Legislature(2015 - 2016)CAPITOL 106
02/18/2016 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 | |
| HB227 | |
| Presentation: Key Coalition | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| += | HB 227 | TELECONFERENCED | |
| + | TELECONFERENCED |
HB 227-MEDICAL ASSISTANCE REFORM
3:03:44 PM
CHAIR SEATON announced that the first order of business would be
HOUSE BILL NO. 227, "An Act relating to medical assistance
reform measures; relating to administrative appeals of civil
penalties for medical assistance providers; relating to the
duties of the Department of Health and Social Services; relating
to audits and civil penalties for medical assistance providers;
relating to medical assistance cost containment measures by the
Department of Health and Social Services; relating to medical
assistance coverage of clinic and rehabilitative services; and
providing for an effective date." He said that the focus would
be on the fiscal notes.
3:07:45 PM
CHAIR SEATON directed attention to the responses from Department
of Health and Social Services to the committee members'
questions from the February 2 meeting [Included in members'
packets].
REPRESENTATIVE VAZQUEZ said that she was not ready with
questions to the fiscal notes.
CHAIR SEATON reiterated that he was asking about the written
responses from the Department of Health and Social Services to
the questions posed by the committee during the last House
Health and Social Services Standing Committee.
3:09:24 PM
The committee took an at-ease from 3:09 p.m. to 3:11 p.m.
3:11:52 PM
CHAIR SEATON directed attention to the fiscal note on HB 227,
labeled OMB Component Number: 2696. [Previously discussed on
February 2, 2016.]
3:13:26 PM
JON SHERWOOD, Deputy Commissioner, Medicaid and Health Care
Policy, Office of the Commissioner, Department of Health and
Social Services, explained that the fiscal note, labeled OMB
2696, was for the Office of Rate Review [Allocation], as Section
12 of proposed HB 227 required one or more demonstration
projects focused on innovative payments, including one for a
global payment fee structure. This fiscal note included the
one-time cost, $500,000 in FY17, for hiring a contractor to
analyze and implement the new payment model. It was estimated
that the ongoing actuarial work in subsequent years would have
an annual cost of $100,000 and that there would not be any
additional positions associated with this activity. He pointed
out that the funding included a 50 percent federal match.
CHAIR SEATON reflected that the demonstration project was
intended as an analysis for saving money and improving health
through a managed care or global payment model for Medicaid
recipients.
MR. SHERWOOD added that the provisions of the bill required the
program to reduce the growth in cost.
3:15:21 PM
CHAIR SEATON directed attention to the fiscal note labeled OMB
Component Number: 2788, Allocation: Women, Children and Family
Health.
MR. SHERWOOD explained that this fiscal note was for Women,
Children and Family Health [Allocation] within the Division of
Public Health [Appropriation] to satisfy the requirement in
Section 15 of the proposed bill which required the Department of
Health and Social Services to design and implement a project
studying the impact of nutrition, including Vitamin D, on pre-
term birth rates. He reported that the fiscal note assumed that
the project would have a cost of $661,100 per year for three
years, beginning in FY17. He noted that $500,000 of this would
include a contract with either the University of Alaska or a
medical school to conduct the study, and the remainder of the
funding would pay for one full time nurse consultant to write
the request for proposals (RFP) and manage the contract. He
noted that funds for travel necessary for training and
counseling expenses was also included in the project cost. He
pointed out that all of these expenditures would come from the
general fund. He compared this to similar language in proposed
HB 148, although HB 148 had not required that the study be
conducted.
CHAIR SEATON shared that amendment language would be forthcoming
to require a third party contract, as currently there were
models for this allowing for its completion at a reasonable
cost. He pointed out that this fiscal note, OMB 2788,
identified what was currently written in the proposed bill. He
referenced a South Carolina project, Protect Our Children Now,
[Included in members' packets] noting that it was also about to
start in Montana. He pointed out that, as the Department of
Health and Social Services had previously stated that it was
"not set up to do research," a contract was much more economic
and efficient.
3:20:03 PM
CHAIR SEATON moved on to the fiscal note, labeled OMB Component
Number: 2663, Allocation: Senior and Disabilities Services
Administration.
MR. SHERWOOD explained that this fiscal note addressed the
administrative costs for the Division of Senior and Disabilities
Services associated with the proposed bill, specifically that
Section 12 of the proposed bill required implementation of the
1915(i) and (k) options. He reported that it was anticipated
that new staff would be required to develop and oversee these
new options. There would be one new staff beginning in FY17,
with two additional staff beginning in FY18. He reported that
the annual cost associated for each staff was $116,300 per year,
and that funds would be necessary to make modifications to the
"Automated Service Plan" management information system used by
the division to manage its home and community based programs, at
an estimated cost of $300,000 over 3 years, of which 90 percent
would be federally funded. He pointed out that there would also
be costs associated with the increase of functional assessments
during the start-up period, as more people applied at program
inception, estimated to be $250,000 over the first three years
of the program. He noted that all of the increased costs, with
the exception of the aforementioned modifications to the
management information system, would have a 50 percent federal
match.
CHAIR SEATON asked if the costs were anticipated to be the same.
MR. SHERWOOD replied that originally it had been envisioned for
savings from the waiver by entering into an agreement to treat
expenditures for tribal beneficiaries which occurred outside the
tribal system as being delivered through a tribal facility,
which was the criteria for receiving 100 percent federal funds.
He relayed that the governor had recently received a letter from
Secretary Burwell [U.S. Department of Health and Human Services]
indicating that the "1115 waiver was not the way they wanted us
to pursue this, and they were actually going to change national
policy." He explained that there was an expectation for
comparable savings to the original forecast with this waiver,
although there was not yet a final policy which allowed for
"some degree of uncertainty in terms of the timing, exactly when
we can start and how fast we can bring it up." He expressed an
expectation for the savings to be at least the same as those for
the waiver projection. He declared that it would reduce the
administrative cost, as it would not be necessary to implement
an 1115 waiver which carried its own administrative burdens for
data reporting and evaluation, not necessary with a change in
federal policy. He directed attention to earlier testimony on a
fiscal note for the cost of a position under the medical
assistance administration component necessary to manage the
claims under the new policy, noting that it would not be seen
under the costs for the Senior and Disabilities Services
Administration.
CHAIR SEATON asked what kind of savings this would generate.
MR. SHERWOOD, in response, said that all the money shown in the
fiscal note for Senior and Disabilities Services was related to
adding the 1915 (i) and (k) optional services, which would
increase federal funding for the currently provided services,
but were not associated with the aforementioned change in policy
for the claims on tribal services or the 1115 waiver initially
proposed.
CHAIR SEATON asked if the Department of Health and Social
Services would help with the language to the amendment so there
would be a request to achieve the desired outcome.
MR. SHERWOOD replied that the language was readily available.
3:27:23 PM
REPRESENTATIVE STUTES, directing attention to the governor's
budget and its departmental cuts, asked how much was actual cuts
as opposed to changing payment from state to federal.
MR. SHERWOOD expressed his agreement that there were some fund
source changes in the budget, although he did not have the
numbers.
REPRESENTATIVE STUTES asked for this to be provided, suggesting
that a significant amount of money was simply a transfer of
funds as opposed to actual cuts in the budget.
CHAIR SEATON emphasized that the object was to provide better
health and social services with more and better service for the
citizens of Alaska, while reducing costs to the state.
MR. SHERWOOD, in response to Chair Seaton, replied that he would
speak about the change in expenditures for long term care during
discussion for other fiscal notes.
REPRESENTATIVE STUTES asked if patient travel fit into the
administrative category.
MR. SHERWOOD replied that travel for Medicaid recipients was
included in the Health Care Medicaid Services component.
3:33:06 PM
REPRESENTATIVE VAZQUEZ, directing attention to the option for a
1915(i) waiver mentioned in the proposed bill, suggested that
there could be additional beneficiaries to Medicaid, including
those individuals suffering from dementia. She asked if these
additional enrollees had been taken into consideration.
MR. SHERWOOD explained that the provisions would increase
services available under 1915(i), but would not expand the
number of eligible individuals. The increase of available
services would expand the Medicaid program, but this would also
provide off-setting reductions in other grant funded programs.
He relayed that the intention was to target the 1915(i) services
as closely as possible to the populations served by those
grants.
REPRESENTATIVE VAZQUEZ suggested that this may merely be
semantics, as there currently were individuals with dementia,
but no other diagnosis, who did not qualify for the waiver
programs, although they received grant benefits. She offered
her understanding that they would be eligible for waiver
services under 1915(i), which would expand the number of
Medicaid beneficiaries.
MR. SHERWOOD explained that these people would have to
financially and generally qualify for Medicaid as individuals
who were not waiver recipients, although there were higher
income eligibility standards for waiver recipients. If that
criteria was not currently met, this would not allow someone to
use those enhanced eligibility standards. However, an
individual would be eligible for waiver like services without
having to qualify for the waiver, if an individual was already
eligible for Medicaid. He expressed agreement that this did add
to the services covered under Medicaid. He acknowledged a
critical point that it was important in the design of 1915(i)
that the state design the functional eligibility criteria for
the services to ensure that "the people we're serving as close
as we can reflect the people that we're providing services to
through our grant programs right now."
REPRESENTATIVE VAZQUEZ offered her belief that implementation of
the 1915(i) and (k) options would not allow a cap to be placed
at a later time.
MR. SHERWOOD explained that, unlike waivers which could restrict
the number of individuals served in any given year, there was no
fixed cap for services for 1915(i) or (k). He noted that it was
critical for the eligibility criteria to be established in a
prudent, conservative way.
3:37:43 PM
REPRESENTATIVE STUTES asked if the 1915(i) or (k) waivers would
allow for a wait list.
MR. SHERWOOD replied that there would not be a wait list for the
optional services.
REPRESENTATIVE STUTES asked about those individuals currently on
the wait list.
MR. SHERWOOD replied that individuals who meet the functional
criteria established for 1915(i) or (k) options would be
entitled to receive the services, and would not be on a wait
list for Medicaid purposes.
REPRESENTATIVE STUTES asked if individuals would have to meet
those obligations to be currently on the wait list.
MR. SHERWOOD replied no, and explained that the only current
wait list was a registry for those with developmental
disabilities. He noted that those individuals had to meet the
developmental disabilities established in statute, and that
there was nothing in the proposed bill that required that the
eligibility criteria for the 1915(i) or (k) options be defined
as equivalent for the eligibility to the development
disabilities registry. He surmised that many individuals would
have conditions that did not qualify them for the registry,
whereas others on the registry would not qualify for the
services. He pointed out that it was necessary for eligibility
to 1915(k) to meet an institutional level of care.
REPRESENTATIVE VAZQUEZ asked for clarification that not everyone
on the present wait list would qualify for the 1915 options.
MR. SHERWOOD replied that was probably true. "Without having
defined what the specific criteria is for those two options,
it's hard for me to make a definitive statement. I don't want
to be glib about it."
3:42:02 PM
DUANE MAYES, Director, Central Office, Division of Senior and
Disabilities Services, Department of Health and Social Services,
reported that there were currently between 610 - 620 people on
the registry. He noted that there were two types on the
registry, those that may qualify for the 1915(k) option as they
need institutional level of care, and those who may qualify for
the 1915 (i) option as they need less than the institutional
level of care. He offered that the implementation of both (k)
and (i) would allow a refinance for the current grant funding so
that 50 percent would be federal dollars. He shared that those
who did not qualify for the (k) option would be served through
the (i) option.
CHAIR SEATON asked for clarification that not everyone on the
registry would meet the new definition for (i).
MR. MAYES replied that it was necessary for a well-defined
eligibility process to ensure good controls.
CHAIR SEATON acknowledged that this was a concern. He asked if
the criteria were totally developed within the Department of
Health and Social Services, or if the Alaska State Legislature
had any role for development.
MR. SHERWOOD replied that, as currently written, the criteria
would be developed by the department. He offered his belief
that (k) required development of the proposal in conjunction
with a consumer advisory board. He stated that the general
options would be cited in the statute, and the department would
define the specific criteria, as it could often get quite
technical, and include a level of detail which was not usually
placed in statute.
CHAIR SEATON asked if intent language from the legislature would
be helpful to the Department of Health and Social Services for
development of the criteria.
MR. SHERWOOD replied that the department could work with
committee to research language that would be useful.
CHAIR SEATON stated that the committee members would talk with
the department "to figure out what some of those parameters
could be." He shared that there was concern for [Medicaid]
expansion without any ability to contract. He noted that there
would also be public input for the development of the intent
language in the bill.
3:47:14 PM
REPRESENTATIVE VAZQUEZ asked if experts had already been hired
by the department for analysis.
MR. SHERWOOD replied that the Alaska Mental Health Trust
Authority had assisted with the hiring of a national consulting
firm, Health Management Associates, which had worked with many
state Medicaid departments and directors. He pointed out that
this had benefited the department. Specifically for the 1915(k)
option, the initial recommendation had been for broad coverage
because of the potential for expanded coverage. Currently, the
recommendation was to focus on personal care services, as this
was already covered as a state plan option, and was available to
everyone who was Medicaid eligible, regardless of current waiver
status. He acknowledged that the advice of experts had brought
some good insights.
CHAIR SEATON asked for any documentation from these study
groups.
3:49:29 PM
CHAIR SEATON directed attention to the fiscal note labeled OMB
Component Number: 2875.
MR. SHERWOOD explained that this fiscal note focused on Section
12 of the proposed bill, and 1915(i), the home and community
based services option. He reiterated that this option was for
Medicaid to replace state funded services, which brought a 50
percent federal funding. He explained that this component,
temporary assisted living, was a program that would be impacted
as it provided assisted living care to individuals who did not
meet criteria for waivers, or whose application was pending. He
reported that use of the 1915(i) would refinance approximately
$4.7 million annually by transferring individuals to it,
beginning in FY19. He noted that this was a general fund
savings, and added that later there would be the associated
Medicaid expenditure. He pointed out that this was not the
entire general relief assisted living program, as there were
still people who were not Medicaid eligible or did not meet the
criteria.
CHAIR SEATON asked for clarification that the general fund
savings would be about 50 percent from this switch.
MR. SHERWOOD replied that this expenditure represented a bit
more than half of the almost $8 million spent for the general
relief program in the current budget. He noted that this
component would save about $4.7 million annually from the
general funds, but the expenditure of the $4.7 million in
Medicaid services would be halved as 50 percent would be federal
funding.
REPRESENTATIVE VAZQUEZ asked if this fiscal note should be
revised.
MR. SHERWOOD explained that the 50 percent would show up in
another fiscal note as an expenditure, and he offered his
understanding that this was the correct way to reflect it as a
budget component.
3:54:16 PM
CHAIR SEATON directed attention to the fiscal note labeled OMB
Component Number: 2787.
MR. SHERWOOD explained that this fiscal note was an allocation
for Senior Community Based Grants in the Senior and Disabilities
Services, and was another grant program which paid for home and
community based services through the general fund. He shared
that Department of Health and Social Services anticipated that
the 1915(i) option would reduce the expenditure by $735,000
annually beginning in FY19. He noted that this was "the same
basic math as the one before, there would be an offsetting
increase later when we look at the Senior and Disabilities
Services Medicaid Services." He reported that it would also be
50 percent federally funded.
3:55:38 PM
CHAIR SEATON directed attention to the fiscal note labeled OMB
Component Number: 309.
MR. SHERWOOD explained that this fiscal note was also an
appropriation for Senior and Disabilities Services and was an
allocation for Community Developmental Disabilities Grants,
which were grants for individuals with developmental
disabilities. He stated that this was the largest grant program
in the Division of Senior and Disabilities Services, as it was
for more than $11 million, that could be refinanced beginning in
FY 19.
CHAIR SEATON stated that it was necessary to ensure that the
Department of Health and Social Services programs and services
were necessary and beneficial, even as the costs were being
shifted to federal funding. He asked that the department share
any necessary changes, as "we [the committee] only have a
certain amount of knowledge and we're relying on you, the
experts, to make sure that ... if the population has grown away
from a previous policy choice, that we make the correct policy
choice at this point in time."
MR. SHERWOOD expressed his appreciation, stating "we really do
want to keep looking at our services and making sure that we're
hitting the needs that individuals have and not simply going on
inertia." He shared that the department was always open to that
conversation.
3:58:50 PM
CHAIR SEATON directed attention to the fiscal note labeled OMB
Component Number: 2660.
MR. SHERWOOD explained that this, for Behavioral Health, was the
first of the three Medicaid Services fiscal notes. He relayed
that Section 12 of the proposed bill included language
instructing the necessity to seek an 1115 demonstration waiver
to improve Medicaid for tribal providers. He noted that DHSS
had received notification from the U.S. Department of Health and
Human Services for a change in policy, which would eliminate the
need for an 1115 waiver. He opined that it was still
appropriate, as there had been changes in some of the other
language around innovation and improving tribal services. He
stated that the change allowed services, presently not
considered to be delivered through a tribal facility, to now be
considered through a tribal facility and allowed DHSS to claim
100 percent federal fund match rate. He reported that this was
anticipated to begin in FY17, and the first year savings were
encompassed in the reductions in the governor's budget.
Although the department did not yet have the final policy, in
order to claim the enhanced match, it was necessary to have
agreements in place between tribal providers and non-tribal
providers around care management. There were assumptions for a
start with agreements with the larger providers of services in
the initial years, before branching out to the smaller
providers. He declared that DHSS did not anticipate substantial
difficulty in obtaining those agreements. He stated that there
was not any change in expenditures for Behavioral Health,
although there was a change in revenue source, as federal
receipts were increased while general fund receipts were
decreased beginning in FY17.
REPRESENTATIVE VAZQUEZ asked how these savings would be
realized, as it did not appear through the implementation of
1915(i) and (k).
MR. SHERWOOD replied that the savings would be realized by
implementing the change in federal policy which CMS had
announced was forthcoming. He stated that it appeared to be
exactly aligned with the intent language in Section 1, paragraph
(2)(A) on page 2, line 5.
REPRESENTATIVE VAZQUEZ asked about the specific federal policy
change.
4:05:47 PM
VALERIE DAVIDSON, Commissioner, Office of the Commissioner,
Department of Health and Social Services (DHSS), explained that
after the initial review of 1115 waiver for partnership
opportunities with tribal health organizations in order to
maximize 100 percent match opportunities, Secretary Burwell
[U.S. Health and Human Services] indicated that an 1115 waiver
process would not necessarily work for some of these services as
it required budget neutrality for the federal government for the
Centers for Medicare and Medicaid Services. The Secretary
suggested that instead, there would be a change in national
policy to provide 100 percent federal match for travel and
accommodation services and that for services initiated in an
Indian Health Services facility but not available and needed to
be referred out, it would still be considered for a 100 percent
federal match. She pointed to the guidance published in the
federal register which indicated the kind of services, including
specialty and long term care and support services.
REPRESENTATIVE VAZQUEZ asked what type of services this would
encompass.
MR. SHERWOOD, in response, asked if this referenced the
aforementioned fiscal note, labeled OMB Component Number: 2660,
and then reported that it would include the residential
psychiatric treatment facilities to which tribal beneficiaries
were currently referred.
CHAIR SEATON asked if this new federal policy was anticipated to
also be for long term care, as well as for any referred tribal
health services when Indian Health Services (IHS) did not have
the capacity.
COMMISSIONER DAVIDSON replied that the federal guidance had
indicated that there had to be agreement between the parties,
such as a Memorandum of Agreement (MOA) or a contract. This
would require that an individual could not self-refer, but would
need to be referred through an IHS facility in order for the
state to claim the 100 percent federal match.
REPRESENTATIVE VAZQUEZ asked whether the federal match was just
a policy, and not in statute.
COMMISSIONER DAVIDSON pointed out that although it was in
federal statute, the Centers for Medicare and Medicaid Services
(CMS) had a narrow interpretation for "through an IHS facility."
She opined that guidance by CMS now indicated that the policy
had been applied too narrowly.
REPRESENTATIVE VAZQUEZ asked if this was based on a current
federal policy.
COMMISSIONER DAVIDSON replied that the CMS policy was created by
whichever current administration, and that it could be changed.
It was stated that the current policy had been in place since
IHS facilities had been permitted to bill Medicaid, in the late
1970s.
REPRESENTATIVE VAZQUEZ asked if this was a recent
interpretation.
COMMISSIONER DAVIDSON replied, "yes."
CHAIR SEATON asked if this guidance had been published in the
federal register.
MR. SHERWOOD clarified that it had been published by CMS, but
not in the federal register.
CHAIR SEATON asked if that could be provided to the committee.
4:11:57 PM
CHAIR SEATON shared that the committee was looking at an
increase in bonding authority for tribal health facilities as it
was beneficial, and he asked whether this would be impacted by
the aforementioned CMS policy.
COMMISSIONER DAVIDSON replied that this would depend on the
community, noting that IHS had an interest for providing care as
close to home as possible, as this care, in a culturally
appropriate environment, led to better health outcomes. She
acknowledged the work to construct long term facilities in some
hub communities, including Kotzebue and Bethel. She opined that
people in rural and urban communities preferred having the care
provided as close to home as possible.
CHAIR SEATON suggested that the proposed bill might receive
intent language to accelerate bringing services and facilities
closer to home.
4:14:59 PM
CHAIR SEATON directed attention to the fiscal note labeled OMB
Component Number: 2077, an allocation for Health Care Medicaid
Services.
MR. SHERWOOD stated that this was another Medicaid Services
fiscal note for the proposed bill, pointing out that, as many
parts of the proposed bill affected Medicaid Services, there
were many things going on in the fiscal note. He explained that
there were fund source shift and changes in expenditures, as
well as capital budget costs for system changes to the MMIS. In
Section 12, there was a fund source shift, decreasing general
funds and increasing federal funds by $6.7 million in FY17 and
growing to $24.2 million in FY22, around the tribal claiming
policy, shifting air travel and ambulance service for tribal
members to 100 percent federal funding. In Sections 5 & 6 of
the proposed bill, provisions would be implemented for the
collection of interest, penalties, and civil fines by DHSS,
reflected in the fiscal note under revenues, as well as
increased expenditures in the grant line, and it was necessary
for the authority to spend those receipts. He noted that there
was an increase in expenditures under Services, to reflect an
increase in administrative hearings, $500,000, and case
management services under the emergency room super utilizers
provision, $600,000, in FY17. He pointed out that these
services had a 50 percent federal match. He directed attention
to Section 9 of the proposed bill, as the super utilizer program
was projected to reduce expenditures in the grant line by $9.2
million annually beginning in FY17, also a 50 percent federal
fund match. He expressed an anticipation for the need for
capital funds to make extensive system modifications to the MMIS
to implement the 1915(i) and (k) options, as well as conduct
required identifications and development for the health
information technology components for some of the listed
projects, $7.85 million with a federal match of 90 percent. He
declared that this was the most complicated fiscal note.
REPRESENTATIVE STUTES asked if these fiscal notes were
sustainable, offering an analogy to school bonding for payments
of 70 percent by the State of Alaska. She questioned whether
projections should be made for 100 percent federal funding.
MR. SHERWOOD explained that the federal funding for the Medicaid
program had been "remarkably stable over its history." He noted
that there had been times of economic hardship when the U.S.
Congress had increased its federal match rate to states to
provide additional relief. He stated that there had never been
a substantial reduction other than back to the base. He allowed
that although it was possible that federal funding could change,
DHSS operated as best as possible on the history and awareness
that Medicaid was a critical program in all 50 states. He
stated that it would be very difficult to get congressional
support to dramatically reduce the program that would have such
a big impact across all the states.
REPRESENTATIVE STUTES relayed that she had held the same
conversation in Kodiak regarding the state school bonding,
"they've been doing it since the what, 60s or 70s, and they've
never changed. Why shouldn't we do it, and guess what, it
changed."
CHAIR SEATON clarified that the Alaska State Legislature had
passed a statute which made that change for school bonding,
pointing out that it was not retroactive, but was, instead for
any new bonds. He declared that there was no more security than
that both houses of congress in the federal government had to
agree, and the president had to sign it, as this was a provision
of law, not regulation. He acknowledged that this could,
however, happen. He pointed out that the Medicaid Expansion
bill allowed an opt-out by the state should the federal
reimbursement rate drop below 90 percent.
4:24:29 PM
CHAIR SEATON directed attention to the fiscal note labeled OMB
Component Number: 2662, an allocation for Senior and
Disabilities Medicaid Services. He noted that some costs had
shown on this fiscal note which mirrored savings on other fiscal
notes, as there was shifting from a grant program to Medicaid.
MR. SHERWOOD expressed his agreement that a substantial portion
of the fiscal note was to show a movement of expenditures from
the current grant programs to the 1915(i) and (k) options, which
were to begin in FY 19. He noted that the other part of the
fiscal note was for the change in tribal policy as it would
impact our long term care services, assuming that this impact
would first be seen in the larger nursing facilities before
moving to the smaller nursing facilities and the home and
community based waiver services. He pointed out that this fund
source shift [from payment through general funds to federal
funds] would increase from FY17 through FY22.
CHAIR SEATON asked for clarification that the term "refinancing"
meant switching to an increased federal match for Medicaid from
100 percent state general funds.
MR. SHERWOOD explained that the terminology came from the
refinancing for a more favorable home mortgage interest rate,
although it now referred to a shift for a more favorable federal
match rate.
REPRESENTATIVE TARR asked how the reform measures already in
existence dovetailed with the proposed changes. She asked what
vehicle would be used to move forward as some of the
recommendations by the Agnew::Beck report would not require
statutory change.
4:30:32 PM
COMMISSIONER DAVIDSON expressed her agreement that there were a
lot of reform activities, and that "it's my heart's dream that
the legislature and the administration are so heavily invested
and providers and stakeholders recognize that health reform,
Medicaid Reform specifically, is not a nice to have, it is a
must have because we realize that our current program in its
current form is not sustainable." She acknowledged the budget
challenge, but stated that challenges necessitate innovation and
a different way of doing things. She listed a variety of reform
opportunities taking advantage of changes, which included
different refinancing opportunities available. She reported
that the Alaska State Hospital and Nursing Home Association
suggested for all the parties to gather and create a public-
private partnership to ensure better primary care management,
monitoring prescription drug information, and over utilization
of the emergency rooms. She referenced the Agnew::Beck report
which partnered with HMA, who also worked on the 1915(i) and (k)
options. She mentioned the Menges report which reviewed the
proposed legislative reform options and offered an assessment
for moving forward. She pointed out that various contractors
recognized that the stakeholders would benefit from more
intensive conversations with Oregon and Colorado for their
experiences about accountable care organizations and care
coordination models. She relayed that there was also a lot of
conversation among the parties, noting that the Agnew::Beck
report was posted on the DHSS website. She reported that
legislation might be required to make mandatory progress on
health care reform.
4:35:37 PM
REPRESENTATIVE TARR suggested that a good exercise for
efficiency and priority would be to place the proposed bill side
by side with the various reports. She expressed concern that
the consideration of multiple proposals would make more work for
the department.
COMMISSIONER DAVIDSON relayed that some of that work had been
done in the Committee Substitute (CS) for SB 78, which included
many of the recommendations from the Agnew::Beck report. She
acknowledged that SB 78 was still in the Senate, and its
Medicaid Committee working group.
CHAIR SEATON relayed that proposed HB 227 had also gone through
the same process, though not in a subcommittee, as the proposed
amendments were looking at the various suggestions. He
expressed a problem that the legislature had given DHSS the
option for a model of care coordination, whereas it was now a
requirement. He pointed out that the demonstration projects
would not necessarily go forward in the future without
requirement. He pointed out the DHSS recognized the legislative
intent to do these things, and that there would be funding to
initiate these requirements.
4:39:18 PM
COMMISSIONER DAVIDSON reflected on a prior provision that had
not been extended which allowed for a $50 million discretionary
budget authority which allowed DHSS to move funds from various
divisions, if necessary, to take advantage of opportunities to
realize savings or reform or redesign programs. She said that,
as this authority was no longer available, there was a lost
opportunity for more flexibility.
CHAIR SEATON asked if this was the authority to move money
already appropriated, and not a new allocation, within the
department to accomplish those specific goals.
COMMISSIONER DAVIDSON replied that it was for money already
appropriated.
REPRESENTATIVE TARR asked for a chart listing the 1915(i) and
(k) services and the 1115 services.
COMMISSIONER DAVIDSON relayed that the department would supply
this chart.
REPRESENTATIVE STUTES asked about payment for travel by
recipients.
COMMISSIONER DAVIDSON explained that the Medicaid program paid
for pre-approved medically necessary travel.
REPRESENTATIVE STUTES asked how this was tracked by the
department, stating that this was "a fairly abused program."
COMMISSIONER DAVIDSON said that DHSS would provide more specific
information about travel. She stated that the no-show rate by
Medicaid appointments was no different than by any other payer,
noting that this was mainly due to weather. She explained that
the pre-authorizations by providers for Medicaid beneficiaries
had to be medically necessary, and was only approved, and valid,
for specific days. She noted that any delays could void the
authorization.
CHAIR SEATON asked for more information as this was a recurring
theme heard by the committee.
4:44:16 PM
CHAIR SEATON stated that the proposed bill was looking at a
change for behavioral health grants, as currently only grant
recipients could bill Medicaid. This would be changed, as well
as the requirement for supervision by psychiatrists when
behavioral health services were provided. He asked if there
were any problems or any "easy fixes that we can accomplish in
the bill if there is a problem."
MR. SHERWOOD replied that he was reluctant to begin the
conversation, as it was very complicated. He relayed that most
often any reference to the psychiatry oversight referred to the
criteria around physicians, mental health clinics, and billings
for services. He reported that psychiatrists could bill
Medicaid for other licensed professionals serving in their
clinic, but it required the psychiatrist be present 30 percent
of the time. He relayed that community behavioral health
clinics could also use non-licensed clinicians for services,
although they had a different standard for medical oversight.
He stated that psychologists were listed in statute as an
optional service, and were only authorized for their independent
service for psychological assessment and testing, not for
therapy, as that would require a regulation change. He said
that most other professionals desiring to bill Medicaid
independently, as "other licensed practitioners of the healing
arts," would need to be named in the statute, AS 47.070.30(b),
which listed the covered optional services.
CHAIR SEATON declared that he wanted to have this conversation
should the need for an amendment be brought forward. He noted
that the proposed bill removed the criteria to be a behavioral
health grant recipient, noting that psychiatrists don't do
therapy, but usually administered drugs. It seemed there was a
disconnect between the services provided for mental health when
trying to integrate behavioral health into primary health under
Medicaid. He stated that there was a requirement that it needed
to be under the auspices of psychiatrist. He asked for the
department to look at this issue, determine whether there was
another category of provider to list in the statute, and what
was the fiscal impact.
4:49:30 PM
CHAIR SEATON declared that he wanted providers to know that the
committee was looking and listening, and if there were any other
aspects of Medicaid reform that could be helpful for improving
health and controlling health care costs, the suggestions would
be welcomed.
[HB 227 was held over]
| Document Name | Date/Time | Subjects |
|---|---|---|
| Key Priorities 2016.pdf |
HHSS 2/18/2016 3:00:00 PM |
Presentation |
| department responses to HB 227 questions_from 2.02.2016.pdf |
HHSS 2/18/2016 3:00:00 PM |
HB 227 |
| HB 227 DHSS response to 2-18-2016 questions_graphs included.pdf |
HHSS 2/18/2016 3:00:00 PM |
HB 227 |