Legislature(1993 - 1994)

03/24/1993 01:30 PM HES

Audio Topic
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
  The only order of business to  come before the committee was                 
  ELLIS, sponsor of the measure,  said there's something wrong                 
  with a  system that  pays for institutional  care but  won't                 
  help a family that wants to care  for its loved one at home.                 
  This  bill  has become  known  by  many of  the  parents and                 
  advocates for Medicaid  waivers and  options as the  Brianna                 
  Hurley bill.  Brianna  is a two year old girl  that was born                 
  with cerebral palsy and her parents  have tried very hard to                 
  keep their daughter  at home, not institutionalize  her, and                 
  keep the family together.  Unfortunately, it has broken up a                 
  marriage  and financially  devastated  the family.   Senator                 
  Ellis said the fact is that the federal and state government                 
  will pay to institutionalize a child costing up to over $100                 
  thousand  a year,  but  is unable  or  unwilling to  provide                 
  support in the  home to keep  the family together.   Project                 
  Choice  offers a  great deal  of hope  for  a change  in the                 
  Medicaid  law.   He said  there is  money in  the  budget to                 
  achieve  that change  and so  the state  is moving  forward.                 
  Senator Ellis said SSSB 5 is sort  of a backup or safety net                 
  to take care of those kids that don't need all  the services                 
  that a waiver would provide.  He said a waiver may  not take                 
  care of all the  people in the state that need  it.  Senator                 
  Ellis  said  while  waivers offer  more  services,  they are                 
  limited in the  number of people who  can receive them.   We                 
  can help people's lives and positively impact the budget  by                 
  having options kick in, after  the department has experience                 
  with the Medicaid  waivers, for  those families that  aren't                 
  able to be served by waivers.   Options offer fewer services                 
  but everyone who  is categorically eligible can  qualify for                 
  an option, and not everybody needs all the services provided                 
  under waivers.   There  is a  very strong  concern that  not                 
  everyone  will be  served with  waivers and  that not  every                 
  family is appropriately served by waivers.                                   
  Number 080                                                                   
  BRENDA TRUMBLE, Klawock,  pointed out  that during the  last                 
  legislative  session  the  bill made  it  through  the whole                 
  committee structure, but didn't  make it to the floor  for a                 
  vote.  She said  she has an eleven year old  boy, Logan, who                 
  has cerebral palsy which was a  result of a DDT immunization                 
  at five weeks  old.   He is developmentally  disabled.   Ms.                 
  Trumble said her family feels very fortunate to receive care                 
  such as respite care, etc.  Ms. Trumble explained that three                 
  years ago her husband left  employment of fourteen years and                 
  started his own business  called "Wood Marine."   He markets                 
  Sitka spruce  for musical instruments  in the  lower 48  and                 
  Europe.  Ms.  Trumble said  her family was  covered by  Blue                 
  Cross before  the  child  was born,  but  when  her  husband                 
  changed employment, they were able  to buy health insurance,                 
  the COBRA option, for eighteen  months.  She explained  that                 
  in order to obtain  Medicaid coverage for her son,  they had                 
  to totally  devest themselves of all their resources and get                 
  below  the  poverty level  severely limiting  their business                 
  opportunities.  She said they had  to get rid of their  life                 
  insurance,  they couldn't have  anything in retirement, they                 
  could't even have  a burial plaque.   Ms. Trumble said  they                 
  are currently trying  to maintain  health insurance for  the                 
  rest of the family which costs $478 per month and the  price                 
  is rising.   The  only way out  of the  situation is  to put                 
  their child in foster care or institutionalize him, which is                 
  against everything she believes in.  Passage of SSSB 5 would                 
  guarantee that no Alaskan family would  have to fall as hard                 
  as her family has.                                                           
  Number 140                                                                   
  LAUREL  PUTNAM,  mother  of  four  children, testified  from                 
  Anchorage.  She informed the committee that her fourth child                 
  was born two years ago.   He had complications at  birth, he                 
  was stillborn and it took approximately seventeen minutes to                 
  resuscitate him.   Because of brain damage,  he suffers from                 
  cerebral palsy and profound mental  retardation.  Ms. Putnam                 
  said prior to the birth of her son, her husband was employed                 
  and they had an insurance policy.  He was laid off  from his                 
  job, but they  were able to hold the COBRA plan for eighteen                 
  months.  She said  her husband was able to  find employment,                 
  but because of their child's  pre-existing condition, he was                 
  not able  to be insured  under that policy.   Since  they no                 
  longer had insurance,  they had  to place their  child in  a                 
  foster home.   She said there needs  to be a safety  net for                 
  those children yet  to be born.   It is important to  have a                 
  program that  is adequate for the  child.  A waiver  will be                 
  great for some children, but SSSB 5 will  be better and more                 
  cost effective for children.  There are a number of families                 
  in this situation and  due to technology there will  be more                 
  families in the  same situation in  the future.  Ms.  Putnam                 
  said if they  placed their child  in Our Lady of  Compassion                 
  Center, it would cost $7,000 per month.   She said last year                 
  her  son  was  fairly  healthy  and  he was  able  to  avoid                 
  hospitalization. By keeping  him at home,  the bill came  to                 
  under $60 thousand per year.  It is much more cost effective                 
  to have her son at home than in an institution.   Ms. Putnam                 
  urged passage of SSSB 5.                                                     
  Number 200                                                                   
  KAROL LIBBEY, testifying from Anchorage, explained she works                 
  with several families that have medically involved children.                 
  Some of them are  served by Medicaid.  She said  some of the                 
  families  are  having to  compromise  their  family economic                 
  situation severely to  receive the Medicaid coverage.   This                 
  can compound the  issues of the  medically fragile child  by                 
  imposing limitations  whereby the  family is  unable to  get                 
  employment that  would adequately support  them and  support                 
  other  children in the  family.  Ms.  Libbey said  it is not                 
  unlikely to  see depression in families where they feel such                 
  a limitation  in what they  are able to  do if they  provide                 
  what is needed for the medically  fragile child.  Ms. Libbey                 
  urged support of the legislation.                                            
  Number 233                                                                   
  ELAINE HURLEY, Mother  of Brianna Hurley,  explained Brianna                 
  has a terminal brain disease which causes a severe amount of                 
  brain damage  and disabilities.  Brianna needs 24 hour care.                 
  She said last year she lobbied very hard for HB 34, which is                 
  the  same  bill as  SSSB 5.    It passed  the House  and two                 
  committees in the Senate, but never made it to the floor for                 
  a vote.   Ms. Hurley said last year  she was married and her                 
  husband had a job  but ended up quitting to  provide Brianna                 
  with Medicaid.   She said  it is cost effective  to keep the                 
  children in the  home and not break up  families.  She urged                 
  support for the bill and passage this year.                                  
  Number 270                                                                   
  CHRISTINE  CULATON, from Juneau, was next  to testify on the                 
  measure.   She informed  the committee she  has a  daughter,                 
  Cortney, who is eight  years old and is a  medically complex                 
  child.    Ms. Culaton  said  her  daughter was  forced  into                 
  institutionalized care and an out of state placement because                 
  the State of Alaska could not  meet her needs with Medicaid.                 
  She said her  insurance and income  were too high to  access                 
  the Medicaid system  and they weren't willing  to impoverish                 
  the  entire  family  in  order   to  meet  Cortney's  needs.                 
  Currently,  Cortney  lives  in a  foster  care  placement in                 
  Juneau.   She was  de-institutionalized under OBRA  89.  The                 
  State of Alaska had  a very difficult time finding  a foster                 
  placement for her daughter.   They searched for over  a year                 
  to  find  a family  that  was  willing to  help  provide the                 
  additional support that her family  would have readily given                 
  her had they been able to access Medicaid for her.  It costs                 
  the  state more money to provide  services or to find out of                 
  state  or  institutionalized  placements  than  it  does  to                 
  provide  the  families with  basic  Medicaid services.   Ms.                 
  Culaton  said the  families that  she  deals with  in Alaska                 
  primarily do not place their children in foster care but, in                 
  fact, impoverish the entire family  and access every service                 
  under  AFDC.   It  is not  cost  effective to  not implement                 
  options  for those  families that will  not be  eligible for                 
  waivers.   She said due to preexisting condition clauses and                 
  unaffordable insurance, these families cannot continue to be                 
  forced to separate or to live at  the poverty level and have                 
  it be acceptable to the state.  Ms. Culaton urged passage of                 
  SSSB 5.                                                                      
  There being no further testimony, CHAIRMAN RIEGER closed the                 
  public hearing.  He indicated there is  a proposed amendment                 
  by Senator  Ellis.   He asked  Senator Ellis  to review  the                 
  ramifications  between options  and waivers.   SENATOR ELLIS                 
  said waivers which are applied  for under Project Choice can                 
  continue to  be applied  for if  the department's  operating                 
  budget requests are approved.   He said the state  is asking                 
  the federal government for waivers of  which there will be a                 
  limited number.   Under  waivers, the  department can  offer                 
  families more services such as  respite care, etc., but they                 
  are limited in  the number of  people who can receive  them.                 
  Senator Ellis said the legislation is structured as sort  of                 
  a backup.   It only kicks  in, if necessary, 180  days after                 
  the department has the waiver  program going.  Options offer                 
  less  services  such as  just a  medical component  but more                 
  people can qualify.   He  said everyone can  qualify who  is                 
  categorically eligible.  Under the waivers, there will still                 
  be families  forced  onto  AFDC.   Senator  Ellis  said  the                 
  department can  give a more  technical definition as  to the                 
  difference between waivers and options.                                      
  JOHN SHERWOOD, Program Coordinator, Project Choice, Division                 
  of Medical  Assistance,  Department  of  Health  and  Social                 
  Services, explained a  waiver is a  waiver from the  federal                 
  government for certain Medicaid restrictions.  It allows the                 
  department to  offer  services that  they couldn't  normally                 
  offer under the  Medicaid Program.   The waivers allows  the                 
  department  to  offer  certain  home  and  community   based                 
  services  for individuals  who otherwise  would qualify  for                 
  care  in   institutions.    At  the  same   time,  the  same                 
  eligibility standards can be used for people who would be in                 
  institutions.     That  is   how  waivers  expand   Medicaid                 
  eligibility.  What the option does for children is it allows                 
  the  department  to  apply  that  same  income  standard  to                 
  children  without   a  waiver  and   without  offering  some                 
  additional services.  He said there are some small technical                 
  difference between the two.                                                  
  CHAIRMAN RIEGER questioned  the meaning of  page 3, lines  4                 
  and  5,  "...to  be  individuals  with  respect  to  whom  a                 
  supplemental security income  is being paid."   MR. SHERWOOD                 
  said  that  wording  means  that  the individuals  would  be                 
  treated  as  if  they qualified  for  supplemental  security                 
  income which is a  federal program for the aged,  the blind,                 
  and  the disabled.   If  you are  eligible  for supplemental                 
  security income, you are eligible  for Medicaid.  That means                 
  you would be  treated as if you  were in a class  of persons                 
  who are eligible for Medicaid.  Most Medicaid eligibility is                 
  tied to your eligibility to another program such as AFDC.                    
  CHAIRMAN RIEGER questioned  the meaning  of the language  on                 
  page  3, lines  28  through 31,  "Sec.  2   AS 47.07.030  is                 
  amended   by  adding  a   new  subsection  to   read:    (c)                 
  Notwithstanding (b)  of  this section,  the  department  may                 
  offer  a service  for which  the department  has received  a                 
  waiver from  the federal  government if  the department  was                 
  authorized, directed, or  requested to apply for  the waiver                 
  by  law  or  by a  concurrent  or  joint  resolution of  the                 
  legislature."    MR. SHERWOOD  said  that is  language which                 
  authorizes the department  to offer services under  a waiver                 
  that  isn't  listed in  section (b).    He said  he believes                 
  section (b) is the statute that lists the services which are                 
  covered and not covered.                                                     
  SENATOR SHARP said there has  been testimony that there  are                 
  children in  institutions because  the families  are at  the                 
  poverty level.  He said he  assumes that the state is paying                 
  50 percent of Medicaid for that.  He  asked Mr. Sherwood how                 
  many people would be eligible to come back under the program                 
  described in the bill.  MR. SHERWOOD said there are children                 
  in institutions, but it is difficult to say if they would be                 
  released  from  institutions.   He  indicated that  he would                 
  check on  the exact  figures, but  his recollection  is that                 
  there were 16 individuals in ICFMRs  who where under the age                 
  of 18.   There are 9  individuals in nursing facilities  and                 
  there are many children  in hospitals for a short  length of                 
  stay, but there  were only 5 who  were in for more  than 100                 
  days.  SENATOR ELLIS  indicated that there are  also several                 
  children in foster care  who would go back to  their parents                 
  and families.                                                                
  CHAIRMAN RIEGER indicated he still  has concern with Sec. 2.                 
  He said he would like to have a better explanation of why it                 
  is in the bill and what it does.                                             
  Number 446                                                                   
  DIANA RHOADES, legislative staff to  Senator Ellis, said the                 
  drafter of the bill, Terri Lauterbach, informed her that the                 
  department really  didn't have  the authority  to officially                 
  apply for the  waivers but they  went ahead and applied  for                 
  the waivers anyway.  She said a law must be passed directing                 
  the department to apply for any service that the legislature                 
  hasn't approved.   The  legislature didn't  pass  a law  but                 
  passed  a  Project Choice  Resolution.    The wording  is  a                 
  technical way to clear up that the department may offer this                 
  service under a resolution rather than a law.                                
  CHAIRMAN RIEGER said he understands  the explanation for the                 
  application of waivers  that have  occurred up to  now.   He                 
  said  he  is  concerned  with  how  this fits  in  with  the                 
  prioritization of medical assistance.  He said it seems that                 
  the language  could bypass the  prioritization process  that                 
  the legislature goes through of  saying what priority status                 
  the  services  are  in.    He  said he  can  see  where  the                 
  legislature could pass  a resolution, next year,  asking the                 
  department  to  look  into  a   waiver  for  another  thing.                 
  Inadvertently, it could be put ahead  of the service that is                 
  in the bill.                                                                 
  SENATOR  ELLIS said a  question had been posed  to him as to                 
  why it was put at the  bottom of the priority list where  it                 
  would be the first  to go if funds are  not appropriated for                 
  the full range  of Medicaid services.  He said if you decide                 
  to prioritize it and put it  above other services, you would                 
  make enemies.   Senator  Ellis said he  does understand  the                 
  concern.   He suggested maybe  tightening up the language on                 
  page 3 to make it more expansive.                                            
  Number 530                                                                   
  MS. PUTNAM informed the committee that in order for a waiver                 
  to take effect, the  Division of Medical Assistance  has the                 
  right to apply for  a waiver without having an  enactment of                 
  law.  In  order for the option to occur, the legislature has                 
  to  enact  a law.    At that  time the  Division  of Medical                 
  Assistance can check the appropriate box that would allow an                 
  option to go  into effect.  That is  why Sec. 2 needs  to be                 
  included in the bill.                                                        
  CHAIRMAN RIEGER  suggested  adding  the  wording  "prior  to                 
  January 1, 1993" on page 3, line 31, after "legislature."                    
  MR. SHERWOOD explained  Sec. 2 refers to  offering services.                 
  The option that the committee currently is discussing is not                 
  a service option.   It is an eligibility option.   Under the                 
  option, people wouldn't be  offered any additional services.                 
  Therefore, the language shouldn't apply to the option in the                 
  Number 560                                                                   
  ELMER  LINDSTROM, Special  Assistant  to Commissioner  Mala,                 
  Department of Health and Social  Services, said the position                 
  of the department and the  administration remains that there                 
  isn't the  need for  specific statutory  authority to  enter                 
  into waivers under the Medicaid Program.  Four waivers  have                 
  already been  approved by the federal government and will be                 
  implemented beginning July 1, 1993.   He said he isn't aware                 
  of any problems that  would arise by including  the language                 
  in the bill.  He said he doesn't want the committee to think                 
  that  the  administration would  feel  precluded from  going                 
  forward  in  the  future with  waiver  applications  and not                 
  having the authority to do so in statute.                                    
  Number 571                                                                   
  SENATOR ELLIS indicated he had  a proposed amendment on page                 
  3, line 25, after "are" delete the  rest of the sentence and                 
  replace  with  "either   not  available   to  them  or   are                 
  inappropriate for them  under this chapter."   The amendment                 
  makes the  point that  waivers currently  being applied  for                 
  under  Project  Choice  would  not  be appropriate  for  all                 
  families.  It would be up to the department to decide  as to                 
  whether the  option is appropriate.  He  moved Amendment #1.                 
  CHAIRMAN RIEGER  objected for the purpose of discussion.  He                 
  asked how the amendment would work  and why it is necessary.                 
  Senator  Ellis   referred  to  respite  services,  which  is                 
  available  under  a  waiver  but  isn't available  under  an                 
  option, and said there may be somebody that might be able to                 
  give  an  experience of  a service  under  a waiver  that is                 
  inappropriate for  that family.   He  said you  can serve  a                 
  family  thorough  an   option  which  is   potentially  less                 
  expensive than a waiver as it is a lessor range of services.                 
  TAPE 93-30                                                                   
  Number 001                                                                   
  SENATOR  SHARP  asked  if  Amendment  #1  is  the  amendment                 
  referred  to in the fiscal note.   SENATOR ELLIS said he was                 
  told that  the  fiscal note  has  changed and  indicated  he                 
  wasn't sure of the answer.                                                   
  MR. SHERWOOD  referred to  page 3,  Sec. (D),  and said  the                 
  federal government does  not waive the requirement  that the                 
  department offers an option to someone.  If the option is in                 
  the  books,  they would  receive  that option  regardless of                 
  whether a waiver was available to them.  The department does                 
  not waive the client's right to be covered under an optional                 
  group when they  get a  waiver.   Mr. Sherwood  said if  the                 
  option is  enacted, people are entitled to  it whether there                 
  is  a waiver space  available or not  if they qualify.   The                 
  option always comes  first and they  can make the choice  of                 
  whether they want the waiver.                                                
  Number 020                                                                   
  MS. CULATON  explained that  many  families access  services                 
  through the public school system and do  not need duplicated                 
  services through Health  and Human  Services other than  the                 
  medical component.   That is a  good example of someone  who                 
  would just  need an  option.   The school  district provides                 
  OTPT speech and other related support services under special                 
  education.  At  age three  the children go  into the  public                 
  school system.    So some  families  just need  the  medical                 
  component and not the other services offered under a waiver.                 
  An optional service  would give  them the Medicaid  coverage                 
  for  the medical condition.   Ms.  Culaton said  many school                 
  districts  contribute a  good  portion  of support  services                 
  through the district program.                                                
  MR. SHERWOOD said he  doesn't believe the fiscal  note would                 
  change if Amendment #1  is adopted.  The client  would still                 
  have the right to  the optional coverage whether or  not the                 
  additional language is added or not.                                         
  Number 040                                                                   
  CHAIRMAN RIEGER  asked if there was an objection to adopting                 
  Amendment #1.  Hearing no objection, the motion carried.                     
  At 2:20 p.m. a recess was  taken while the committee awaited                 
  the  arrival of  Terri Lauterbach.    At 2:30  p.m. Chairman                 
  Rieger called the meeting back to order.                                     
  CHAIRMAN RIEGER  referred  to language  on page  3, line  28                 
  through 31 and asked  why the language has been  included in                 
  the bill.  He also asked  what the effect will be on  future                 
  legislative  requests  for  the  department  to  investigate                 
  waivers or options.   He asked  if the language would  allow                 
  such  a waiver or option to take a precedence ahead of other                 
  things on  the optional  services list.   TERRI  LAUTERBACH,                 
  Legislative  Legal  Counsel,  Legislative   Affairs  Agency,                 
  explained that Sec.  2 of  SSSB 5 ratifies  a past  practice                 
  that the department has already been  doing.  They have been                 
  applying for waivers  from the  federal government to  offer                 
  services  allowed  under federal  waivers,   and  they offer                 
  those services even  though they haven't been  authorized by                 
  the legislature.   Ms. Lauterbach  said the statute  that is                 
  amended by  Sec. 2  says that  the department  has to  offer                 
  things that are mandatory under federal  law.  The bill says                 
  "the  department  may  offer  only  the  following  optional                 
  services,"  and  the  legislature has  laid  out  what those                 
  optional  services  are.    Ms.   Lauterbach  said  the  new                 
  subsection (c) would ratify what  the department has already                 
  been  doing and  would let  them continue  to  do it  in the                 
  future.    She noted  that it  wouldn't  do anything  to the                 
  priority  listing.   In  order to  offer something  that the                 
  federal government allows  under waiver, it would  seem that                 
  there needs to be  a statute to authorize the  department to                 
  do that.  That is why Sec. 2 is in the bill.                                 
  CHAIRMAN RIEGER said if next year the legislature authorizes                 
  the department  to pursue another  waiver for a  service and                 
  they would  commence offering that  service and if  money is                 
  tight and  not all  the services  can be  provided that  are                 
  listed on the  optional list of priority  medical assistance                 
  list,  would the  law require  the  department to  follow AS                 
  47.07.035 about how they would reduce those services so that                 
  the  waivered  service that  the  department has  started in                 
  effect would be the last to go because the statute says that                 
  the others  have to go  first in the  following order.   MS.                 
  LAUTERBACH said she believes so.  Sec. 2 could be amended to                 
  achieve a different result so  that a waivered service could                 
  be the first to go.                                                          
  CHAIRMAN  RIEGER asked what difference there would be if the                 
  words "prior to January 1, 1993" were  added to Sec. 2.  MS.                 
  LAUTERBACH said if there wasn't  a strict understanding with                 
  the department that they  couldn't do it in the  future, she                 
  would expect them to keep  doing what they have done in  the                 
  past.   Chairman  Rieger said  his concern is  that anything                 
  that is offered as  a waivered service under Sec.  2 ends up                 
  being automatically top  priority.  Ms. Lauterbach  said the                 
  bill  is ratifying something that is  already occurring.  It                 
  is not giving the department new authority.                                  
  Chairman  Rieger  asked  Ms.  Lauterbach  if  in  Sec.  3  a                 
  reference  could  be   made  to  waivered  services.     Ms.                 
  Lauterbach  said a  general reference could  be made  to any                 
  service offered  by the department  under a waiver  from the                 
  federal government that they were not directed to get by the                 
  legislature.  It could be added as "(1)."                                    
  Number 167                                                                   
  Chairman Rieger  asked Mr.  Lindstrom if  he had  a comment.                 
  MR.  LINDSTROM  said  he believes  that  the  Project Choice                 
  waivers are the  only waivers that  the department has  ever                 
  sought or contemplates  seeking at this  point.  He said  he                 
  doesn't think  it would be  possible or conceivable  for the                 
  current administration or for any  future administrations to                 
  go forward with a waiver without being in close contact with                 
  the legislature and seeking their advice.                                    
  Number 200                                                                   
  CHAIRMAN RIEGER said he had a proposed amendment.  In Sec. 2                 
  after  "legislature"  add a  sentence  which would  say "The                 
  department  shall  annually  submit to  the  legislature its                 
  recommendations about  where  a service  offered under  this                 
  subsection  should  be  placed  on   the  priority  list  in                 
  AS 47.07.035."   He asked Ms. Lauterbach if it would address                 
  the problem.   MS. LAUTERBACH said  if you don't put  a time                 
  deadline on the department to do  that, it would address the                 
  problem.  Chairman Rieger  moved Amendment #2.  He  asked if                 
  there was an objection to the motion.  Hearing no objection,                 
  Amendment #2 was adopted.                                                    
  Number 255                                                                   
  There  being  no  further  discussion  on  the  legislation,                 
  SENATOR MILLER  moved to  pass SSSB  5, with amendments  and                 
  accompanying fiscal notes, out of  the Senate HESS Committee                 
  with individual recommendations.  Hearing no  objection, the                 
  motion carried.                                                              

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