03/11/2023 03:00 PM House HEALTH & SOCIAL SERVICES

        HB 16-MEDICAID OPTIONAL SVCS & COST CONTAINMENT                                                                     
                                                                                                                                
4:17:28 PM                                                                                                                    
                                                                                                                                
CHAIR PRAX  announced that the  final order of business  would be                                                               
the SPONSOR  SUBSTITUTE FOR HOUSE  BILL NO. 16 "An  Act requiring                                                               
the  state   medical  assistance   program  to   provide  certain                                                               
services;  relating to  cost containment  measures for  the state                                                               
medical assistance program; relating  to payment for adult dental                                                               
services; and providing for an effective date."                                                                                 
                                                                                                                                
4:18:02 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  ANDY  JOSEPHSON,  Alaska  State  Legislature,  as                                                               
prime  sponsor  of SSHB  16,  paraphrased  the sponsor  statement                                                               
[included  in  the  committee  packet],  which  read  as  follows                                                               
[original punctuation provided]:                                                                                                
                                                                                                                                
     Medicaid offers a myriad of  optional services, many of                                                                    
     which Alaska chooses to offer  to program recipients in                                                                    
     our  state.   As  listed  in  AS   47.07.030(b),  these                                                                    
     services  cover a  wide variety  of health  care needs,                                                                    
     whether  preventative  (e.g.   nutrition  services  for                                                                    
     pregnant   women,   clinic   services,   and   low-dose                                                                    
     mammography  screening), chronic  (e.g. long-term  care                                                                    
     and   hospice  care),   or  emergent   (e.g.  emergency                                                                    
     hospital  services),  or combinations  thereof.  Alaska                                                                    
     also   chooses   to   cover   dental   services,   both                                                                    
     preventative and restorative, for eligible adults.                                                                         
                                                                                                                                
     In June  of 2019, all funds  appropriated towards adult                                                                    
     dental Medicaid benefits were vetoed  days prior to the                                                                    
     beginning of the new fiscal  year. This forced numerous                                                                    
     program   recipients   to  cease   treatment,   leaving                                                                    
     multiple Alaskans who were in  the process of receiving                                                                    
     dentures  literally  toothless. Ultimately,  reinstated                                                                    
     funding ensured  that this program would  continue, but                                                                    
     not until months after the initial veto.                                                                                   
                                                                                                                                
     HB  16  aims to  prevent  such  uncertainty to  program                                                                    
     recipients in  the future. This  bill ensures  that the                                                                    
     listed services in AS  47.07.030(b) would be maintained                                                                    
     in future  years and not  be subject to  similar future                                                                    
     cuts. Please join me in  maintaining coverage for these                                                                    
     individuals by supporting HB 16.                                                                                           
                                                                                                                                
4:28:39 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  JOSEPHSON   gave  the   PowerPoint  presentation,                                                               
titled  "House Bill  16"  [hard copy  included  in the  committee                                                               
packet].   On  slide  2, he  showed a  graph  of Alaska  Medicaid                                                               
funding from fiscal year 2012 (FY  12) to (FY 21) and pointed out                                                               
that there  was an increase  in FY 15.   He  moved to slide  3 to                                                               
present a list  of mandatory and optional Medicaid  services.  He                                                               
said the  bill would add  two services,  and this would  cost $35                                                               
million.   He  moved to  slide 4  and showed  a table  that lists                                                               
Medicaid optional  services by  state.   The table  indicates the                                                               
services each state  has selected, and he indicated  that the red                                                               
denotes  rejected  services.    He pointed  out  that  Maine  and                                                               
Wisconsin  are more  generous  with the  services  selected.   He                                                               
moved to slide  5 to explain Medicaid eligibility in  Alaska.  On                                                               
slide 6, he explained that  optional services have already been a                                                               
target for  cost-cutting measures, and  he referred to  an action                                                               
by  the  governor to  remove  adult  dental services,  which  was                                                               
rejected by the legislature.                                                                                                    
                                                                                                                                
REPRESENTATIVE JOSEPHSON  showed slide  7, which  listed intended                                                               
Medicaid  cuts  in 2020.    He  expressed  the opinion  that  the                                                               
administration would need flexibility;  therefore, nothing in the                                                               
proposed  legislation would  stop cost-containing  measures.   He                                                               
informed members that  he would have to confirm  whether the $102                                                               
million total  was the  governor's goal  in FY 20.   He  moved to                                                               
slide  9 and  explained  that the  legislature  had weighed  many                                                               
options,  while slide  10  depicted a  graph  of annual  Medicaid                                                               
funding and the  governor's proposed reductions.   He advanced to                                                               
slide  13 to  explain Maine's  Medicaid law.   He  said slide  14                                                               
provides a  breakdown of  the states  that have,  in one  form or                                                               
another, a required check in order  to modify a state's plan.  He                                                               
concluded  on  slide  15  and  expressed  eagerness  to  see  the                                                               
proposed bill move to the  next committee, because in some states                                                               
the governor alone can make significant changes.                                                                                
                                                                                                                                
4:38:32 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  MINA shared  that she  has spoken  with residents                                                               
who  voiced that  adult  dental  should be  a  necessary part  of                                                               
primary care and  not just an optional service.   She offered the                                                               
understanding that  amendments to the state's  Medicaid plan must                                                               
be subject  to legislative approval, and  this is why there  is a                                                               
proposed  bill to  allow  post-partum  treatment under  Medicaid.                                                               
She questioned which  [parts of the Medicaid  plan] are currently                                                               
subject to legislative approval.                                                                                                
                                                                                                                                
REPRESENTATIVE JOSEPHSON expressed the  opinion that the question                                                               
highlights  the  point  that  there  is  a  need  for  authority;                                                               
otherwise, the  governor would have  filed a bill.   He expressed                                                               
uncertainty  concerning why  the  governor  removed adult  dental                                                               
[services  from   the  Medicaid  plan]  without   filing  a  bill                                                               
requesting  it.    He  further  elaborated  that  little  in  the                                                               
Medicaid  program is  subject to  legislative  authority, and  he                                                               
relayed that  AS 47.07 provides  that the department  "may" offer                                                               
the following optional services.                                                                                                
                                                                                                                                
REPRESENTATIVE  MINA asked  what else  is subject  to legislative                                                               
approval besides optional services.                                                                                             
                                                                                                                                
REPRESENTATIVE JOSEPHSON answered  that cost-containment measures                                                               
in AS 47.07.036 are also  at the administration's discretion.  He                                                               
referred to  slide 6 of  the presentation  regarding cost-cutting                                                               
measures and said that the governor  made the changes so he could                                                               
reach the  $102 million; however,  the legislature  rejected this                                                               
action.  He read from AS 47.07.036, which read as follows:                                                                      
                                                                                                                                
     If  the  department finds  that  the  costs of  medical                                                                    
     assistance for all persons  eligible under this chapter                                                                    
     will exceed  the amount allocated  in the  state budget                                                                    
     for a  fiscal year,  the department may  implement cost                                                                    
     containment  measures  to  reduce  anticipated  program                                                                    
     costs                                                                                                                      
                                                                                                                                
4:44:47 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SUMNER  asked what  the effect  would be  if there                                                               
was  a reduction  in Medicaid  funding.   He opined  that if  the                                                               
department "shall" instead of "may"  do optional services, and it                                                               
did not have  the funding, it would have to  cut some fraction of                                                               
all services, rather than selectively.                                                                                          
                                                                                                                                
REPRESENTATIVE  JOSEPHSON responded  that the  administration was                                                               
going to the Centers for  Medicare and Medicaid Services (CMS) to                                                               
cut  adult  dental service.    He  explained  that the  bill  was                                                               
written at the time of the adult dental cut.                                                                                    
                                                                                                                                
REPRESENTATIVE SUMNER  suggested that instead of  focusing on the                                                               
veto,  the focus  should be  on a  potential situation  where the                                                               
earnings reserve  account goes  empty.   He asked  whether, under                                                               
SSHB  16,  the state  would  not  be  allowing the  selection  of                                                               
prioritized vital health services.                                                                                              
                                                                                                                                
REPRESENTATIVE JOSEPHSON  responded that, under SSHB  16, members                                                               
would not  be allowed  to change who  is eligible,  nor eliminate                                                               
optional programs;  the bill would have  the legislature involved                                                               
in the process.                                                                                                                 
                                                                                                                                
4:49:01 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SADDLER  referred to  Representative  Josephson's                                                               
suggestion that the  governor opted in 2019 not  to fund optional                                                               
dental  services  in order  to  create  a larger  permanent  fund                                                               
dividend  (PFD).   He  expressed the  understanding  that on  the                                                               
floor  of the  House of  Representatives, no  one should  ascribe                                                               
motives to people,  and members can debate the merits  of SSHB 16                                                               
without ascribing the governor's motives.                                                                                       
                                                                                                                                
4:49:53 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE RUFFRIDGE  inquired whether,  if the bill  were to                                                               
pass  but  the  state  cannot   pay  the  necessary  services  on                                                               
Medicaid, no  individual programs would  be cut, but  rather, the                                                               
cuts  would be  across the  board because  all services  would be                                                               
required.   He asked  for confirmation  that in  order to  make a                                                               
cut, the  legislature would need to  convene and move to  cut the                                                               
service.                                                                                                                        
                                                                                                                                
REPRESENTATIVE JOSEPHSON responded in the affirmative.                                                                          
                                                                                                                                
4:50:50 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  MINA, looking  at the  list of  optional services                                                               
provided  under AS  47.07.30(b), questioned  whether the  federal                                                               
match rate is just 70/30.                                                                                                       
                                                                                                                                
REPRESENTATIVE  JOSEPHSON  expressed  uncertainty  and  suggested                                                               
that for some services the state's share may be higher.                                                                         
                                                                                                                                
REPRESENTATIVE MINA  asked about the  fiscal note and  how brain-                                                               
injury case  management would be  funded, as it is  not currently                                                               
funded by general fund grants.                                                                                                  
                                                                                                                                
REPRESENTATIVE  JOSEPHSON offered  his understanding  that it  is                                                               
not funded through the Medicaid program.   He said this was added                                                               
because  of the  concern that  the  governor wanted  to cut  $250                                                               
million from Medicaid.  He  expressed the opinion that there must                                                               
be some way for the legislature to be involved.                                                                                 
                                                                                                                                
REPRESENTATIVE MINA  offered her understanding  that brain-injury                                                               
case management, as  well as pregnant women  case management, are                                                               
listed  in  statute;  however,  these services  are  not  in  the                                                               
current state plan,  which is why there is the  fiscal note.  She                                                               
expressed  the desire  not to  ascribe the  worth of  one service                                                               
over another.   She questioned whether  there is a way  to narrow                                                               
the bill,  so it focuses  on the  services that are  currently in                                                               
the state plan.                                                                                                                 
                                                                                                                                
REPRESENTATIVE  JOSEPHSON  concurred  that the  cost  comes  from                                                               
putting a  service into  the state  plan.   He observed  that the                                                               
2019 administration is  not the same as  the 2023 administration,                                                               
and he reiterated that SSHB 16 is a legacy bill.                                                                                
                                                                                                                                
REPRESENTATIVE MINA offered her  understanding that the intent of                                                               
the  bill is  that  optional Medicaid  services,  whether cut  or                                                               
changed  by  the  executive  branch,  would  require  legislative                                                               
authority.   She  noted  that the  bill would  also  add two  new                                                               
services to the state plan.                                                                                                     
                                                                                                                                
REPRESENTATIVE JOSEPHSON  concurred that  the intent  of drafting                                                               
the  bill was  to  not allow  the governor  alone  to strip  away                                                               
programs.   Furthermore,  he noted  that there  is a  $30 million                                                               
savings  to the  state  because the  proposed sponsor  substitute                                                               
would remove chiropractic care.                                                                                                 
                                                                                                                                
REPRESENTATIVE  MINA  commented  that  the  biggest  impact  from                                                               
cutting  Medicaid and  optional  services is  losing the  federal                                                               
dollars.                                                                                                                        
                                                                                                                                
REPRESENTATIVE  JOSEPHSON  suggested  removing the  two  programs                                                               
that  he   added,  because  they   are  costly.     He  suggested                                                               
implementing a  Wisconsin- or Maine-style amendment,  which would                                                               
add the involvement of the legislature.                                                                                         
                                                                                                                                
4:58:43 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  SUMNER questioned  whether chiropractic  care was                                                               
removed  because   of  the   fiscal  note   or  because   of  the                                                               
reimbursement rate.                                                                                                             
                                                                                                                                
REPRESENTATIVE JOSEPHSON answered that  it was removed because of                                                               
the cost on the fiscal note.                                                                                                    
                                                                                                                                
4:59:07 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE  RUFFRIDGE  asked  whether  chiropractic  services                                                               
fall under the language "may offer".                                                                                            
                                                                                                                                
REPRESENTATIVE JOSEPHSON  responded that it does  fall under this                                                               
language, but the state does not.                                                                                               
                                                                                                                                
4:59:32 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE SUMNER asked whether  it would require legislative                                                               
action to remove chiropractic care  from the "may offer" list and                                                               
add it to the "shall offer" list.                                                                                               
                                                                                                                                
REPRESENTATIVE  JOSEPHSON suggested  that it  could be  taken off                                                               
the  "may  offer  list,"  and then  the  legislature  could  move                                                               
forward with the Wisconsin- and Maine-style of reform.                                                                          
                                                                                                                                
REPRESENTATIVE  SUMNER offered  his understanding  that the  bill                                                               
just  changes "may"  to "shall",  striking chiropractic  from the                                                               
list; however, it would take a  future legislative act to make it                                                               
possible.  He further opined that  the reason there needs to be a                                                               
bill for post-partum care is that it is an eligibility issue,                                                                   
not a service issue.                                                                                                            
                                                                                                                                
5:01:11 PM                                                                                                                    
                                                                                                                                
REPRESENTATIVE MINA pointed out that an amendment to the state                                                                  
Medicaid plan requires legislative action.                                                                                      
                                                                                                                                
REPRESENTATIVE JOSEPHSON suggested that Representative Mina                                                                     
knows more than the bill sponsor does.                                                                                          
                                                                                                                                
5:02:25 PM                                                                                                                    
                                                                                                                                
CHAIR PRAX announced that SSHB 16 was held over.