Legislature(2015 - 2016)SENATE FINANCE 532
02/29/2016 09:30 AM Senate FINANCE
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| Audio | Topic |
|---|---|
| Start | |
| SB74 | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | SB 74 | TELECONFERENCED | |
| + | TELECONFERENCED |
SENATE FINANCE COMMITTEE
February 29, 2016
9:32 a.m.
9:32:03 AM
CALL TO ORDER
Co-Chair MacKinnon called the Senate Finance Committee
meeting to order at 9:32 a.m.
MEMBERS PRESENT
Senator Anna MacKinnon, Co-Chair
Senator Pete Kelly, Co-Chair
Senator Peter Micciche, Vice-Chair
Senator Click Bishop
Senator Mike Dunleavy
Senator Lyman Hoffman
Senator Donny Olson
MEMBERS ABSENT
None
ALSO PRESENT
Karen Forrest, Deputy Commissioner, Department of Health
and Social Services; Stacie Kraly, Assistant Attorney
General, Department of Law; Tom Chard, Executive Director,
Alaska Behavioral Health Association(ABHA); Dr. Carlton
Heine, Emergency Room Doctor, Juneau; Valerie Davidson,
Commissioner, Department of Health and Social Services.
PRESENT VIA TELECONFERENCE
Dr. Jay Butler, Chief Medical Officer, Department of Health
and Social Services; Dr. Erin Narus, State Medicaid
Pharmacist, Department of Health and Social Services; Dr.
Andrew Elsberg, Emergency Medicine, Providence Alaska
Medical Center, Anchorage; Doug Jones, Division of
Healthcare Services, Anchorage; Becky Hultberg, President
and CEO, Alaska State Hospital and Nursing Home
Association, Anchorage.
SUMMARY
SB 74 MEDICAID REFORM/PFD/HSAS/ER USE/STUDIES
SB 74 was HEARD and HELD in committee for further
consideration.
SENATE BILL NO. 74
"An Act relating to permanent fund dividends; relating
to a medical assistance reform program; establishing a
personal health savings account program for medical
assistance recipients; relating to the duties of the
Department of Health and Social Services; establishing
medical assistance demonstration projects; and
relating to a study by the Department of Health and
Social Services."
9:32:31 AM
Co-Chair MacKinnon discussed housekeeping.
9:33:57 AM
KAREN FORREST, DEPUTY COMMISSIONER, DEPARTMENT OF HEALTH
AND SOCIAL SERVICES, offered brief remarks on the language
in the bill that would remove the language in the bill
pertaining to the community grantee requirement. She
explained that the Center for Medicare and Medicaid
Services (CMS) required that the department change their
practice in the area of community grantee requirement. She
stated that in the last onsite evaluation, CMS had informed
the department that the requirement had to be removed
because the requirement that a provider be a grantee in
order to bill Medicaid restricted the freedom of choice for
Medicaid recipients by restricting access. She said that
the department had the ability to set reasonable standards
related to the qualifications of a provider; however, CMS
generally questioned state established qualifications that
would effectively limit services only to providers of the
state's choosing. She said that the department had promised
CMS to change the requirement, and in return CMS would
provide technical assistance with the change. She furthered
that CMS had stated that, while the department could
continue its practice if it used general funds, but would
not be allowed to continue to claim federal funds.
Additionally, the department believed the change was needed
because the current behavioral health system needed
foundational reform. She stated that some aspects of the
current system no longer worked, and the requirement to be
a grantee in order to bill Medicaid was one of those
features. She shared that the requirement had been
established 25 years ago, when behavioral health grants
were first refinanced to Medicaid with the intention to
avoid excessive growth in Medicaid, ensure accountability,
and track outcomes. She relayed that, overtime, the
department's model of the comprehensive community mental
health center had eroded, and highlighted that additional
providers were needed in order to address gaps. She said
that the department had developed and alternative in which
it provided $100 grants in order for an agency to bill
Medicaid, which had resulted in a patchwork of services
across the state as well as gaps in continuum of care. She
stressed that the change would be the beginning of needed
reform by initiating increased access for services.
9:37:36 AM
Co-Chair MacKinnon clarified that the committee was
discussing Page 28, line 22 of the bill.
9:38:00 AM
Ms. Forrest relented that, while the change would increase
access; access needed to be balanced with quality and cost.
She related that the vehicle for addressing the balance
would be the 1115 Behavioral Health Medicaid Waiver. She
explained that the purpose of the waiver was to improve
care, increase efficiency, and reduce costs. She shared
that once the waiver was complete the department would be
evaluated by CMS on whether the waiver increased access to,
and strengthened, providers and provider networks. She
related that providers had expressed concern about the
administrative burden placed on behavioral health grantees,
and the department anticipated brining changes before the
legislature concerning the complexities in behavioral
health statutes and regulations. She stressed the
importance for all parties of having a coordinated and
thoughtful process for discussion moving forward. She
assured the committee that the department was committed to
a thriving behavioral health system, and hoped that the
legislature and the administration could work on the issue
collectively. She said that removing the requirement for a
grantee was an important first step and was foundational to
behavioral health reform, which was foundational to
Medicaid reform.
9:39:21 AM
Co-Chair MacKinnon reiterated the version of bill under
consideration. She explained that the word "community" had
been removed from the language on Line 22 of page 28, which
caused a discrepancy between the federal government and the
state. She said that under current Alaska State Statute,
only grantees could bill Medicaid. She solicited additional
comments concerning the deletion of the word "community".
9:40:41 AM
STACIE KRALY, ASSISTANT ATTORNEY GENERAL, DEPARTMENT OF
LAW, reminded the committee that she would be referencing
Sections 22 and 23 of the bill. She relayed that a further
edit to state statute that had been contemplated in the
current bill version removed the word "community" in the
two different sections. She said that the desire to examine
the removal for unintended consequences had been previously
discussed. She stated that after considerable review she
believed that the purpose of the amendment had been to
create a broader framework of what would constitute a
clinic. She noted that by removing the word "community" the
section of the statute that was being amended contained the
definition of "clinic". She thought that the intent of the
removal was to increase the number of providers that could
be considered a clinic for purposes of billing Medicaid.
She felt that the goal was laudable, but expressed concern
that the edit would do what was intended. She furthered
that Community Mental Health Clinic was already a term of
art already articulated in state statute under AS 47.30.520
- 47.30.620; an entire statutory scheme existed to identify
the Community Behavioral Health System, developed 25 years
ago. She stressed that removal of the word "community"
eliminated a term that was part of the term of art written
into another provision of statute, which could create
conflict and confusion as the behavior health system
redesign moved forward.
9:43:45 AM
Co-Chair MacKinnon referred to a letter from the Alaska
Behavioral Health Association (ABHA) (copy on file).
TOM CHARD, EXECUTIVE DIRECTOR, ALASKA BEHAVIORAL HEALTH
ASSOCIATION (ABHA), testified that the association was
comprised of mental health and drug and alcohol treatment
centers throughout the state and was the provider
association. He highlighted the letter referred to by Co-
Chair MacKinnon. He expressed that the association
appreciated the idea of removing the grant requirement in
order to increase access, but felt that it should be
balanced with quality and cost effectiveness. He relayed
that the association recommended that the committee
consider copying language form Section 19, pages 23 and 24,
in order to balance the increased access recommended in the
provisions discussed in Section 22 and 23. He spoke
specifically of language in Section 19 that ensured access
to healthcare without reducing the quality of care; a
component for cost effectiveness should additionally be
considered.
9:46:32 AM
AT EASE
9:47:29 AM
RECONVENED
Mr. Chard expressed appreciation to the committee for
having the discussion, and reiterated the importance of
moving with caution during this time of reform.
9:48:11 AM
Co-Chair MacKinnon stated that the committee review the
proposed language compromise, and elucidated that her lead
legislative staff, Erin Shine, would work with all parties
involved to address concerns.
Co-Chair MacKinnon shifted the committee focus to mandatory
language for prescription drugs.
9:48:45 AM
AT EASE
9:49:17 AM
RECONVENED
Co-Chair MacKinnon related that a change had been proposed
to make language pertaining to a prescription drug
monitoring program mandatory in response to the state's
opioid drug problem. She stated that the recommendation had
received push back from physician groups that would be
impacted by the reporting requirements contained in the
language. She directed committee attention to Page 10, line
30, sections 4, 5, 6, 7, and 8. She added that there was an
online document that spoke to the issue from DHSS, dated
February 26, 2016(copy on file).
9:51:04 AM
DR. JAY BUTLER, CHIEF MEDICAL OFFICER, DEPARTMENT OF HEALTH
AND SOCIAL SERVICES (via teleconference), related that the
current bill version included improvement in the
prescription drug monitoring program (PDMP) in keeping with
recommendations of the Controlled Substances Advisory
Committee. He shared that PDMPs were important
communication tools for providers to get a more complete
picture of a patient's recent medical history. He relayed
that the changes to Alaska's PDMP were intended to strike a
balance between maintaining access to opioids for
appropriate use, supporting provider autonomy, and
maintaining the right to patient privacy, while
simultaneously assuring safe and effective utilization of
drugs while minimizing the risk of drug fraud and drug
diversion. He stated that opioids could be medically
useful, but that the previous decade had seen an epidemic
of opioid related deaths and disabilities that had
highlighted the need for better management. He said that
concerns from providers had been related to the language in
Section 8, page 14, lines 7 through 9, which required a
prescriber to check the database before dispensing,
prescribing, or administering a controlled substance. He
noted that other states had regulatory language that
required providers to check the PDMP; however, the current
language could go beyond what was necessary to address the
current public health problem. He stressed that the goal
was to remove barriers, and to encourage providers that did
not currently use the PDMP to do so. He elucidated that the
two greatest risk factors for overdose were escalation of
dosage, often needed to achieve continued analgesia among
persons receiving opioids over long periods of time, and
co-administration with other controlled substances. He
recommended providing the following exemptions to the
requirements:
· an exemption in patient settings
· an exemption for anesthesia or analgesia
administered immediately to during, or after,
outpatient surgery
· an exemption for emergency situations - emergency
medical services at scene, or during transport, or
in the emergency department.
· an exemption for hospice care
Dr. Butler reminded the committee the PDMP was a
communication tool for providers and dispensers, which had
proven useful to reduce the misuse of opioids, and address
the epidemic of dependency and overdose.
9:54:39 AM
Senator Olson expressed a concern for rural hospitals that
were staffed by health aides working directly from manuals.
He wondered whether the PDMP would interfere with emergency
medical situations.
Mr. Butler felt that the question highlighted the need for
an exemption for emergency situations. He added that
emergencies often overlaid the day-to-day practice of
medicine in clinics and emergency departments. He felt that
this was an area that made delegation authority critical;
the authority would allow the day to day practice of
providing pain management, and accessing the PDMP, to be
delegated to an assistant in the clinic who could provide
information to the provider in a timely manner.
9:56:41 AM
Senator Olson understood that the emergency room exemption
would extend to emergency patients.
Dr. Butler replied in the affirmative. He added that the
intent of the emergency situations was broad, the main
focus should be on limiting barriers to the administration
of drugs in a timely fashion in emergency situations where
opioid medication would be beneficial.
9:57:24 AM
Vice-Chair Micciche asserted that over prescription by
providers could be partially responsible for the opioid
problem.
Mr. Butler responded that when looking at the national data
on the patterns of opioid use it had been observed that
certain specialty providers did prescribe a greater
proportion of opioids upon initial prescription, but the
overall volume also included primary care providers; over
half of all prescriptions for opioids were by general
internists, family practice doctors, and advanced practice
nurse practitioners. He believed that the issue was much
broader than only what occurred in the emergency
department. He said safeguards existed for patients that
came into the emergency room on a recurrent basis, but
stressed the importance of striking a balance and avoiding
unintended barriers to administering opioids in emergency
situations. He believed that the question was specific to
emergency departments and should be further addressed.
10:00:07 AM
Vice-Chair Micciche maintained that there was a lack of
accountability for providers. He understood that exemptions
should be made for hospice care, but believed that there
should be accountability for the opioids used to care for
the hospice patient. He feared that relatives of the
hospice patient could misuse prescribed opioids if the PDMP
was not adequately populated and monitored. He believed the
issue required further discussion.
10:01:08 AM
Co-Chair MacKinnon relayed that she had proposed an
amendment to her staff regarding Section 8, page 14, line
8:
(4) that a pharmacist or practitioner shall access the
database to check a patient's prescription records
before dispensing, prescribing, or administering a
controlled substance to the patient.
Co-Chair MacKinnon wondered whether using best practices
before, and then following up and reporting the opioid
after could work.
Mr. Butler thought that the amendment would be a more
simplistic approach. He cautioned whether the highest risk
situations would be sufficiently addressed. He explained
that a person with a broken leg receiving morphine in an
ambulance was probably not at risk for becoming opioid
dependent; the bigger risk factor was the patient
prescribed a bottle of 100 tablets from their orthopedic
surgeon upon discharge from the hospital. He asserted that
focusing the PDMP on the higher risk situations should be
the goal. He admitted that it would be a challenge to
capture all of the at risk situations, but believed that
progress could be made by working with providers and
dispensers.
10:03:50 AM
Co-Chair MacKinnon clarified that the amendment that she
would possibly propose would look at the word "before",
while mandating the reporting.
10:04:15 AM
Vice-Chair Micciche liked the current language. He thought
that if there was going to be an exemption that it should
be in a subsection, and should state that only in emergency
situations should a pain medication be distributed before
checking the database.
Co-Chair MacKinnon simply wanted the burden to report to be
placed on a lower level employee so that doctors did not
have to use their time in that manner.
10:05:18 AM
Vice-Chair Micciche though that pressure should be placed
on the medical community to only dispense opioids when a
certain level of need had been established, rather than in
anticipation of the need. He felt that medical providers
were not conservative enough in their assumptions of
pharmaceutical need.
10:06:13 AM
Co-Chair MacKinnon stated that her sister was a registered
nurse, and that a conversation about what doctors were
mandated to do in regard to prescription drugs could be had
offline.
10:06:37 AM
Senator Dunleavy wondered whether a time frame of 24 or 48
hours, with a definitive end-period would help. He believed
that everyone understood the idea of the immediacy of
emergency situations, and wondered at what point it became
reasonable that the information would become part of the
database.
Co-Chair MacKinnon agreed and thought that a doctor needed
to work without regard to legislative requirements and in
the best interest of the patient. She admitted that the
state was suffering from a significant problem and that
lenient prescription providers could be part of the
problem.
10:07:56 AM
Co-Chair Kelly spoke in support of Co-Chair MacKinnon's
language. He thought that an accurate database would be a
useful tool for pushing back on opioid abuse.
10:08:29 AM
Co-Chair MacKinnon relayed that amendments would be due by
noon of the following day.
10:09:01 AM
DR. ERIN NARUS, STATE MEDICAID PHARMACIST, DEPARTMENT OF
HEALTH AND SOCIAL SERVICES (via teleconference), testified
that she was available for questions.
10:09:35 AM
DR. CARLTON HEINE, EMERGENCY ROOM DOCTOR, JUNEAU, testified
that he agreed 90 percent with the changes to the PDMP
proposed in the legislation. He recognized that opiate
addiction was a significant problem in the state that was
causing numerous deaths. He asserted that there were
physicians in the state that overprescribed narcotics. He
expressed concern that the language in the bill attempted
to address a problem, but would not be successful in its
intent. He offered a background of the opioid epidemic. He
shared that the epidemic had gotten worse in the late
1990s, early 2000s, after the Joint Commission asserted
that pain was a 5th vital sign that was not being treated
aggressively enough. He said that current patient
satisfaction surveys included a question about the adequate
control of pain, and that one of the quality metrics CMS
held doctors to was the length of time before narcotics
were administered to a person with a long bone fracture. He
felt that there was significant pressure on doctors to
prescribe pain medication. He felt that finding a way to
identify the providers that were overprescribing was
necessary, but he did not believe that the current language
in the bill would address the problem effectively, and
would cause more work for the majority of patients and
providers. He likened it to a "really big hammer trying to
hit a small nail." He thought that work could be done to
craft better language to identify the providers that were
the problem. He reiterated previous testimony that the
issue of addiction did not stem from a person with a broken
leg receiving intravenous (IV) narcotics in an ambulance.
He state that the addiction issue stemmed from the longer
term prescription of opioid for pain. He echoed previous
testimony that the problem was not stemming from the
administering of pain medication, but rather the
prescription and dispensing of inappropriate amounts and
quantities of pain medication. He explained his process for
distribution of pain medication. He explained that if a
patient came to him in acute pain, he administered IV or
acute medication without delay. He furthered that if the
injury were going to cause prolonged pain, he would write a
short prescription for pain medication: 5 to 15 tablets of
pain medicine. He admitted that the short prescription
could lead to an addiction issue, but that it was
predominately the long-term prescribing patters that were
driving addiction.
10:14:25 AM
Senator Dunleavy asked whether there was an established
science that indicated how many pills a person had to take
to be at risk for addiction. He wondered whether the
database would help doctors to flag possible addicts.
Dr. Heine responded that the PDMP was currently used to
flag over prescription. He said that the system was used to
look up patients that might be receiving multiple
prescriptions from multiple providers, which was a red flag
for abuse. He stated that there was science available on
addiction and who was at risk, as well as screening tools
that had been established to give providers information
concerning higher risk patients. He concluded that there
was not a set number of pills or a length of time of use
that lead to addiction, but characteristics of the patient
that were complicated. He added that it had been documented
that high doses of pain medication administered for long-
periods to terminal cancer patients had been effective, but
chronic narcotic use for chronic pain had not been shown to
be effective.
10:17:37 AM
Senator Bishop wondered whether opioids were always the
first choice for a pain medication. He shared that he used
Flexeril, a nonnarcotic, for pain management from compound
fractures.
Dr. Heine replied that an opioid was not always the first
choice; many different medications were considered for pain
management depending upon the source of the pain. He
relayed that Flexeril was a muscle relaxer that was great
for chronic back pain from muscle spasms. He added that
there were other situations where an over-the-counter pain
medicine, or a prescription nonsteroidal anti-inflammatory
drug (NSAID), could be a more appropriate pain treatment.
He noted that all of the above were used, but that the
latter choices were not problems and were therefore less
well known.
10:18:36 AM
Co-Chair MacKinnon asked whether Dr. Heine used electronic
records.
Dr. Heine replied in the affirmative.
Co-Chair MacKinnon queried whether he had the capability of
making an electronic transmission of the opioid use.
Dr. Heine responded that currently the PDMP was web-based,
a log on was required and then patient information needed
to be entered.
Co-Chair MacKinnon interrupted asking whether he had the
technology available to streamline the information.
Dr. Heine replied that he did not currently have the
technology because electronic medical records had numerous
firewalls. He noted that the State of Washington had a
system that could be studied for potential implementation.
10:19:48 AM
Vice-Chair Micciche commented that 15 percent of the
state's physicians currently used the PDMP. He said that
physicians in his district had expressed concerns about
over prescription of pain medication. He felt that many
people could manage pain with over-the-counter pain
medications. He felt that people should be encouraged to
use over-the-counter drugs.
10:21:59 AM
DR. ANDREW ELSBERG, EMERGENCY MEDICINE, PROVIDENCE ALASKA
MEDICAL CENTER, ANCHORAGE (via teleconference), agreed with
Dr. Heine's perspective on the matter. He said that working
in a busy emergency department made logging into the PDMP
time intensive. He felt that mandating login before
administration of drugs was unrealistic and unnecessary. He
believed that prescription of pain medications was the root
of the addiction problem in the state. He said that the
center was working to identify repeat emergency department
visitors. He reiterated that mandating a login in emergency
situations would affect his ability to serve patients. He
stated that he supported and information exchange that
would automatically provide patient information from other
providers, which he believed would take any bias out of
looking up patients, and would be more efficient.
10:25:43 AM
AT EASE
10:26:18 AM
RECONVENED
Co-Chair MacKinnon discussed housekeeping.
10:26:55 AM
RECESSED
1:35:46 PM
RECONVENED
Co-Chair MacKinnon related that the committee would
continue by discussing the audits.
1:37:16 PM
AT EASE
1:37:50 PM
RECONVENED
Co-Chair MacKinnon invited Ms. Kraly to the table. She
directed the committee's attention to a letter from DHSS
dated February 26, 2016 (copy on file):
2. Duty to identify and repay self-identified
overpayments
• Section 16, Page 17, Lines 14 - 15
"An enrolled medical assistance provider shall conduct
at least one annual review or audit of all claims
submitted to the department…"
• For the committee's consideration: "Unless a
provider is being audited under 47.05.200(a), an
enrolled medical assistance provider shall conduct a
biennial review or audit of a statistically valid
sample of claims submitted to the department…"
1:39:10 PM
Ms. Kraly testified that concerns had arisen in previous
committee meetings regarding Section 16 of the legislation.
She state that the primary concern that had been raised by
providers had been a reference to the words "all claims" on
live 15 of the section. She said that the language would
have been unduly burdensome upon providers to have to audit
all claims going forward. She relayed that in an effort to
allay some of the concern the department crafted some
conceptual language that would ensure that individuals that
were currently under an audit under AS 47.05.200, would hot
have to do a self-audit that would be duplicative of that
effort. She said that language was also provided that a
biennial review of a statistically valid sample would be
sufficient to performing an annual review of all claims.
She stated that the hope was that providers would examine
their records every 2 years and to review a valid sample of
those claims to identify overpayments.
1:41:10 PM
DOUG JONES, DIVISION OF HEALTHCARE SERVICES, ANCHORAGE (via
teleconference), shared that he was available for
questions.
1:42:02 PM
BECKY HULTBERG, PRESIDENT AND CEO, ALASKA STATE HOSPITAL
AND NURSING HOME ASSOCIATION, ANCHORAGE (via
teleconference), believed that the language would mitigate
the administrative burden that had been referenced in
previous testimony. She noted that there were existing
concerns related to the timing of the Medicaid Management
Information System (MMIS); some claims and some categories
were consistently overpaid. She did not think that the
problem would be a barrier, but that audits would be
"cleaner" once the system was performing better. She
thought that the effective date should be beyond the point
at which the system was paying timely and accurately on
claims.
1:44:07 PM
Co-Chair MacKinnon reminded the committee that amendments
had been due by 12pm, but that she would accept significant
input from committee members for a limited time extension.
Co-Chair MacKinnon requested further discussion of the
issues of fraud and false claims, which had been raised
during public testimony.
Ms. Kraly stated that the Medicaid Assistance False Claim
Act provisions could be found beginning in Section 1, and
through Section 3, pages 2 through 10. She relayed that
provider testimony from the previous week had indicated
that there were concerns about the private right of action
and how individuals would have the ability to potentially
bring a suit. She said that the department believed that
the language in current bill version properly balanced the
concerns. She related that the department was comfortable
with the balance provided by the legislation.
1:46:24 PM
Ms. Hultberg testified that this was a new legal framework
for Alaska that had already existed on the federal level,
and had resulted in significant judgements, often against
institutional providers, for fraud. She pointed out that
many of the cases were not for intentional wrongdoing, but
from provider's running afoul of very complex federal
regulatory or billing regimes. She remained concerned that
the framework could result in the filing of frivolous
lawsuits. She did not believe that the provision was
targeted at large institutions, which were low-risk
providers, but it was likely that cases would come against
them because they billed significant Medicaid dollars.
1:47:55 PM
Co-Chair MacKinnon discussed the extension of the amendment
deadline for 12pm the following day.
1:48:42 PM
VALERIE DAVIDSON, COMMISSIONER, DEPARTMENT OF HEALTH AND
SOCIAL SERVICES, reiterated her comments from the previous
week lauding the efforts of the subcommittee on Medicaid
reform. She said that the department had spoken to all of
the recommendations in the previously referenced letter.
Co-Chair MacKinnon directed attention to a letter from the
U.S. Department of Health and Human Services Centers for
Medicare & Medicaid Services (CMS) dated February 26, 2016;
and asked Commissioner Davidson to walk the committee
through the letter and highlight any concerns.
1:49:58 PM
AT EASE
1:50:51 PM
RECONVENED
Co-Chair MacKinnon explained that she had requested DHSS
view on the Indian Health Travel Policy, and how the
government had responded to the state on the issue.
Commissioner Davidson explained that the letter was
received the previous week, and provided more detail to the
states on how to implement policy changes. She directed
attention to Page 2 of the letter, which reiterated that
CMS was modifying the scope of services eligible for
enhanced Federal Medical Assistance Percentage (FMAP), and
were expanding the meaning of contractual agent to be an
enrolled Medicaid provider, which would allow state's more
flexibility. She relayed that the letter also stated that
flexibility would be increased for billion arrangements so
that Indian Health Services (IHS)/Tribal facilities or
their contractual agents could bill Medicaid directly for
services.
Commissioner Davidson directed attention to Page 3, under
"Permitting a Wider Scope of Services," explaining that
that services that were considered through an IHS facility
would be interpreted more broadly than the services that
they had prior. She noted that the middle of Page 3
clarified that the Freedom of Choice requirement for
Medicaid beneficiaries had not been changed. She continued
to the bottom of Page 3, which reflected that CMS had
indicated that there had to be a written care coordination
agreement, the form of which was flexible.
Commissioner Davidson stated that Page 4 indicated that an
IHS beneficiary, that was also a Medicaid beneficiary,
could not self-refer to a non-IHS provider, and
additionally indicated that a non-IHS provider could not
self-refer.
Commissioner Davidson stated that the bottom of Page 4
described the minimum requirements for care coordination:
(1) The IHS/Tribal facility practitioner providing a
request for specific services (by electronic or other
verifiable means) and relevant information about his
or her patient to the non-IHS/Tribal provider;
(2) The non-IHS/Tribal provider sending information
about the care it provides to the patient, including
the results of any screening, diagnostic or treatment
procedures, to the IHS/Tribal facility practitioner;
(3) The IHS/Tribal facility practitioner continuing to
assume responsibility for the patient's care by
assessing the information and taking appropriate
action, including, when necessary, furnishing or
requesting additional services; and
(4) The IHS/Tribal facility incorporating the
patient's information in the medical record through
the Health Information Exchange or other agreed-upon
means.
Commissioner Davidson stated that the bottom of Page 5
offered the government's willingness to be flexible in term
of the form that the agreements took: a contract, a
provider agreement, a memorandum of understanding or
agreement; as long as the form was consistent with what an
Indian health facility was in their authority to provide.
She said that the department had requested the CMS have
some flexibility regarding who performed the billing, and
the letter indicated that they were willing to be flexible
as long as the state met the requested requirements.
1:57:05 PM
Commissioner Davidson stated that Page 6 provided
clarification for that the state could claim 100 percent
for care management opportunities. She relayed that CMS had
indicated that they were not "willing to write states blank
checks", and that the understanding should be that there
was a significant amount of work that needed to be done in
order for them to provide the state with 100 percent
federal match. She relayed that the requirements written at
the top of Page 7:
(1) the item or service was furnished to an AI/AN
patient of an IHS/Tribal facility practitioner
pursuant to a request for services from the
practitioner;
(2) the requested service was within the scope of a
written care coordination agreement under which the
IHS/Tribal facility practitioner maintains
responsibility for the patient's care;
(3) the rate of payment is authorized under the state
plan and is consistent with the requirements set forth
in this letter; and
(4) there is no duplicate billing by both the facility
and the provider for the same service to the same
beneficiary.
Commissioner Davidson spoke further on Page 7, and related
that state expenditures for services under section 115
demonstration authority were eligible for 100 percent FMAP
as long as all of the required elements of being "received
through" an IHS or Tribal facility were present. She
explained that the letter clarified that if there were
other special enhanced matching rate, that the 100 percent
FMAP matching rate would supersede other rates.
2:00:14 PM
Co-Chair MacKinnon asked whether it was possible for the
department to issue a fiscal note on the issue now that the
letter had been received.
Commissioner Davidson related that the department would be
focusing on fiscal notes under the recognition that a
change in the system would be required by CMS, and that all
parties involved would need to provide agreements for this
benefit that accrued to the state, and DHSS received the
benefit of 100 percent match. She noted that it would take
time to craft the agreements, so the current fiscal notes
had been conservative estimations that would be built up
over time. She related that it would be nice to be able to
claim services soon, but that it would take more time
because of the system and audit requirements that CMS had
placed on the department. She stressed that the fiscal
notes have been conservatively estimated but that it was
expected that savings would accrue.
2:01:44 PM
Co-Chair MacKinnon said that the legislature expected some
of the savings to begin at the start of FY 17.
2:02:08 PM
Vice-Chair Micciche commented that the letter comprised a
significant "win" for the state, and expressed appreciation
for the work of any committee members who had been
involved.
2:02:41 PM
Commissioner Davidson asserted that her staff had worked
long hours in order to prepare information for the
committee.
2:03:04 PM
Co-Chair MacKinnon reiterated that amendments were due to
her office by noon the following day.
2:04:18 PM
Senator Olson queried page 14, section 8, line 7 pertaining
to the requirement that pharmacists check a prescription
record database before dispensing, administering, or
prescribing pain medication.
Co-Chair MacKinnon shared that she was accepting amendments
until noon the following day. She said that her
recommendation to the committee was that it should be
mandatory, period. She reiterated that Senator Olson could
bring an amendment to the contrary, but that she would be
voting no on such an amendment.
2:05:35 PM
Senator Olson contended that the language addressed all
controlled substances, of all schedules, and not just
opioids. He said that his office would craft an amendment.
Co-Chair MacKinnon hoped that future conversation on the
issue would be helpful for not overburdening doctors, which
providing them the tools necessary to administer quality
care.
SB 74 was HEARD and HELD in committee for further
consideration.
ADJOURNMENT
2:06:53 PM
The meeting was adjourned at 2:06 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SB 74 ASMA Testimony CS SB 74 Changes.pdf |
SFIN 2/29/2016 9:30:00 AM |
SB 74 |
| SB 74 ABHA ltr to Sen Fin re-CSSB74 elimination of grant req.pdf |
SFIN 2/29/2016 9:30:00 AM |
SB 74 |
| SB 74 CMS Testimony.pdf |
SFIN 2/29/2016 9:30:00 AM |
SB 74 |