Legislature(2025 - 2026)ADAMS 519
04/09/2025 01:30 PM House FINANCE
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| Audio | Topic |
|---|---|
| Adjourn | |
| Start | |
| HB23 | |
| HB10 | |
| HB73 |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 23 | TELECONFERENCED | |
| + | HB 73 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| += | HB 10 | TELECONFERENCED | |
HOUSE BILL NO. 73
"An Act relating to complex care residential homes;
and providing for an effective date."
Co-Chair Foster moved to the next item on the agenda.
2:05:47 PM
EMILY RICCI, DEPUTY COMMISSIONER, DEPARTMENT OF HEALTH,
introduced the bill. She relayed that the bill was the
result of a collaborative effort by the Department of
Family and Community Services (DFCS) and the Department of
Health (DOH). The bill focused on developing a new license
type to fill a critical care gap in residential care in
Alaska for those with complex needs.
ROBERT LAWRENCE, CHIEF MEDICAL OFFICER, DEPARTMENT OF
HEALTH, introduced the PowerPoint presentation "HB 73:
Complex Care Residential Homes" dated February 6, 2025
(copy on file). He continued to slide 2 titled "HB 73
Supports Alaska's System of Care
HB 73 strengthens Alaska's health care system,
enabling Alaskans to access services in settings
tailored to their specific care needs.
He explained the vision for the regulation that was
developed in partnership between DFCS and DOH as part of
the Complex Care Initiative. He detailed that the
initiative brought together two "foundational components."
The first was a case response team that met weekly to
review individual cases and develop solutions for
individual care needs. The second was a higher level
complex care committee that met quarterly to review systems
and policies from information gathered via the
collaborative work of identifying systems gaps in complex
cases. The bill's inception was born out of the work.
Dr. Lawrence pointed to slide 3 titled "What Is Complex
Care
Definition: Co-occurring behavioral, medical, or
disability-related needs requiring a multi-
disciplinary team and multiple programs.
Vision: A coordinated system that delivers
compassionate, timely, and person-centered care for
the most vulnerable and complex Alaskans.
Dr. Lawrence elaborated that while services currently
existed to meet the vast majority of individuals with
medical or mental health conditions, the team recognized an
existing gap for a subset of individuals with compounded
severe or extreme behaviors in mental health or medical
conditions.
Dr. Lawrence turned to slide 4 titled "What Is Complex
Care? and continued with the discussion. He expounded that
the complex care committees identified patterns in the
response to individuals with mental health or complex
medical care needs. The individuals received care from
multiple different professionals in different agencies
across various systems. Without a compassionate appropriate
setting the individuals often cycle through emergency
departments, correctional facilities, and various
hospitals. They utilize multiple different services like
social services, medical care, substance abuse treatment,
etc. It was often complicated by an array of medical
conditions and unmanageable and disruptive behaviors making
it difficult for the various staff to deal with. He felt
that a Complex Care Residential Homes (CCRHs) license type
was critical to build a "continuum" that allowed Alaskans
with complex needs "to live their best lives in a least
restrictive type setting."
2:10:46 PM
Ms. Ricci highlighted slide 5 titled "What Does HB 73 Do
HB 73 creates the necessary statutory framework to
allow the Department of Health to license and regulate
a new setting:
Complex Care Residential
Homes (CCRHs)
Ms. Ricci delineated that the department envisioned a
homelike setting that was specific to the different types
of specialized services and populations where care needs
were met through a multi-disciplinary support team and 24
hour seven (24/7) day a week care. The needs exceeded those
that could be met by the current continuum of care.
Ms. Ricci discussed Slide 6 titled "CCRHs Fill a Gap in the
Care Continuum
There is a gap in Alaska's current continuum of care
for ongoing, specialized residential settings.
Ms. Ricci pointed to the graphic that illustrated the gap
in care and how CCRHs would meet the gap. She pointed to
the right side of the slide listing the acute settings:
Residential Psychiatric Treatment Center, Skilled Nursing
Facility, Inpatient Psychiatric Hospital, Assisted Living
Home and General Acute Hospital. She related that the
department received calls from hospitals about patients
with extreme needs and they were struggling to find a
placement for them. She referenced the right side of the
slide that depicted the lower levels of care facilities:
Foster Home, Private Residence, and Assisted Living Home.
She noted that all of the facilities were supported by Home
and Community Based Waiver Services. She furthered that one
of the gaps identified was for a complex care individual
that also had some type of cognitive impairment yet was not
at the level to qualify them for intellectual and
developmental disability. She reported that the department
did not have the means or system to care for the individual
in a long-term residential care setting. Currently, when
complex care individuals were released from an acute
facility their general needs were being met through the
general relief program and assisted living home. The
services were simply not appropriate to meet the level of
care required for the special population to remain in a
community based setting.
2:13:59 PM
Representative Galvin was appreciative of the bill. She
pointed to the lower level care facilities and wondered
what their maximum capacity was versus the maximum capacity
for a CCRH. Ms. Ricci answered that she would follow up
with the answer for lower level care facilities. She
communicated that there were federal requirements that the
CCRHs needed to comply with and there were some
restrictions relative to Medicaid funding called the
"Institute for Mental Disease Exclusion" (IMD). The
department wanted to address the issues via regulation in
terms of limitations due to the varied needs of complex
care. She envisioned via regulation building out the
different requirements depending on the different needs of
the different populations the homes would serve. She noted
that the individual needs would change over time.
Representative Galvin thought it was too varied for a
specific answer the question, however, she pointed to
language stating, "fewer than 15 residents" She determined
that the maximum was 15 in a CCRH. She was concerned that
15 was a high number for individuals with multidisciplinary
care needs. Ms. Ricci responded that the number was based
on the team's interpretation of an IMD exclusion. She added
that after further discussion with stakeholders it would be
better address via regulation rather than statute. She
heard from some providers that in order for it to be
financially viable they might need more individuals, and
some thought a smaller home was more appropriate. She
deemed that it would be based on the type and level of
complex care and reiterated that it was better addressed
through regulation.
2:18:34 PM
Representative Galvin thought that there was a high number
of complex care individuals, and it was not a small
population. She was aware that many individuals were in
continued care at Providence Extended Care because there
was not another facility that could accept them, and the
hospital was not allowed to send the patients off without
proper placement. She asked why she referred to the
population as a small number. Ms. Ricci responded that
there was a large need for behavioral health support in the
state. She explained that the team tried to be very
specific to a narrow set of individuals whose needs were
not able to be met in other settings. It was different than
the need to build out existing settings. The CCRH would
likely be a resource intensive setting and not everyone
with complex needs required that level of care. She
emphasized that it was a small subset of individuals that
cycled through the various facilities and general assisted
living homes. The necessary care would be long-term and
substantial in order for the individuals to remain stable
and in their community. Representative Galvin shared her
experience visiting multiple places offering extended care
that were considered residents. She relayed that there were
many still living in the homes that would do better in a
smaller home if it was available.
Co-Chair Josephson asked if Ms. Ricci could explain how the
IMD exclusion related to CCRHs. Ms. Ricci replied that the
IMD was meant to ensure that Medicaid dollars were not
being used to support unnecessary institutionalization,
especially for individuals with disabilities and mental
health issues. The regulation was a reaction to the number
of large institutions that used to exist in the country and
served the belief that individuals should receive services
in their communities versus larger institutions.
2:23:19 PM
Ms. Ricci moved to slide 7 titled "Establishing a New
Residential Setting
1. Identify Needs and Define Scope
2. Create New License Type HB 73
3. Determine Services to be Provided
4. Establish Reimbursement Mechanisms
Ms. Ricci indicated that the slide depicted the multi-step
process the departments identified to address the issue.
The first step discovered the gap in care for the
individuals that were not eligible for the intellectual and
developmental disability waivers. She stressed that the
need was prominent. The second step determined the need for
a new license type. The third step would be accomplished in
coordination with stakeholders and provider groups. The
last step would be based on the individual and the type of
services needed, which would vary. The departments wanted
to take time to explore the different options for waivers
and had engaged in preliminary discussions with other
states. She emphasized that the departments were currently
at the second step.
Dr. Lawrence continued on slide 8 titled "Who Would Benefit
from CCRHs
Youth:
Multiple behavioral health diagnoses
Treatment in an out-of-state facility
Fetal alcohol and autism spectrum disorders
Adult:
Severe and persistent mental illness
Frequent hospital visits and self-harm history
Cognitive impairment
Senior:
Dementia with behavioral health diagnoses
Does not qualify for Medicaid waiver services
Highly disruptive behaviors
Dr. Lawrence discussed and exemplified the populations of
individuals who would benefit from CCRH's as described on
the slide. He reminded the committee that the departments
wanted to establish a homelike setting that addressed the
complexity of needs. He pointed out that each of the
categories demonstrated distinct and costly needs that
prevented those affected from currently being served
appropriately. However, the conditions were not so severe
to preclude a residential setting.
Dr. Lawrence examined slide 9 titled "Key Features of a
CCRH
CCRHs will offer a new residential care setting in
Alaska.
• Fewer than 15 residents
• 24/7 care from a multi-disciplinary team
• More supportive than assisted living homes and
less restrictive than a psychiatric hospital
• Specialized monitoring, intervention, and/or
treatment to meet the needs of residents
2:29:12 PM
Dr. Lawrence reviewed slide 10 titled "Benefits of a CCRH
• Improves care for Alaskans with complex needs
• Adds a license type for home-like settings that
offer care in the most clinically appropriate
environment
• Allows for service specialization and for specific
requirements to be set forth in regulations
• Promotes community safety by offering a new service
setting for individuals with complex behavioral
health needs
Dr. Lawrence reiterated that the bill envisioned a home
where individuals received services in a setting tailored
to their specific needs in a least restrictive environment.
Ms. Ricci presented slide 11 titled "Sectional Analysis:"
Section 1. Amends AS 47.32.010(b) to add "complex care
residential homes" to the list of entities regulated
by the Department of Health.
Section 2. Amends AS 47.32.900(2) to update the
definition of "assisted living home" to exclude
complex care residential homes.
Section 3. Adds AS 47.32.900(11) to modify the
definition of "hospital" to clarify that it does not
include complex care residential homes.
Ms. Ricci continued with the sectional on slide 12:
Section 4. Adds AS 47.32.900(22) to introduce a new
definition for "complex care residential home." It is
defined as a residential setting that provides 24-hour
multi-disciplinary care on a continuing basis for up
to 15 individuals with mental, behavioral, medical, or
disability-related needs requiring specialized care,
services and monitoring.
Section 5. Amends the uncodified law by adding a new
section that requires the Department of Health to
submit for approval by the United States Department of
Health and Human Services amendments to the state
Medicaid plan or apply for waivers necessary to
implement the provisions of Sections 1-4.
Ms. Ricci concluded with the remaining sections on slide
13:
Section 6. Amends the uncodified law by adding a new
section specifying that sections 1-4 of the bill will
only take effect if the United States Department of
Health and Human Services approves the required
Medicaid waivers or amendments by July 1, 2031. The
commissioner of health is required to notify the
reviser of statutes within 30 days once the necessary
approvals are received.
Section 7. Provides that sections 1-4 take effect the
day after the United States Department of Health and
Human Services approves amendments to the state plan
or waivers submitted under Section 5.
2:31:41 PM
Representative Bynum wondered how long it would take for an
applicant to receive their license. Ms. Ricci responded
the expectation was within the standard time frame for
other residential licensing. She mentioned time lags due to
staff turnover and she hoped the situation could be
mitigated soon. Representative Bynum referenced the extreme
needs of individuals with behavioral issues impacted by
drug use. He asked if CCHRs would include this type of
individual.
Dr. Lawrence answered that the inquiry highlighted the
broader question of who would be served in the setting. He
explained that CCHR's were not meant to treat everyone with
the same set of particular complex conditions but would
treat a subset of those that had other underlying
behavioral or health conditions. He summarized that the
CCRHs would serve a subset of individuals that did not fit
into the current system.
Representative Bynum was looking at the fiscal notes and
wondered what the impact on Medicaid would be for providing
the facilities. He inquired whether the departments
anticipated that services would grow by adding the CCHR
option and if there would be growth in other expenses not
included in the fiscal note.
2:35:58 PM
Ms. Ricci responded that it was currently difficult to
determine and definitively extrapolate the need because
currently there were multiple state funding streams that
were supporting the individuals including Medicaid. She
added that Medicaid was the funder for long-term
institutional care and Medicaid would be the funder the
CCRH program. She anticipated applying for different
Medicaid waivers to pay for the program. The waivers had to
meet federal budget neutrality requirements to be approved.
The program could not stand up a service that would
increase Medicaid funding via the waivers.
Co-Chair Foster moved to the fiscal note discussion.
2:38:18 PM
TRACY DOMPELING, DIRECTOR, DIVISION OF BEHAVIORAL HEALTH,
FAIRBANKS (via teleconference), explained the published
fiscal impact note (FN1(DOH) allocated to the Behavioral
Health Administration. She indicated that the bill would
require developing a licensing and regulatory standard
requiring one full time position for a total cost of $153.2
thousand paid for via federal receipts at $76.6 thousand
and $76.6 thousand in undesignated general fund match
(UGF). She described that breakdown of expenses as: $128.2
thousand in Personal services, $20 thousand in services, $2
thousand in commodities, and $3 thousand in one-time
commodities for a computer and office equipment.
2:40:10 PM
ROBERT NAVE, DEPUTY DIRECTOR, DIVISION OF HEALTH CARE
SERVICES, DEPARTMENT OF HEALTH (via teleconference),
reviewed the published fiscal impact from DOH (FN2(DOH). He
delineated that the Division of Health Care Services,
Health Facilities Licensing and Certification section will
require one Nurse Consultant 1 beginning in FY 2027. The
position would assist in program development, create
licensing fees and regulations, design necessary forms,
provide training, and other necessary framework to support
this new facility type. He broke down the costs associated
with the position and the necessary support infrastructure
as follows:
Personal Services: $172.1 annually, beginning in
FY2027, for one Nurse Consultant 1 (including
benefits) at Range 24 in Anchorage. Services: $20.0
annually, starting in FY2027, for office space, phone,
and reimbursable service agreements to support the
position.
One-Time Commodities Cost: $3.0 one-time, in FY2027,
for computer, software, and office equipment.
Travel: $10.0 annually, starting in FY2028, for travel
to license and recertify facilities.
Commodities: $2.0 annually, beginning in FY2028, for
office supplies.
Mr. Nave summarized that the costs would support the
licensing and regulation of the new facilities and leverage
federal funding.
Mr. Nave reviewed the zero fiscal note from DOH(FN3(DOH)
allocated to Medicaid Services. He elucidated that many
individuals who would be served by CCRHs are already
accessing residential or facility-based services. In some
cases, CCRH services may be more cost-effective than
current options, while in others, they may be more
expensive. As such, the department estimated a net zero
cost impact.
2:42:44 PM
Representative Hannan asked about page 3, line 7 of the
bill and cited the term "frontier extended stay clinic."
She wondered what type of facility it was. Ms. Ricci would
follow up. Representative Hannan speculated on what it
could be. Ms. Ricci replied that frequently, when
references were made to frontiers, it was likely a federal
reference for a setting or clinic type that may or may not
exist in Alaska. She restated that she would follow up.
Representative Galvin asked about what other states had
done to meet a similar need addressed in the legislation.
She wondered what happened to Medicaid costs and if the 15
limit capacity was what other states had implemented. Ms.
Ricci answered that she had talked with other states and
there were no states that had figured out the best way to
meet the need. She communicated that the need was not
unique to Alaska and was common in all states. She
indicated that the department worked with Milliman
[Insurance Company] who supported the 1115 Behavioral
Health Waiver and asked what they saw in other states
regarding the issue. She listed the states she examined:
Indiana, North Carolina, Michigan, Washington, and Oregon.
She discovered that they all took different approaches to
meet complex care needs. However, they all utilized
different combinations of waivers due to the difference in
Medicaid structures among the states. She currently, did
not have definitive answers to the ratios, staffing, or
services and wanted to build onto those in succeeding
phases working with consultants and stakeholders.
Presently, the departments had identified that a new
license type was necessary due to existing assisted living
statutes that were insufficient for the need. She
emphasized that the need was acute to fill the gap and
establishing the new license type now saved time to
implementation.
2:49:09 PM
Representative Galvin appreciated the answer. Ms. Ricci
commented that every state was struggling with the issue
and attempting to figure it out. Representative Galvin
asked whether the emphasis was to create more placements
for the specific complex care population addressed while
maintaining the current number of care providers in
existing assisted living facilities. She asked whether it
was a balance the departments were attempting to work out.
Ms. Ricci responded in the affirmative. She explained that
individuals in the population were accessing services in a
way that did not meet their needs. She described situations
where current assisted living facilities could not meet the
needs of the patient and where health care workers and the
other residents were negatively impacted as well.
Co-Chair Josephson wanted more information about what other
states were doing. He deduced that Alaska did not invent
the term "complex care residential homes." He thought that
there was some sort of model somewhere the state was aware
of. Ms. Ricci replied that the term existed in other
formats in other states but did not necessarily mean the
same thing as Alaska's term. She elaborated that the
departments went through a lengthy process for naming the
residential homes and it changed many times behind the
scenes before deciding on CCRH. She relayed that it was
difficult for her to acknowledge that a clear solution did
not exist elsewhere that could be leveraged in Alaska. She
stressed that an exact model that would work in Alaska did
not exist.
2:53:29 PM
Representative Bynum asked about zoning and mentioned
possible push back from the community. He asked whether the
departments engaged in discussions about zoning and the
CCRHs. Ms. Ricci answered in the negative. Representative
Bynum asked if it had been a consideration in other states.
Ms. Ricci was unaware of any discussion on the topic.
Representative Bynum wondered if the bill was to pass but
the fiscal notes were not accepted and there were no
resources added to the department, could the mission still
be carried out. Ms. Ricci responded that it would be very
difficult. She commented that the Health Facilities
Licensing and Certification section had taken on a
tremendous amount of work over the last many years. In
addition, the residential licensing team in the Division of
Health Care Services was arduously working to meet the
demand that was increasing as the state's population aged,
and more residential homes were opening. She furthered that
the current behavioral health team lacked a staff position
to carry out developing the certification and working on
the necessary Medicaid waivers. The department would
prioritize currently existing programs versus building out
a new program. Representative Bynum inquired whether there
would be a positive economic impact to the communities
where the homes were located. Ms. Ricci replied that she
had not done an economic analysis but shared that many
hospitals relayed positive feedback regarding the concept
and were eager to see the program implemented. In addition,
existing assisted living homes offered positive responses
on the concept since they were unable to provide adequate
care for the individuals within the existing structure. She
deemed that there would be positive community feedback.
Some of the individuals displayed disruptive behaviors in
public and there was a community safety element to the
concept. She mentioned that in Washington and Oregon some
of their programs were called "Community Safety Programs."
2:59:07 PM
Representative Tomaszewski asked about carceral system
involvement. He wondered how that would work with zoning
and in the community. Ms. Ricci answered that the bill did
not address the issue of secure vs unsecured or locked
versus unlocked, but the topic was discussed. The statutes
did not address it for any existing license types. She
shared that one of the things that they had heard was when
the individual received the appropriate level of
additional, consistent, support and medical care the level
of disruptions decreased, and consistent behaviors
increased. She deduced that it likely reduced the need for
the security measures necessary when the patient was highly
agitated. She shared discussions with other providers who
confirmed that appropriate support and care helped the
patient remain stable, lowering the security need. The CCRH
model had 24/7 monitoring built into it and she reported
that the security issue was still being figured out along
with how to build it into the regulations.
3:02:29 PM
Dr. Lawrence responded that it was important to separate
what was meant by carceral setting versus CCRH. He pointed
out that carceral settings were correctional facilities and
the services provided were completely different than what
would be provided in a CCRH. He wanted to clarify that a
CCRH concept would not be set up in a correctional
facility. He added that involuntary placement was not
envisioned for a CCRH. He reiterated that regulation would
address many of the details that were not yet figured out.
Representative Tomaszewski thought it was good to hear, and
he would not think anyone in a cul-de-sac would want a
locked-down facility next door. He believed that zoning was
a critical need to address.
HB 73 was HEARD and HELD in committee for further
consideration.
3:04:46 PM
Co-Chair Foster reviewed the agenda for the following day's
meeting. Some discussion ensued regarding the upcoming
agenda.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB073 Bill Summary version A, 2.5.25.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 73 |
| HB073 Presenter List Version A, 2.5.25.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 73 |
| HB073 Presentation Version A, 2.5.25.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 73 |
| HB073 Sectional Analysis Version A, 2.5.25.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 73 |
| HB073 Transmittal Letter Version A, 1.27.25.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 73 |
| HB 23 ASCHR BFOQ memo FINAL 4.8.25.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 23 |
| HB 23 ASCHR BFOQ memo FINAL 4.8.25.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 23 |
| HB 73 CDSE Complex Care Res Homes 040825.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 73 |
| HB 73 Responses to HFIN 4.10.25.Final.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 73 |
| HB 73 Public Testimony Rec'd by 041525.pdf |
HFIN 4/9/2025 1:30:00 PM |
HB 73 |