Legislature(2019 - 2020)BUTROVICH 205

02/19/2020 01:30 PM HEALTH & SOCIAL SERVICES

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Audio Topic
01:31:09 PM Start
01:31:31 PM HB29
01:36:35 PM Presentation: Department of Health and Social Services Update
02:56:59 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ Presentation: TELECONFERENCED
Department of Health & Social Services Update by
Commissioner Adam Crum
-- Testimony <Invitation Only> --
+ Bills Previously Heard/Scheduled: TELECONFERENCED
+= HB 29 INSURANCE COVERAGE FOR TELEHEALTH TELECONFERENCED
Moved SCS HB 29(HSS) Out of Committee
                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                       February 19, 2020                                                                                        
                           1:31 p.m.                                                                                            
                                                                                                                                
                                                                                                                                
MEMBERS PRESENT                                                                                                               
                                                                                                                                
Senator David Wilson, Chair                                                                                                     
Senator Natasha von Imhof, Vice Chair                                                                                           
Senator Cathy Giessel                                                                                                           
Senator Mike Shower                                                                                                             
Senator Tom Begich                                                                                                              
                                                                                                                                
MEMBERS ABSENT                                                                                                                
                                                                                                                                
All members present                                                                                                             
                                                                                                                                
COMMITTEE CALENDAR                                                                                                            
                                                                                                                              
PRESENTATION: DEPARTMENT OF HEALTH AND SOCIAL SERVICES UPDATE                                                                   
                                                                                                                                
     - HEARD                                                                                                                    
                                                                                                                                
HOUSE BILL NO. 29                                                                                                               
"An Act relating to insurance coverage for benefits provided                                                                    
through telehealth; and providing for an effective date."                                                                       
                                                                                                                                
     - MOVED SCS HB 29(HSS) OUT OF COMMITTEE                                                                                    
                                                                                                                                
PREVIOUS COMMITTEE ACTION                                                                                                     
                                                                                                                                
BILL: HB 29                                                                                                                   
SHORT TITLE: INSURANCE COVERAGE FOR TELEHEALTH                                                                                  
SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ                                                                                         
                                                                                                                                
02/20/19       (H)       PREFILE RELEASED 1/11/19                                                                               
02/20/19       (H)       READ THE FIRST TIME - REFERRALS                                                                        
02/20/19       (H)       HSS, L&C                                                                                               
03/26/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
03/26/19       (H)       Heard & Held                                                                                           
03/26/19       (H)       MINUTE(HSS)                                                                                            
03/28/19       (H)       HSS AT 3:00 PM CAPITOL 106                                                                             
03/28/19       (H)       Moved HB 29 Out of Committee                                                                           
03/28/19       (H)       MINUTE(HSS)                                                                                            
03/29/19       (H)       HSS RPT 3DP 1NR                                                                                        
03/29/19       (H)       DP: CLAMAN, DRUMMOND, SPOHNHOLZ                                                                        
03/29/19       (H)       NR: PRUITT                                                                                             
04/12/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/12/19       (H)       -- MEETING CANCELED --                                                                                 
04/15/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/15/19       (H)       Scheduled but Not Heard                                                                                
04/24/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/24/19       (H)       Heard & Held                                                                                           
04/24/19       (H)       MINUTE(L&C)                                                                                            
04/26/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/26/19       (H)       <Bill Hearing Canceled>                                                                                
04/29/19       (H)       L&C AT 3:15 PM BARNES 124                                                                              
04/29/19       (H)       Moved HB 29 Out of Committee                                                                           
04/29/19       (H)       MINUTE(L&C)                                                                                            
04/30/19       (H)       L&C RPT 5DP 2NR                                                                                        
04/30/19       (H)       DP: HANNAN, STUTES, FIELDS, WOOL,                                                                      
                         LEDOUX                                                                                                 
04/30/19       (H)       NR: REVAK, TALERICO                                                                                    
05/07/19       (H)       TRANSMITTED TO (S)                                                                                     
05/07/19       (H)       VERSION: HB 29                                                                                         
05/08/19       (S)       READ THE FIRST TIME - REFERRALS                                                                        
05/08/19       (S)       HSS                                                                                                    
02/14/20       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
02/14/20       (S)       Heard & Held                                                                                           
02/14/20       (S)       MINUTE(HSS)                                                                                            
02/19/20       (S)       HSS AT 1:30 PM BUTROVICH 205                                                                           
                                                                                                                                
WITNESS REGISTER                                                                                                              
                                                                                                                                
LORI WING-HEIER, Director                                                                                                       
Division of Insurance                                                                                                           
Department of Commerce, Community and Economic Development                                                                      
(DCCED)                                                                                                                         
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Answered questions about HB 29.                                                                           
                                                                                                                                
REPRESENTATIVE IVY SPOHNHOLZ                                                                                                    
Alaska State Legislature                                                                                                        
Juneau, Alaska                                                                                                                  
POSITION STATEMENT: Spoke as sponsor of HB 29.                                                                                
                                                                                                                                
ADAM CRUM, Commissioner                                                                                                         
Department of Health and Social Services (DHSS)                                                                                 
Anchorage, Alaska                                                                                                               
POSITION STATEMENT: Presented an update on the Department of                                                                  
Health and Social Services (DHSS).                                                                                              
                                                                                                                                
ALBERT WALL, Deputy Commissioner                                                                                                
Medicaid & Health Care Policy                                                                                                   
Anchorage, Alaska                                                                                                               
POSITION  STATEMENT: Presented  an  update on  the Department  of                                                             
Health and Social Services (DHSS).                                                                                              
                                                                                                                                
                                                                                                                                
ACTION NARRATIVE                                                                                                              
                                                                                                                                
1:31:09 PM                                                                                                                    
CHAIR DAVID WILSON  called the Senate Health  and Social Services                                                             
Standing Committee meeting  to order at 1:31 p.m.  Present at the                                                               
call  to  order  were  Senators von  Imhof,  Giessel,  and  Chair                                                               
Wilson. Senators Begich and Shower  arrived as the meeting was in                                                               
progress.                                                                                                                       
                                                                                                                                
            HB 29-INSURANCE COVERAGE FOR TELEHEALTH                                                                         
                                                                                                                                
1:31:31 PM                                                                                                                    
CHAIR WILSON  announced the consideration  of HOUSE BILL  NO. 29,                                                               
"An  Act relating  to insurance  coverage  for benefits  provided                                                               
through telehealth; and providing for an effective date."                                                                       
                                                                                                                                
He  noted there  had  been  a discussion  about  an amendment  on                                                               
parity  pay   but  that  was   deemed  unnecessary.   He  invited                                                               
Representative  Spohnholz and  Lori  Wing-Heier to  speak to  the                                                               
issue of pay parity.                                                                                                            
                                                                                                                                
1:32:51 PM                                                                                                                    
LORI WING-HEIER,  Director, Division of Insurance,  Department of                                                               
Commerce, Community and  Economic Development (DCCED), Anchorage,                                                               
Alaska, stated that this bill  was heard numerous times last year                                                               
and  the issue  of pay  parity never  come up.  She had  not seen                                                               
concern about  parity from  the providers  until last  week. Most                                                               
providers have negotiated agreements that  would take care of the                                                               
concern of parity.                                                                                                              
                                                                                                                                
1:33:28 PM                                                                                                                    
REPRESENTATIVE IVY  SPOHNHOLZ, Alaska State  Legislature, Juneau,                                                               
Alaska, said  that based on Director  Wing-Heier's recommendation                                                               
and after consultations with insurers  and providers, she decided                                                               
not  to ask  for  an  amendment to  address  parity because  that                                                               
allows the market flexibility to be  able to negotiate on a case-                                                               
by-case  basis around  rates. That  will allow  for collaboration                                                               
and innovation on ways to reduce  health care costs. Later on, if                                                               
there are problems with parity, the legislature can address it.                                                                 
                                                                                                                                
CHAIR WILSON noted that the  Division of Insurance recommended an                                                               
effective date change. He solicited a motion.                                                                                   
                                                                                                                                
1:34:37 PM                                                                                                                    
SENATOR VON IMHOF moved to adopt Amendment 1, A.3:                                                                              
                                                                                                                                
                                               31-LS0274\A.3                                                                    
                                                        Marx                                                                    
                                                     2/18/20                                                                    
                                                                                                                                
                              AMENDMENT 1                                                                                       
                                                                                                                                
    OFFERED IN THE SENATE              BY SENATOR VON IMHOF                                                                     
     TO: HB 29                                                                                                                  
                                                                                                                                
     Page 2, line 15:                                                                                                           
          Delete "July 1, 2020"                                                                                                 
          Insert "January 1, 2021"                                                                                              
                                                                                                                                
1:34:42 PM                                                                                                                    
CHAIR  WILSON objected  for  purposes of  discussion  and for  an                                                               
explanation of the change.                                                                                                      
                                                                                                                                
MS.  WING-HEIER said  her division  discussed with  the sponsor's                                                               
office the  need for  an extended effective  date because  of the                                                               
forms  and  filings   that  have  to  be  made.   Under  the  ACA                                                               
(Affordable  Care  Act),  the division  cannot  amend  the  forms                                                               
midyear. Forms are filed in the  spring for an effective date the                                                               
following  January. The  timeframe for  when insurers  could make                                                               
this effective needs  to be reasonable. The  individual market is                                                               
very  strict about  when the  forms are  filed and  the effective                                                               
date.                                                                                                                           
                                                                                                                                
1:35:41 PM                                                                                                                    
CHAIR WILSON  removed his  objection and  there being  no further                                                               
objection, Amendment 1 was adopted.                                                                                             
                                                                                                                                
1:35:58 PM                                                                                                                    
CHAIR WILSON solicited a motion.                                                                                                
                                                                                                                                
1:36:03 PM                                                                                                                    
SENATOR  VON  IMHOF moved  to  report  HB  29, as  amended,  from                                                               
committee  with  individual  recommendations and  updated  fiscal                                                               
notes.                                                                                                                          
                                                                                                                                
1:36:18 PM                                                                                                                    
CHAIR WILSON found  no objection and SCS HB  29(HSS) was reported                                                               
from the Senate Health and Social Services Standing Committee.                                                                  
                                                                                                                                
1:36:29 PM                                                                                                                    
At ease                                                                                                                         
                                                                                                                                
^Presentation: Department of Health and Social Services Update                                                                  
 Presentation: Department of Health and Social Services Update                                                              
                                                                                                                                
1:36:35 PM                                                                                                                    
CHAIR   WILSON  reconvened   the   meeting   and  announced   the                                                               
presentation:  Department of  Health and  Social Services  (DHSS)                                                               
Update. He called Commissioner Adam  Crum and Deputy Commissioner                                                               
Albert Wall to the table.                                                                                                       
                                                                                                                                
1:38:28 PM                                                                                                                    
ADAM  CRUM,   Commissioner,  Department  of  Health   and  Social                                                               
Services  (DHSS), Anchorage,  Alaska, began  a PowerPoint  on the                                                               
Department   of  Health   and  Social   Services.  He   read  the                                                               
department's  mission on  slide 1,  "To promote  and protect  the                                                               
health and  well-being of Alaskans."  He turned to slide  2, DHSS                                                               
Three-year Vision:                                                                                                              
                                                                                                                                
     •  Systems Alignment and Change                                                                                            
     •  Focus on IT Systems                                                                                                     
     •  Behavioral Health Continuum of Care                                                                                     
     •  Emergency Readiness and Response                                                                                        
                                                                                                                                
COMMISSIONER  CRUM explained  that systems  alignment and  change                                                               
involves   helping  families   climb  the   economic  ladder   by                                                               
addressing the  benefits cliff. This  topic is of  great interest                                                               
to  Governor  Dunleavy.  The  benefits   cliff  is  when  program                                                               
participants lose  more in benefits than  these employees receive                                                               
through employment. This issue has  been raised at recent federal                                                               
conferences and the U.S. Department  of Health and Human Services                                                               
(HHS) is  taking the  lead on  this nationally.  HHS is  the lead                                                               
agency in the development of  the new federal Council on Economic                                                               
Mobility, which  will focus on  cross-cutting issues  that cannot                                                               
be accomplished by a single agency.                                                                                             
                                                                                                                                
COMMISSIONER CRUM  said this will include  other federal agencies                                                               
such  as the  U.S. Department  of Agriculture  (USDA), Education,                                                               
Housing and Urban Development, and  the U.S. Department of Labor.                                                               
The  Administration  for Children  and  Families,  under HSS,  is                                                               
encouraging states to share best  practices to support parents in                                                               
achieving  greater  gains  and economic  stability.  Examples  of                                                               
short-term solutions  are phasing out benefits  slowly, extending                                                               
certification  periods or  using sliding  fee schedules,  raising                                                               
eligibility limits, or  allowing a longer stay  on benefits while                                                               
working  to   accompany  the  change   in  loss   of  eligibility                                                               
standards.  These   options  came  from  an   Administration  for                                                               
Children  and  Families  working  group.  The  administration  is                                                               
encouraging  other states  and regions  to review  how this  will                                                               
work with other federal programs.                                                                                               
                                                                                                                                
1:40:37 PM                                                                                                                    
COMMISSIONER  CRUM  said  long-term strategies  are  to  increase                                                               
educational  and work  support  through job  training and  skills                                                               
development   initiatives  to   provide   employer  supports   to                                                               
encourage  the  hiring  of  these   early  stage  workers.  These                                                               
strategies are  being approached  through the Division  of Public                                                               
Assistance (DPA)  and Work  Services. Work  Services is  the TANF                                                               
(Temporary  Assistance for  Needy  Families)  work program.  This                                                               
program  is for  all participants  who are  not otherwise  exempt                                                               
from  participation  in  work  or job  search  activity.  DPA  is                                                               
looking  to  integrate  services   and  provide  funding  streams                                                               
between  the  TANF  program  and  the  Workforce  Innovation  and                                                               
Opportunity Act (WIOA) program in the Department of Labor.                                                                      
                                                                                                                                
COMMISSIONER  CRUM  said  the  Administration  for  Children  and                                                               
Families  hosted  summits  to demonstrate  how  states  can  take                                                               
advantage of  braiding funding streams  to maximize  the outcomes                                                               
through  these  services. DPA  is  acting  on increased  employer                                                               
supports   programs  through   more  formalized   incentives  for                                                               
employers and  job seekers.  DPA also  is addressing  an expected                                                               
increase  in  the  SNAP [the  Supplemental  Nutrition  Assistance                                                               
Program]  by switching  to a  provider agreement  rather than  an                                                               
operating  grant program.  This  will allow  more flexibility  in                                                               
onboarding new providers throughout the year.                                                                                   
                                                                                                                                
COMMISSIONER CRUM said another part  of the systems and alignment                                                               
change  is that  Medicaid has  been integrated  on one  platform.                                                               
Behavioral health  with Deputy Commissioner  Wall has  been moved                                                               
to the Medicaid  area. The Division of  Public Assistance, Senior                                                               
and Disabilities Services, the Division  of Health Care Services,                                                               
and  the  Division  of  Behavioral   Health  all  have  important                                                               
missions that  overlap. This allows  better program  alignment to                                                               
better serve the Medicaid population.                                                                                           
                                                                                                                                
COMMISSIONER CRUM  said that DHSS  works with sister  agencies in                                                               
the  Department of  Administration's Division  of Retirement  and                                                               
Benefits and  the Department of Commerce,  Community and Economic                                                               
Development  (DCCED)'s, Division  of  Insurance to  find ways  to                                                               
work together  for economies  of scale  and gain  efficiencies in                                                               
technology or service delivery.                                                                                                 
                                                                                                                                
1:42:34 PM                                                                                                                    
SENATOR  BEGICH said  governors can  apply for  SNAP waivers  for                                                               
areas  of chronic,  high unemployment.  The Anchorage  and Mat-Su                                                               
communities were  excluded from the  waiver, but those  areas now                                                               
meet  the  unemployment  criteria.  He  asked  if  there  is  any                                                               
intention of including  those two areas in  the governor's waiver                                                               
request. He  expressed concern both  because of the  reduction of                                                               
resources  that will  be  coming  into the  state  and because  a                                                               
substantial number of Alaskans could experience food insecurity.                                                                
                                                                                                                                
COMMISSIONER CRUM clarified that  Senator Begich was referring to                                                               
the  Food and  Nutrition Service  (FNS) ABAWD  (able-bodied adult                                                               
without dependents) rule  for SNAP. That proposed  rule goes into                                                               
effect in April.  This rule allows for  different definitions for                                                               
labor  market areas.  For  years Alaska  worked  under a  blanket                                                               
exemption from the  work requirements, but there  are now closely                                                               
defined areas. FNS  has provided several options,  one strict and                                                               
the  other more  lenient. The  governor chose  the second,  which                                                               
allows more Alaskans in tougher areas  to be exempt from the work                                                               
requirements. Advocacy groups reached  out to DHSS about changing                                                               
it.  DHSS  is working  with  the  USDA and  FNS  to  see if  this                                                               
exemption is  permitted under the  intent of the rule.  The state                                                               
has been given additional time to submit the waiver.                                                                            
                                                                                                                                
SENATOR BEGICH expressed hope that  the commissioner will provide                                                               
the committee with updates as  those talks proceed. He encouraged                                                               
the state not  to leave federal dollars on the  table since these                                                               
funds can feed Alaskans. Everyone wants  to see more jobs so that                                                               
Alaska falls  below the  unemployment level  for the  waiver, but                                                               
the state has not yet accomplished that goal.                                                                                   
                                                                                                                                
1:46:28 PM                                                                                                                    
COMMISSIONER CRUM  replied DHSS  would provide  updates regarding                                                               
whether an  individual outside  of a [labor  market] area  can be                                                               
exempt  from   the  work  requirement.  He   offered  to  provide                                                               
information  to  food coalition  groups  on  exemptions for  work                                                               
requirements.  He said  that the  department anticipates  hearing                                                               
from FNS  within the next  few weeks so  that DHSS can  amend the                                                               
waiver and be ready to go.                                                                                                      
                                                                                                                                
COMMISSIONER CRUM  said DHSS collects tremendous  amounts of data                                                               
that must  be analyzed before it  can be used. In  the last year,                                                               
the  DHSS  has  made  progress  to improve  and  upgrade  its  IT                                                               
systems,   including   implementing    an   electronic   document                                                               
management  system.  This  step  provides  a  single  application                                                               
interface for  all assistance programs  and helps  the department                                                               
be  more  responsive  to  Alaskans  in their  time  of  need.  In                                                               
collaboration with  the Department of Administration  (DOA), DHSS                                                               
has  made progress  to update  its  software on  a HIPAA  (Health                                                               
Insurance  Portability and  Accountability Act)  compliant system                                                               
for mobile devices. This means  the Office of Children's Services                                                               
(OCS)  employees will  have secure  phones document  and transmit                                                               
data  securely while  in the  field. Currently,  because DHSS  in                                                               
order to have HIPAA-complaint messaging,  employees must log into                                                               
a separate direct service mail  protocol, which is burdensome for                                                               
staff.                                                                                                                          
                                                                                                                                
COMMISSIONER CRUM  highlighted the project to  implement a viable                                                               
information  exchange to  meet  the needs  of  providers and  the                                                               
state. He  said DHSS is focused  on an addressing the  need of an                                                               
HIE  (health information  exchange) with  its chief  data officer                                                               
and  chief medical  officer. Upcoming  IT projects  that will  be                                                               
implemented by  the end of  the calendar year are  the electronic                                                               
visit verification for  the personal care attendants,  which is a                                                               
mandatory  compliance issue  from CMS  (Centers for  Medicare and                                                               
Medicaid  Services)  for  the  home  and  community-based  waiver                                                               
population, and  the eligibility verification system  for DPA. SB                                                               
74 encouraged DHSS to pursue that  and it is also part of federal                                                               
compliance.  Both of  these systems  will  help maintain  program                                                               
integrity  so resources  are  available to  serve  those who  are                                                               
truly  eligible  and in  need.  DHSS  will  work to  continue  to                                                               
implement innovative IT solutions so  that it can be agile enough                                                               
to respond  to health care  providers and recipients  and broadly                                                               
utilize data analytics to combat fraud, waste, and abuse.                                                                       
                                                                                                                                
1:49:54 PM                                                                                                                    
SENATOR GIESSEL shared that it  causes her great concern when she                                                               
hears  DHSS talk  about innovation  in IT  systems. She  asked if                                                               
DHSS   ever  got   certification  of   its  Medicaid   Management                                                               
Information System (MMIS).                                                                                                      
                                                                                                                                
COMMISSIONER  CRUM   answered  yes;   it  is  the   fiscal  agent                                                               
responsible  for   Medicaid.  The  DHSS   is  IT  trying   to  be                                                               
innovative. The  IT system  was archaic.  FBI agents  shared with                                                               
the security  staff that hackers  in other countries  used Alaska                                                               
as a testing ground for their  protocols to deploy in the rest of                                                               
the country. The IT staff has  done a fantastic job over the last                                                               
few  years  improving that.  DHSS  recently  had a  death-to-the-                                                               
dinosaur  party because  all  Windows 7  programs,  which are  no                                                               
longer supported  by Microsoft, throughout the  entire department                                                               
were removed. DHSS  collects data for the state,  and many people                                                               
request that  data. DHSS  needs to respond  faster so  people can                                                               
have live information.                                                                                                          
                                                                                                                                
1:51:56 PM                                                                                                                    
SENATOR SHOWER joined the committee.                                                                                            
                                                                                                                                
COMMISSIONER CRUM said  one of the goals of the  department is to                                                               
continually  improve  and  make   it  a  better  running,  faster                                                               
machine.                                                                                                                        
                                                                                                                                
SENATOR GIESSEL said she hopes things go well.                                                                                  
                                                                                                                                
CHAIR WILSON said  he also shares that concern, and  not just for                                                               
this department. At  the beginning of last year,  there were over                                                               
34  upgrades to  different IT  systems  in the  state, all  using                                                               
different contractors  and programming  that did  not communicate                                                               
with  each other.  He noted  that Senator  Shower had  joined the                                                               
committee.                                                                                                                      
                                                                                                                                
COMMISSIONER CRUM  responded that the federal  process has gotten                                                               
much more  prescriptive when  looking at  large IT  systems. DHSS                                                               
has  to get  program advanced  planning documents  (PAPD). During                                                               
the planning stage the feds  look at everything including the way                                                               
the  Request  for   Proposals  is  written  and   the  goals  and                                                               
timelines.  The   federal  agency  can  approve,   based  on  the                                                               
thresholds DHSS  meets, even more  advanced federal match  to pay                                                               
for  these IT  systems. Once  those are  approved, DHSS  gets the                                                               
IAPD (Implementation  Advanced Planning  Document), which  is the                                                               
guidance  document. The  job  of  the chief  data  officer is  to                                                               
coordinate  these projects  through federal  partners and  across                                                               
divisions to meet each one of these prescriptive thresholds.                                                                    
                                                                                                                                
1:54:02 PM                                                                                                                    
SENATOR  VON IMHOF  said she  was pleased  to hear  that DHSS  is                                                               
bringing on  a chief data  officer. She  is seeing that  more and                                                               
more  in   different  entities.  This   has  become  a   new  job                                                               
description to  make sure that the  large, overarching accounting                                                               
software,  as well  as  small  systems, match  and  talk to  each                                                               
other. One  example of a small  system is the use  of debit cards                                                               
for Medicaid recipients to  purchase medical supplies. Electronic                                                               
purchases are uploaded automatically  into a system and purchases                                                               
can  be tracked.  Then  no one  has  to do  data  entry for  that                                                               
information. She asked if the  commissioner was considering those                                                               
options.                                                                                                                        
                                                                                                                                
COMMISSIONER CRUM said that was  brought to the attention of DHSS                                                               
by the Key  Coalition and the Governor's  Council on Disabilities                                                               
and  Special  Education. DHSS  is  trying  to navigate  that  and                                                               
recognizes the  utility of it. DHSS  is working to see  if it can                                                               
be justified with the federal partners.                                                                                         
                                                                                                                                
SENATOR VON IMHOF  noted that Commissioner Crum sits  with her on                                                               
the  executive  committee  of   the  Health  Care  Transformation                                                               
Council. She and Representative Spohnholz  have a bill on an all-                                                               
payer  claims   database.  Along  with  the   health  information                                                               
exchange,  the council  seeks  to eventually  lower  the cost  of                                                               
health  care  by  understanding  where health  care  dollars  are                                                               
spent. She  asked him  to comment  on the  ability to  use HIPPA-                                                               
compliant data,  whether it  is through  this particular  bill or                                                               
any  other platform,  to run  reports  on Medicaid  data to  show                                                               
where  health care  dollars are  being spent  regionally and  for                                                               
what ailments, etc.                                                                                                             
                                                                                                                                
COMMISSIONER  CRUM  said  any  time  that  DHSS  can  knock  down                                                               
barriers for  data in an  appropriate way,  it is better  for the                                                               
consumer.  As  DHSS works  with  the  Division of  Insurance  and                                                               
Retirement and Benefits, a formal  agreement could be beneficial.                                                               
DHSS has had  internal working groups to  address that particular                                                               
bill to  find out what  are some department suggestions  and what                                                               
would benefit  the state.  The first goal  the governor  gave him                                                               
when he  became commissioner  was to address  the cost  of health                                                               
care to  the state  of Alaska  with the  Medicaid program  and to                                                               
address  the  cost  of  health   care  costs  for  all  Alaskans.                                                               
Information  about the  30 to  35  percent of  the population  on                                                               
Medicaid, along with state employees  and retirees, could be used                                                               
to help health care costs in Alaska.                                                                                            
                                                                                                                                
1:58:12 PM                                                                                                                    
COMMISSIONER CRUM pointed out, moving  to emergency readiness and                                                               
response,  that many  states have  counties  that perform  public                                                               
health  services. Alaska  has the  benefit of  centralized public                                                               
health at  the state  level with the  Division of  Public Health.                                                               
That allows  Alaska to have  a rapid crisis response.  The public                                                               
health  and  emergency response  issues  have  changed, from  the                                                               
creation of the  OSMAP (Office of Substance  Misuse and Addiction                                                               
Prevention)   to  deal   with  the   opioid  issue   to  sexually                                                               
transmitted diseases,  alcohol abuse, and tobacco  cessation. Now                                                               
there are greatly increased fire  seasons and earthquakes and new                                                               
viruses. The importance of public health has never been greater.                                                                
                                                                                                                                
COMMISSIONER  CRUM said  he is  immensely proud  and humble  that                                                               
Chief Medical  Officer Dr. Zink  wanted to  work with him  as the                                                               
administration  addresses these  complex issues  and to  continue                                                               
efforts to  modernize the  Division of  Public Health.  He quoted                                                               
from  the  1993 publication.  "A  History  of Health  and  Social                                                               
Services in Alaska":                                                                                                            
                                                                                                                                
     Public  health  in  Alaska started  in  1893  with  the                                                                    
     arrival  of the  first  professional  nurse in  Bethel,                                                                    
     three  years before  the first  doctor  arrived and  23                                                                    
     years before the first hospital  was built in the area.                                                                    
     For many,  the traveling nurse  was the only  source of                                                                    
     health  care. They  incorporated  health education  and                                                                    
     disease  prevention  into  their  primary  health  care                                                                    
     practices.  Today public  health  nurses continue  that                                                                    
     mission by being  on the front lines  in communities to                                                                    
     address local issues.                                                                                                      
                                                                                                                                
COMMISSINER  CRUM   said  the  Division   of  Public   Health  is                                                               
responsible for health emergency  operations and response, crisis                                                               
communications, strategy, data  building and information sharing.                                                               
Dr. Anne  Zink mentioned two  weeks ago that the  division's goal                                                               
was to  activate the emergency  operations center and  respond to                                                               
issues  before  there  are  outbreaks.   A  prime  example  is  a                                                               
confirmed  case of  measles  last summer  that  was isolated  and                                                               
contained to  that single case.  As emergencies occur,  this team                                                               
coordinates  with local  municipalities,  health facilities,  and                                                               
responders to  ensure that health  care systems have  the support                                                               
and needed  supplies to remain open.  An example of this  was the                                                               
earthquake of 2018.  The team worked not only  with hospitals but                                                               
with  small assisted  living  homes to  make  sure residents  had                                                               
proper medical supplies when the roads were shut down.                                                                          
                                                                                                                                
2:00:57 PM                                                                                                                    
COMMISSIONER  CRUM  said  Public  Health  has  been  running  the                                                               
emergency operations center to monitor  the situation with COVID-                                                               
19.  Public Health  has weekly  if not  daily calls  with federal                                                               
partners  and fellow  state agencies  to  make sure  it is  fully                                                               
prepared to respond.                                                                                                            
                                                                                                                                
COMMISSIONER CRUM said  the Division of Public  Health is working                                                               
on chronic health conditions and  preventative measures. The MESA                                                               
(Medicaid Enrollment  and Spending  in Alaska)  report identified                                                               
that  chronic  conditions  are  the  main  cost  drivers  of  the                                                               
Medicaid program. Getting  in front of that with  prevention is a                                                               
key aspect.  Division of Public  Health Director Hedberg  is part                                                               
of  the weekly  Medicaid director  meetings to  integrate efforts                                                               
regarding education programs and processes.                                                                                     
                                                                                                                                
CHAIR WILSON asked, regarding the  MESA report, whether the state                                                               
is looking at a managed care  system to help manage those chronic                                                               
conditions. The report  shows that these cases  represent a small                                                               
percentage who live in Anchorage, Mat-Su, and Kenai.                                                                            
                                                                                                                                
COMMISSIONER  CRUM replied  that  DHSS  identified those  chronic                                                               
conditions in the MESA report.  One, end state renal disease, was                                                               
addressed last  year through regulation. DHSS  found cost savings                                                               
of $1 million a year by  dropping it to Medicare rates instead of                                                               
cost  base rate.  DHSS has  lots of  different projects  in play.                                                               
Senate Bill 74 included other  authorities like exploring bundled                                                               
payments  for   innovations  and  incentives  to   providers  for                                                               
savings. Commissioner Crum described  various initiatives such as                                                               
employee   engagement,  PLAAY   Summit,   alcohol,  and   tobacco                                                               
education  in schools.  DHSS does  the CDC  (Centers for  Disease                                                               
Control  and Prevention)  Youth  Risk Behavior  Survey every  two                                                               
years  to  use  for  policy   decisions.  The  Petersburg  School                                                               
District has removed sugary drinks  from its vending machines and                                                               
cafeteria and put water bottle  fillers in schools. Public Health                                                               
is working on little investments  like that in education that can                                                               
have generational effects.                                                                                                      
                                                                                                                                
SENATOR  GIESSEL   noted  that  diabetes  is   a  common  chronic                                                               
condition.   It  is   often  challenging   for  people   to  find                                                               
comprehensive  care  for  diabetes.   A  nurse  practitioner  who                                                               
specializes  in  that  is  in the  committee  room  today.  Nurse                                                               
practitioners are only reimbursed at  85 percent of the physician                                                               
rate,  but  often  can  provide   better  care.  Sometimes  those                                                               
financial things make  all the difference in  combating a chronic                                                               
condition that ultimately results in renal disease.                                                                             
                                                                                                                                
COMMISSIONER CRUM  replied that the governor  has encouraged DHSS                                                               
to consider not  only the initial cost but long  term savings. He                                                               
said  that is  always part  of the  discussion when  DHSS pursues                                                               
different regulatory packages or other actions.                                                                                 
                                                                                                                                
2:06:06 PM                                                                                                                    
SENATOR BEGICH  said looking beyond the  governmental expense was                                                               
not  the   message  from  the   administration  last   year.  The                                                               
implications are  not just  for the state  budget but  impact the                                                               
health  care cost  in  Alaska to  the average  person  or to  the                                                               
provider.  He  agreed  with Commissioner  that  there  are  other                                                               
things that need to be considered  besides the budget, such as if                                                               
a policy in the long run will benefit society.                                                                                  
                                                                                                                                
COMMISSIONER CRUM  addressed the  last topic  of the  DHSS three-                                                               
year vision, the behavioral health  continuum of care. Because of                                                               
legislative  efforts  in  prior   years,  his  predecessors,  and                                                               
dedicated  stakeholders,  the state  has  had  great progress  in                                                               
breaking down the stigma of  behavioral health. Behavioral health                                                               
issues affect many. Because of  the diminishing stigma, the stage                                                               
is set to  focus on the buildup of a  behavioral health continuum                                                               
of care.  There has been  progress in  community-level investment                                                               
over the last two years.  The Fairbanks Memorial Hospital brought                                                               
online  a  dedicated  behavioral treatment  unit  and  designated                                                               
evaluation and treatment center  in January 2019. Mat-Su Regional                                                               
recently unveiled its behavioral  health treatment and designated                                                               
evaluation  and treatment  center. This  community investment  is                                                               
necessary  to   provide  acute  behavioral  health   services  in                                                               
community.  DHSS is  grateful these  community organizations  are                                                               
stepping up and building capacity.                                                                                              
                                                                                                                                
COMMISSIONER CRUM said  a key piece has been  the 1115 Behavioral                                                               
Health  Medicaid  Waiver  for mental  health  and  substance  use                                                               
disorders.  It  is a  multi-year  effort  with parties  from  all                                                               
across the  state. With  the 1115 waiver,  two dozen  new service                                                               
types  have  been  added  that  can  bill  Medicaid  and  provide                                                               
services sooner at a more appropriate  level of care that is more                                                               
localized than  before. The goal  is to keep  individuals working                                                               
and  families  together by  getting  them  the crucial  help  and                                                               
necessary treatment before much  more expensive interventions are                                                               
required. The 1115  waiver opens up a  possible funding mechanism                                                               
for behavioral health crisis stabilization.                                                                                     
                                                                                                                                
COMMISSIONER CRUM  said, moving into addressing  the divisions of                                                               
DHSS, Alaska Pioneer Homes did  receive approval for construction                                                               
of a dementia  floor at the Anchorage Pioneer Home.  It has taken                                                               
time to  work on  zoning issues with  the municipality.  This had                                                               
been  a hole  in the  system  of behavioral  health. The  Pioneer                                                               
Homes  Division is  exploring the  addition  of 22  beds for  the                                                               
higher Veterans Affairs (VA) per  diem rate at the Palmer Pioneer                                                               
Home. Fourteen beds  have been transitioned. That has  to be done                                                               
in  complete units.  There  are certain  protocols  that must  be                                                               
followed, but it does bring in additional VA revenue.                                                                           
                                                                                                                                
2:10:10 PM                                                                                                                    
SENATOR BEGICH  said the committee  heard that the  Pioneer Homes                                                               
could qualify  for higher reimbursement  rates if  buildings were                                                               
brought up to  code. He asked if there were  any efforts to bring                                                               
up the homes up to the nursing home standard.                                                                                   
                                                                                                                                
COMMISSIONER  CRUM answered  that Pioneer  Homes are  licensed as                                                               
assisted  living homes.  To be  a skilled  nursing facility  or a                                                               
nursing home is a completely  different license type. Some of the                                                               
Pioneer Homes may provide nursing home  level of care. He can get                                                               
information  on  whether  that is  something  the  division  will                                                               
pursue.                                                                                                                         
                                                                                                                                
SENATOR  BEGICH  referred  to the  bottom  line  issue  discussed                                                               
earlier. The Senate and House  might consider the capital expense                                                               
if it  allowed the Pioneer  Homes to  provide a greater  level of                                                               
care and a  greater level of reimbursement that could  pay off in                                                               
the long run.                                                                                                                   
                                                                                                                                
2:12:21 PM                                                                                                                    
ALBERT WALL, Deputy Commissioner,  Medicaid & Health Care Policy,                                                               
Anchorage,  Alaska, replied  that capital  expenditures to  bring                                                               
buildings up to code is  one of several considerations. A skilled                                                               
nursing  facility has  other requirements  that have  to do  with                                                               
staffing  and training  and  the type  of  services provided.  He                                                               
offered to provide that information to the committee.                                                                           
                                                                                                                                
COMMISSIONER CRUM said the mission  of the Division of Behavioral                                                               
Health is  to manage an  integrated and  comprehensive behavioral                                                               
health  system based  on sound  policy, effective  practices, and                                                               
open partnerships.  Partners are the Alaska  Mental Health Trust,                                                               
community-based   hospitals,   the   Alaska   Behavioral   Health                                                               
Association, the  Alaska Psychiatric  Association, and  others to                                                               
build the full  continuum of care needed in  Alaska. The question                                                               
is how  to provide services sooner  and closer to home  at a more                                                               
appropriate level.                                                                                                              
                                                                                                                                
MR.  WALL  reviewed  slide 5,  1115  Behavioral  Health  Medicaid                                                               
Waiver:                                                                                                                         
                                                                                                                                
     The    1115   Behavioral    Health   Medicaid    Waiver                                                                    
     demonstration  project   focuses  on   establishing  an                                                                    
     enhanced set  of benefits for three  target populations                                                                    
     of Medicaid recipients:                                                                                                    
                                                                                                                                
   • Children, adolescents, and their parents or caretakers                                                                     
      with  or at risk of  mental health and/or substance-                                                                      
     use disorders.                                                                                                             
   • Individuals with acute mental health needs.                                                                                
   • Individuals with substance-use disorders.                                                                                  
                                                                                                                                
     More    detailed   information    about   the    waiver                                                                    
     demonstration's goals and objectives  for each of these                                                                    
     target  populations  is  found  on  the  1115  webpage:                                                                    
     http://dhss.alaska.gov/dbh/Pages/1115/                                                                                     
                                                                                                                                
MR.  WALL  said  this  was  implemented  under  Senate  Bill  74.                                                               
Commissioner  Crum  spoke  earlier about  the  behavioral  health                                                               
continuum of care.  One challenge that DHSS faces  is the funding                                                               
mechanism for  behavioral health services in  the state. Services                                                               
were  grant-funded  with  UGF [unrestricted  general  funds]  and                                                               
Medicaid since Medicaid  did not quite pay for  the services. The                                                               
second challenge  was that  services were  not covered  under the                                                               
old  Medicaid  system  for  behavioral health,  so  gaps  in  the                                                               
continuum of  service were created.  The 1115 waiver  is designed                                                               
to remedy that by allowing  new billable services under Medicaid,                                                               
which will reduce the need for UGF grants.                                                                                      
                                                                                                                                
MR. WALL reviewed slide 6, 1115 Behavioral Health Waiver:                                                                       
                                                                                                                                
   • Substance Misuse Disorder Treatment Component                                                                              
     •  Approved in November 2018                                                                                               
     •  Became effective January 1, 2019                                                                                        
                                                                                                                                
   • Behavioral Health Component                                                                                                
     •  Approved September 2019                                                                                                 
     •  Will be implemented by June 30, 2020                                                                                    
                                                                                                                                
   • Administrative Services Organization                                                                                       
     •  Contracted with Optum Health in November 2019                                                                           
     •  Went live on February 1, 2020                                                                                           
                                                                                                                                
MR. WALL  said CMS asked the  state to break the  1115 Behavioral                                                               
Health Waiver  into the  above two  components. He  explained the                                                               
CMS  structure  will  not  allow  states  to  bill  for  Medicaid                                                               
services in an Institute for  Mental Diseases (IMD) that has over                                                               
16 beds. He said this provision  has a long federal history. This                                                               
has limited  the state's ability  to pay for substance  abuse and                                                               
serious mental illness in institutes  with over 16 beds. The 1115                                                               
behavioral health  waiver allows  service providers  to currently                                                               
bill Medicaid for more than 16 beds for substance use treatment.                                                                
                                                                                                                                
MR. WALL said  the behavioral health component  covers the mental                                                               
health portion,  those with serious mental  illnesses or children                                                               
with  serious emotional  disturbances.  That  also addresses  the                                                               
IMD.  If  that  is  fully  approved,  implementation  will  allow                                                               
billing for inpatient  psychiatry in institutes of  over 16 beds.                                                               
That would also include the Alaska Psychiatric Institute.                                                                       
                                                                                                                                
2:17:41 PM                                                                                                                    
SENATOR VON  IMHOF said  she toured  the facilities  at Fairbanks                                                               
Memorial  Hospital  this  fall.  She acknowledged  Mr.  Wall  was                                                               
alluding to  the fact  that funding  is potentially  in jeopardy.                                                               
She stated  that the hospital  has a $2  million Disproportionate                                                               
Share Hospital  (DSH) grant. She  asked what will happen  to this                                                               
great program that fills a gap  in the mental health continuum of                                                               
care in Fairbanks if the DSH funding goes away.                                                                                 
                                                                                                                                
MR.  WALL  replied it  is  a  very  complex issue.  For  example,                                                               
different  sections   and  services  of  Medicaid   are  paid  at                                                               
different  rates.   Some  sections  relate  to   age,  others  to                                                               
diagnoses  or  types  of treatment.  Typically,  under  Medicaid,                                                               
services are billed under the  titles, federal authority given to                                                               
that particular  portion of  Medicaid. For  example, Title  19 is                                                               
for  adults and  Title  21  is for  Denali  KidCare services  for                                                               
children  and  pregnant  women. The  behavioral  health  services                                                               
provided  in the  past under  Medicaid were  billed under  clinic                                                               
services and rehab, not how  physicians or hospitals or any other                                                               
service would bill.  The 1115 waiver takes  those clinic services                                                               
and  rehab and  "outdates"  them, replacing  them typically  with                                                               
bundled payments.  Under the old  system, billing  for behavioral                                                               
health  interventions   was  in  small  increments,   perhaps  15                                                               
minutes.  Under the  1115 waiver,  billings  can be  billed at  a                                                               
bundled rate of up to 23  hours of stabilization for a variety of                                                               
services.  The   1115  waiver  allows   more  services   and  the                                                               
administrative overhead is much less than under the old system.                                                                 
                                                                                                                                
MR. WALL explained  that the issue of  inpatient psychiatric care                                                               
is a  little different. The  1115 waiver allows  Medicaid billing                                                               
for over  16 beds for  inpatient psychiatric care.  However, that                                                               
care  is  still  billed  under hospital  services  for  Medicaid.                                                               
Senator  von Imhof  was referring  to Disproportionate  Share for                                                               
Hospitals, which  is divided  into "two  buckets" for  the state.                                                               
One is an allocation from  the federal government that allows for                                                               
Disproportionate  Share to  go to  hospitals  that are  providing                                                               
care for  people who  do not  have coverage.  A large  portion of                                                               
that  goes to  API  because  the state  is  not  allowed to  bill                                                               
Medicaid for  API patients because  it has  more than 16  beds. A                                                               
second  allocation  of DSH  funding  was  made available  by  the                                                               
legislature  that   gave  DHSS  more  federal   authority,  which                                                               
requires a  general fund match.  That federal authority  will end                                                               
on June 30, 2020.                                                                                                               
                                                                                                                                
2:22:16 PM                                                                                                                    
COMMISSIONER CRUM  added that the  $4.5 million general  fund and                                                               
matching $4.5 million  in federal funds for DHS is  part of a 90-                                                               
day plan to satisfy a pending  court case [that was filed in 2018                                                               
by the Disability Law Center of  Alaska (DLC) and heard by Alaska                                                               
Superior  Court   Judge  William  Morse].  This   recognizes  the                                                               
importance of  designated evaluation and treatment  centers. DHSS                                                               
is  working  to  finalize  the  plan  with  Judge  W.  Morse  and                                                               
plaintiff.  This  funding was  put  forward  in the  department's                                                               
amended budget for FY 2021.                                                                                                     
                                                                                                                                
SENATOR VON  IMHOF noted  that Fairbanks is  under a  Morse plan,                                                               
and will get DHS funds this year to continue this program.                                                                      
                                                                                                                                
COMMISSIONER CRUM replied  that Fairbanks is one  of the intended                                                               
recipients of that program.                                                                                                     
                                                                                                                                
CHAIR  WILSON  said  the   prior  administration  indicated  that                                                               
Medicaid  expansion  would  lessen  the  need  for  state  grants                                                               
because there would  be billable services. The  influx never came                                                               
through to a lot of  behavioral health grantees. Others asked for                                                               
the  data  to show  that  the  amount  of billable  services  was                                                               
offsetting the cost of grants,  but that data never came through.                                                               
The Alaska  Native Health Board  wrote a white paper  that showed                                                               
the funds  did not  come. With the  additional billing  under the                                                               
1115 waiver,  he asked if  providers are billing for  Medicaid to                                                               
make up  for grant  services. If  so, is the  state going  to see                                                               
further reductions  in grant services to  those behavioral health                                                               
providers.                                                                                                                      
                                                                                                                                
COMMISSIONER CRUM  replied that  grant recipients that  are large                                                               
providers  of  substance  use disorders  services,  through  this                                                               
initial  billing  phase, have  been  made  more than  whole  with                                                               
Medicaid funding  for any  decrease in grants.  That was  the way                                                               
the process  was supposed to  work because these providers  see a                                                               
higher  proportion of  the Medicaid  expansion population  at the                                                               
higher  90   percent  federal  match.   DHSS  has   not  proposed                                                               
behavioral health grants for this  coming year because DHSS wants                                                               
to  maintain stability  through the  system for  this year  while                                                               
DHSS  gets  the  rest  of   the  providers  signed  up  with  the                                                               
Administrative  Service  Organization  to  become  1115  Medicaid                                                               
providers.  Technical  assistance  and   guidance  to  make  sure                                                               
providers   are  up   and  running   can  be   provided  by   the                                                               
Administrative  Service  Organization  and the  department.  Then                                                               
DHSS can  evaluate and  put forward  further grant  reductions if                                                               
necessary.                                                                                                                      
                                                                                                                                
2:25:40 PM                                                                                                                    
CHAIR WILSON  asked whether the  federal match rate for  the 1115                                                               
waiver is at 90 percent instead of 50 percent.                                                                                  
                                                                                                                                
MR. WALL answered that it is based on the eligibility type.                                                                     
                                                                                                                                
COMMISSIONER CRUM turned  to the tables in slides 7,8,  and  that                                                               
show the  different services  in the  mental health  continuum of                                                               
care for children  and adolescents, for individuals  18 and over,                                                               
and the substance use disorder  continuum of care for individuals                                                               
12 and  older. The services  are color  coded to show  which were                                                               
added under the 1115 waiver.                                                                                                    
                                                                                                                                
CHAIR WILSON  asked if  the state has  enough providers  that can                                                               
currently bill and if 12 new provider types were enough.                                                                        
                                                                                                                                
MR. WALL  replied it is a  mixed bag at this  point. For example,                                                               
the  state  has  no  crisis stabilization  centers,  which  is  a                                                               
facility-based  service.  The  state  would  have  to  build  the                                                               
licensure type,  provide staff, and  stand them up as  a separate                                                               
provider type. Some of the  other provider types are licensed and                                                               
up  and  running.  Some  will  be  licensed  and  bring  in  more                                                               
providers and others will not.                                                                                                  
                                                                                                                                
SENATOR GIESSEL observed that the  law was changed a couple years                                                               
ago to remove psychiatrist supervision.  So, now, a physician can                                                               
supervise  clinical  social  workers,  clinical  counselors,  and                                                               
family  therapists. She  asked if  that been  implemented and  if                                                               
more services were available.                                                                                                   
                                                                                                                                
COMMISSIONER  CRUM replied  the regulatory  package is  completed                                                               
and  waiting  for  a signature  from  the  lieutenant  governor's                                                               
office.                                                                                                                         
                                                                                                                                
SENATOR GIESSEL noted that that bill was passed two years ago.                                                                  
                                                                                                                                
CHAIR WILSON  asked if statutory  or regulatory change  is needed                                                               
to add providers and if so when that will occur.                                                                                
                                                                                                                                
MR.  WALL answered  that  it  depends on  the  provider type  and                                                               
licensure. Both  types of changes  will be needed, but  some will                                                               
require no change.                                                                                                              
                                                                                                                                
2:29:20 PM                                                                                                                    
SENATOR  BEGICH   asked  if  the  legislature   will  be  getting                                                               
guidance. If  a statutory change  is needed on top  of regulatory                                                               
change, it could take four or five years to pass.                                                                               
                                                                                                                                
MR.  WALL  acknowledged  his  frustration,  noting  he  has  been                                                               
working  on this  for  many years.  For  example, a  psychiatrist                                                               
having  to provide  30 percent  supervision of  behavioral health                                                               
providers has been  an ongoing frustration for  many years. Under                                                               
the old state  plan for behavioral health, there  were only three                                                               
defined  provider groups  that  could  provide behavioral  health                                                               
services. A clinic  with a psychiatrist to  provide oversight was                                                               
one.  Psychologist and  LCSW  (licensed  clinical social  worker)                                                               
could  only  provide  limited  services. He  said  that  DHSS  is                                                               
developing  a  plan  to  [provide  more  services].  The  biggest                                                               
partners DHSS has in this  process are associations and groups in                                                               
the  [Alaska  Mental Health]  Trust  Authority  (AMHTA). DHSS  is                                                               
working closely  with the  Alaska Behavioral  Health Association.                                                               
The  AMHTA has  been the  driving force  behind the  movement for                                                               
crisis stabilization.  DHSS has held discussions  with the Alaska                                                               
Primary  Care  Association,   the  Hospital  Association,  Alaska                                                               
Association  of Homes  for Children,  about the  1115 waiver  and                                                               
what needs to be in place to ensure its delivery of services.                                                                   
                                                                                                                                
MR. WALL said the first phase  was substance abuse. The state has                                                               
all  the  license types  and  service  lines for  implementation.                                                               
Moving  forward,  the  road  map  is  being  developed.  DHSS  is                                                               
grateful for  the Trust's  involvement in that.  The Trust  has a                                                               
vendor who has put together a  report that can be shared with the                                                               
committee.                                                                                                                      
                                                                                                                                
2:31:43 PM                                                                                                                    
SENATOR VON  IMHOF recapped that the  blue on slides 7,  8, and 9                                                               
are for the new services. She  asked what the fiscal note will be                                                               
with  the  varying demands  of  all  the  blue services  and  the                                                               
various matching rates.  She said she understands there  may be a                                                               
transition from traditional behavioral  health grants. The grants                                                               
will be  decreased and the match  will be ramped up.  She offered                                                               
her belief  that it will  not be net  zero. Although he  does not                                                               
need to answer  today, he should just know  that the subcommittee                                                               
process starts tomorrow.                                                                                                        
                                                                                                                                
COMMISSIONER  CRUM replied  DHSS will  provide that  information.                                                               
The  1115  waiver process  must  be  cost  neutral or  provide  a                                                               
savings to  the federal  government over time.  Each waiver  is a                                                               
five-year process. DHSS  had to pay for an  actuarial analysis of                                                               
its plan to make sure that was the case.                                                                                        
                                                                                                                                
SENATOR  VON IMHOF  asked  about  it being  cost  neutral to  the                                                               
state.                                                                                                                          
                                                                                                                                
2:33:25 PM                                                                                                                    
COMMISSIONER  CRUM replied  the DHSS  plan for  expanded services                                                               
would have cost savings for the  state because it is a buildup of                                                               
the  continuum. The  idea  is to  get  individuals services  more                                                               
quickly  so  these  patients  do  not end  up  in  the  emergency                                                               
departments. There  would be anticipated  savings for  that. DHSS                                                               
has specific tracking mechanisms to report back to CMS.                                                                         
                                                                                                                                
MR. WALL  added that  a good  portion of this  is already  in the                                                               
operational budget for  this year. It is already  included in the                                                               
next  Medicaid  budget.  The  fiscal   notes  have  already  been                                                               
accomplished.                                                                                                                   
                                                                                                                                
MR.  WALL  said he  is  excited  about behavioral  health  crisis                                                               
stabilization because  he thinks it  solves a lot of  problems in                                                               
the state around  behavioral health. The state  is rapidly moving                                                               
toward a  behavioral health crisis stabilization  approach, which                                                               
some organizations and  some states have. DHSS  has had technical                                                               
assistance trips  to the state  of Arizona because  Alaska's 1115                                                               
waiver is most closely similar  to Arizona's. Arizona's system of                                                               
care  is  built around  this  idea  of behavioral  health  crisis                                                               
stabilization which has four pillars.                                                                                           
                                                                                                                                
He reviewed slide 10, Behavioral Health Crisis Stabilization:                                                                   
                                                                                                                                
     The four "pillars":                                                                                                        
     1. Call In Center                                                                                                          
     2. Crisis Response Teams                                                                                                   
     3. Crisis Stabilization Centers                                                                                            
     4. A robust behavioral health continuum of care                                                                            
                                                                                                                                
He said  that in Anchorage  when someone has a  behavioral health                                                               
crisis, that  person is  picked up  by an  ambulance or  a police                                                               
officer on some  charge. That person goes either  to an emergency                                                               
room or jail. Sometimes that person  sits there for a long period                                                               
of  time waiting  for services.  Under  the crisis  stabilization                                                               
approach, it  is turned upside down.  That person does not  go to                                                               
jail or an emergency room.                                                                                                      
                                                                                                                                
2:35:43 PM                                                                                                                    
MR. WALL  described how the  situation would be handled  with the                                                               
four  pillars of  crisis  stabilization. The  call  in center  is                                                               
designated to handle  all crisis calls and  deescalate. All calls                                                               
come  to a  central  location, including  suicidal  threats or  a                                                               
behavioral health disturbance  on a street. In 75  percent of the                                                               
cases ,the call center is  able to de-escalate the crisis without                                                               
any further intervention.                                                                                                       
                                                                                                                                
MR. WALL said if the call  center cannot stabilize someone on the                                                               
phone, it launches a crisis response  team made up of two people,                                                               
a mental  health professional and  a peer. Many times,  those two                                                               
individuals are able  to de-escalate on site  without any further                                                               
intervention.  If the  team  cannot  do so  or  the person  needs                                                               
further help, the  individual is taken to  a crisis stabilization                                                               
center,  which is  a facility.  The  center receives  individuals                                                               
brought  by police  officers, EMT  vehicles, and  crisis response                                                               
teams. The  primary goal of the  center is not the  diagnosis and                                                               
treatment received in  an emergency room. The goal  of the crisis                                                               
center  is to  stabilize.  The center  wants  to de-escalate  the                                                               
problem and connect the individual with ongoing services.                                                                       
                                                                                                                                
MR. WALL said Alaska currently  does not have a robust behavioral                                                               
health continuum of care, the  fourth pillar of behavioral health                                                               
crisis stabilization. It  will be built. This  really changes the                                                               
approach of a  social response to behavioral  health. Rather than                                                               
having an individual who is acting  out in an emergency room with                                                               
police  officers waiting  for hours  to hand  that person  off to                                                               
medical staff,  in Arizona the handoff  is done in three  to five                                                               
minutes and the police officers  return to public safety work. He                                                               
appreciates the involvement of many  legislators who have gone to                                                               
Arizona  on  those  trips,   including  Senator  Wilson,  Senator                                                               
Micciche, Representative Spohnholz, and Representative Johnston.                                                                
                                                                                                                                
CHAIR WILSON  added that  this is not  done with  huge government                                                               
involvement. It  is done  by a lot  of community  members. Alaska                                                               
has  many   of  these  pieces   in  place.  It   requires  better                                                               
coordination of the resources the  state already has to pull this                                                               
together   with   limited   government   growth   in   terms   of                                                               
administration.                                                                                                                 
                                                                                                                                
2:39:08 PM                                                                                                                    
SENATOR BEGICH  asked how this  would work in rural  Alaska where                                                               
there is  no law enforcement and  no capacity for a  crisis team.                                                               
He acknowledged that it is a good idea for urban Alaska.                                                                        
                                                                                                                                
MR. WALL  replied DHSS has  had a robust discussion  around that.                                                               
On  one trip,  the Alaska  group had  a question-and-answer  time                                                               
with  a   tribal  liaison.  Like   Alaska,  Arizona   has  unique                                                               
challenges also.  Arizona has a  tribal village at the  bottom of                                                               
the Grand Canyon  that is only accessible by mule.  The system is                                                               
built to be  flexible. CMS is working with tribes  on how to make                                                               
it work  with them.  In one village,  all able-bodied  adults are                                                               
trained to be  the crisis response team and the  team handles the                                                               
phone calls in  shifts. CMS has taken  some innovative approaches                                                               
with  this.   In  Arizona,  transportation  by   horseback  is  a                                                               
Medicaid-reimbursable service.  CMS is willing to  do innovations                                                               
around this issue.  This approach is proven to  bring down costs,                                                               
provide better care and long-term  stability, and change the face                                                               
of  the culture.  He  was  very impressed  with  what  he saw  in                                                               
Arizona and he is very hopeful for what it can do in Alaska.                                                                    
                                                                                                                                
SENATOR BEGICH said he looks  forward to seeing those innovations                                                               
written up.                                                                                                                     
                                                                                                                                
CHAIR WILSON shared that he was very hopeful.                                                                                   
                                                                                                                                
2:41:11 PM                                                                                                                    
COMMISSIONER   CRUM  reviewed   slide   11,  Alaska   Psychiatric                                                               
Institute:                                                                                                                      
                                                                                                                                
     To  provide   emergency  and   court-ordered  inpatient                                                                    
     psychiatric  services  in   a  safe  environment  using                                                                    
     culturally-sensitive,     effective,    person-centered                                                                    
     treatment  followed by  a  referral  to an  appropriate                                                                    
     level  of care  and  support for  recovery from  mental                                                                    
     illness                                                                                                                    
                                                                                                                                
He said it is  important to know that API is  a hospital and DHSS                                                               
is trying to manage it like  a hospital with an active governance                                                               
board.  The board  has 26  members  from the  public and  private                                                               
sector who  take an active role.  The board is going  through the                                                               
process of  hiring a  permanent CEO  at API. It  has been  a good                                                               
process to get that level of  involvement. Last spring API was in                                                               
an emergency situation  with almost 400 cases  of violations from                                                               
its certifying  and accrediting bodies.  There was a  real threat                                                               
of being  shut down and  losing federal dollars. DHSS  brought in                                                               
Wellpath  to  help manage  API.  Wellpath  brought stability  and                                                               
national training standards. API has  corrected 92 percent of the                                                               
violations. Most  of the  plans of  correction were  written with                                                               
Wellpath's guidance.  Wellpath also  helped to  recruit employees                                                               
because  of its  national  reach  and the  overall  image of  the                                                               
facility improved.  API has a  completely different feel  than in                                                               
years past.  DHSS is looking  forward to growing  and stabilizing                                                               
API further.                                                                                                                    
                                                                                                                                
COMMISSIONER CRUM read  the new mission statement  for the Office                                                               
of Children's Services (OCS) on slide 13.                                                                                       
                                                                                                                                
     Ensuring  the  safety,  permanency  and  well-being  of                                                                    
     children    by    strengthening   families,    engaging                                                                    
     communities, and partnering with tribes.                                                                                   
                                                                                                                                
He  said  OCS  deals  with   families  and  kids  at  their  most                                                               
vulnerable time.  DHSS tries  to provide  support to  families so                                                               
these  families can  develop resiliency  tools to  stay together.                                                               
OCS has  worked on innovative recruitment  and retention efforts.                                                               
Turnover  has  been  reduced  from  51  percent  to  43  percent.                                                               
Although, hat is still  not where DHSS wants to be,  but it is an                                                               
improvement.                                                                                                                    
                                                                                                                                
DHSS  is working  to relieve  front-line staff  of administrative                                                               
functions.  The  number of  children  placed  with relatives  has                                                               
increased  thanks to  tribal compacting  and family  and relative                                                               
searches. More youth are exiting  foster care to enter college or                                                               
vocational  programs than  in the  past.  The independent  living                                                               
program takes an innovative approach  to make sure kids aging out                                                               
of the foster care system have  an active path for their futures.                                                               
This stems  from a partnership  that has expanded to  include all                                                               
at-risk youth.  The Department  of Labor  hired a  coordinator to                                                               
coordinate funds  from the  Workforce Innovation  and Opportunity                                                               
Act (WIOA)  program and Division of  Vocational Rehabilitation to                                                               
work with foster  kids and kids leaving  juvenile justice because                                                               
these youth  may not  have family supports  when these  youth are                                                               
out on their own.                                                                                                               
                                                                                                                                
SENATOR VON  IMHOF said the  legislature passed [House  Bill 151]                                                               
for OCS that  added more money for case  managers with provisions                                                               
to allow siblings staying together or  teens as young as 14 being                                                               
able to  participate in their  care plan. One  provision required                                                               
an annual  report for  three years  about how  it was  going. She                                                               
asked if  the legislature would be  getting a report in  the next                                                               
six months or so.                                                                                                               
                                                                                                                                
COMMISSIONER CRUM responded  that DHSS would be  doing an updated                                                               
report.                                                                                                                         
                                                                                                                                
2:46:06 PM                                                                                                                    
COMMISSIONER  CRUM  reviewed  slide   13,  Division  of  Juvenile                                                               
Justice:                                                                                                                        
     To  hold  juvenile   offenders  accountable  for  their                                                                    
     behavior,  promote   the  safety  and   restoration  of                                                                    
     victims  and  communities,  and  assist  offenders  and                                                                    
     their families in developing skills to prevent crime.                                                                      
                                                                                                                                
He said  the Division of  Juvenile Justice (DJJ) had  a reduction                                                               
in recidivism for  youth released from DJJ  secure treatment from                                                               
a high of 71 percent in FY 2012  to 35.9 percent in FY 2019. That                                                               
is a  massive achievement  to give youth  the support,  care, and                                                               
tools needed to return and thrive  back in the community. DJJ has                                                               
expanded   its  trauma-informed   response   practices.  DJJ   is                                                               
training  to help  staff work  with youth  to address  behavioral                                                               
health issues  and multiple projects  have expanded  services for                                                               
youth substance abuse and mental health.                                                                                        
                                                                                                                                
SENATOR BEGICH asked if the  recidivism measures were the same in                                                               
FY 2012  as FY  2019. In  2012 recidivism  was measured  over two                                                               
years. He wanted to know if that was still the same.                                                                            
                                                                                                                                
COMMISSIONER CRUM replied he would confirm the measures used.                                                                   
                                                                                                                                
SENATOR BEGICH said  he previously worked in the  division, so he                                                               
is very  conscious of how  to measure  recidivism. It is  often a                                                               
moving target. He asked what the plan is for the Nome facility.                                                                 
                                                                                                                                
2:47:54 PM                                                                                                                    
COMMISSIONER  CRUM  replied DHSS  transitioned  out  of the  Nome                                                               
Youth  Facility over  the last  year. Kids  are now  able to  use                                                               
videoconferencing  to  connect  with  their  families.  Kids  are                                                               
issued dedicated tablets to call  and talk to families. With only                                                               
six  facilities around  the state,  it means  there are  only six                                                               
places where kids  are local. DHSS wanted to make  sure that kids                                                               
had access and ties to their communities.                                                                                       
                                                                                                                                
CHAIR WILSON  said the Mat-Su  members have done a  wonderful job                                                               
with recidivism and implementing programs.                                                                                      
                                                                                                                                
COMMISSIONER  CRUM  said he  has  visited  most of  the  Juvenile                                                               
Justice facilities.  The Juvenile  Justice staff speak  about the                                                               
consistency of staff leadership. He  is grateful for that because                                                               
he thinks  the division is  on the right track.  Juvenile Justice                                                               
is not  just the facilities  but includes probation,  making sure                                                               
kids are engaged,  and making the right choices  when these youth                                                               
are released.                                                                                                                   
                                                                                                                                
CHAIR  WILSON  pointed  out  that  Commissioner  Crum  began  his                                                               
presentation  talking  about  the  reorganization  of  DHSS.  The                                                               
commissioner's  eight  predecessors  spent about  95  percent  of                                                               
their time  on Medicaid-related  issues. The  deputy commissioner                                                               
for Family  and Protective Services  has been negated.  The other                                                               
body  defunded that  deputy commissioner.  He asked  Commissioner                                                               
Crum  to  talk   about  the  benefit  of   an  additional  deputy                                                               
commissioner and the reorganization.                                                                                            
                                                                                                                                
2:51:05 PM                                                                                                                    
COMMISSIONER CRUM reviewed slide  14, Alaska Department of Health                                                               
and  Social  Services  (DHSS).  The  slide  showed  the  proposed                                                               
organization chart that is an  item is in the governor's proposed                                                               
FY  2021 budget.  It  would  add a  new  deputy commissioner  and                                                               
policy staff  to oversee the  Office of Children's  Services, the                                                               
Division of  Juvenile Justice, and  Adult Protective  Services to                                                               
ensure alignment and  mission focus. The two  main divisions that                                                               
the  new   deputy  commissioner   would  oversee   manage  urgent                                                               
situations in  which families, children,  parents, and  lives are                                                               
frequently  at  stake.  These  are some  of  the  most  important                                                               
decisions  state  government  can make.  It  includes  separating                                                               
parents  from their  children, determining  how to  handle minors                                                               
who have  committed serious offenses, and  intervening when lives                                                               
are in crisis.                                                                                                                  
                                                                                                                                
COMMISSIONER CRUM  said OCS issues  are the most  frequent reason                                                               
why   constituents   contact   the  commissioner's   office   and                                                               
legislators.  Last  year,  DHSS  recorded  over  100  independent                                                               
inquiries regarding  OCS, most  of them  from unhappy  parents or                                                               
confused foster parents. The OCS and  DJJ has a staff of almost a                                                               
thousand  people.  The OCS  works  directly  with the  public  on                                                               
stressful, painful issues, which  demands an extraordinary amount                                                               
of time and attention. This  involves debriefing stressful cases,                                                               
finding   creative    solutions   for   placement    for   family                                                               
preservation,  supporting OCS  in recruiting  and retaining  more                                                               
frontline social  workers, and supporting the  director positions                                                               
and leadership staff.                                                                                                           
                                                                                                                                
COMMISSIONER CRUM  explained that decisions from  these divisions                                                               
must be  supported or given final  clearance at the level  of the                                                               
commissioner's    office.   Jon    Sherwood   described    deputy                                                               
commissioners as  traffic cops because  of the constant  pace and                                                               
time  of  decisions.  The  directors   work  closely  with  their                                                               
assigned  deputy commissioner  for policy  support and  emergency                                                               
decisions. Examples are emergency  placement of kids with complex                                                               
behaviors  or   medical  conditions  or  approval   of  emergency                                                               
transports. These  positions will  provide better support  to the                                                               
divisions  to  help staff  navigate  their  difficult work.  More                                                               
importantly, this  will allow DHSS  to take substantial  steps to                                                               
change the  conditions under which  child protection  systems and                                                               
juvenile justice systems are needed.                                                                                            
                                                                                                                                
COMMISSIONER CRUM  said it requires  substantial work  to enhance                                                               
partnerships with tribes, communities,  and stakeholders, but the                                                               
day-to-day work does  not allow that kind of  effort. To continue                                                               
to work on  tribal compacts takes time and leadership.  It is too                                                               
important  an effort  to  try to  fit  in a  few  hours a  month.                                                               
Growing government  is not  something people  typically associate                                                               
with this  administration, but the  administration views  this as                                                               
an investment.  Everyone has seen  the data on  Adverse Childhood                                                               
Experiences (ACEs) and how higher  ACEs scores directly correlate                                                               
to increases  in chronic conditions like  diabetes, hypertension,                                                               
and heart  attack. Recently in  the Senate Finance  Committee, an                                                               
economist  addressed   the  disproportionate  costs   of  chronic                                                               
conditions  to the  Medicaid  program as  well  as the  projected                                                               
growth of  the program. The cost  is calculated to be  $5 billion                                                               
by 2040.  If the state can  work on keeping families  together by                                                               
giving  them  the  tools  to   thrive  so  these  families  don't                                                               
contribute to ACEs  or trauma, then that is an  investment in the                                                               
next  generation and  the state  can  finally bend  the curve  on                                                               
multigenerational  issues that  result in  child abuse,  neglect,                                                               
and delinquent behavior.                                                                                                        
                                                                                                                                
2:54:32 PM                                                                                                                    
COMMISSIONER CRUM  said the department  has several  cost drivers                                                               
that demand  attention from all  current leadership. The  goal of                                                               
the  dedicated deputy  commissioner and  policy team  is to  work                                                               
upstream and  focus on systemic  changes that will not  be siloed                                                               
from other divisions.  The team will be charged  with taking care                                                               
of  young  Alaskans  and  making   families  stronger.  The  DHSS                                                               
requested   four   new  positions   for   the   team:  a   deputy                                                               
commissioner, a  project coordinator, a special  assistant, and a                                                               
program coordinator.  The project  coordinator would  be assigned                                                               
as  an  ICWA  (Indian  Child   Welfare  Act)  or  tribal  liaison                                                               
specialist.  The coordinator  would represent  the department  in                                                               
building relationships  with tribal partners as  the tribes build                                                               
up their infrastructure  to deal with child  welfare issues while                                                               
the DHSS tries  to make sure these services are  provided more at                                                               
the local level.                                                                                                                
                                                                                                                                
CHAIR WILSON  asked for any  closing comments as well  as written                                                               
comments about  updates with the Divisions  of Public Assistance,                                                               
Public  Health, Senior  Disabilities  and  Services, Health  Care                                                               
Services, and Medicaid Services.                                                                                                
                                                                                                                                
COMMISSIONER CRUM  said he  loves the people  he works  with, the                                                               
department's mission, and the citizens  that DHSS serves. This is                                                               
an opportunity  for Alaskans to  address some of  these difficult                                                               
situations for the next 20 years.                                                                                               
                                                                                                                                
2:56:59 PM                                                                                                                    
There being  no further  business to  come before  the committee,                                                               
Chair  Wilson adjourned  the Senate  Health  and Social  Services                                                               
Standing Committee at 2:56 p.m.                                                                                                 

Document Name Date/Time Subjects
DHSS Overview Senate HSS 2-19-20.pdf SHSS 2/19/2020 1:30:00 PM
DHSS Departmental Update 2.19.20
HB029 Sponsor Statement 2.25.19.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB029 Supporting Document-Letter of Support 2.25.19.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB029 Fiscal Note DCCED-DOI 3.22.2019.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB029 Letter of Support Moda Health 03.25.2019.pdf HHSS 3/26/2019 3:00:00 PM
HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB029 Letter of Support ACoA 03.25.2019.pdf HHSS 3/28/2019 3:00:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup ADN Article.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup Letters of Support.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Bill Version A.PDF HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Fiscal Note.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Presentation.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Sectional.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Sponsor.pdf HL&C 4/15/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Sponsor.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup Letters of Support.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup ADN Article.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Bill Version A.PDF HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Fiscal Note.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Presentation.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Sectional.pdf HL&C 4/24/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup Letter of Support AARP.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup ADN Article.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Backup Letters of Support.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Bill Version A.PDF HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Fiscal Note.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29
HB29 Dr. Evans Letter of Support 2.14.20.pdf SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29 Premera Letter of Support 2.14.20.pdf SHSS 2/19/2020 1:30:00 PM
HB 29
HB 29.Sponsor.pdf HL&C 4/29/2019 3:15:00 PM
SHSS 2/14/2020 1:30:00 PM
SHSS 2/19/2020 1:30:00 PM
HB 29