Legislature(2017 - 2018)BUTROVICH 205

01/27/2017 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:32:08 PM Start
01:32:48 PM Presentation: Update on Medicaid Reform
02:59:37 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Presentation: Update on Medicaid Reform TELECONFERENCED
Monique Martin, DHSS Health Care Policy Advisor
-- Testimony <Invitation Only> --
**Streamed live on AKL.tv**
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                        January 27, 2017                                                                                        
                           1:32 p.m.                                                                                            
                                                                                                                                
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Senator David Wilson, Chair                                                                                                     
Senator Natasha von Imhof, Vice Chair                                                                                           
Senator Cathy Giessel                                                                                                           
Senator Tom Begich                                                                                                              
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
Senator Peter Micciche                                                                                                          
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                                
PRESENTATION: UPDATE ON MEDICAID REFORM                                                                                         
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
VALERIE DAVIDSON, Commissioner                                                                                                  
Alaska Department of Health and Social Services                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT: Addressed Medicaid reform.                                                                                
                                                                                                                                
MONIQUE MARTIN, Health Care Policy Advisor                                                                                      
Alaska Department of Health and Social Services                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT: Addressed Medicaid reform.                                                                                
                                                                                                                                
RANDALL BURNS, Director                                                                                                         
Division of Behavioral Health                                                                                                   
Alaska Department of Health and Social Services                                                                                 
Juneau, Alaska                                                                                                                  
POSITION STATEMENT: Addressed Medicaid reform.                                                                                
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
1:32:08 PM                                                                                                                  
CHAIR DAVID WILSON  called the Senate Health  and Social Services                                                             
Standing Committee meeting  to order at 1:32 p.m.  Present at the                                                               
call  to order  were  Senators Begich,  Giessel,  von Imhof,  and                                                               
Chair Wilson.                                                                                                                   
                                                                                                                                
^Presentation: Update on Medicaid Reform                                                                                        
            PRESENTATION: Update on Medicaid Reform                                                                         
                                                                                                                              
1:32:48 PM                                                                                                                    
CHAIR   WILSON  announced   that  the   committee  will   hear  a                                                               
presentation  on Medicaid  reform from  the Alaska  Department of                                                               
Health and Social Services (DHSS).                                                                                              
                                                                                                                                
1:33:29 PM                                                                                                                    
At ease.                                                                                                                        
                                                                                                                                
1:35:05 PM                                                                                                                    
CHAIR WILSON called the committee back to order.                                                                                
                                                                                                                                
1:35:15 PM                                                                                                                    
VALERIE DAVIDSON,  Commissioner, Alaska Department of  Health and                                                               
Social  Services,  Juneau,  Alaska,   announced  that  DHSS  will                                                               
address Medicaid redesign and implementation,  the progress of SB
74,  Medicaid  expansion,  and the  "landscape"  on  the  federal                                                               
level.                                                                                                                          
                                                                                                                                
CHAIR WILSON welcomed  the Alaska League of Women  Voters and Ms.                                                               
Epstein and her class from  the Dzantik'i Henni Middle School for                                                               
attending the meeting.                                                                                                          
                                                                                                                                
COMMISSIONER  DAVIDSON exclaimed  that one  of the  highlights of                                                               
last  year's legislative  session  was the  incredible work  that                                                               
went into the  bipartisan Medicaid reform bill, [SB  74]. She set                                                               
forth  that  workable timelines  have  been  established to  take                                                               
advantage  of  the  impetus  for change  within  the  DHSS's  and                                                               
provider community's limitations.                                                                                               
                                                                                                                                
1:37:59 PM                                                                                                                    
MONIQUE MARTIN, Health Care Policy  Advisor, Alaska Department of                                                               
Health and  Social Services, Juneau, Alaska,  explained that DHSS                                                               
broke down the  reforms in SB 74 into 16  initiatives in order to                                                               
stay on time and achieve the  savings stated in the bill's fiscal                                                               
notes.   She    divulged   that   DHSS    gathered   25-different                                                               
organizations from across  the state in 2015  for assistance with                                                               
Medicaid redesign  and expansion.  She pointed  out that  many of                                                               
the  reforms  in  SB  74  were the  result  of  the  key-partners                                                               
process. She summarized that the  DHSS's presentation is a way to                                                               
communicate  to the  public  what  is really  in  SB  74 and  how                                                               
providers  or  Medicaid  recipients  might  be  affected  by  the                                                               
reforms in  the bill. She  referenced "Alaska  Medicaid Redesign"                                                               
as follows:                                                                                                                     
                                                                                                                                
   · Delivery system reforms:                                                                                                   
     ƒPrimary care case management and Health Homes;                                                                           
     ƒBehavioral health system reform;                                                                                         
     ƒCoordinated care demonstration project;                                                                                  
     ƒ1915(i) and (k);                                                                                                         
     ƒCriminal  justice reform (SB 91), led by the Department of                                                               
        Corrections;                                                                                                            
     ƒEmergency  department care improvement, led  by the Alaska                                                               
        State Hospital and Nursing Home Association (ASHNHA).                                                                   
   · Delivery system infrastructure:                                                                                            
     ƒTelehealth;                                                                                                              
     ƒHealth information infrastructure plan;                                                                                  
     ƒImplementation of tribal claiming policy;                                                                                
     ƒMedicaid  reform program:  quality and  cost effectiveness                                                               
        metrics, explanation of benefits;                                                                                       
     ƒPrescription  drug monitoring  program (PDMP), led  by the                                                               
        Alaska Department of Commerce, Community and Economic                                                                   
        Development.                                                                                                            
   · Internal systems improvements:                                                                                             
     ƒRegular   progress   reports   to   the  Legislature   and                                                               
        stakeholders;                                                                                                           
     ƒMedicaid fraud and abuse prevention;                                                                                     
     ƒEligibility verification system.                                                                                         
   · Exploring options:                                                                                                         
     ƒPrivatization   studies:  Alaska   Psychiatric  Institute,                                                               
        Division, Division of Juvenile Justice facilities,                                                                      
        Pioneer Home pharmacy;                                                                                                  
     ƒHealth  care  authority  feasibility  study,  let  by  the                                                               
        Alaska Department of Administration.                                                                                    
                                                                                                                                
1:39:36 PM                                                                                                                    
MS. MARTIN  said DHSS reconvened  the key partners to  talk about                                                               
SB  74 implementation  and  the  need for  a  vision  in what  to                                                               
achieve   in  Medicaid   redesign.  She   referenced  a   visual-                                                               
representation document that summarized  the "Vision for Medicaid                                                               
Redesign" regarding  "principles and  values" and  "key features"                                                               
pertaining to  a "system of  whole person" and "high  value care"                                                               
to achieve the desired outcome from SB 74.                                                                                      
                                                                                                                                
She said  when putting the  initiatives together, the  intent was                                                               
for  the  two  biggest  reforms:   "behavioral  health"  and  the                                                               
"coordinated care  demonstration projects"  to take the  lead and                                                               
reshape  Alaska's health-care  delivery  system.  She noted  that                                                               
implementation deadlines  are a  bit later to  allow the  "tip of                                                               
the spear" to proceed first in  order to allow reforms to come in                                                               
line afterwards.                                                                                                                
                                                                                                                                
MS.  MARTIN  informed  that Primary  Care  Case  Management,  and                                                               
Health Homes are  the first initiatives. She said  the intent for                                                               
Primary  Care  Case  Management is  to  allow  Behavioral  Health                                                               
Reforms  to   go  through  its   process  and   Coordinated  Care                                                               
Demonstration Projects proposals to  come forward to do something                                                               
for Medicaid recipients  instead of waiting. She  detailed that a                                                               
program  was ramped-up  to address  super-utilizers that  utilize                                                               
emergency rooms  more than  five times in  a calendar  year; that                                                               
program is called the Alaska  Medicaid Coordinate Care Initiative                                                               
(AMCCI). DHSS sends 30,000 Medicaid-recipient  names per month to                                                               
a  contractor  to  ask  individuals if  they  are  interested  in                                                               
participating in AMCCI to assist  with navigating the Health Care                                                               
Delivery System. She revealed that  AMCCI has been well received.                                                               
She summarized  that as  Coordinated Care  Demonstration Projects                                                               
and  behavioral health  come on  line,  Medicaid recipients  will                                                               
transition to  the more  appropriate program  that is  focused to                                                               
their specific health-care needs.                                                                                               
                                                                                                                                
She  detailed  that  Health  Homes  is the  second  part  of  the                                                               
initiative that allows providers  to identify Medicaid recipients                                                               
in order to "wrap" added  services; for example, a recipient that                                                               
has both  a behavioral health  and chronic health-care  need. She                                                               
noted that the  Affordable Care Act and Social  Security Act have                                                               
specific  sections  for  Health   Homes:  Section  2703  for  the                                                               
Affordable  Care Act  and Section  1945 for  the Social  Security                                                               
Act.  She  detailed  that  DHSS  goes  through  the  Centers  for                                                               
Medicare and  Medicaid Services (CMS)  to identify  a health-home                                                               
project that results in an  enhanced federal match. She specified                                                               
that depending on  the program covered by Medicaid,  the first 8-                                                               
quarter  matches  range  from  50-50,  90-10  where  the  federal                                                               
government pays  90 percent, up  to a 100 percent  federal match.                                                               
She  asserted that  DHSS is  conscientious in  maximizing federal                                                               
matches when rolling out a Health Home in order for a ready-set-                                                                
go process  when identifying  a need and  ramping up  the program                                                               
with providers.                                                                                                                 
                                                                                                                                
1:44:18 PM                                                                                                                    
CHAIR  WILSON noted  that DHSS  rolled out  a "patients  in their                                                               
medical home" model in 2008 and  asked if the Health Home program                                                               
was a continuation or a separate model.                                                                                         
                                                                                                                                
MS. MARTIN answered  that Health Homes require a  patient to have                                                               
two or more healthcare needs for the model to exist.                                                                            
                                                                                                                                
CHAIR  WILSON  asked  if  the  Health Homes  model  is  based  on                                                               
national or state-based models that are currently ongoing.                                                                      
                                                                                                                                
1:47:39 PM                                                                                                                    
MS. MARTIN  explained that participants in  the Medicaid redesign                                                               
process  from  the Alaska  Primary  Care  Association see  Health                                                               
Homes as the next step in the patient-centered medical home.                                                                    
                                                                                                                                
SENATOR BEGICH noted that Ms.  Martin referenced federal matching                                                               
for  Health Homes  for the  first eight-quarters  and asked  what                                                               
happens afterwards.                                                                                                             
                                                                                                                                
MS. MARTIN  answered that  the federal match  would revert  to an                                                               
individual's qualified Medicaid-match category.                                                                                 
                                                                                                                                
She  said one  of the  biggest concerns  about DHSS's  behavioral                                                               
health  system  was  the  gaps   in  the  continuum-of-care.  She                                                               
explained that the language in  SB 74 allows DHSS the flexibility                                                               
to design  a comprehensive behavioral-health system.  She said SB
74 calls out  that DHSS work specifically with  the Alaska Mental                                                               
Health Trust Authority and noted  that their trustees contributed                                                               
$10 million over  next three years to help  implement the reforms                                                               
in  SB   74,  funding  that   is  critical  to  the   success  of                                                               
implementing the reforms.                                                                                                       
                                                                                                                                
She set forth  that the biggest part of  behavioral health reform                                                               
will  be  the  Section  1115   Waiver.  She  detailed  that  DHSS                                                               
submitted  a   waiver-concept  paper  in  January   to  CMS  that                                                               
addressed  the vision  for the  new health-care  delivery system.                                                               
She added  that DHSS will submit  a waiver application to  CMS in                                                               
July.  She  detailed  that  the  1115  Waiver  must  show  budget                                                               
neutrality for the  federal government that care  can be provided                                                               
at no additional  cost to the federal government.  She added that                                                               
another  part  of  SB  74  requires DHSS  to  contract  with  the                                                               
Administrative Services Organization (ASO)  to support systems of                                                               
care. The  Division of Behavioral  Health manages the  new system                                                               
of care and focuses on outcomes before there is a problem.                                                                      
                                                                                                                                
1:51:53 PM                                                                                                                    
SENATOR GIESSEL pointed  out that part of the 1115  Waiver was to                                                               
increase  the  latitude  of qualified  health-care  providers  to                                                               
provide  mental-health  services.  She   noted  that  there  were                                                               
regulations in place that  constrained service opportunities. She                                                               
asked  if increasing  the latitude  of health-care  providers was                                                               
addressed in  the DHSS's concept  paper and if the  concept paper                                                               
was available for legislative review.                                                                                           
                                                                                                                                
MS. MARTIN answered that the  concept paper along with additional                                                               
initiative  information  are  available online  for  review.  She                                                               
asked  that the  Division  of Behavioral  Health address  Senator                                                               
Giessel's question regarding  the 1115 Waiver and  the removal of                                                               
the grantee requirements.                                                                                                       
                                                                                                                                
1:53:57 PM                                                                                                                    
At ease.                                                                                                                        
                                                                                                                                
1:54:36 PM                                                                                                                    
CHAIR WILSON called the committee back to order.                                                                                
                                                                                                                                
1:57:34 PM                                                                                                                    
RANDALL BURNS,  Director, Division  of Behavioral  Health, Alaska                                                               
Department  of  Health  and   Social  Services,  Juneau,  Alaska,                                                               
explained  that the  legislative  impact on  grantees was  fairly                                                               
dramatic, but not on individual  providers. He specified that the                                                               
Legislature  would have  to amend  the statute  to list  licensed                                                               
professional  counselors  and marriage-and-family  therapists  as                                                               
possible  Medicaid billers.  He said  the division  is addressing                                                               
the scope  of practices and  the cost  of the Medicaid  system to                                                               
broaden  the  ability  of mental  health  and  behavioral  health                                                               
professions to join  in the work. He set forth  that the focus is                                                               
on  the  changes   that  will  bring  the  most   access  to  the                                                               
individuals  who really  need  the services.  He  noted that  the                                                               
attorney general's  office believes that the  regulation needs to                                                               
be  amended.  He  admitted that  the  situation  with  individual                                                               
therapists is extraordinarily complex.                                                                                          
                                                                                                                                
2:01:15 PM                                                                                                                    
SENATOR GIESSEL noted her  frustration because qualified non-drug                                                               
prescribing  people  are  available   to  provide  services.  She                                                               
explained  that not  everyone  needs  drugs and  that  is what  a                                                               
psychiatrist  does.   She  said  there  are   psych-mental  nurse                                                               
practitioners that  are equally qualified to  provide supervision                                                               
and do  not charge  the high fees  that psychiatrist  charge, and                                                               
are more  numerous and assessable  in many situations.  She noted                                                               
that her comments  are based on testimony from  the previous year                                                               
by  a  psych-mental nurse  practitioner.  She  opined that  state                                                               
government  is  "glacial"  and often  antiquated,  a  frustrating                                                               
situation when there  are people that can  benefit from qualified                                                               
mental health and family therapist services.                                                                                    
                                                                                                                                
MR. BURNS  answered that he agreed.  He noted that DHSS  tries to                                                               
balance  the Legislature's  concern while  also maintaining  cost                                                               
neutrality.                                                                                                                     
                                                                                                                                
2:03:39 PM                                                                                                                    
SENATOR BEGICH  noted that a  number of his  constituents brought                                                               
up the  supervision issue. He  pointed out that Mr.  Burns stated                                                               
that the division  is going through a  supervision change process                                                               
and asked if  there is a timeline for the  change. He stated that                                                               
he shared Senator Giessel's access concern.                                                                                     
                                                                                                                                
MR.  BURNS  explained that  there  is  pressure during  the  1115                                                               
Waiver  process  to  deal with  individual  systems  rather  than                                                               
looking  at  the  whole.  He remarked  that  given  the  attorney                                                               
general office's opinion on the  physician's clinic, the division                                                               
is going to move forward and seek a change.                                                                                     
                                                                                                                                
SENATOR BEGICH  asked Mr. Burns  how long the process  might take                                                               
and if a  recommendation will be given to the  Legislature to add                                                               
statutory classes for billing.                                                                                                  
                                                                                                                                
MR. BURNS replied that the  timing on most regulation projects is                                                               
six months. He  added the Legislature could amend  the statute to                                                               
include professions,  but the  division would  have to  prepare a                                                               
fiscal note and gauging the cost  to the Medicaid system would be                                                               
a best-guess; the  division wants to do that as  part of the 1115                                                               
Waiver process due  to concerns regarding the  cost neutrality of                                                               
future Medicaid.                                                                                                                
                                                                                                                                
2:07:40 PM                                                                                                                    
MS. MARTIN said  the second of DHSS's two biggest  reforms is the                                                               
Coordinated  Care Demonstration  Projects, which  allows DHSS  to                                                               
test  new  delivery system  and  payment  models. DHSS  issued  a                                                               
request  for  information in  September  2016  with 12  responses                                                               
received   that   ranged   from   a   regional   accountable-care                                                               
organization type model to  full-risk-statewide managed care, the                                                               
result allowed  DHSS to draft  a request for proposal  (RFP) that                                                               
was  released in  December  2016. She  said  DHSS anticipates  an                                                               
intensive proposal evaluation process  throughout 2017. She noted                                                               
that  Senator   Giessel  was  selected  to   participate  in  the                                                               
proposal-review  committee. She  noted  that the  proposal-review                                                               
committee's time  process is extensive due  to: possible approval                                                               
from  CMS, waivers,  state-plan amendments,  or regulations.  She                                                               
summarized  that  the  intent is  to  have  process  requirements                                                               
clarified for both the RFP proposal and the state.                                                                              
                                                                                                                                
2:11:54 PM                                                                                                                    
MS. MARTIN  said another reform is  the 1915 (i) and  (k) options                                                               
that is  related to home  and community-based  services currently                                                               
provided  through   the  Division  of  Senior   and  Disabilities                                                               
Services. DHSS contracts with  Health Management Associates (HMA)                                                               
to  analyze service  opportunities to  maximize savings  and make                                                               
sure Alaskans are getting the  needed service in their homes. She                                                               
disclosed that  a lot  of the home  and community  based services                                                               
are  optional,  but the  services  are  in  lieu of  more  costly                                                               
nursing-level of  care where  people can stay  in their  homes or                                                               
communities.                                                                                                                    
                                                                                                                                
She detailed that  the 1915 (i) and (k) option  is an entitlement                                                               
program  that DHSS  must  provide if  an  Alaskan qualifies.  She                                                               
pointed out  that the current  home and  community-based services                                                               
allows DHSS  to control the  budget by capping the  dollar amount                                                               
or the  number of participants.  She noted that HMA  has assisted                                                               
DHSS in  deciding whether the 1915  (i) and (k) options  are good                                                               
for  Alaskans and  their potential  budget  impact. She  revealed                                                               
that  HMA suggested  moving forward  with  the 1915  (i) and  (k)                                                               
options   with  specific   recommendations   for  Alaskans   with                                                               
intellectual and developmental  disabilities versus Alaskans with                                                               
traumatic  and  acquired brain  injury.  She  disclosed that  HMA                                                               
recommended that the  1915 (i) option may not be  the best choice                                                               
and the state  should look at other waiver  opportunities such as                                                               
the 1915 (c)  option. She pointed out that savings  from the 1915                                                               
(i)  and  (k)  options  were  attached to  SB  74,  but  DHSS  is                                                               
confident that  the same  savings can also  be realized  from the                                                               
1915  (c) option.  She revealed  that  some of  the services  are                                                               
currently provided at  100-percent cost to the state,  some are a                                                               
50-50   split   with   the  federal   government;   however,   by                                                               
implementing the 1915  (c) option the state  would gain 6-percent                                                               
for a 44-56 split with the federal government.                                                                                  
                                                                                                                                
2:15:06 PM                                                                                                                    
She said though  not specifically called out in SB  74, DHSS felt                                                               
it  needed  to work  in  conjunction  with the  criminal  justice                                                               
reforms  that  were enacted  from  SB  91. She  said  integrating                                                               
criminal justice  reforms is one  of four reform efforts  that is                                                               
really led  by another  agency, but DHSS  plays a  critical role.                                                               
She revealed that the "SB  74/SB 91 integration work group" meets                                                               
monthly with other agencies and  boards on getting Alaskans about                                                               
to be  released from correctional  facilities ready  by enrolling                                                               
them in Medicaid  and needed programs for  a successful community                                                               
transition on day-one.                                                                                                          
                                                                                                                                
CHAIR  WILSON asked  to address  Medicaid enrollment  for inmates                                                               
that may  need enrollment and  behavioral health. He  pointed out                                                               
that Medicaid  expansion has  not seen  increased numbers  on the                                                               
behavioral health  side of the  sector. He noted that  Ms. Martin                                                               
mentioned  that  granting agencies  have  decreased  in hopes  of                                                               
making that  back on the  Medicaid billing side. He  inquired how                                                               
DHSS  plans  to  remedy  the   situations  he  described  without                                                               
increased numbers.                                                                                                              
                                                                                                                                
MS.  MARTIN  noted  that  DHSS   publishes  a  monthly  "Medicaid                                                               
dashboard" that tracks enrollment in Medicaid expansion.                                                                        
                                                                                                                                
2:17:30 PM                                                                                                                    
COMMISSIONER DAVIDSON  noted that  additional information  on the                                                               
dollar  amount of  claims that  have been  paid will  be provided                                                               
later in the presentation.                                                                                                      
                                                                                                                                
MS. MARTIN disclosed  that one of the other reforms  that DHSS is                                                               
not  the lead  on is  the Emergency  Department Care  Improvement                                                               
Initiative, which  is led by  the ASHNHA in conjunction  with the                                                               
Alaska Chapter  of the American College  of Emergency Physicians.                                                               
She detailed that  program is designed on  Washington state's "ER                                                               
is for Emergencies" program. She  detailed that the working group                                                               
has  selected   a  real-time  information  exchange   called  the                                                               
Emergency Department  Information Exchange (EDIE).  She disclosed                                                               
that EDIE  is scheduled  to go "live"  in the  Providence system,                                                               
[Anchorage,  Kodiak,  Valdez  and  Seward],  in  February;  other                                                               
hospitals will review  the EDIE system in February  2017 as well.                                                               
She specified  that EDIE  is designed  to provide  emergency room                                                               
providers real-time  information access; for example,  people who                                                               
repeatedly use  an emergency room  can be identified,  and opioid                                                               
or narcotics  abuse can be singled  out in the emergency  room as                                                               
well. She  noted that  the working group  also put  together some                                                               
uniformed   narcotic  prescription   guidelines  for   hospitals,                                                               
emphasizing that  the guidelines are not  requirements. She added                                                               
that  consultants  from  Milliman,  Inc.  are  assisting  with  a                                                               
shared-savings  model to  assist  physicians  and providers  with                                                               
reducing costs for emergency department care.                                                                                   
                                                                                                                                
2:20:45 PM                                                                                                                    
She  revealed  that  the  Telehealth   Workgroup  was  formed  to                                                               
identify  opportunities  or  barriers  to  expand  telehealth  in                                                               
Alaska.  She noted  that the  workgroup's membership  is a  cross                                                               
section  of  Alaskans  across  the  state.  She  noted  that  the                                                               
workgroup's final report will be  included in the annual Medicaid                                                               
Reform Report  that is  annually provided  to the  Legislature in                                                               
November.                                                                                                                       
                                                                                                                                
MS. MARTIN  revealed that the key-partner  process emphasized the                                                               
real   need   to   enhance   the   state's   health   information                                                               
infrastructure.  She  detailed   that  HealthTech  Solutions  was                                                               
brought  on  to  assist  with designing  the  Health  Information                                                               
Infrastructure Plan and  the programs have an  opportunity to get                                                               
some  enhanced  funding that  is  90  percent reimbursed  by  the                                                               
federal government.                                                                                                             
                                                                                                                                
2:23:03 PM                                                                                                                    
COMMISSIONER DAVIDSON revealed  that DHSS is working  with CMA to                                                               
make  improvements to  their  tribal-claiming  policy. She  noted                                                               
that three things must come together  for the state to get a 100-                                                               
percent federal match:                                                                                                          
                                                                                                                                
   1. Individual must be an Alaskan native or American Indian;                                                                  
   2. Individual must be a Medicaid beneficiary;                                                                                
   3. Care must be received through an Indian Health Service                                                                    
     (IHS) facility.                                                                                                            
                                                                                                                                
She disclosed that  DHSS is negotiating with CMS  for 100 percent                                                               
federal  match for  additional tribal-claiming  considerations as                                                               
follows:                                                                                                                        
                                                                                                                                
   · Travel expenses to be considered medically necessary for                                                                   
     care access.                                                                                                               
   · Federal responsibility should continue for referrals that                                                                  
     start in IHS facilities and transferred to a non-tribal                                                                    
     facility.                                                                                                                  
                                                                                                                                
She noted that DHSS has been  acting as a matchmaker for referral                                                               
agreements between tribal and  non-tribal organizations to ensure                                                               
CMS  claim   terms  have  been  satisfied.   DHSS  believes  that                                                               
extending  the  level  of  care   available  to  Alaskans  avoids                                                               
services duplication and provides savings.                                                                                      
                                                                                                                                
2:30:27 PM                                                                                                                    
MS. MARTIN explained  that the Medicaid Reform  Program calls out                                                               
11-specific reforms  for DHSS to undertake,  including Electronic                                                               
Distribution of  Explanation of Benefits (EOB)  for recipients to                                                               
understand  the  cost of  the  care  being  received as  well  as                                                               
helping  DHSS to  identify  fraud. She  added  that the  Medicaid                                                               
Reform Program includes an annual  report to the Legislature that                                                               
addresses reform measures,  benchmarks and specifically requested                                                               
data.                                                                                                                           
                                                                                                                                
SENATOR  BEGICH asked  if  an IHS  person could  be  posted at  a                                                               
juvenile justice facility for referring  Alaskan native youth for                                                               
Medicaid reimbursement eligibility.                                                                                             
                                                                                                                                
2:32:06 PM                                                                                                                    
COMMISSIONER  DAVIDSON  pointed  out   that  there  are  Medicaid                                                               
eligibility  limitations for  individuals within  facilities. She                                                               
set forth that  DHSS is working to align all  the reform packages                                                               
to yield better results and maximize general fund savings.                                                                      
                                                                                                                                
MS. MARTIN  revealed that the  other work  group DHSS has  is the                                                               
Quality and  Cost Effectiveness Workgroup  that is called  out by                                                               
the  Medicaid  reform   program  in  SB  74;   their  report  and                                                               
recommendations will be  included in the November  2017 report to                                                               
the Legislature.                                                                                                                
                                                                                                                                
She  said the  Prescription  Drug Monitoring  Program (PDMP)  had                                                               
significant language  included from SB 74  due to recommendations                                                               
by the  Controlled Substances  Advisory Committee,  including the                                                               
change in  requiring data  submission on a  weekly rather  than a                                                               
monthly  basis. She  asserted that  the  more timely  information                                                               
will  help  address  the opioid  epidemic  and  provide  Medicaid                                                               
pharmacists  with  data  access.  She  noted  that  the  Internal                                                               
Systems Improvements Reporting  Requirements workgroup makes sure                                                               
that annual,  one-time and time-limited  reports are  created and                                                               
posted online.                                                                                                                  
                                                                                                                                
2:34:49 PM                                                                                                                    
She explained that  SB 74 also created the  Alaska Medicaid False                                                               
Claim and Reporting Act:                                                                                                        
                                                                                                                                
   · AK Health Reform has a webinar about reporting false claims                                                                
     and ASHNA brought in experts to provide education.                                                                         
   · DHSS assesses interest and penalties on any identified                                                                     
     over-payments.                                                                                                             
   · Providers are required to conduct self-audits every two                                                                    
     years.                                                                                                                     
   · The Fraud, Abuse, Waste, Payment and Eligibility Errors                                                                    
     Report was transmitted in November 2016 to the Legislature                                                                 
     and is accessible online.                                                                                                  
                                                                                                                                
2:35:51 PM                                                                                                                    
SENATOR VON IMHOF asked if Ms.  Martin knows what type of savings                                                               
the state  might see  once the  previously described  efforts are                                                               
implemented.                                                                                                                    
                                                                                                                                
MS.  MARTIN replied  that savings  are identified  in the  fiscal                                                               
notes and  additional information  will be provided  to committee                                                               
members.                                                                                                                        
                                                                                                                                
She said another reform in  SB 74 is the Eligibility Verification                                                               
System where  a third-party vendor  verifies incomes,  assets and                                                               
identities  for Alaskans  receiving  programs  through DHSS.  She                                                               
specified that the legislation requires  annual savings to exceed                                                               
the  system  implementation  cost;  its intent  is  to  eliminate                                                               
payment duplication, fraud, waste  and abuse in public-assistance                                                               
programs. She  added that  DHSS is moving  to version-two  of the                                                               
Alaska's  Resource  for  Integrated  Enrollment  System  where  a                                                               
third-party  will  start  performing  the  work  once  additional                                                               
eligibility is moved into the new system.                                                                                       
                                                                                                                                
2:37:44 PM                                                                                                                    
CHAIR WILSON  asked if the public-assistance  "hiccups" that were                                                               
mentioned  in the  previous committee  meeting  will be  relieved                                                               
through the version-two implementation  or are the issues related                                                               
to waiting for assistance-eligibility enrollment.                                                                               
                                                                                                                                
COMMISSIONER DAVIDSON  answered that  moving into phase  two will                                                               
result in eligibility-processing-time  improvements; however, the                                                               
Eligibility  Verification  System  differs by  looking  at  fraud                                                               
prevention. She  revealed that DHSS  faces a  significant backlog                                                               
challenge  with  phase two  due  to  not  having the  bodies  for                                                               
providing eligibility processing.                                                                                               
                                                                                                                                
2:39:44 PM                                                                                                                    
MS.  MARTIN  reiterated  that three  privatization  studies  were                                                               
identified  in SB  74 and  the  studies were  transmitted to  the                                                               
Legislature.                                                                                                                    
                                                                                                                                
She   said   DHSS   is  partnering   with   the   Department   of                                                               
Administration on the Health Care  Authority Feasibility Study to                                                               
look  at creating  a health-care  authority like  those found  in                                                               
Washington  state or  Oregon for  coordinating and  consolidating                                                               
the  state's  health-care  purchasing.  She added  that  the  PRM                                                               
Consulting  Group is  assisting with  the feasibility  study. She                                                               
revealed that  the first round  has been completed with  a report                                                               
due out in February 2017.  State and local employees and retirees                                                               
were surveyed to  see what health-care benefits  are provided and                                                               
at what  cost. She informed  that the  second part of  the report                                                               
will look at other Medicaid  opportunities as well as the state's                                                               
health-care purchases  for retirees  and employees.  She divulged                                                               
that the second-part report will be released in July 2017.                                                                      
                                                                                                                                
2:41:19 PM                                                                                                                    
MS. MARTIN set  forth that DHSS informs the public  on signing up                                                               
regarding Medicaid redesign and detailed as follows:                                                                            
                                                                                                                                
   · Sign-up emails for the Medicaid Redesign List-Serv update                                                                  
     are sent out.                                                                                                              
   · DHSS fields Medicaid redesign e-mail questions.                                                                            
   · Public Notices for meetings are announced online.                                                                          
   · Reports, webinars and documents for the Medicaid Redesign                                                                  
     Planning Process (2015) can be accessed online.                                                                            
                                                                                                                                
COMMISSIONER  DAVIDSON  noted  that  Medicaid  is  a  significant                                                               
portion  of   the  state's   budget  and   in  the   interest  of                                                               
transparency,  DHSS publishes  a  monthly point-in-time  Medicaid                                                               
"dashboard" on the DHSS website.                                                                                                
                                                                                                                                
She detailed  the information that  is presented on  the Medicaid                                                               
dashboard and  referenced data that  was dated from  December 28,                                                               
2016 as follows:                                                                                                                
                                                                                                                                
   · Cumulative number of enrollees since Medicaid expansion                                                                    
     starting on September 1, 2015: 27,415 enrollees.                                                                           
   · Includes age group and sex demographics.                                                                                   
   · $316.3 million in claims paid.                                                                                             
   · Approximately $19 million in mental-health claims paid.                                                                    
   · Approximately 50 percent of all Medicaid beneficiaries are                                                                 
     children, 16 percent are covered through expansion; 5-                                                                     
     percent seniors; 20-percent parent-caretakers; 9-percent                                                                   
     adults   with   disabilities;    1-percent   children   with                                                               
     disabilities.                                                                                                              
   · Includes regional enrollee information.                                                                                    
   · 169,999 total enrollees, including the 27,415 covered by                                                                   
     Medicaid expansion.                                                                                                        
                                                                                                                                
She  noted  that  Medicaid  expansion  covers  Alaskans  who  are                                                               
without dependent children.  A single Alaskan can  be eligible if                                                               
the individual earns less than $20,000 year.                                                                                    
                                                                                                                                
2:44:07 PM                                                                                                                    
SENATOR VON  IMHOF pointed out  that the dashboard  lists 169,999                                                               
enrollees as being totally covered  by Medicaid, approximately 15                                                               
to  20  percent  of  Alaska's total  population.  She  asked  how                                                               
Alaska's Medicaid participation compares with other states.                                                                     
                                                                                                                                
COMMISSIONER  DAVIDSON  replied  that   the  number  of  Medicaid                                                               
eligible Alaskans  is a little  bit higher than in  other states,                                                               
especially in areas of high unemployment.                                                                                       
                                                                                                                                
SENATOR  VON  IMHOF  asked  how  many  of  the  169,999  Medicaid                                                               
enrollees have secondary federally-covered insurance.                                                                           
                                                                                                                                
COMMISSIONER  DAVIDSON answered  that Medicaid  is the  secondary                                                               
payer for individuals with private  insurance with an employer or                                                               
other ways.                                                                                                                     
                                                                                                                                
2:47:32 PM                                                                                                                    
She  said  DHSS  has  received inquiries  on  what  is  happening                                                               
nationally and  its impact  on Alaskans  in terms  of health-care                                                               
coverage,  Medicaid, and  Medicaid  expansion.  She said  private                                                               
insurance, marketplace plans, and  Medicaid go hand-in-hand. What                                                               
impacts one  is going  to impact  the other.  She opined  that it                                                               
really  is  a  matter  of time  before  individuals  qualify  for                                                               
Medicaid   when   changes   are   made   that   limit   insurance                                                               
availability.  She said  when looking  at marketplace  plans, and                                                               
Medicaid expansion  combined, about  50,000 Alaskans  are covered                                                               
through  one of  the  programs. She  referenced  a meeting  where                                                               
providers  and  insurance  companies  all  said  losing  Medicaid                                                               
expansion  would  eliminate  a  cushion that  will  impact  their                                                               
ability to participate in reform  opportunities and to creatively                                                               
do things.                                                                                                                      
                                                                                                                                
2:50:00 PM                                                                                                                    
SENATOR BEGICH  remarked that the  previous year's work  by DHSS,                                                               
Senator Giessel and  the Legislature in getting SB  74 passed had                                                               
a profound impact that resulted  in Commissioner Davidson getting                                                               
"a seat  at the table" in  being able to define  where the policy                                                               
goes in the future. He asked if his assertion is true.                                                                          
                                                                                                                                
COMMISSIONER  DAVIDSON concurred  and noted  that the  result was                                                               
due  to DHSS  being aggressive  and  progressive as  well as  its                                                               
partnership  with the  Legislature on  reform efforts.  She added                                                               
that  Alaska benefits  from its  political position  with Senator                                                               
Murkowski  being on  the Health,  Education,  Labor and  Pensions                                                               
(HELP) Committee. She  added that Alaska also  benefited from the                                                               
Affordable  Care  Act  through   Section  1945  to  demonstration                                                               
programs  like  Health  Homes,  1915  (k)  and  (c)  options,  in                                                               
addition to the authorities and  resources made available to DHSS                                                               
and  its  partners  to  do   a  better  job  of  community-health                                                               
surveillance and  emergency preparedness.  She added  that DHSS's                                                               
instate partner,  the Division of  Insurance, is pursuing  a 1332                                                               
Waiver  with   CMS  to  allow   for  high-risk  pools,   and  the                                                               
Legislature's passage  of critical legislation that  allowed DHSS                                                               
to   stabilize  insurance   plans.  She   summarized  that   DHSS                                                               
recognizes  that  some  change  is   going  to  happen,  and  the                                                               
department is  committed to  being at the  table to  move forward                                                               
and get the best deal possible for Alaska.                                                                                      
                                                                                                                                
2:52:40 PM                                                                                                                    
COMMISSIONER  DAVIDSON  said  DHSS is  concerned  about  Medicaid                                                               
block  grants for  states.  She noted  that  typical comments  in                                                               
favor of block grants claim the following:                                                                                      
                                                                                                                                
   · Great deal for states,                                                                                                     
   · Flexibility to tailor programs to meet needs,                                                                              
   · Payment based on a per capita rate.                                                                                        
                                                                                                                                
She remarked  that the  favorable comments  may sound  great, but                                                               
DHSS  sees  block   grants  as  a  mechanism   to  shift  federal                                                               
responsibility to states. She said  DHSS has seen Medicaid block-                                                               
grant proposals  that do not  favor Alaska and favor  states with                                                               
the following attributes:                                                                                                       
                                                                                                                                
   · High population,                                                                                                           
   · Concentrated in a relatively small number of urban centers,                                                                
   · Travel or access to care is not an issue,                                                                                  
   · Health care is provided pretty much the same,                                                                              
   · No large tribal population,                                                                                                
   · Relatively stable economy.                                                                                                 
                                                                                                                                
She addressed block-grant allocation concerns as follows:                                                                       
                                                                                                                                
   · Alaska's small population dispersed throughout a large                                                                     
     geography will always make travel a consideration. Alaska                                                                  
     is going to lose under a realm that does not take travel                                                                   
     into consideration.                                                                                                        
   · 20 percent of Alaska's population are IHS beneficiaries and                                                                
     part of the federal trust responsibility should be paid at                                                                 
     100-percent match and not counted against the state's grant                                                                
     allocation.                                                                                                                
   · Alaska's creative health-care delivery through community-                                                                  
     health aides, behavioral-health aides, or dental health                                                                    
     aides in small communities, all the way up to advanced-                                                                    
     hospital care; those are two very different things.                                                                        
   · Allocations for Medicaid enrollees are made at the                                                                         
     beginning of the year and Alaska cannot catch up to                                                                        
     increasing enrollees during a continued economic downturn                                                                  
     until the following year.                                                                                                  
   · Considerations made for high-cost states versus low-cost                                                                   
     states.                                                                                                                    
                                                                                                                                
COMMISSIONER   DAVIDSON   summarized    that   Medicaid   changes                                                               
continuously occur.                                                                                                             
                                                                                                                                
2:56:34 PM                                                                                                                    
CHAIR WILSON asked if DHSS has come up with contingency plans.                                                                  
                                                                                                                                
COMMISSIONER   DAVIDSON  answered   that  DHSS   is  working   on                                                               
contingency  plans,  but  there are  several  possibilities.  She                                                               
noted  that  there  are  three  versions of  the  bill  with  400                                                               
different  possibilities.  She  said   DHSS  has  asked  Alaska's                                                               
delegation  to review  all allocations  over a  five-year period.                                                               
She opined that block grants will  look great for the first year,                                                               
but  allocations   for  the  second  through   fifth  years  will                                                               
diminish.                                                                                                                       
                                                                                                                                
2:59:06 PM                                                                                                                    
CHAIR  WILSON  thanked  Commissioner Davidson  and  reviewed  the                                                               
committee's agenda for future meetings.                                                                                         
                                                                                                                                
2:59:37 PM                                                                                                                    
There being  no further  business to  come before  the committee,                                                               
Chair  Wilson adjourned  the Senate  Health  and Social  Services                                                               
Committee at 2:59 p.m.                                                                                                          

Document Name Date/Time Subjects
20170127_Senate HSS.pdf SHSS 1/27/2017 1:30:00 PM
DHSS presentation on Medicaid Reform