treat PMS; treat acne, and excess hair growth; and balance hormone deficiency. She declared that, as it was beneficial for women to have access to birth control pills, there were not any negatives associated with the proposed bill. 3:23:58 PM CATRIONA REYNOLDS, Clinic Manager, Kachemak Bay Family Planning Clinic, pointed out that she had sent in two pages of facts and data. She stated that consistent access to birth control should not be dependent on an insurance carrier. She listed the benefits for supplying 12 months of birth control protection, which included consistent use. 3:26:32 PM STEVEN SAMUELSON stated his support of the proposed bill, noting that people should not be hindered by legislation in pursuit of health, especially when discussed with a doctor. He pointed out that many women were working in the field and did not have immediate access to refills. He declared "people like sex, so why not have them be prepared." He reiterated his support of HB 345. 3:28:48 PM ELIZABETH FIGUS reported that during the summer fishing season she did not have time to visit a doctor. She allowed that, although some medical issues were unavoidable, it was "silly" and "unnecessary" not to pre-approve a birth control prescription. She declared that the proposed bill would save money and time for individual women, and would save the costs for unplanned pregnancies. She pointed out that, as contraception was already legal, it was only necessary to make the system be more fiscally efficient. She stated her support for proposed HB 345. 3:30:53 PM CHRISTINE NIEMI, The League of Women Voters - Alaska, paraphrased from a prepared statement [included in members' packets], which read as follows [original punctuation provided]: The League of Women Voters of Alaska strongly supports HB 345 (companion to SB 156), a bill related to insurance coverage for contraceptives and other services that reduce the risk of unintended pregnancies. At the national level, the League of Women Voters of the United States supports primary care for all, care that includes "prenatal and reproductive health." When women have the consistent ability to plan their pregnancies, their families benefit through greater financial well-being, healthier living conditions, healthier children, greater opportunities, and a myriad of additional benefits. While improving the quality of life for families, the ability to avoid unintended pregnancies also reduces costs for state and federal governments. In 2010 according to the Guttmacher Institute, the State of Alaska spent nearly $43 million on health costs related to unintended pregnancies while the federal government added another $71 million for a total cost of $114 million. Guttmacher reports that 48% of all pregnancies in Alaska in 2010 were unplanned and 64% of Alaska's unplanned pregnancies were publicly funded, representing the $43 million cost. In addition, the cost benefits of supporting women in their efforts to plan their pregnancies goes far beyond the cost of the pregnancy itself. A woman who is able to plan a pregnancy can better guarantee that her health is at optimum level prior to pregnancy, reducing the risk of a difficult pregnancy and trauma to the child. Such planning reduces the possibility of increased health problems for the child, problems which can follow the child for years and require increased health and education costs for the State. A planned pregnancy increases a woman's ability to manage her role as income provider for a family and allows that family the best opportunity to remain as financially independent as possible. Supporting affordable contraceptives prescribed on a 12-month basis will undoubtedly reduce the number of unintended pregnancies in Alaska, thereby increasing family wellbeing and reducing State costs. 2 HB 345 can assist women and families to plan pregnancies so they are ready for the added responsibility of a child. In addition, costs to the State for unintended pregnancies can be reduced. This is a win-win bill that deserves consideration by the Legislature especially as it struggles with the budget crisis. Thank you for your consideration. 3:32:36 PM ALYSON CURREY, Planned Parenthood of the Great Northwest and the Hawaiian Islands, stated support for insurance coverage for a 12 month supply of birth control when supplied by a health care provider. She added that 1 in 4 women said they had missed pills because of not being able to get them in time. She reported that a one year supply dramatically improved consistent use, lowered unintended pregnancies, and hence, reduced abortions. 3:34:10 PM SAMANTHA SAVAGE stated her support for HB 345 and she paraphrased from a prepared statement [included in members' packets], which read as follows [original punctuation provided]: I am writing today to encourage you to support SB 156. For many many women oral contraception is their method of choice for various personal medical reasons. Alaskan women face more barriers trying to access all medications due to geographic and occupational reasons (women who live and work in rural communities or on fishing vessels for example). Speaking from my own life as someone who left the Mat-Su Valley to attend school in Fairbanks, trying to get my prescription refilled was an incredible burden as I could only have it refilled on a month by month basis. Having the ability to have 12 months of birth control covered by an insurance plan and Medicaid at one time saves in costs related to doctors visits to the women seeking medication, and it saves money related to unintended pregnancy. I urge your support of this bill that would have a positive impact on the lives of many Alaskan women. 3:35:36 PM CAITLIN HEDBERG urged support of the proposed bill. She shared that she is a professional woman, and that she often traveled for work. She noted that it was a burden having to re-supply birth control, reporting that missing a pill or starting a new cycle because of an interruption to access wreaks havoc on the human body. She had experienced an unintended pregnancy due to a lack of access for birth control. She pointed out that her insurance would only allow a one month supply at a time. She concluded that the proposed bill was the fiscally responsible choice for the state and for the women of the state. 3:38:49 PM MAXINE DOOGAN, Community United for Safety and Protection, reported that she represented current and former sex workers in Alaska, sex trafficking victims, and their allies. She declared support for HB 345 as it expanded access to health care. 3:39:33 PM CHAIR SEATON closed public testimony on HB 345 after ascertaining no one further wished to testify. 3:39:41 PM REPRESENTATIVE WOOL stated that he supported the proposed bill as it "totally makes sense." He asked if this was an insurance bill, and whether it had been previously possible for a 12 month prescription for birth control pills. MS. CAVANAUGH replied that currently women could not get a 12 month supply of oral contraceptives at one time, as it was usually limited to one or three month supplies. REPRESENTATIVE WOOL mused that the current state of insurance regulations would not cover the payments for more than three months. 3:41:32 PM MARGARET BRODIE, Director, Director's Office, Division of Health Care Services, Department of Health and Social Services, explained that a Medicaid prescription was on a month-by-month basis, with those individuals under 18 years of age able to get a 3 month prescription. In response to Chair Seaton, she said that the proposed bill would change the situation for a 12 month prescription, but that it would be necessary to ensure that the individual was eligible for all 12 months, and if not, the department would have to reimburse the federal government for its share of the prescription that the individual was not eligible. MS. BRODIE, in response to Chair Seaton, replied that private insurance, dependent on the plan, was for either a one month or a three month prescription. REPRESENTATIVE WOOL directed attention to the benefit savings in the analysis of the fiscal note, and asked about the difference between the 9 percent failure rate and the 7 percent failure rate, resulting in 120 unintended pregnancies. He questioned whether all of the unintended pregnancies had resulted in childbirth. MS. BRODIE expressed her agreement that the 120 pregnancies would not all result in live birth, and she offered her belief that this had been taken into consideration in the calculations. 3:45:14 PM CHAIR SEATON said that HB 345 would be held over. 3:45:45 PM REPRESENTATIVE TARR declared that this problem with access had been long standing. She pointed out that young families had not testified, noting that they were very challenged with the demands of parenthood and working. She opined that the proposed bill would be very beneficial to young families. 3:46:58 PM CHAIR SEATON removed his objection to the proposed committee substitute. There being no further objection, Version H was adopted as the working draft. [HB 345 was held over.] 3:47:25 PM The committee took a brief at-ease. HB 334-CHILD CUSTODY;DOM. VIOLENCE;CHILD ABUSE 3:47:47 PM CHAIR SEATON announced that the next order of business would be HOUSE BILL NO. 334, "An Act relating to visitation and child custody." 3:48:30 PM CRYSTAL KOENEMAN, Staff, Representative Cathy Munoz, Alaska State Legislature, on behalf of Representative Munoz, prime sponsor of HB 334, reported that the committee recommendations had been taken into consideration and that she would provide a proposed committee substitute (CS) for review and approval. 3:49:31 PM The committee took a brief at-ease. 3:50:18 PM CHAIR SEATON brought the committee back to order. He reopened public testimony on HB 334, [which had been closed at the previous bill hearing on 3/29/16]. 3:50:56 PM KEELEY OLSON, Executive Director, Standing Together Against Rape (STAR), shared her background working against domestic violence and sexual assault since 1989. She testified in opposition to the proposed bill, as it did not provide the necessary protections for the victims of domestic violence and their children. She offered her belief that the requirement for criminal conviction was too high a standard to be placed on the victims of domestic violence when they were seeking civil and legal protections. She suggested that the rebuttal of presumption was a very effective tool to protect the safety of victims and children, and that much of the testimony by attorneys were complaints that this created havoc in the family law courts. She stated that domestic violence was a messy business, and was one of most underreported crimes in America. She said that there would not be an increase of criminal law convictions with this, and that the requirement for the conviction would not offer any protection to the victims. She declared that it was necessary to be cautious and to properly vet the claimed experts of family law, as opposed to those who have worked in the field and understand the dynamics of domestic abuse. She said that for courts to take on the issue of custody, it needed to be prepared to hear "some of the messy business that goes on behind closed doors that is the typical situation of domestic abuse." She stated her opposition to the proposed bill. 3:56:13 PM CHAIR SEATON relayed that the proposed CS had been revised to change the standard from conviction to clear and convincing evidence that there was a history of performing domestic violence. 3:56:56 PM CHRISTINE PATE, Legal Program Director, Alaska Network on Domestic Violence & Sexual Assault (ANDVSA), stated opposition to the proposed bill. She relayed that the legal program provided civil legal assistance, primarily in family law cases, to victims of domestic violence and sexual assault, as well as legal advice and counsel to advocates in the ANDVSA member programs. She shared her background in family law. She expressed her understanding of how the custody statutes affected victims, both before and since the enactment of the rebuttable presumption law. She expressed concern for the effect on children of this proposed legislation. She stated that the rebuttable presumption law was enacted to protect Alaskan children from the harmful effects of exposure to domestic violence. She expressed agreement with the sponsor statement that fathers were a critical part of a child's life; although, she declared, it was most important for a child to have two healthy parents. She stated that Alaska consistently ranked near the top nationally for domestic violence and sexual assault. She pointed out that the emotional, physical, and mental health of children in homes with domestic violence was detrimentally affected. She explained that the rebuttable presumption against awarding a parent custody was enacted to ensure that the court made consideration of domestic violence a top priority in the decisions for custody of children, as prior to this, domestic violence was only one of nine best interest factors that could be considered by the court in these custody decisions. She said that domestic violence was such an enormous issue in Alaska that it needed to be more than one of the nine best interest factors, declaring that the proposed bill would return Alaska to these considerations unless there had been a criminal conviction for domestic violence. She shared her concerns for the proposed committee substitute regarding a clear and convincing evidence standard. She offered her belief that domestic violence was very hard to prove in court, as victims often did not want to come forward because of fear or shame, and often there was not extraneous evidence. She stated that the clear and convincing standard made domestic violence even harder to prove in a custody case, and she expressed support for the removal of the criminal conviction standard. She opined that this standard was an enormous burden to overcome, especially in Rural Alaska. She stated that there was nothing in the legislative history of the rebuttable presumption law that indicated its purpose was to require a criminal history of domestic violence, as the current law required a history of perpetrating domestic violence to invoke the rebuttable presumption. She reported that rebuttable presumption was defined as one act which caused serious physical injury, a very high standard, or more than one act of domestic violence found by a preponderance of the evidence, 51 percent or more. She declared that the history of domestic violence was well defined in the statute. She stated that an accusation of domestic violence was not enough to invoke the presumption and lose custody of the children, as there had to be a finding by the trial court that it was more likely than not, the civil legal standard, that one incident of serious physical injury or two or more incidences occurred. She pointed out that this finding could not happen in an ex parte protection order hearing, but could only occur after a long term domestic violence hearing, or in a custody case where both parties had the opportunity to fully present evidence and testify about the incidences. She emphasized that courts are hesitant to make findings of domestic violence in long term protection order cases because of an understanding to the significance of the findings in a custody case. She declared that supervised visitation was free in most areas of Alaska. CHAIR SEATON pointed out that the proposed bill would next go to the House Judiciary Standing Committee. 4:04:00 PM CHAIR SEATON closed public testimony on HB 334 after pointing out that the above two testifiers had been cut off during the previous hearing on HB 334 due to technical difficulties. 4:04:32 PM REPRESENTATIVE TARR reflected that her struggle with the proposed bill was that the testimony had been in such contrast. She pointed out that the testimony regarding supervised visits had ranged from not being available, to very costly at $75 per hour, to being free in most communities. 4:05:58 PM REPRESENTATIVE TALERICO moved to adopt the proposed committee substitute (CS) for HB 334, Version 29-LS1409\N, Bruce, 4/5/16, as the working draft. There being no objection, Version N was before the committee. 4:06:38 PM MS. KOENEMAN stated that the proposed bill was a complicated issue, and that the sponsor was trying to find a more middle ground for the best interest of the children. She directed attention to the original intent language adopted by the legislature in 1981, which essentially stated that it was in the best interest for parents to share the rights and responsibilities of child bearing. While actual physical custody may not be practical or appropriate in all cases, it was the intent of the legislature that both parents had the opportunity to guide and nurture the child and to meet the needs of the children on an equal footing beyond the considerations of support or actual custody. She declared that the proposed bill was seeking to ensure that the needs of the child were met. CHAIR SEATON, in response to Representative Talerico, asked Ms. Koeneman to explain the changes made for the proposed committee substitute, Version N. 4:08:43 PM MS. KOENEMAN directed attention to Section 1, which removed the rebuttable presumption language in AS 25.24.150(g). She reported that Section 2 added language for clear and convincing evidence to establish a history of perpetrating domestic violence, as well as the language for the conviction of a crime, for the judge to use in determination of visitation rights. She moved on to Section 3 which removed the rebuttable presumption language. She explained the changes to Section 4 which dealt with the delegation of visitation rights to a family member by deployed parents. She relayed that Section 5 was the modification of a custody or visitation order that removed the rebuttable presumption. She pointed out that Section 6 removed the rebuttable presumption language for military families for the delegation of visitation rights to a family member. She reported that Section 7 referenced AS 25.24.150(c)(6), which removed the current language and changed it to "clear and convincing evidence." She reported that Section 8 contained all new language, which brought all the custody arrangements back to AS 25.20.061 if there was any clear and convincing evidence of domestic violence, and that language was set out in Section 2 of the proposed bill. She noted that the court could order these pieces referenced in Section 2. She pointed out that AS 25.24.150(m) added a time frame around the acts of domestic violence. She shared that AS 25.24.150(n) was in regard to both parents committing domestic violence, and the award of custody to the parent least likely to perpetrate domestic violence, or to a suitable third party as ordered by the court. She moved on to the changes for Section 9 which repealed the rebuttable presumption language as well as the language regarding both parents committing a domestic violence crime. She concluded with Section 10 which stated that this act only applied to visitation or custody orders issued on or after the effective date of the proposed bill. CHAIR SEATON directed attention to page 5, line 14, and asked if this language was applicable if this was a child of either one of the parents. MS. KOENEMAN replied that the intent was to include step- children or foster children. REPRESENTATIVE WOOL suggested that it could read "a child of either of the two parents." CHAIR SEATON opined that it would be a child within the family. 4:16:46 PM LINDA BRUCE, Attorney, Legislative Legal and Research Services, Legislative Affairs Agency, in response to Chair Seaton, said that the language currently exists under AS 25.20.061, and that it could be altered to apply to a child of either of the two parents. CHAIR SEATON asked if this would cover foster children in the home. MS. BRUCE offered her belief that the alteration would cover this, although she would review this further and provide a written response. 4:17:52 PM NANCY MEADE, General Counsel, Administrative Staff, Office of the Administrative Director, Alaska Court System, said that she would defer to the Legislative Legal and Research Services for the wording. She stated that definitions of domestic violence and household member already exist. 4:18:20 PM REPRESENTATIVE VAZQUEZ offered her belief that there was a definition of child in the adoption chapter, AS 25.23.240. She relayed that her problem was that it was very restrictive, and she pointed out that if the child was not biological, and had yet to be adopted, they would not be technically covered. She suggested the use of "household member" or similar. CHAIR SEATON asked if this could be resolved so to cover domestic violence within the household. MS. BRUCE said that she would. 4:19:20 PM REPRESENTATIVE TARR asked about a circumstance with two adults and a blended family of biological children from previous relationships, although the adults were not legally married. She asked about a time frame for legal custody or visitation rights by each parent. MS. MEADE replied that there were grandparent rights and that she would research the rights for a person with a long standing relationship with the child. 4:20:53 PM CHAIR SEATON suggested a letter outlining the questions be sent to the next committee of referral. REPRESENTATIVE TARR asked that the circumstances around non- married couples be addressed. CHAIR SEATON reiterated that a letter asking House Judiciary Standing Committee to address certain issues could be sent along with the proposed bill. He directed attention to page 4, lines 11 - 14, and asked for an explanation. MS. KOENEMAN expressed her agreement that the language should also conform to "clear and convincing evidence" or "has committed a crime" in order for there to be consistency in all the areas. MS. MEADE replied to an earlier question by Representative Tarr about supervised visitation, and its availability in different communities. She explained that she had also heard different things. She stated that it was most common for the judge to seek that the parties agree on a family friend or relative to supervise the visitation, and only if there was not agreement would there be the need for professional supervision. She opined that there was no longer such an entity in Juneau, although this did vary by community. REPRESENTATIVE TARR asked about participation in a batterer intervention program, offering her belief that the only programs available would be prison based, as the funding for community based programs was being eliminated. She opined that a judge could not order this intervention if there was not a program within fifty miles. She asked if this would impact the ability for these situations to be resolved favorably. MS. MEADE, in response to Representative Tarr, offered her belief that, in Section 9, the presumption was eliminated, hence there would not be any need for the batterers intervention program; however, directing attention to page 2, lines 8 - 12, she relayed that if there was a finding by clear and convincing evidence of domestic violence or a conviction of domestic violence, the court may order that the perpetrator go to one of these programs. She noted that if a program did not exist, she would not expect that the judge would order this. 4:28:39 PM CHAIR SEATON, noting that telehealth programs had better results as they had full attendance, asked if there was a batterers program offered electronically. MS. KOENEMAN relayed that there were batterer prevention programs available on-line, although they were new and not yet used in the state. 4:29:54 PM The committee took a brief at-ease. 4:31:21 PM CHAIR SEATON announced that HB 334 would be held over. 4:32:14 PM The committee took an at-ease from 4:32 p.m. to 4:37 p.m. HB 315-ELECTRONIC VISIT VERIFICATION: MEDICAID 4:37:41 PM CHAIR SEATON announced that the final order of business would be HOUSE BILL NO. 315, "An Act relating to an electronic visit verification system for providers of certain medical assistance services." 4:38:03 PM REPRESENTATIVE VAZQUEZ moved to adopt the proposed committee substitute (CS) for HB 315, labeled 29-LS1287\N, Glover, 4/1/16, as the working draft. CHAIR SEATON objected for discussion. 4:38:35 PM TANEEKA HANSEN, Staff, Representative Paul Seaton, Alaska State Legislature, explained that the proposed committee substitute would narrow the approach for the electronic visit verification (EVV) system for the first few years by directing the Department of Health and Social Services to establish pilot projects for these EVV systems. She reported that Section 1 of the proposed CS was legislative intent language, stating that it was the intent of the legislature to protect vulnerable Alaskans and the integrity of the medical assistance program by reducing the number of fraudulent claims and insuring that services were provided to medical recipients. She relayed that it would use technology to improve accountability for personal care services and home and community based services delivered to medical assistance recipients. MS. HANSEN discussed Section 2, uncodified law, as this established a pilot project and directed the Department of Health and Social Services to adopt standards for an electronic visit verification (EVV) system under this project. This system would be used to verify visits conducted to provide personal care services in the home or other setting and visits conducted to provide home and community based services. She noted that this should establish the providers eligible to participate and require that the EVV system will document, at a minimum, the name of the provider, or their employee, the recipient, the date and time the contractor begins and ends the delivery of services, and the location of services. She explained that subsection (b) stated that DHSS would review the EVV systems implemented under this section and prepare a report with recommendations for statewide application of an EVV system, which would be due on or before January 1, 2018, and delivered to the Alaska State Legislature. 4:41:20 PM CHAIR SEATON removed his objection to the proposed committee substitute, Version N. There being no further objection, it was adopted as the working draft. REPRESENTATIVE WOOL asked whether the pilot program was at the discretion of the department for hiring a vendor or creating it in-house. CHAIR SEATON explained that this would be clarified in a yet to be introduced amendment. He offered some possibilities for the pilot projects to ensure that the department had the flexibility "to get something that will work and that people are willing to participate in." In response to Representative Wool, he pointed out that there was a fiscal note and testimony from the department. 4:44:07 PM DEB ETHERIDGE, Deputy Director, Central Office, Division of Senior and Disabilities Services, Department of Health and Social Services, asked for clarification to which fiscal note was being referenced. CHAIR SEATON clarified that the fiscal note was for the original bill and included information about the vendor. MS. ETHERIDGE said that she could speak on some of the anticipated costs associated with the pilot project. She said that she had not calculated the necessary statistically valid sample for an effective pilot program, although consultations with industry experts and other states had indicated that the transaction fee per transaction was about $0.15, with each visit consisting of two transactions. She noted that the cost would depend on the number of services a person received each day. She suggested that a pilot project for only personal care services, and not for home and community based services, would have fewer per day transactions. She reported that a person could have personal care services three times each day, although this could change if there were home and community based services, as well. She stated that the draft fiscal note had anticipated costs for two visits each day, five days each week, and 20 days each month. CHAIR SEATON asked if this yielded an overall savings. MS. ETHERIDGE replied that the savings were associated with a 1.5 percent efficiency found in administrative claims for Medicaid. She explained that there would be an actual time associated, and there would be a savings as the time for service would no longer be rounded. 4:48:31 PM CHAIR SEATON pointed out that the savings in other states had accrued in the first year, although, as the providers adjusted, those savings did not continue. MS. ETHERIDGE expressed her agreement, noting that there was considerable savings in small populations, which did not always continue when moved into a larger population. She stated that the pilot program was a good way to ensure the savings. CHAIR SEATON asked that the pilot program be large enough to be statistically significant, so there would be a better idea for its savings on a larger scale. He asked if the pilot would be designed for different locations. MS. ETHERIDGE replied that this would be necessary, as some associated expenditures which were difficult to anticipate were with connectivity, and it would be necessary to pay for a solution. She relayed that it would be necessary to target different areas in the state to ensure an understanding for the costs, and then to realize the savings. REPRESENTATIVE WOOL suggested that some savings would be a result of reduction in fraud if the verification system was working. He surmised that these savings would diminish as "people sort of start playing by the rules." MS. ETHERIDGE stated that the expectation was for ongoing compliance and adherence when billing for services using the EVV system, and an overall reduction and savings was anticipated for each year. She referenced a concern by Representative Seaton that some states had implemented the EVV system without allocating enough funds for a system which provided recognition of a service provider in the home. She said that this required extra funding, noting that, without it, the verifications were not as valid. She shared that it was necessary to weigh the cost of the solution against the cost of the Medicaid program. She reported that any additional administrative costs on the service from the Medicaid program were captured in a cost report and would be reflected in the reimbursement. She said that all of these factors were considered when implementing programs for the state. REPRESENTATIVE WOOL mused that the EVV system would eliminate fraud, and the resultant criminal convictions for fraud, as the care and the time was accurately recorded. He suggested that the costs should then stabilize. MS. ETHERIDGE clarified that most authorized services were in 15 minute units, and it was anticipated that more people would receive their authorized services. REPRESENTATIVE VAZQUEZ added that there was also a quality assurance component with the verification program, noting that Florida and Oklahoma had savings over the first few years. 4:55:55 PM REPRESENTATIVE WOOL observed that the system appeared to be necessary, and that the pilot program could determine if it would work and if there would be a savings. CHAIR SEATON explained that the purpose of the pilot was to determine if the data could be fully utilized and avoid implementing a big system to cover the entire state and solve all the problems at one time, which could then fail. 4:58:13 PM CHAIR SEATON moved to adopt proposed Amendment 1, labeled 29- LS1287\N.5, Glover, 4/5/16, which read: Page 2, following line 19: Insert a new subsection to read: "(b) The Department of Health and Social Services may consider a third-party vendor system for the pilot project under this section." Reletter the following subsection accordingly. 4:58:42 PM REPRESENTATIVE VAZQUEZ objected for the purpose of discussion. She said that she supported the proposed amendment as it provided the department with further flexibility for implementing the program. 4:59:03 PM REPRESENTATIVE VAZQUEZ removed her objection. There being no further objection, Amendment 1 was adopted. 4:59:29 PM CHAIR SEATON moved to adopt proposed Conceptual Amendment 1, which read: Page 2 line 7: replace "and" with "or" There being no objection, Conceptual Amendment 1 was adopted. 5:01:02 PM CHAIR SEATON moved to adopt proposed Conceptual Amendment 2, which read: Page 2 line 23: Delete "January" and replace with "July" There being no objection, Conceptual Amendment 2 was adopted. 5:01:46 PM CHAIR SEATON moved to adopt Conceptual Amendment 3, which read: Page 2 lines 5, 8, 10: Delete "standards" and replace with "regulations" CHAIR SEATON explained that the purpose of this proposed amendment was to clarify for the Department of Health and Social Services that it was not necessary for a standards based pilot, but instead, as they were adopting regulations, they had the freedom to adopt a pilot with a vendor, from a current provider's system, or another design. 5:02:35 PM REPRESENTATIVE TARR objected for discussion. She asked if, as it was a pilot program, this had been developed with standards language, instead of regulations, because regulations would make it necessary for the formal process of drafting regulations. CHAIR SEATON asked if the use of "regulations" [in the proposed conceptual amendment] would interfere with the interpretation of formal regulations, or could "guidelines" replace "standards" and retain the meaning. MS. ETHERIDGE, in response, said that Department of Health and Social Services would prefer to have "guidelines" or "standards" [in the proposed conceptual amendment] for flexibility in order to implement the pilot program on a timely basis and then the department could adopt regulations if necessary to ensure funding through the Medicaid program. CHAIR SEATON asked which would be better. REPRESENTATIVE VAZQUEZ interjected that the usage of "regulations" was for a formal process, and could be overly burdensome for a pilot project. She expressed her agreement with the intent to avoid confusion by not imposing a standards based. She suggested that "standards" be replaced by "guidelines" [in the proposed conceptual amendment] to avoid any confusion. MS. ETHERIDGE expressed her agreement. 5:06:22 PM REPRESENTATIVE VAZQUEZ moved to adopt a friendly amendment to Conceptual Amendment 3, which read: Page 2 lines 5, 8, 10 Delete "standards" and replace with "guidelines" [The committee treated the friendly amendment as adopted.] REPRESENTATIVE TARR removed her objection. There being no further objection, Conceptual Amendment 3, as amended, was adopted. 5:07:40 PM REPRESENTATIVE TARR pointed out that there needed to be consideration for the unique circumstances of Alaska, that cost effectiveness and quality assurance be considered, and that expectations be realistic. She reminded that, as personal care attendant services were only provided for individuals able to live independently, a no-show was often reported by the client. She declared her support of the personal care attendant program to allow people to stay in their homes and be closer to their families. 5:11:50 PM REPRESENTATIVE VAZQUEZ moved to report CSHB 315, labeled 29- LS1287\N, Glover, 4/1/16, as amended, out of committee with individual recommendations and the accompanying fiscal notes. There being no objection, CSHB 315(HSS) was moved from the House Health and Social Services Standing Committee. CHAIR SEATON said that new fiscal notes for Version N would be forthcoming. 5:12:40 PM ADJOURNMENT There being no further business before the committee, the House Health and Social Services Standing Committee meeting was recessed at 5:12 p.m., until 4/6/16, at 3:30.