Legislature(2019 - 2020)CAPITOL 106
04/25/2019 03:00 PM House HEALTH & SOCIAL SERVICES
Note: the audio ![]()
and video ![]()
recordings are distinct records and are obtained from different sources. As such there may be key differences between the two. The audio recordings are captured by our records offices as the official record of the meeting and will have more accurate timestamps. Use the icons to switch between them.
| Audio | Topic |
|---|---|
| Start | |
| HB133 | |
| HB84 | |
| Presentation(s): Sb 74 Implementation Update | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 133 | TELECONFERENCED | |
| += | HB 84 | TELECONFERENCED | |
| + | TELECONFERENCED | ||
| + | TELECONFERENCED | ||
| += | HB 89 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
April 25, 2019
3:03 p.m.
MEMBERS PRESENT
Representative Ivy Spohnholz, Co-Chair
Representative Tiffany Zulkosky, Co-Chair
Representative Matt Claman
Representative Harriet Drummond
Representative Geran Tarr
Representative Lance Pruitt
MEMBERS ABSENT
Representative Sharon Jackson
COMMITTEE CALENDAR
HOUSE BILL NO. 133
"An Act relating to care of juveniles and to juvenile justice;
relating to employment of juvenile probation officers by the
Department of Health and Social Services; relating to terms used
in juvenile justice; relating to mandatory reporters of child
abuse or neglect; relating to sexual assault in the third
degree; relating to sexual assault in the fourth degree;
repealing a requirement for administrative revocation of a
minor's driver's license, permit, privilege to drive, or
privilege to obtain a license for consumption or possession of
alcohol or drugs; and providing for an effective date."
- MOVED HB 133 OUT OF COMMITTEE
HOUSE BILL NO. 84
"An Act relating to the presumption of compensability for a
disability resulting from certain diseases for firefighters,
emergency medical technicians, paramedics, and peace officers."
- MOVED HB 84 OUT OF COMMITTEE
PRESENTATION(S): SB 74 IMPLEMENTATION UPDATE
- HEARD
HOUSE BILL NO. 89
"An Act relating to the prescription of opioids; relating to the
practice of dentistry; relating to the practice of medicine;
relating to the practice of podiatry; relating to the practice
of osteopathy; relating to the practice of nursing; relating to
the practice of optometry; and relating to the practice of
pharmacy."
- SCHEDULED BUT NOT HEARD
PREVIOUS COMMITTEE ACTION
BILL: HB 133
SHORT TITLE: JUVENILES: JUSTICE,FACILITES,TREATMENT
SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ
04/15/19 (H) READ THE FIRST TIME - REFERRALS
04/15/19 (H) HSS, JUD
04/23/19 (H) HSS AT 3:00 PM CAPITOL 106
04/23/19 (H) Heard & Held
04/23/19 (H) MINUTE(HSS)
04/25/19 (H) HSS AT 3:00 PM CAPITOL 106
BILL: HB 84
SHORT TITLE: WORKERS' COMP: POLICE, FIRE, EMT, PARAMED
SPONSOR(s): REPRESENTATIVE(s) JOSEPHSON
03/06/19 (H) READ THE FIRST TIME - REFERRALS
03/06/19 (H) HSS, L&C
04/04/19 (H) HSS AT 3:00 PM CAPITOL 106
04/04/19 (H) Heard & Held
04/04/19 (H) MINUTE(HSS)
04/25/19 (H) HSS AT 3:00 PM CAPITOL 106
WITNESS REGISTER
MEGAN HOLLAND, Staff
Representative Ivy Spohnholz
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Reviewed HB 133 on behalf of the bill
sponsor, Representative Spohnholz.
REPRESENTATIVE ANDY JOSEPHSON
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Speaking as the sponsor, testified during
the hearing of HB 84.
ELISE SORUM-BIRK, Staff
Representative Andy Josephson
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Reviewed HB 84 on behalf of the bill
sponsor, Representative Josephson.
HEATHER CARPENTER, Health Care Policy Advisor
Office of the Commissioner
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Introduced and co-provided a PowerPoint
presentation entitled, "SB 74 (2016) Implementation Update,"
dated 4/25/19.
GENNIFER MOREAU-JOHNSON, Acting Director
Division of Behavioral Health
Department of Health and Social Services
Anchorage, Alaska
POSITION STATEMENT: Co-provided a PowerPoint presentation
entitled, "SB 74 (2016) Implementation Update," dated 4/25/19.
DEB ETHERIDGE, Acting Director
Juneau Office
Division of Senior and Disabilities Services
Department of Health and Social Services
Juneau, Alaska
POSITION STATEMENT: Co-provided a PowerPoint presentation
entitled, "SB 74 Implementation Update," dated 4/25/19.
BECKY HULTBERG, President/CEO
Alaska State Hospital and Nursing Home Association
Anchorage, Alaska
POSITION STATEMENT: Co-provided a PowerPoint presentation
entitled, "SB 74 Implementation Update," dated 4/25/19.
SARA CHAMBERS, Acting Director
Division of Corporations, Business, and Professional Licensing
Department of Commerce, Community & Economic Development
Juneau, Alaska
POSITION STATEMENT: Co-provided a PowerPoint presentation
entitled, "SB 74 Implementation Update," dated 4/25/19.
ACTION NARRATIVE
3:03:28 PM
CO-CHAIR IVY SPOHNHOLZ called the House Health and Social
Services Standing Committee meeting to order at 3:03 p.m.
Representatives Zulkosky, Tarr, Drummond, and Spohnholz were
present at the call to order. Representatives Pruitt and Claman
arrived as the meeting was in progress.
HB 133-JUVENILES: JUSTICE,FACILITES,TREATMENT
3:04:00 PM
CO-CHAIR SPOHNHOLZ announced the first order of business would
be HOUSE BILL NO. 133, "An Act relating to care of juveniles and
to juvenile justice; relating to employment of juvenile
probation officers by the Department of Health and Social
Services; relating to terms used in juvenile justice; relating
to mandatory reporters of child abuse or neglect; relating to
sexual assault in the third degree; relating to sexual assault
in the fourth degree; repealing a requirement for administrative
revocation of a minor's driver's license, permit, privilege to
drive, or privilege to obtain a license for consumption or
possession of alcohol or drugs; and providing for an effective
date."
3:04:44 PM
MEGAN HOLLAND, Staff, Representative Ivy Spohnholz, Alaska State
Legislature, on behalf of Representative Spohnholz, sponsor of
HB 133, reminded the committee HB 133 is a Division of Juvenile
Justice (DJJ), Department of Health and Social Services (DHSS),
"clean-up" bill which updates the language used to refer to
facilities that are operated by DJJ and to the authorities held
by the division. The bill also contains several policy
clarifications to ensure DJJ can complete its mission and also
to ensure relevant state statutes accurately reflect DJJ
authorities. She referred to a previous hearing in which the
committee discussed section 6 of the bill - which would close a
loophole in statutes related to sexual abuse of a minor - and
offered to provide invited testimony in this regard.
3:07:17 PM
CO-CHAIR ZULKOSKY moved to report HB 133 out of committee with
individual recommendations and the accompanying zero fiscal
notes. There being no objection, HB 133 was reported out of the
House Health and Social Services Standing Committee.
3:07:35 PM
The committee took an at-ease from 3:07 p.m. to 3:09 p.m.
HB 84-WORKERS' COMP: POLICE, FIRE, EMT, PARAMED
3:09:00 PM
CO-CHAIR SPOHNHOLZ announced the next order of business would be
HOUSE BILL NO. 84, "An Act relating to the presumption of
compensability for a disability resulting from certain diseases
for firefighters, emergency medical technicians, paramedics, and
peace officers."
3:09:10 PM
REPRESENTATIVE ANDY JOSEPHSON, Alaska State Legislature, sponsor
of HB 84, informed the committee the bill would broaden and
further explain the intent of the original presumptive illness
bill.
3:09:36 PM
ELISE SORUM-BIRK, Staff, Representative Andy Josephson, Alaska
State Legislature, on behalf of Representative Josephson,
sponsor of HB 84, stated HB 84 adds new categories of emergency
worker to the existing presumptive legislation that provides
presumptive coverage for certain diseases; the new categories
are emergency medical technicians, paramedics, and peace
officers. Further, the bill adds breast cancer to the list of
diseases covered by presumptive coverage and also extends
coverage to professionals who entered service prior to August
2008, who have gone through all official medical examinations,
and who did not show evidence of disease in their first seven
years of service.
REPRESENTATIVE JOSEPHSON related the case of a firefighter who
developed prostate cancer and who had difficulty establishing
"presumption"; he pointed out - if HB 84 had been in effect -
the firefighter's presumptive coverage would have been clear
because he was working before 2008, and thus he could have been
exposed to a toxic substance that later gave him cancer.
Further, this example clarified that compliance with the medical
examination requirements [within existing statute] was adequate
even though there was not an established system for medical
examinations. Representative Josephson restated the bill also
expands the categories to other first responders. He further
explained:
[HB 84] is still a very limited benefit in that it can
only last for 60 months total following the last day
of employment. ... It can only be earned, or one can
only qualify if they fought fires, for example, for
seven years, and then there's also some burden of
proof to say, "This is the thing that I think I was
exposed to." So, this doesn't just come flowing in
just at one's beck and call. It has, it has some ...
sideboards, and those would still exist.
CO-CHAIR SPOHNHOLZ has heard testimony reporting breast cancer
rates are approximately six times higher amongst female
firefighters; she questioned whether breast cancer victims would
still have to demonstrate exposure to a chemical documented to
increase the incidence of breast cancer in order to establish
presumptive coverage for breast cancer.
REPRESENTATIVE JOSEPHSON indicated yes. He noted the
aforementioned testimony was reported from a study limited to
the San Francisco [California] Fire Department.
3:13:49 PM
CO-CHAIR ZULKOSKY moved to report HB 84 out of committee with
individual recommendations and the accompanying zero fiscal
note. There being no objection, HB 84 was reported out of the
House Health and Social Services Standing Committee.
3:14:07 PM
The committee took an at-ease from 3:14 p.m. to 3:18 p.m.
^PRESENTATION(S): SB 74 IMPLEMENTATION UPDATE
PRESENTATION(S): SB 74 IMPLEMENTATION UPDATE
3:18:41 PM
CO-CHAIR SPOHNHOLZ announced the final order of business would
be a presentation updating the implementation of Senate Bill 74,
[passed in the Twenty-ninth Alaska State Legislature].
3:19:03 PM
HEATHER CARPENTER, Health Care Policy Advisor, Office of the
Commissioner, Department of Health and Social Services (DHSS),
introduced a PowerPoint presentation entitled, "SB 74 (2016)
Implementation Update." Ms. Carpenter said Medicaid reform
covers the many topics shown on slide 2, and directed attention
to slide 3, noting the first topic for discussion, [section 1115
of the Social Security Act Behavioral Health Waiver (1115
waiver)], would be presented by the Division of Behavioral
Health, DHSS.
3:20:11 PM
GENNIFER MOREAU-JOHNSON, Acting Director, Division of Behavioral
Health (DBH), DHSS, informed the committee DBH submitted its
1115 waiver demonstration project application in January 2018,
which was followed by a federal public comment period, and
approval was received from the Centers for Medicare and Medicaid
Services (CMS). In March 2018, negotiations with CMS began
during which CMS offered to "fast track" the Substance Misuse
Disorder (SUD) treatment component. In November 2018, approval
for the SUD component was received, followed by approval of the
DBH implementation plan, which requires DBH to meet six
milestones, including: access to critical levels of care for
SUD treatment; use of evidence-based criteria; use of
nationally-recognized program standards for residential
treatment provider qualifications; sufficient provider capacity.
Further, DBH will use a phased-in approach focused initially on
Anchorage, the Matanuska-Susitna (Mat-Su) area, Southeast,
Fairbanks, Nome, and Kodiak (slide 4).
REPRESENTATIVE TARR asked what Nome and Kodiak have done to
prepare so they can participate in the initial implementation of
the plan.
MS. MOREAU-JOHNSON was unsure. She said DBH has made the plan
available to any area that is ready to implement the services,
and Kodiak and Nome "voiced their interest." She offered to
provide additional information in this regard. In further
response to Representative Tarr, she agreed the regions across
the state are very different.
3:25:51 PM
MS. MOREAU-JOHNSON directed attention to slide 5 which described
the population [affected by SUD]. She clarified the 1115 waiver
is not a "level of care" waiver; however, DBH's data has shown
SUD [patients] are typically served at the acute end of the
behavioral health continuum of care, and thus the division
identified certain populations in order to provide early
prevention and intervention services. The division is approved
through the 1115 waiver to provide the following services:
residential treatment for those with SUD; opioid treatment
services for persons experiencing opioid use disorder; intensive
outpatient services; partial hospitalization services; medically
monitored intensive inpatient services in a hospital setting;
medically managed intensive inpatient services in a hospital
setting; ambulatory withdrawal management services in an
outpatient setting; clinically managed residential withdrawal
management; medically monitored inpatient withdrawal management;
medically managed intensive inpatient withdrawal management;
recovery peer support services. Ms. Moreau-Johnson pointed out
DBH has an exemption from the Institute for Mental Diseases
(IMD) exclusion and thereby is allowed to provide Medicaid
coverage in certain facilities for individuals over the age of
21, or under the of age 64. Continuing to the present status of
implementation, she noted DBH has drafted regulations to support
the implementation of SUD treatment services and will have
Medicaid coverage for services beginning July 1, [2019]; in
addition, DBH is working with providers to complete the
statewide gap analysis, is holding roundtables, and is working
to ensure providers will be ready to access services. Further,
DBH noticed its intent to award a contract to an administrative
services organization and targets July 1, [2019] for service
delivery. Also, DBH continues to negotiate with CMS for federal
approval of the remaining components of the 1115 waiver (slide
6).
3:30:27 PM
MS. MOREAU-JOHNSON restated DBH identified the aforementioned
component of the 1115 waiver by the population of those needing
acute care; the remaining populations that are pending approval
are at-risk families and youth, and individuals who experience
serious mental illness. Those identified needing acute care
require a diagnosis from the Diagnostic and Statistical Manual
(DSM) of mental disorders; at-risk families and youth are
identified by the Alaska Longitudinal Child Abuse and Neglect
study social determinants. She advised CMS has indicated DBH is
very close to receiving approval for the components awaiting
approval (slide 7). Ms. Moreau-Johnson returned attention to
the notice of intent to award an administrative services
organization contract and recalled the Senate Bill 74 fiscal
note directed DBH to contract with an administrative services
organization (ASO). Therefore, DBH issued a request for
proposal and is approaching contract negotiations which could
take two months. Functions of the administrative services
organization include utilization management, clinical reviews,
provider development and support, recipient outreach, quality
management, data management, and potentially claims processing
(slide 8). In response to Co-Chair Spohnholz, she said the
proposal evaluation committee intends to award [the ASO
contract] to Optum.
CO-CHAIR ZULKOSKY referred to slide 3 and asked for a further
description of the intent and functionality of the 1115 waiver.
For example, whether the 1115 waiver intends to streamline
access to integrated care services, so Alaskans who are affected
by SUD, do not suffer significant impacts to their health.
3:36:22 PM
MS. MOREAU-JOHNSON agreed with Co-Chair Zulkosky's description
of the 1115 waiver; she added the 1115 waiver allows the state
"to fund, through the 1115 authority, the acute end of care
also." Further, the 1115 waiver allows the state the
opportunity to innovate and provide Medicaid services in ways
that go beyond the constraints of the Medicaid state plan. She
noted the state's application achieved budget neutrality by
identifying populations that have been served at the acute end
of care, thus the state will show a savings in Medicaid
expenditures by increasing the availability and access to
community-based care, prevention, and early intervention, and at
the same time meet the needs of the acute end of care [patients]
by "waiving some of the rules that appear in the state plan."
For example, in the state plan, Medicaid cannot pay a daily rate
outside of a medical facility thus providers are "piece-mealing
together" charges that the 1115 waiver will allow.
REPRESENTATIVE TARR returned attention to DBH's award for ASO
services as described on slide 8. She asked whether all
providers will be required to participate in the ASO structure
for behavioral health management, or whether participation will
be limited to Medicaid patients.
MS. MOREAU-JOHNSON explained the ASO will be assisting DBH in
administering all publicly funded behavioral health services
administered by DHSS. She stressed the ASO will not contract
with providers - as would a managed care entity - and the state
will not delegate authority to the ASO; therefore, providers of
Medicaid services will enroll with Medicaid and the ASO will
provide support and expertise to DBH.
3:40:47 PM
REPRESENTATIVE CLAMAN remarked:
As I understand, the substance use disorder approval
had come under the 1115 waiver, and we were waiting, I
think, for the behavioral health waiver and it sounds
like what we've now got is this, is the procedure for
the administrative services which will essentially be
administering the behavioral health part of the
waiver. ... Is there another waiver we're still
waiting to receive?
MS. MOREAU-JOHNSON clarified the ASO will assist DBH in
administering all behavioral health services that are publicly
funded, including SUD services. In fact, the section of the
1115 waiver that was approved was the SUD treatment services;
the remainder of the services, such as mental health and
behavioral health support, are due to be approved and the ASO
will assist DBH in administering all of the [Medicaid] services.
REPRESENTATIVE CLAMAN surmised the behavioral health component
waiver is pending, and after approval is received, ASO will help
administer all the waivers.
MS. MOREAU-JOHNSON said correct.
REPRESENTATIVE CLAMAN asked when the behavioral health approval
is expected and whether there are other outstanding waivers.
MS. MOREAU-JOHNSON related a representative of CMS reported CMS
is drafting the approval document for behavioral health services
and thus she is confident the approval will be forthcoming
within one month. Speaking from her knowledge of the 1115
waiver demonstration project, she said she knows of no other
waivers.
CO-CHAIR SPOHNHOLZ clarified the 1115 waiver is the only
application currently in process, although there are multiple
parts to the 1115 waiver. She pointed out elements of the 1115
waiver include intervention and prevention work, which are new
to Medicaid services. She discussed how the collection of data
could be used to identify families that are at risk for serious
problems and then respond by using the 1115 waiver to provide
outreach and support to families. Co-Chair Spohnholz returned
attention to the selection of Optum, noting Optum's sister
company is UnitedHealthcare, which is administering the
[Medicare Coordinated Care Demonstration Project] in
Southcentral, and asked about the possibility of integrating the
coordination of care through the structure of the ASO.
3:46:10 PM
MS. MOREAU-JOHNSON said the proposal evaluation committee did
not include a reference to the relationship between Optum and
UnitedHealthcare in its recommendation; however, one of the
performance measures of the ASO is to help integrate behavioral
health care, and it is important to identify at-risk families
outside of behavioral health settings.
CO-CHAIR SPOHNHOLZ urged for any method to identify at-risk
populations and connect individuals to care.
MS. MOREAU-JOHNSON advised DBH works with the Office of
Children's Services (OCS), DHSS, staff to "loop-in the social
services agencies that work with the child welfare systems
because we're really trying to cast the net wide."
MS. CARPENTER directed attention to slide 9, DBH's Comprehensive
Integrated Mental Health Program Plan (Comp Plan) entitled,
"Strengthening the System," which was developed by DHSS in
collaboration with the Alaska Mental Health Trust Authority
(AMHTA) and their advisory boards. The Comp Plan seeks to
coordinate services across target recipients' lifespans; by law,
recipients, also known as trust beneficiaries, are Alaskans who
experience mental illness or a developmental disability, chronic
alcoholism, Alzheimer's Disease or related dementia, or have
experienced a traumatic brain injury (TMI). The target
population also includes persons of all ages who are vulnerable
to developing beneficiary conditions. The Comp Plan also seeks
to prevent the aforementioned conditions, when possible. She
advised the plan's public comment period closed [4/12/19]; the
previous Comp Plan was completed in 2006 and expired in 2011,
thus the Comp Plan should be updated now along with the 1115
waiver and other Medicaid reforms (slide 10). Ms. Carpenter
said the next topic, State Plan Options, would be presented by
the Division of Senior and Disabilities Services, DHSS.
3:50:08 PM
DEB ETHERIDGE, Acting Director, Juneau Office, Division of
Senior and Disabilities Services (DSDS), DHSS, informed the
committee Senate Bill 74 engaged DSDS in two initiatives:
refinance general fund (GF) dollars, and maintain services to
individuals with disabilities. In response to the first
initiative, DSDS utilized the [federal section 1915(c) of the
Social Security Act Individualized Supports Waiver (ISW)].
Prior to 2016, DSDS administered the Community and Developmental
Disabilities Grant for individuals with developmental
disabilities who were waiting on the DSDS registry - also known
as the waitlist - for an Individuals with Developmental
Disabilities Waiver, which is a 100 percent GF grant program.
After a review of the program and its services, DSDS chose to
refinance the GF grant program with a new ISW that would serve
over 600 individuals, and she described the history of the
change. The new program was implemented in October 2018 and can
serve up to 620 individuals to a cap amount of $17,500; she
stressed DSDS determined the cap amount of $17,500 would serve
most individuals. The ISW cap is lower because residential
services are not provided.
CO-CHAIR SPOHNHOLZ asked about services for those whose needs
are not addressed within the cap amount of $17,500.
MS. ETHERIDGE said DSDS identified eight individuals on the
Community and Developmental Disabilities Grant who would be
better served by the Individuals with Developmental Disabilities
Waiver which allows payment for residential services.
MS. ETHERIDGE explained the implementation of the program was
delayed for some individuals, so DSDS used $450,000 to continue
their services.
MS. CARPENTER recalled DHSS purposefully used language in
[Senate Bill 74] that ensures the state receives maximum
benefits from the legislation.
3:55:03 PM
REPRESENTATIVE TARR asked for clarification of "the waitlist."
MS. ETHERIDGE said there are over 700 individuals on the
Developmental Disability Registry and Review (DDRR); DSDS drew
from the registry to create the ISW waitlist; however, all
individuals remain on the waitlist for the Individuals with
Developmental Disabilities Waiver. Currently, DSDS is updating
the waitlist; of the 700 individuals, 425 have been identified
for the ISW and more have opted not to remain on the waitlist
for the Individuals with Developmental Disabilities Waiver. She
said she expected that next year, there will be a difference in
the number of individuals on the DDRR who receive 1115 waiver
services. In further response to Representative Tarr, she said
625 individuals were identified for the ISW, and 425 have
decided to remain on the waitlist for the Individuals with
Developmental Disabilities Waiver.
REPRESENTATIVE TARR surmised a different level of need is met
for individuals through the new ISW and there remains a group of
people who need to receive more extensive services through the
Individuals with Developmental Disabilities Waiver.
MS. ETHERIDGE said the ISW provides services for individuals at
service levels that were received through the Community and
Developmental Disabilities Grant program. In response to Co-
Chair Spohnholz, she clarified the "larger" waiver is the
Individuals with Developmental Disabilities (IDD) Waiver,
formerly known as the People with Intellectual and Developmental
Disabilities Waiver.
3:59:24 PM
MS. ETHERIDGE returned attention to the second DSDS initiative
within Senate Bill 74, which directed DSDS to apply for the
Community First Choice program, section 1915(k), which is a
different type of state plan option through CMS. She remarked:
The reason I point that out is because once a service
becomes a state plan service, it becomes an
entitlement. And that is really important for you to
know because we are very careful with implementing an
entitlement program in Alaska. The Community First
Choice program ... offers services very similar to our
state plan personal care services for people with, who
require nursing, or nursing facility level of care, or
an institutional level of care. It also offers the
state an opportunity to draw down an additional 6
percent enhanced match.
MS. ETHERIDGE further explained, through the Community First
Choice state plan option, DSDS provides personal care services,
education and training on how to hire, fire, and train a
personal care attendant, personal emergency response, and
training to do a task; for all these services the state's
enhanced federal medical assistance percentage (FMAP)
reimbursement is 56 percent. Further, DSDS auto-enrolled 826
individuals in the Community First Choice program who were
receiving state plan personal care services, and Home- and
Community-Based Services, for an estimated savings in 2019 of
over $2 million (slide 12).
REPRESENTATIVE CLAMAN asked if enrollees are primarily an
elderly population or others with significant disabilities.
MS. ETHERIDGE said the population consists of any individual who
meets requirements for an institutional level of care, and so
may be a person with disabilities, intellectual developmental
disabilities, physical disabilities, or a senior.
4:02:38 PM
REPRESENTATIVE TARR asked for clarification of how services are
being reorganized through existing and new waivers.
MS. ETHERIDGE explained the existing 1915(c) waivers remain;
however, if a service currently offered by a Home- and
Community-Based Waiver is now offered through the Community
First Choice program, DBH will transition to Community First
Choice and save an additional 6 percent. She further explained
DBH did not initially transition all services because there are
two institutional levels of care: under 21 in a residential
treatment facility or over 65 in an institution for mental
disease, and DBH was unsure of the number of individuals
receiving these two levels of care who may transition. She
cautioned DBH expects the number of individuals identified for
personal care, personal emergency response, and chore services
to be low, but the population of individuals entering respite
care is not well understood and therefore creates a higher risk
to DBH.
CO-CHAIR SPOHNHOLZ questioned how respite care could carry a
higher risk.
MS. ETHERIDGE advised respite care could be expensive because it
could be expanded to a population not currently served by DBH.
4:04:54 PM
CO-CHAIR ZULKOSKY asked for a "high level perspective" on the
mission of the aforementioned programs and how the waivers
reform the Medicaid system.
MS. ETHERIDGE explained Home- and Community-Based Services,
including personal care, provide people with assistance so they
can remain in their home and community - without risk to their
health - and avoid transitioning into a nursing home. The
mission of DSDS is to provide services so individuals can remain
safe and secure, and federal waivers allow DSDS to do so. For
example, the state plan is a contract with CMS; the waivers
provide permission to waive some of the rules of the contract so
that DSDS can provide services at lesser levels of care and at
lower cost. Another example is that DSDS currently serves 14
individuals out of state at an intermediate care facility for
Individuals with Intellectual and Developmental Disabilities; if
they could be served in a Home-and Community-Based setting,
their care would be less expensive.
CO-CHAIR SPOHNHOLZ recalled at one time the state funded grants
to organizations that were then obligated to provide services to
a specific group of people; however, the system is now
facilitated through the waiver structure. She asked whether the
new system comes with tools to help the community develop "the
right kinds of services to support ... the population we need to
care for?"
MS. ETHERIDGE acknowledged there is a tremendous change from
providers having the flexibility of a grant to instead having a
reimbursement system such as the Home- and Community-Based
Waiver, which is more of a medical model and a more restrictive
system. She said DSDS seeks a balance in order to provide
services the state can afford; for example, DSDS administers
services to seniors and as seniors reach more expensive levels
of care, services cannot be managed in a grant but must be
leveraged with federal funds. Further, as DSDS increases
Medicaid services through the ISW, it seeks to ensure there is
the workforce needed to deliver services.
CO-CHAIR SPOHNHOLZ asked about challenges faced by the provider
community as the system moves from a grant-based model to a
medical billing-based model.
MS. ETHERIDGE advised many providers served the Community and
Developmental Disability Grant program and the Home- and
Community-Based Waiver thus some issues, such as conflict-free
case management, have arisen. In further response to Co-Chair
Spohnholz, she acknowledged the change from a grant to a
reimbursement system for expenditures is difficult. She
remarked:
Because you do have to have the money up front.
Medicaid pays you back for incurred expenditures, so
you do have to have the capacity to provide that
service up front, where the grants are the opposite.
And so, we've ... definitely gotten feedback about how
that's structured ....
4:12:44 PM
MS. CARPENTER pointed out DHSS is moving forward with the ASO to
address this issue; the ASO will assist behavioral health
providers - who have not participated in Medicaid billings -
through the transition.
REPRESENTATIVE TARR related an example of personal services that
were cut back for an individual who receives 24-hour care, and
an example of an individual whose services through the
Developmental Disabilities (DD) Waiver were cut back, both due
to budget pressure. She expressed her concern there may be
unmet needs due to cost adjustments in personal care assistance
(PCA) services.
MS. ETHERIDGE recalled last legislative session DSDS was tasked
with completing a data analysis of 2017-2018 data; the division
found a significant decrease in spending for personal care and
Home- and Community-Based [care], and increased expenditures for
long-term care. She said DSDS seeks to "re-balance that."
REPRESENTATIVE TARR observed PCA services are much less costly
than institutional-level care.
4:18:24 PM
MS. CARPENTER redirected attention to slide 13 and noted Senate
Bill 74 also focused on "superutilizer" reduction. She
explained superutilizers are individuals comprising about 5
percent of the Medicaid population who use approximately 95
percent of the services; Senate Bill 74 identified two areas
with which to reduce the percentage of superutilizers, the
Alaska Emergency Department Coordination Project, facilitated by
the Alaska State Hospital and Nursing Home Association (ASHNHA),
and Primary Care Case Management. Primary Care Case Management
has two components: the Alaska Medicaid Coordinated Care
Initiative and the Care Management Program. The Care Management
Program identifies superutilizers by reviewing claims that
indicate high emergency room (ER) usage and abnormal
prescription usage behaviors and refers those claims to case
management. The Care Management Program is also known as the
Locked-In Program, which covers about 300 participants per
month, who are assigned one primary care provider and one
pharmacy. She said participants are "locked in" with a provider
with whom they have a relationship, or one is assigned by DBH.
The Alaska Medicaid Coordinated Care Initiative is available to
all Medicaid recipients who are not otherwise enrolled in a case
management program; approximately 30,000-50,000 individuals per
month have access to the program, mostly telephonically through
MedExpert, and another 55 individuals are served by Qualis
Health. She discussed further coordination of care with other
agencies such as the Department of Corrections, OCS, and the
Division of Public Health, DHSS. Ms. Carpenter concluded,
estimating the savings from fewer ER visits, fewer duplicative
services, and fewer prescriptions, are approximately $8 million
per year. She turned attention to the second area of
superutilizer reduction and said the Alaska Emergency Department
Coordination Project would be presented by ASHNHA.
4:21:22 PM
BECKY HULTBERG, President/CEO, Alaska State Hospital and Nursing
Home Association (ASHNHA), informed the committee ASHNHA brought
the Alaska Emergency Department (ED) Coordination Project to the
legislature with the goals to improve care in EDs and reduce the
inappropriate utilization of ED services (slide 14). The model
ASHNHA implemented was the Seven Best Practices Model from
Washington State; she said the key elements of the project
include implementation of an ED electronic information exchange
system that "pushes" complete critical information to a
clinician at the point of care, without further research. She
said the model was implemented at eleven hospitals in Alaska
beginning in February 2017. Ms. Hultberg noted the system
provides regional and nationwide records of care; a second key
element of the model is the Prescription Drug Monitoring Program
(PDMP) which reports patient use of narcotic prescriptions.
Other elements of the model are statewide guidelines for
prescribing narcotics and care coordination (slide 15). Slide
17 further described the electronic ED information system which
provides "flags" in a patient's record that will alert the ED
physician of pertinent information. Ms. Hultberg related ED
physicians support the system because it improves patient care.
4:25:24 PM
CO-CHAIR SPOHNHOLZ asked whether the Alaska Psychiatric
Institute (API) is part of the electronic information system.
MS. HULTBERG advised API is "technically not at a point where
they are able ... to join."
REPRESENTATIVE TARR noted the system only provides ER
information and asked if this information is only a part of
electronic hospital records or is a separate system.
MS. HULTBERG explained one problem with medical records is there
is a huge volume of electronic information that must be
searched; even if records are interoperable, patients may not
volunteer information about their visits to other hospitals, and
the system "pulls the information they need to know, at that
point in time, and it pushes it to them so they don't have to go
hunt for it ...."
REPRESENTATIVE TARR asked whether the system would integrate
health records beyond the ER.
MS. HULTBERG advised the system is a separate piece to help in
the ER care setting and is not a substitute for interoperability
[of medical records].
REPRESENTATIVE CLAMAN questioned whether the system will provide
information to the Mat-Su Regional Medical Center ER about a
patient's recent visits to "Providence family practice," or only
about visits to the Providence Alaska Medical Center ER.
MS. HULTBERG said the system does not provide full records but
uses "flags" to alert an ER physician of pertinent information.
However, if Providence family practice were connected to the
system, and a patient has a care plan, Providence family
practice can upload the care plan, which would then be available
to the ER physician.
4:29:41 PM
MS. HULTBERG returned attention to slide 17 and said the system
is operational at eleven hospitals and at six other entities.
Slide 18 listed participating organizations; she noted the
system will be expanded to additional hospitals and to include
primary care providers.
CO-CHAIR SPOHNHOLZ opined communication between EDs and primary
care providers is critical to reducing healthcare costs, and she
elaborated.
MS. HULTBERG agreed. She said another element of the project is
the ED narcotic prescribing guidelines that were voluntarily
developed by ED physicians. The guidelines allow physicians to
inform patients that every ED in Alaska is following the
guidelines and thus avoid having patients visiting multiple EDs
seeking narcotics. Further, the guidelines have been endorsed
by every provider and hospital, have reduced prescriptions
issued by EDs, and have connected PDMP information to the
exchange system (slides 19 and 20). Slide 21 illustrated a case
study conducted by CollectiveMedical with Mat-Su Regional
Medical Center to identify the impact of the combination of the
narcotics guidelines, the ED information exchange, and case
management work. The study reported a 79 percent reduction in
opioid scripts written in EDs while maintaining positive patient
satisfaction rates. Ms. Hultberg closed, reviewing the
project's goals of improving patient care and, thereby, reducing
ED costs; although not accompanied by a major data study, ASHNHA
believes both goals have been accomplished (slide 23).
4:34:40 PM
MS. CARPENTER recalled during the drafting of Senate Bill 74,
DHSS sought language that would allow the state to test for
projects and determine value over volume; in fact, discussion of
the bill covered managed care organizations, accountable care
organizations, and provider-based models. However, DHSS decided
upon coordinated care demonstration projects that would be
proposed by providers on a regional basis. For example, on
9/1/18, Providence Family Medicine Center began testing a
patient-centered medical home model project which provides
participating Medicaid patients the services of an
interdisciplinary care team: primary care, case management,
care coordination, social work, health education, and
transitional and follow-up care. The state is paying a partial
capitation rate for additional services. She said the project
is voluntary, involves approximately 5,000 patients per month,
and the state is currently assessing the project's outcomes.
The other project is a contract with UnitedHealthcare on a
Managed Care Organization that is expected to begin operation
[10/1/19]; discussions regarding the project are underway and
are related to rates. In addition, provisions of House Bill 176
[passed in the Thirtieth Alaska State Legislature], known as the
ground emergency medical transport (GEMT) bill, allow local
governments to receive cost-based payments outside of the
managed care organization structure, and this provision is
also being reviewed by DHSS (slide 24).
REPRESENTATIVE TARR asked whether already existing models were
considered.
4:39:01 PM
MS. CARPENTER explained the state issued a request for proposal
(RFP) and responded to proposals that were submitted. She
turned attention to section 43 of Senate Bill 74 which is the
Medicaid Reform Program statute that requires several specific
reports. One of the reports required is the Electronic
Explanation of Medical Benefits (EOMBs), which intends to
encourage Medicaid recipients to review their explanation of
benefit (EOB), so that mistakes, fraud, and abuse may be
reported, and she described the procedure. Currently, 2,500 of
100,000 adult recipients have registered for the service, which
will be expanded to include children (slides 25 and 26). In
response to Co-Chair Spohnholz, Ms. Carpenter said she would
provide examples of the type of problems that have been reported
by recipients.
MS. CARPENTER said another aspect of the Medicaid Reform Program
is redesigning the payment process; although DHSS received one
proposal to bundle payments, DHSS determined the proposal would
not be cost-neutral, and she elaborated. No proposal for global
payments was received.
CO-CHAIR SPOHNHOLZ asked for descriptions of health maintenance
organization (HMO) capitation, bundled payments, and global
payments.
MS. CARPENTER explained bundled payments are charged from a
variety of providers related to one service, for example, all
the charges related to a surgery, with the exception of
diagnoses. A capitated rate is charged by a managed care
organization with which DHSS has an agreement for a certain
cost. She said she would provide a comparison between bundled
and global payments.
4:44:36 PM
REPRESENTATIVE TARR asked whether the aforementioned reforms are
intended to reduce the administrative costs of the delivery of
services.
MS. CARPENTER said DHSS always seeks to reduce administrative
costs; for example, through regulation, DHSS was able to
eliminate "the 72-hour rule" in order to remove "an
administrative nightmare" for physicians, and she elaborated.
She restated DHSS seeks to redesign the payment process in order
to pay for value over volume; Alaska Medicaid is a fee for
service system, which encourages providers to charge "for
everything, so if [we] change the system in how we're paying -
we want to pay for outcomes - we don't want to just pay for sick
care ...."
REPRESENTATIVE TARR returned to the topic of bundled payments
and questioned how DHSS determined bundled payments were not a
good option.
MS. CARPENTER said she would provide copies of a report to
explain why bundled payments would not save costs for smaller
communities at this time.
CO-CHAIR SPOHNHOLZ observed there is less opportunity for cost
savings "the narrower the range of services you're providing
..." Capitated rates are an incentive for providers to change
the way they provide care because they wish to raise the level
of health for recipients; however, [in small communities] there
is less opportunity to find costs savings in administrative
reforms such as billing.
MS. CARPENTER returned to the topic of Medicaid reform within
Senate Bill 74 and said in 2016, DHSS engaged a stakeholder
group that developed 18 quality and cost effectiveness measures
to monitor the Medicaid program throughout the reform process.
A report released "year 1" results in December [2018] and DHSS
will continue to report results in this regard. The annual
Medicaid reform report to the legislature is transmitted every
November and includes information related to policy and finance
related to Medicaid. In addition, Senate Bill 74 required a
biannual report on the Alaska Medicaid Management Information
System (MMIS), which was certified by CMS on 9/28/18; CMS
certification allows Alaska to receive federal funds for 75
percent of operations and maintenance (slide 27).
4:51:10 PM
MS. CARPENTER continued to slide 30 which indicated DHSS has
achieved three-quarters of claims for FY 19, totaling $65
million, and is on track to meet or exceed its target of $84
million in savings through efforts such as Tribal reclaiming.
CO-CHAIR ZULKOSKY disclosed she works for the Alaska Native
Tribal Health Consortium during interim and acknowledged DHSS's
work to ensure Tribal reclaiming is audit-proof and free from
abuse or fraud.
MS. CARPENTER continued to the topic of fraud, waste, and abuse
and pointed out another annual legislative report is issued
jointly by DHSS and the Department of Law every November (slide
31). Also, Senate Bill 74 requires an eligibility verification
system conducted by a third party, and CMS requires an Asset
Verification System and an Independent Verification and
Validation System. There have been three responses to a request
of interest issued by the Division of Public Assistance, DHSS,
and the systems will be implemented.
4:54:44 PM
The committee took an at-ease from 4:54 p.m. to 4:56 p.m.
MS. CARPENTER added the aforementioned systems will be
implemented this fiscal year upon approval by CMS. The
Eligibility Verification System will also satisfy federal
requirements under the Food and Nutrition Service, U.S.
Department of Agriculture (slide 32). She continued to the
topic of Pioneer Homes, noting Senate Bill 74 required residents
to show proof of Medicaid when applying for payment assistance;
the goal of this provision is to have elders first apply for
federal [assistance]. She pointed out the provision is a
successful strategy to increase Medicaid receipts and reduce
cost for elders residing in Pioneer Homes. Although it takes
about six months to obtain proof of a Medicaid application due
to staffing issues, the strategy has increased the federal match
to 50 percent and reduced GF payment assistance to elders living
in Pioneer Homes (slide 33).
4:59:20 PM
REPRESENTATIVE TARR asked whether there is a Medicaid waiver to
address the issues that arise when an elder, who needs to move
to a Pioneer Home, has assets.
MS. CARPENTER advised elders can place assets into a [Miller
Trust, also known as a Qualified Income Trust] and said she
would provide more information in this regard.
CO-CHAIR ZULKOSKY, in response to Representative Tarr, advised
Alaska is not unique in its requirement that elders divest their
assets to qualify for Pioneer Home payment assistance.
MS. CARPENTER said the topic of Telehealth would be provided by
the Department of Commerce, Community & Economic Development
(DCCED).
5:01:40 PM
SARA CHAMBERS, Acting Director, Division of Corporations,
Business, and Professional Licensing, DCCED, informed the
committee Senate Bill 74 expanded telehealth services - in which
physicians provide services while not in the room with a patient
- to audiologists, speech language pathologists, marital and
family therapists, occupational therapists, and others who may
reasonably provide telehealth services through videoconferencing
and audioconferencing. In this provision, Senate Bill 74
required the state to create a registry for telemedicine
businesses and thus 245 individual and corporate businesses have
registered with the Division of Corporations, Business, and
Professional Licensing (slide 34). She pointed out the PDMP,
under the purview of the Board of Pharmacy, Division of
Corporations, Business and Professional Licensing, DCCED, was
changed by Senate Bill 74 from an optional report to mandated
registration and reporting for pharmacists, physicians, nurse
practitioners, optometrists, and dentists. This ensures
providers check the PDMP prior to dispensing or issuing a
prescription to a patient; mandated registration has increased
the number of users; however, a number of affected providers
have not yet registered and await further action by the board
(slide 35).
CO-CHAIR SPOHNHOLZ asked for the difference in number between
providers who are registered with the U. S. Drug Enforcement
Administration (DEA), U.S. Department of Justice, and those
registered with the PDMP.
MS. CARPENTER explained about 25 percent of each licensing
category is not registered.
REPRESENTATIVE PRUITT questioned whether there is a sunset
related to the PDMP.
MS. CARPENTER recalled Senate Bill 74 included a sunset on the
PDMP provision which was removed in House Bill 159 [passed in
the Thirtieth Alaska State Legislature].
5:06:48 PM
CO-CHAIR SPOHNHOLZ shared other uses for the PDMP such as to
notify providers of a drug overdose.
MS. CHAMBERS directed attention to slide 36 which illustrated
increased use of the PDMP by providers.
REPRESENTATIVE PRUITT questioned whether the division has
options if a provider refuses to register or use the PDMP.
MS. CHAMBERS said at this time the division can review the rate
of a provider's use of the PDMP and she discussed future
options.
REPRESENTATIVE PRUITT urged for a legislative solution to
[address providers who do not register or use the PDMP].
MS. CHAMBERS advised Senate Bill 74 was also designed to allow
subordinates to access and check the PDMP so as not to overwhelm
providers.
CO-CHAIR SPOHNHOLZ added [House Bill 159] expanded the number of
people who are allowed to perform data entry [into the PDMP].
MS. CHAMBERS directed attention to slide 37 which illustrated
the number of prescriptions reported in 2016 and 2017; there was
about a 10 percent decrease in opioid prescriptions in the first
year of the PDMP.
5:12:47 PM
CO-CHAIR ZULKOSKY observed some hospitals have strengthened or
instituted pain management plans in response to the rise in
opioid use and asked whether the division considered the effect
of programs, such as pill counts and drug testing, on the
decreased availability of opioids.
MS. CHAMBERS acknowledged there may be other elements [affecting
drug use] that are outside of the scope of the PDMP. She noted
the related boards are encouraging more collaboration to
consider how DCCED can help facilitate conversations between
pharmacists and prescribers; pharmacies need to be in contact
with all licensed providers so they can efficiently question or
confirm appropriate drug use. In fact, this is a recent issue
that has led to crises for some patients.
CO-CHAIR SPOHNHOLZ related concerns about the PDMP for those
with issues of chronic pain who may suffer unintended
consequences.
5:18:11 PM
MS. CHAMBERS opined the aforementioned crises are not a negative
consequence of Senate Bill 74 but are "growing pains." She
directed attention to slide 38 which illustrated the number of
patients receiving opioid prescriptions has decreased except for
prescriptions greater than 100 milligram (mg) morphine
equivalent per day (MME). She pointed out Senate Bill 74
required prescriber boards to submit recommendations about
prescriptive guidelines to the legislature; guidelines were
completed in 2016 and were primarily based on the Centers for
Disease Control (CDC), U.S. Department of Health and Human
Services, guidelines. She cautioned there are no "hard and fast
rules" in this regard, thus education for patients and
prescribers is warranted. Slide 39 provided detailed
information about the PDMP annual report delivered to the
legislature in March 2019, and available online at:
pdmp.alaska.gov.
MS. CARPENTER directed attention to slide 40 which identified
savings from Medicaid reform and other adjustments. She noted
DHSS has already incorporated the shown savings into its budget.
CO-CHAIR SPOHNHOLZ pointed out DHSS has saved over $139 million
by finding ways to better achieve its mission.
CO-CHAIR ZULKOSKY observed many of the reforms were
administrative but have also improved access to programs.
MS. CARPENTER said the section 1115 Behavioral Health Waiver
will have the most impact to access because some services that
were previously not Medicaid billable now are.
CO-CHAIR ZULKOSKY returned attention to slide 40 and asked Ms.
Carpenter to differentiate between GF savings and cost
avoidance.
5:24:39 PM
MS. CARPENTER said she would provide details in this regard. In
further response to Co-Chair Zulkosky, she explained an area
that may turn out to be an offset - and not cost avoidance - is
telehealth because DHSS did not estimate a specific money value
of the savings in telehealth; telehealth savings include DSDS
services and have the most potential for offset savings.
CO-CHAIR ZULKOSKY suggested savings and realized investment
under Medicaid reform and expansion may approach $250 million.
CO-CHAIR SPOHNHOLZ questioned why savings related to telehealth
are not measured.
MS. CARPENTER advised major savings from telehealth fall within
DCCED licensing and would not be reflected in Medicaid reform;
for example, most telehealth savings are part of "Tribal health"
and thus are 100 percent GF. She offered to conduct additional
research.
CO-CHAIR SPOHNHOLZ recalled telehealth was identified as a
"strategy" as a part of Senate Bill 74; however, no one is
tracking how much money the state is saving - or spending on
travel that could be avoided - by expanding access to
telehealth. She characterized telehealth as a future redesign
opportunity.
5:29:49 PM
MS. CARPENTER agreed the cost of travel is significant for
Alaska. She continued to slide 41 which was a graph that showed
enrollment has grown over the past four years due to the
economic recession and Medicaid expansion; however, reforms have
allowed DHSS to hold state GF spending per enrollee flat as
Medicaid spending has increased. Slide 42 indicated the per
enrollee cost curve was held well below DHSS's original
forecast. She concluded Medicaid reforms are effective and an
accomplishment by DHSS.
CO-CHAIR ZULKOSKY urged DHSS to provide more general information
on the focus and mission of its programs and services, and to
provide additional information on what percent of Senate Bill 74
has been fully realized and the timeline required to reach 100
percent of implementation.
MS. CARPENTER agreed there are outstanding provisions of Senate
Bill 74; for example, one state plan option is the [section
2703/1945 of the Social Security Act] Health Home State Plan,
which has been delayed until the results of the Providence
Family Medicine Center medical home model project become known,
because the state would only receive eight quarters of enhanced
90 percent federal match. Other provisions of Senate Bill 74
have been delayed due to "the right timing as well as just the,
the mass amount of work for the department ... [that] would fall
on the same, you know, handful of individuals."
CO-CHAIR ZULKOSKY restated her question.
MS. CARPENTER said she would provide a percentage of the reforms
within the purview of DHSS that have been implemented.
CO-CHAIR SPOHNHOLZ acknowledged the amount of time and work
needed to implement Senate Bill 74 and other reforms.
5:38:31 PM
ADJOURNMENT
There being no further business before the committee, the House
Health and Social Services Standing Committee meeting was
adjourned at [5:38] p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| HB133 Supporting Document-Carey Case 4.22.19.pdf |
HHSS 4/23/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM |
HB 133 |
| HB133 Sectional Analysis ver M 4.24.19.pdf |
HHSS 4/25/2019 3:00:00 PM |
HB 133 |
| HB133 Supporting Document-Reference by Definition 4.22.19.pdf |
HHSS 4/23/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM |
HB 133 |
| HB133 Sponsor Statement 4.22.19.pdf |
HHSS 4/23/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM |
HB 133 |
| HB133 Fiscal Note DHSS DJJ 4.21.2019.pdf |
HHSS 4/23/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM |
HB 133 |
| HB084 Sectional Analysis 4.3.19.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM HL&C 2/26/2020 3:15:00 PM |
HB 84 |
| HB084 Sponsor Statement 3.28.19.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM HL&C 2/26/2020 3:15:00 PM |
HB 84 |
| HB084 Supporting Document- Breast Cancer in Women Firefighters.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM HL&C 2/26/2020 3:15:00 PM |
HB 84 |
| HB084 Supporting Document- Asbestos 03.28.19.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM HL&C 2/26/2020 3:15:00 PM |
HB 84 |
| HB084 Supporting Document- Letter of Support ACAT 4.3.19.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM HL&C 2/26/2020 3:15:00 PM |
HB 84 |
| HB084 Supporting Document- RADS in Police from Chemical Spill 3.28.19.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM HL&C 2/26/2020 3:15:00 PM |
HB 84 |
| HB084 Fiscal Note DLWD WC 04.03.19.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM HL&C 2/26/2020 3:15:00 PM |
HB 84 |
| HB084 Letter of Support- APOA 3.28.19.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM HL&C 2/26/2020 3:15:00 PM |
HB 84 |
| HB084 Opposition Document- AML Joint Insurance Association 3.29.2019.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM HL&C 2/26/2020 3:15:00 PM |
HB 84 |
| HB084 Presentation 4.3.19.pdf |
HHSS 4/4/2019 3:00:00 PM HHSS 4/25/2019 3:00:00 PM |
HB 84 |
| Medicaid Reform Update Presentation for HHSS April 25 2019.pdf |
HHSS 4/25/2019 3:00:00 PM |
Medicaid Reform Update |