04/13/2017 03:00 PM House HEALTH & SOCIAL SERVICES
| Audio | Topic |
|---|---|
| Start | |
| HB118 | |
| SB32 | |
| HB176 | |
| Adjourn |
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 118 | TELECONFERENCED | |
| += | SB 32 | TELECONFERENCED | |
| *+ | HB 176 | TELECONFERENCED | |
| *+ | HB 196 | TELECONFERENCED | |
| + | TELECONFERENCED |
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
April 13, 2017
3:04 p.m.
MEMBERS PRESENT
Representative Ivy Spohnholz, Chair
Representative Bryce Edgmon, Vice Chair
Representative Sam Kito
Representative Geran Tarr
Representative David Eastman
Representative Jennifer Johnston
Representative Colleen Sullivan-Leonard
MEMBERS ABSENT
Representative Matt Claman (alternate)
Representative Dan Saddler (alternate)
COMMITTEE CALENDAR
HOUSE BILL NO. 118
"An Act relating to compensation for wrongful conviction and
imprisonment."
- HEARD & HELD
SENATE BILL NO. 32
"An Act relating to biological products; relating to the
practice of pharmacy; relating to the Board of Pharmacy; and
providing for an effective date."
- MOVED SB 32 OUT OF COMMITTEE
HOUSE BILL NO. 176
"An Act relating to medical assistance reimbursement for ground
emergency medical transportation services; and providing for an
effective date."
- HEARD & HELD
HOUSE BILL NO. 196
"An Act relating to a tax on certain opioids; relating to the
alcohol and other drug abuse treatment and prevention fund; and
providing for an effective date."
- BILL HEARING CANCELED
PREVIOUS COMMITTEE ACTION
BILL: HB 118
SHORT TITLE: COMPENSATION FOR WRONGFUL CONVICTION
SPONSOR(s): REPRESENTATIVE(s) KAWASAKI
02/13/17 (H) READ THE FIRST TIME - REFERRALS
02/13/17 (H) HSS, JUD, FIN
04/11/17 (H) HSS AT 3:00 PM CAPITOL 106
04/11/17 (H) Heard & Held
04/11/17 (H) MINUTE(HSS)
04/13/17 (H) HSS AT 3:00 PM CAPITOL 106
BILL: SB 32
SHORT TITLE: PRESCRIPTIONS FOR BIOLOGICAL PRODUCTS
SPONSOR(s): SENATOR(s) HUGHES
01/23/17 (S) READ THE FIRST TIME - REFERRALS
01/23/17 (S) HSS, L&C
02/10/17 (S) HSS AT 1:30 PM BUTROVICH 205
02/10/17 (S) Heard & Held
02/10/17 (S) MINUTE(HSS)
02/15/17 (S) HSS AT 1:30 PM BUTROVICH 205
02/15/17 (S) Moved SB 32 Out of Committee
02/15/17 (S) MINUTE(HSS)
02/17/17 (S) HSS RPT 2DP 1NR 1AM
02/17/17 (S) NR: WILSON
02/17/17 (S) DP: VON IMHOF, BEGICH
02/17/17 (S) AM: GIESSEL
03/07/17 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
03/07/17 (S) Heard & Held
03/07/17 (S) MINUTE(L&C)
03/14/17 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg)
03/14/17 (S) Moved SB 32 Out of Committee
03/14/17 (S) MINUTE(L&C)
03/15/17 (S) L&C RPT 5DP
03/15/17 (S) DP: COSTELLO, HUGHES, MEYER, STEVENS,
GARDNER
03/15/17 (S) FIN REFERRAL ADDED AFTER L&C
03/29/17 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/29/17 (S) Heard & Held
03/29/17 (S) MINUTE(FIN)
03/30/17 (S) FIN AT 9:00 AM SENATE FINANCE 532
03/30/17 (S) Moved SB 32 Out of Committee
03/30/17 (S) MINUTE(FIN)
03/31/17 (S) FIN AT 1:30 PM SENATE FINANCE 532
03/31/17 (S) -- MEETING CANCELED --
04/03/17 (S) FIN RPT 1DP 3NR 1AM
04/03/17 (S) NR: MACKINNON, BISHOP, DUNLEAVY
04/03/17 (S) DP: VON IMHOF
04/03/17 (S) AM: OLSON
04/04/17 (S) TRANSMITTED TO (H)
04/04/17 (S) VERSION: SB 32
04/05/17 (H) READ THE FIRST TIME - REFERRALS
04/05/17 (H) HSS, FIN
04/11/17 (H) HSS AT 3:00 PM CAPITOL 106
04/11/17 (H) Heard & Held
04/11/17 (H) MINUTE(HSS)
04/13/17 (H) HSS AT 3:00 PM CAPITOL 106
BILL: HB 176
SHORT TITLE: GROUND EMER. MEDICAL TRANSPORT PAYMENTS
SPONSOR(s): REPRESENTATIVE(s) FANSLER
03/14/17 (H) READ THE FIRST TIME - REFERRALS
03/14/17 (H) HSS, FIN
04/13/17 (H) HSS AT 3:00 PM CAPITOL 106
WITNESS REGISTER
OLIVIA GARRETT, Staff
Representative Scott Kawasaki
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented HB 118 on behalf of the bill
sponsor, Representative Kawasaki.
TIFFANY MERRITT, Graduate Student
University of North Carolina
Greensboro, North Carolina
POSITION STATEMENT: Testified in support of HB 118.
WILLIAM HARRINGTON
Anchorage, Alaska
POSITION STATEMENT: Testified during discussion of HB 118.
AIMEE BUSHNELL, Staff
Senator Shelley Hughes
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented SB 32 on behalf of the bill
sponsor, Senator Hughes.
SENATOR SHELLEY HUGHES
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Reviewed SB 32 as the sponsor of the bill.
ROBERT THOMS
Wasilla, Alaska
POSITION STATEMENT: Testified in support of SB 32.
CINDY CASERTA
Wasilla, Alaska
POSITION STATEMENT: Testified in support of SB 32.
BECKY HULTBERG, President/CEO
Alaska State Hospital and Nursing Home Association (ASHNHA)
Juneau, Alaska
POSITION STATEMENT: Testified in support of SB 32.
PHIL SCHNEIDER
Alliance for Safe Biologic Medicines
Phoenix, Arizona
POSITION STATEMENT: Testified in support of SB 32.
KERRY McCLELLAND
Colon Cancer Alliance
Anchorage, Alaska
POSITION STATEMENT: Testified in support of SB 32.
MARK GUIMOND, Director
Legislative Affairs
Arthritis Foundation
Washington, DC
POSITION STATEMENT: Testified in support of SB 32.
THOMAS FELIX, MD
Amgen
Washington, DC
POSITION STATEMENT: Testified in support of SB 32.
CRYSTAL KOENEMAN
Juneau, Alaska
POSITION STATEMENT: Testified during discussion of SB 32.
REPRESENTATIVE ZACH FANSLER
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Presented HB 176 as the sponsor of the
bill.
MARGARET BRODIE, Director
Director's Office
Division of Health Care Services
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Answered questions during discussion of HB
176.
BILL HOWELL, Fire Chief
City of Bethel
Bethel, Alaska
POSITION STATEMENT: Testified in support of HB 176.
ALEX BOYD, Assistant Chief
Anchorage Fire Department
Anchorage, Alaska
POSITION STATEMENT: Testified in support of HB 176.
RICHARD ETHERIDGE, Fire Chief
Juneau, Alaska
Juneau, Alaska
POSITION STATEMENT: Testified in support of HB 176.
SCOTT CLOUGH
AP Triton
Retired Fire Chief
Sacramento, California
POSITION STATEMENT: Testified during discussion of HB 176.
ACTION NARRATIVE
3:04:54 PM
CHAIR IVY SPOHNHOLZ called the House Health and Social Services
Standing Committee meeting to order at 3:04 p.m.
Representatives Spohnholz, Sullivan-Leonard, Edgmon, Johnston,
and Tarr were present at the call to order. Representatives
Kito and Eastman arrived as the meeting was in progress.
HB 118-COMPENSATION FOR WRONGFUL CONVICTION
3:05:50 PM
CHAIR SPOHNHOLZ announced that the first order of business would
be HOUSE BILL NO. 118, "An Act relating to compensation for
wrongful conviction and imprisonment."
3:06:17 PM
OLIVIA GARRETT, Staff, Representative Scott Kawasaki, Alaska
State Legislature, summarized from the Sponsor Statement
[Included in members' packets], which read:
Our judicial system is meant to incarcerate the guilty
and protect the innocent. If the system fails
Alaskans, then the state is responsible to help the
innocent get back on their feet.
With increasing technology, DNA exonerations have been
on the rise. There have been 349 postconviction DNA
exonerations since 1989 with the vast majority
occurring since 2000. These individuals spent an
average of 14 years behind bars and were released into
a changed world. House Bill 118 gives these wrongfully
imprisoned victims a chance to start a new life and
integrate back into society.
Specifically, HB 118 creates an administrative process
whereby victims of overturned criminal convictions can
request compensation from the state for time served.
They can be compensated up to $50,000 per year with a
lifetime cap at $2 million, University of Alaska
tuition for themselves and their children, state-
funded health care including mental health services,
up to 3 years of state funded job training services
and economic damages including lost wages and attorney
fees. In order to qualify for the compensation, the
claimant must have served time in prison and then have
been exonerated via retrial, dismissed charges, or
executive pardon because of innocence.
While there is no price on the emotional and personal
suffering of those who were wrongfully imprisoned, HB
118 would bring Alaska up to the federal compensation
standards to help right the state's wrong. Financial
compensation would help victims of wrongful
imprisonment repair their lives by covering costs of
education, healthcare, housing and transportation.
Thirty-two states and the District of Columbia have
some sort of compensation statute. Every innocent
person, regardless of how they became incarcerated,
deserves just compensation for the time they wrongly
served. HB 118 is a stepping stone in a long process
towards ensuring justice for all Alaskans.
3:07:10 PM
CHAIR SPOHNHOLZ opened public testimony on HB 118.
3:07:28 PM
TIFFANY MERRITT, Graduate Student, University of North Carolina,
noted that she was born and raised in Alaska and was currently
attending graduate school at the University of North Carolina.
She shared that her master's research was in Sociology, with a
concentration in Criminology. She reported that, for three
years, she had been doing research on wrongful convictions and
she had created a database for the amount of financial redress
received by death row exonerees. She stated that only 40
percent of death row exonerees received redress, and that only
31 states had compensation statutes, pointing out that Alaska
did not have this statute, even as former Senator Ted Stevens
was "technically an exoneree." She reported that exonerees had
had everything taken from them. After years of incarceration
and the loss of many workable years with the attendant job
experience, they were released with a host of health and mental
health problems. She relayed that much of this could be
addressed by the proposed bill. She stated that the
compensation package in the proposed bill was "probably one of
the best I've seen in my research." She declared her support
for the proposed bill, noting that the United Nations had
mandated for countries to provide compensation for those who
were wrongfully convicted within their borders.
3:09:42 PM
WILLIAM HARRINGTON urged swift passage of the proposed bill, and
he suggested to amend the bill to include past incidences. He
stated that the current treatment of wrongfully convicted in
Alaska showed "no dignity." He said that it was necessary for a
strong message of dignity to be sent from the Alaska State
Legislature and the governor to its citizens.
3:11:44 PM
CHAIR SPOHNHOLZ closed public testimony.
3:12:04 PM
CHAIR SPOHNHOLZ announced that HB 118 would be held over.
SB 32-PRESCRIPTIONS FOR BIOLOGICAL PRODUCTS
3:12:06 PM
CHAIR SPOHNHOLZ announced that the next order of business would
be SENATE BILL NO. 32, "An Act relating to biological products;
relating to the practice of pharmacy; relating to the Board of
Pharmacy; and providing for an effective date."
3:12:35 PM
AIMEE BUSHNELL, Staff, Senator Shelley Hughes, Alaska State
Legislature, briefly recapped the main points of the proposed
bill, which included: only bio-similars approved by the U.S.
Food and Drug Administration (FDA) as interchangeables could be
substituted for the original prescription; within three days of
dispensation of the product to the patient, a notification must
be sent to the original prescriber; and, the prescriber can
write "dispense as written" on the prescription, if this is the
only product the prescriber wants for the patient.
SENATOR SHELLEY HUGHES, Alaska State Legislature, reiterated
that access to these medications was important to many Alaskans,
and that the proposed bill described the arrangement and
notifications between the doctor and the pharmacist.
3:15:13 PM
CHAIR SPOHNHOLZ opened public testimony on SB 32.
3:15:22 PM
ROBERT THOMS stated that he was also known as Cajun Bob and that
he was a Vietnam combat veteran and a recipient of the Silver
Star medal, as well as six Purple Hearts. He declared that he
had chronic pain for more than 45 years, and that he had been
diagnosed with severe rheumatoid arthritis. He reported that
his original medication was not a biologic, which "after three
years, it almost killed me." He said that he was then
prescribed a biologic, Humera, which allowed him to enjoy a
functional life after being bed ridden. He noted that, although
he was not yet 100 percent, this had allowed him to do chores
and projects with his wife. He declared that, although this
biologic "was a miracle," he did not know if it would always
work. He emphasized that it was necessary to approve this
proposed legislation immediately, as he wanted to have
immediately available any approved substitute, should this
current biologic cease to work.
3:18:25 PM
CINDY CASERTA shared that she was also a chronic pain sufferer,
and that she spoke as an ambassador for the U.S. Pain Foundation
in support of the proposed bill. She referenced a Stanford
study of 6200 rheumatoid arthritis patients on biologics,
pointing out that 33 percent of these patients stopped taking a
biologic within two years because of a loss of effectiveness.
She surmised that bio-similars could be the answer for Alaskans.
3:20:10 PM
BECKY HULTBERG, President/CEO, Alaska State Hospital and Nursing
Home Association (ASHNHA), reported that the Alaska State
Hospital and Nursing Home Association had consulted with
hospital-based pharmacists and physicians to ensure that the
proposed bill would supply the necessary guidance to ensure safe
and effective treatments for patients, while providing the
potential to lower pharmaceutical costs. She reported that,
following this consultation, ASHNHA decided to support the
proposed bill. She declared that critical components of the
bill included its specific communication requirements and
timelines for pharmacists associated with dispensing bio-similar
medication. She stated that the proposed bill would meet the
needs of pharmacists in a variety of settings, and that the
proposed bill strikes the right balance for notification and
communication. She reported that bio-similars and
interchangeable biological products offered affordability as
they would provide competition to biologic drugs, similar to the
way generic drugs did for brand name drugs. She offered her
belief that proposed SB 32 would protect patients and would
benefit the state.
3:21:43 PM
PHIL SCHNEIDER, Alliance for Safe Biologic Medicines,
paraphrased from a letter of support [included in members'
packets], which read as follows [original punctuation provided]:
As the chairman and advisory board chair of the
Alliance for Safe Biologic Medicines (ASBM), we are
writing to urge you to support Senate Bill 32 (SB 32)
regarding the pharmacy substitution of biosimilar
medical products. ASBM is an organization of patients,
physicians, pharmacists, manufacturers of both
innovative and biosimilar medicines, researchers and
others who are working together to ensure patient
safety is at the forefront of the biosimilars policy
discussion.
As a retired pediatric rheumatologist and a former
president of the American Society of Health-system
Pharmacists, we are keenly aware of the benefits of
biologics in treating serious conditions like cancer,
rheumatoid arthritis, diabetes, and MS. "Copies" of
these medicines, called "biosimilars" have the
potential to provide these therapies at reduced cost.
Yet unlike generic versions of chemical drugs
biosimilars are not exact duplicates of their
reference products. Indeed, the complexity of
biologics and their proprietary manufacturing
processes mean that these "copies" can only ever be
similar, never the same. Even the smallest structural
difference between a biologic and its attempted copy
can have a significant impact on a patient, including
reduced efficacy or unwanted immune responses.
We believe that when interchangeable biosimilar
products are substituted, communication between
patients, pharmacists, and health care providers is
essential to patient care. We fully support and are
concerned that patient safety will be compromised if
this legislation is not enacted.
Since 2012, ASBM has conducted surveys of physicians
in eleven countries, to gather their perspectives on
biosimilars. The results of these surveys have since
been shared with policymakers in the U.S., Canada,
Europe, and the World Health Organization in Geneva,
Switzerland.
Our survey of 376 U.S. physicians found that 80% of
those surveyed called communication in the event of a
biosimilar substitution "very important" or
"critical".
Further, 82% of U.S. physicians called the authority
to block a substitution by indicating "do not
substitute" or "dispense as written" on a prescription
"very important" or "critical".
These results are consistent with those of physicians
around the world, including those surveyed in Canada
and Europe, where biosimilars are currently in
clinical use. All ASBM surveys are available on our
website at www.safebiologics.org/surveys.
It is our view that SB 32 appropriately reflects the
importance of pharmacist-physician communication and
keeping treatment decisions the purview of the
physician and patient, without posing undue or onerous
burdens upon the pharmacist:
It provides that only "interchangeable" biosimilars
(those determined by the FDA to produce the same
effects in a patient as the reference product without
additional risks) may ever be substituted.
It allows a physician to prevent a substitution they
consider inappropriate for their patient by writing on
the prescription "dispense as written".
It provides that the pharmacist receive the patient's
consent in order to make a substitution. The Alliance
for Safe Biologic Medicines - PO Box 3691 Arlington,
VA 22203 www.safebiologics.org - (703) 971-1700
Finally, SB 32 requires that the pharmacist
communicate to the physician within a reasonable time
frame (3 days) which biologic the patient actually
received whether that prescribed by the physician,
or a substituted biosimilar- so that an accurate
patient record can be kept by all parties.
SB 32 will extend these valuable protections to
Alaska's patients while increasing their access to
biologic therapies. For these reasons, lawmakers in 26
states and Puerto Rico have passed similar bills in
the past few years.
3:24:49 PM
CHAIR SPOHNHOLZ asked about the substantial differences for side
effects and efficacy for interchangeables. She asked whether it
was safe for pharmacists to recommend changes at the pharmacy
point of sale, rather than from the prescriber.
MR. SCHNEIDER explained that biologics were medicines produced
by living cells and that bio-similars were biologics, similar
for the therapeutic effect and safety profile, but with minor
differences which needed to be considered. He clarified that
these were not considered to be interchangeable. He said that
the third category was interchangeable bio-similar, which had
been categorized by the FDA, based on studies which involved
switching patients back and forth between the reference product
to the bio-similar, and then back again. These studies had to
demonstrate that the interchangeable bio-similar had no
differences for both its effectiveness and its safety. He
stated that the proposed bill only related to interchangeable
bio-similars as considered by the FDA based on the switching
studies. He added that the FDA stated that a pharmacist could
switch those medicines. The purpose of the state laws was to
ensure communication with the prescriber, even though that
happened after the fact.
3:28:09 PM
KERRY McCLELLAND, Colon Cancer Alliance, stating that he was
advocating for all cancer patients, shared his history with
cancer and various treatments. He declared that it was
important to pass the proposed bill so that Alaskans would not
have to travel out of state.
3:30:11 PM
MARK GUIMOND, Director, Legislative Affairs, Arthritis
Foundation, stated that the Foundation fully supported proposed
SB 32. He pointed out that arthritis was a lifelong chronic
disease, which could be debilitating. He stated that biologics
offered a benefit, as they changed lives to a good quality of
life. He pointed out that these were complex medications
because they were live cells and were also very expensive.
These represented .01 percent of prescriptions filled at
pharmacies. He expressed hope that bio-similiars would have the
same effect on the market as generic drugs. He suggested that
it was best to pass this legislation immediately. He declared
that the communication aspect of the proposed bill was
essential, as it created a complete medical record for the
patients. He declared support for the proposed bill.
3:33:24 PM
THOMAS FELIX, MD, Amgen, stated support for the proposed bill,
and he discussed one of the five provisions, key to the bill,
which was a departure from existing generic substitution law in
Alaska. He pointed to the requirement for a pharmacist to
communicate with a physician following the substitution of an
interchangeable bio-similar. He said that this ensured that
members of the health care team were talking with each other, as
this created transparency and accessibility to needed
information. He allowed that some had advocated for no
communication as it was too burdensome. He stated that there
had been work with both pharmacists and stakeholders to make
sure their perspectives were represented in the proposed bill to
make it less burdensome. He said that communication prior to
the substitution went against the spirit of the designation of
interchangeability. He shared that the federal law which
allowed the bio-similar pathway, the description for
interchangeability was for the pharmacist to exercise their
discretion for substitution without the consent of the
prescriber. He relayed that it was important to understand that
this facilitated drug safety surveillance, which was required
for all biologics, and that bio-similars were also included. He
reminded the committee that there were currently four approved
bio-similars in the United States, of which two had not yet been
distributed. He pointed out that, as two were self-
administered, this legislation provided clear terms of use to
both the health care team and the patient. He directed attention
to a recent draft guidance for interchangeability, which was
intended to provide clarity to the community for what was
required to receive an interchangeability designation. He added
that, as the FDA was very busy developing bio-similars which
were trying to mimic 23 reference products coming off patent,
there was a need to ensure that the health care community and
patients had a clear understanding for use of these products,
both when they were interchangeable and when they should not be
substituted. He reminded that the FDA had set an appropriate
scientific bar for approval of these products and that, once
approved, they would be highly similar to an existing reference
product and the differences in efficacy and safety should not be
a concern. When an interchangeable was approved, it signaled
that there was not a concern for its use when switching with the
original product. Patients suffering from grievous illness will
be comforted by knowing that the appropriate measures that
comport with new technologies were being passed.
3:41:11 PM
CRYSTAL KOENEMAN shared her personal story for the use of a
biologic, Humera. She reported that, although this allowed her
to play with her young child and function on a day to day basis,
these were "scary. They change your chemical make-up and you
are no longer the same." She reported that she had recently
developed three lesions on her brain, which appeared similar to
multiple sclerosis. She was then unable to take biologics for a
few months, and now she relied on a name brand. She expressed
her concern that with bio-similars, insurance companies would no
longer cover name brands. She expressed her understanding that
others could not afford the cost and that some bio-similars
would work for some when the name brand did not. She expressed
support for the proposed bill as it allowed for choice, but she
expressed concern for her ability to choose to be taken away as
an unintended consequence. She reported that she was not able
to take any other biologic that would in any way affect her
nervous system. She asked that the committee be cautious.
3:47:10 PM
CHAIR SPOHNHOLZ closed public testimony.
3:47:20 PM
CHAIR SPOHNHOLZ moved to adopt Amendment 1, labeled 30-
LS0188\J.3, Wallace/Bruce, 4/13/17, which read:
Page 4, following line 10:
Insert a new bill section to read:
"* Sec. 8. AS 21.42 is amended by adding a new
section to read:
Sec. 21.42.435. Coverage for biological products.
(a) A health care insurer that offers, issues for
delivery, delivers, or renews in this state a health
care insurance plan that provides coverage for
biological products shall provide coverage for a
biological product or interchangeable biological
product without requiring prior authorization if the
biological product or interchangeable biological
product is to be dispensed as prescribed.
(b) In this section, "biological product" and
"interchangeable biological product" have the meanings
given AS 08.80.480."
Renumber the following bill sections accordingly.
Page 4, line 17:
Delete "Section 8"
Insert "Section 9"
Page 4, line 18:
Delete "sec. 9"
Insert "sec. 10"
CHAIR SPOHNHOLZ objected for discussion.
CHAIR SPOHNHOLZ explained that a "tsunami" of as many as 41
biologic interchangeables was coming and working through the FDA
process. She noted how important biologics were for those who
took them, as well as the transformative nature they could have
for individuals. She shared the story of a biologic that cost
$2000 each day. She explained that her proposed amendment would
require that health insurance plans provide coverage for
biological products, both interchangeables and biologicals,
without prior authorization if the product was to be dispensed
as prescribed. She said that this would require coverage of a
medication prescribed by a doctor and not necessarily the
cheapest one, as a small difference in a product could have a
big impact on the health and well-being of an individual. She
wanted to ensure that people with serious health care issues in
the state be able to have health care coverage by the insurance
providers, and that cost not be the only consideration.
3:50:09 PM
REPRESENTATIVE KITO reflected on the history of the change to
generic drugs from name brand drugs, noting that, as there were
some changes, some individuals reacted adversely. He encouraged
that the insurance companies be sensitive to provide medications
as needed for the patient as identified by the medical team.
3:51:26 PM
CHAIR SPOHNHOLZ withdrew proposed Amendment 1.
3:51:40 PM
REPRESENTATIVE EASTMAN expressed his support of the proposed
bill.
3:51:45 PM
REPRESENTATIVE EDGMON moved to report SB 32 out of committee
with individual recommendations and the accompanying fiscal
notes. There being no objection, SB 32 was moved from the House
Health and Social Services Standing Committee.
3:52:03 PM
The committee took an at-ease from 3:52 p.m. to 3:54 p.m.
HB 176-GROUND EMER. MEDICAL TRANSPORT PAYMENTS
3:54:44 PM
CHAIR SPOHNHOLZ announced that the final order of business would
be HOUSE BILL NO. 176, "An Act relating to medical assistance
reimbursement for ground emergency medical transportation
services; and providing for an effective date."
3:55:47 PM
REPRESENTATIVE EDGMON moved to adopt the proposed committee
substitute (CS) for HB 176, labeled 30-LS0705\J, Glover, 4/7/17,
as the working draft.
3:56:08 PM
CHAIR SPOHNHOLZ objected for discussion.
3:56:17 PM
REPRESENTATIVE ZACH FANSLER, Alaska State Legislature,
paraphrased from the Sponsor Statement [Included in members'
packets], which read:
"An Act relating to medical assistance reimbursement
for emergency medical transportation services; and
providing for an effective date."
Emergency Medical Transportation Services (EMTS)
relates to the emergency transportation of patients.
For what is traditionally considered an ambulance
ride, EMTS reflects Alaska's unique geographical
challenges to include air, water, and other approved
medical transport services. As it currently stands,
Alaska's emergency medical service providers incur
additional uncompensated costs when providing services
to Medicaid beneficiaries, by as much as sixty
percent.
Reimbursement for ground emergency medical
transportation services occurs when the providers
submit a billing to the department (specifically to
the Medicaid fiscal agent Conduent) for eligible
services provided; the department reimburses the
provider using the established Medicaid methodology
and rate; the department submits documentation
supporting the payment of the federal financial
participation (FFP) to Centers for Medicare and
Medicaid Services (CMS); and once it is approved, the
department receives reimbursement for the FFP from CMS
that amounts to the appropriate federal assistance
percentage (FMAP).
By enacting this legislation along with an amendment
to the state Medicaid plan, public EMS providers are
eligible to access enhanced federal funding for
emergency medical transportation of Medicaid patients.
The use of transfers is clearly authorized in federal
statute and is both legal and useful. Further, CMS
provides reimbursement for the administrative costs
associated with administrating EMTS by as much as
twenty percent.
Anchorage, Juneau, Kenai, and Ketchikan, combined
serve approximately forty-eight percent of the state's
population. In 2015 (for Kenai) and 2016 for the
others, these departments provided 7,035 transports to
Medicaid patients, without EMTS, the departments
received just $2.1 million in reimbursements; a total
collective under-compensation of roughly $3.9 million.
Were they EMTS eligible, they could have collected a
total of $6 million.
HB 176 would allow EMS providers around the state to
collect underfunded costs from the effective date,
providing a financial boon to those organizations and
communities. Even smaller communities such as Bethel
can see over a quarter of a million dollars in EMTS
reimbursements per year.
As you can see from the attached bill packet, there is
widespread support for HB 176 throughout the state to
help our local communities receive payments to
actively cover the services they provide.
4:01:46 PM
REPRESENTATIVE KITO asked if the entities that would be eligible
for reimbursement had to meet any licensing or registration
status.
REPRESENTATIVE FANSLER replied that they did have to meet
certain requirements.
REPRESENTATIVE KITO offered his belief that there was a
significance difference between ground and air ambulance
transportation for how the services were provided and paid. He
asked to better understand these cost and payment structures.
REPRESENTATIVE FANSLER deferred to the Department of Health and
Social Services and directed attention to the different codes
for transportation [Included in members' packets].
4:03:58 PM
REPRESENTATIVE SULLIVAN-LEONARD asked how many people who used
the ambulances paid cash or billed insurance. She asked if
there was a large number of patients who used Medicare or
Medicaid, hence the need for this proposed bill.
REPRESENTATIVE FANSLER offered his belief that there was an
average of 15,000 transports processed annually throughout the
state. He opined that, in Bethel, there was flexibility in the
municipal code to waive the fee for those who did not have
insurance and were not a Medicaid recipient, rather than leave
the patient behind.
4:06:32 PM
REPRESENTATIVE KITO asked how the transport services were
regulated as a designated carrier for emergency services,
whether there was any licensing or affiliation with a medical
facility.
4:07:14 PM
MARGARET BRODIE, Director, Director's Office, Division of Health
Care Services, Department of Health and Social Services,
explained that the proposed bill was addressing government
entities which provide these services. These providers would
have to be a government entity, as well as a Medicaid provider.
REPRESENTATIVE KITO asked how many communities this included,
noting that several communities had both non-profit and for
profit medical service providers.
MS. BRODIE offered to research the exact number.
REPRESENTATIVE KITO asked about the air ambulances.
MS. BRODIE said that she did not know if any rescue units were
run by municipalities or government entities.
4:09:01 PM
REPRESENTATIVE SULLIVAN-LEONARD asked how many of the 15,000
annual transports were eligible for insurance reimbursement,
Medicaid or Medicare reimbursement, or were self-payment.
MS. BRODIE replied that she could only report on the annual
amount of Medicaid paid for ground transportation, $50,362. She
said she did not have the figures for private insurance or
Medicare.
4:10:22 PM
CHAIR SPOHNHOLZ removed her objection. There being no further
objection, the proposed committee substitute (CS) for HB 176,
labeled 30-LS0705\J, Glover, 4/7/17, was adopted as the working
draft.
4:10:52 PM
BILL HOWELL, Fire Chief, City of Bethel, reported that he had
been with the department for 25 years and had been the fire
chief for the past two years. He shared some of the challenges
for providing emergency medical care in Bethel, and stated
support for proposed HB 176. He stated that the proposed bill
would have a positive, significant, and long-lasting impact on
the Emergency Medical Service (EMS) providers. He shared that
the Bethel Fire Department EMS call volume had increased by 10
percent over the past six years. He reported that the majority
of funding to the City of Bethel was from local sales, lodging,
and alcohol taxes, with the balance coming from community
support and fees for services, including ambulance service. He
declared that a recent analysis had shown that the ambulance
service was losing about $972,000 per year, noting that Medicaid
recipients were the largest users of the service in 2016. He
reported that, as Medicaid paid an average of $455 per call
toward an overall cost per transport of $1287, there was a heavy
burden on the City of Bethel. He stated that the financial
needs of the Bethel Fire Department were significant, pointing
out that additional staff were necessary to cover the increased
EMS call volume and that about $1.5 million was necessary to
replace an aging ambulance, a 1980 tanker, and a 1980 ladder
truck. He added that the fleet would frequently break down and
not allow for response, as they did not have any back-up or
mutual aid. He shared that there had been efforts to increase
revenue, which included an increase in ambulance fees and close
work with the third-party biller to ensure proper documentation
for the services and reception of the maximum allowed. He said
that funds were raised through the volunteer group and from
grants for staffing and equipment. He added that the City of
Bethel had also made capital requests to the Alaska State
Legislature for a new tanker and ladder truck. He pointed out
that the proposed bill would reimburse local EMS providers for
the uncompensated costs of providing care to Medicaid
recipients. He listed support for the proposed bill from the
Bethel City Council, the Alaska Fire Chiefs, and the Bethel Fire
Department.
4:15:02 PM
ALEX BOYD, Assistant Chief, Anchorage Fire Department,
emphasized that the scale of the issue was growing exponentially
and was impacting the Anchorage Fire Department to an almost
unmanageable level. He reported that there had been a 74
percent increase in transport for Medicaid recipients during the
past year, resulting in an unrecovered cost of nearly $3
million. He stated that the proposed bill would provide a
dramatic impact on the service to the municipality and would
allow the department to improve its system delivery and its
impact on the city. He noted that this current trend would
result in unrecovered expenses of $3.2 million for more than
7,000 transports during the calendar year 2017. He said that
Anchorage currently collected about $440 of the $926 fee. He
pointed out that this significant impact on the budget brought
challenges for the expansion of staffing to meet these growing
needs.
4:18:12 PM
RICHARD ETHERIDGE, Fire Chief, Juneau, Alaska, shared that
Alaska had the most complex, diverse EMS delivery system in the
nation, as there were challenges unlike most other areas,
including the often high expenses for even getting to a patient.
He reported that there had been an increase in demand for EMS
services, which made it difficult for fire departments. He
stated that the proposed bill provided the authorization to
develop a program where local agencies could recover some of
their costs for the provision of EMS. He acknowledged that the
Medicaid Expansion had an impact on emergency services, noting
that in Juneau the number of Medicaid patients transported had
more than doubled. He added that the call volumes across the
state were increasing, in Juneau there had been a 13 percent
increase last year, an amount not uncommon across the state. He
pointed out that Medicaid did not reimburse for all expenses,
sharing that the average cost of basic life support transport
was $1,680, of which Medicaid paid about $455. The balance due
was absorbed by the fire department, the local community, and
the tax payers. He reported that the program utilized funds set
aside by the federal Medicaid program just for this purpose and
was not tied to the Patient Protection and Affordable Care Act
or Medicaid Expansion. He reported that the state could also
collect administrative fees, up to 20 percent, an estimated $2.5
- $3 million back to the state. He estimated that this could
put between $12 - $15 million into the local economies for fire
departments. He shared that California was already setting up
this program. He stated that Alaska relied heavily on the EMS,
and that the proposed bill provided a foundation for first
responders in local communities to recover "some of the
desperately needed financial support and stability across the
state."
4:22:36 PM
REPRESENTATIVE SULLIVAN-LEONARD asked if the borough paid
reimbursement of transportation services through local sales and
property tax.
MR. ETHERIDGE replied that fire departments were funded out of
general fund or fire service area funds.
REPRESENTATIVE SULLIVAN-LEONARD asked if implementation of the
proposed bill would free funds from local taxation.
MR. ETHERIDGE replied that this would be up to each
municipality, although it would provide money back to the local
municipalities.
REPRESENTATIVE SULLIVAN-LEONARD asked how much this would be.
MR. ETHERIDGE said that each community was different, stating
that Anchorage could receive up to $4 million annually, Nome
could receive up to $16,000 annually, and Juneau could receive
between $600,000 and $1 million.
4:24:01 PM
REPRESENTATIVE KITO reflected on the increase in calls statewide
and asked what was driving this increase.
MR. ETHERIDGE said that this was actively being researched. He
mused that more people were eligible for health care and were no
longer self-payers, and that, as it was more difficult to access
primary care providers, more people came to emergency rooms and
EMS for primary care.
4:24:45 PM
REPRESENTATIVE JOHNSTON shared that she had read that the impact
of Medicaid Expansion on emergency rooms had been far greater
than anticipated. She acknowledged that emergency rooms were
now being reimbursed, but that the desired policy was not
happening. She asked if volunteer fire departments could also
participate.
MR. ETHERIDGE said that any fire department which was eligible
to bill and did bill for EMS services could participate in the
program.
4:26:28 PM
SCOTT CLOUGH, AP Triton, Retired Fire Chief, explained that he
was a retired assistant fire chief from Sacramento and was now a
consultant with fire agencies looking to pursue this
legislation. He pointed to his initial research in Alaska,
which had identified 55 agencies eligible to participate in the
program, including the university system and a health care
district. He clarified that some public agencies had been
identified as eligible to participate in the program, although
it did not preclude that private enterprise also benefit. He
said that municipalities which utilized the services of a
private provider, as well as non-profit and volunteer agencies,
could structure to use these revenues. He added that it was
important to understand that this was an emergency medical
transport bill tied to a federal cost structure for providing
these services. He explained that provider programs, if related
to the EMS, could count as a cost. He offered an example for
Juneau investing in new extrication equipment, and a new squad
for this equipment. Even though this was not a transport
vehicle, it was a unit and equipment utilized for delivery of
emergency medical services and could be rolled into the new cost
of service for a draw down of federal funding. He said there
were tremendous benefits to the communities and the Medicaid
beneficiaries as it allowed for an opportunity to expand the
services and recoup some of that investment. He declared that
Alaska was unique, and it was important to include both land and
air transport.
4:32:25 PM
CHAIR SPOHNHOLZ announced that HB 176 would be held over.
4:32:38 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at 4:33 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 32 Legislation - Version J.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM SHSS 2/15/2017 1:30:00 PM |
SB 32 |
| SB 32 Sponsor Statement - Biosimilars.pdf |
HHSS 4/13/2017 3:00:00 PM |
SB 32 |
| SB 32 - Sectional Analysis.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Fiscal Note DCCED CBPL.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| AK SB 32 Biosimilar Support Letter.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| ALF_AK SB 32__2 1 17 support.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Alliance of Specialty Medicine AK SB 32 020317.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| GHLF AK SB 32 Comment Letter_Support 2-3-17.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| LADAAK support.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| NORD AK_SB 32_ltr.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| 2-6-17 biosimilar AK support.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| NFK BioSimilars State Letter - Alaska 2.1.17.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Alliance for Patient Access AfAP - SB32.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Alliance for Safe Biologic Medicines AK-SB 32 -FNL.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| American Liver Foundation ALF_AK SB 32__2 1 17.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| SB 32 AARDA support.docx |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| SB 32 AARDA support.docx |
HHSS 4/13/2017 3:00:00 PM |
SB 32 |
| Digestive Disease National Coalition Support for SB 32.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Global Healthy Living Foundation GHLF AK SB 32 Comment Letter_Support 2-3-17.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| International Cancer Advocacy Network (ICAN) letter of support SB32.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| National Hispanic Medical Association (NHMA) _AK SB 32.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Pharmaceutical Research and Manufacturers of America (PhRMA) Support SB32.PDF |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Bios for Dr. Charles and Dr. Schneider.docx |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| SB 32 - BIO Support Letter 2-2-17 Biotechnology Innovation Organization.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| SB 32 - BIO Support Letter 2-2-17.pdf |
HHSS 4/13/2017 3:00:00 PM |
SB 32 |
| RetireSafe support SB32 2-6-17 biosimilar AK.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| 1-12-17 Group letter.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| SB 32 - 1 page handout explaining biosimilar legislation.docx |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Alaska ACS CAN Biosimilars Fact Sheet 2017.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| SB032 Supporting Documents-Support Letters 04.04.17.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
SB 32 |
| Senate Bill 32 opposition AK Rheumatoloty Alliance.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Alaska SB 32 - Merriman Comments 20170209.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| SupportLetter_Bio_SB32_psoriasis.docx |
HHSS 4/13/2017 3:00:00 PM SHSS 2/10/2017 1:30:00 PM |
SB 32 |
| Alaska Biosimilars Arth Fdn oppose amendment sb 32.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/15/2017 1:30:00 PM |
SB 32 |
| SB32_ASMA.pdf |
HHSS 4/13/2017 3:00:00 PM SHSS 2/15/2017 1:30:00 PM |
SB 32 |
| SB32 - Clarification on Questions Asked in the Committee (Sen Hughes).doc |
HHSS 4/13/2017 3:00:00 PM SHSS 2/15/2017 1:30:00 PM |
SB 32 |
| SB 32 - Sectional Analysis.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB 32 - Background Document - Potential Cost Savings of Biosimilar Drugs.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB 32 - Background Document - H&SS Comm. Q&A.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB 32 - Background Letter - State Medical Board.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB 32 - Fiscal Note - DCCED.PDF |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB 32 - Opposition Letter - Alaska State Medical Association.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB 32 - Support Documents - Fact Sheet.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB 32 - Support Letter - Alliance of Specialty Medicine.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB032 Sponsor Statement 04.04.17.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
SB 32 |
| SB032 Opposing Document-Opposition Letters 04.04.17.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
SB 32 |
| SB032 Sectional Analysis ver J 04.04.17.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
SB 32 |
| SB32 Letters of Opposition.pdf |
HHSS 4/13/2017 3:00:00 PM SFIN 3/30/2017 9:00:00 AM |
SB 32 |
| SB32 Letters of Support.pdf |
HHSS 4/13/2017 3:00:00 PM SFIN 3/30/2017 9:00:00 AM |
SB 32 |
| SB 32 Am No. 1.PDF |
HHSS 4/13/2017 3:00:00 PM |
SB 32 |
| SB 32 - Support Letter - U.S. Pain Foundation.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB 32 - Support Letter - State Advocacy & Alliance Development.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| SB 32 - Support Letter - Safe Biologics.pdf |
HHSS 4/13/2017 3:00:00 PM SL&C 3/7/2017 1:30:00 PM |
SB 32 |
| HB 176 Sponsor Statement 4.12.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Supporting Document - City of Bethel resolution 4.5.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Supporting Document - FNSB memo 4.5.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Supporting Document - FNSB resolution 4.5.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Supporting Document - Letter AK Fire Chiefs Assoc 4.5.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Supporting Document - letter AK Prof Firefighters Assoc 4.11.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Supporting Document - memo Bethel FD 4.5.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Supporting Document - North Pole resolution 4.5.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 ver A.PDF |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Additional Document AK FD budget reimb process 4.5.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Additional Document DHSS review 4.5.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Draft Proposed CS ver J 4.5.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Fiscal Note DHSS--HCMS 4.10.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 176 Fiscal Note DHSS--MAA 4.10.17.pdf |
HHSS 4/13/2017 3:00:00 PM HHSS 4/18/2017 3:00:00 PM |
HB 176 |
| HB 118 Sponsor Satement 4.10.2017.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 Supporting Document - Doyon support letter 4.10.2017.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 Supporting Document - Medical Compsensation by State 4.10.2017.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 Supporting Document - PBS Article 4.10.2017.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 Supporting Document - Support letters 4.10.2017.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 Supporting Document - TCC letter of support 4.10.2017.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 Supporting Documents 4.10.2017.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 ver A 4.10.2017.PDF |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 Fiscal Note DHSS--BHTRG 4.10.17.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 Fiscal Note DOL--CJL 4.10.17.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |
| HB 118 Sectional Analysis ver A 4.10.2017.pdf |
HHSS 4/11/2017 3:00:00 PM HHSS 4/13/2017 3:00:00 PM |
HB 118 |