Legislature(2017 - 2018)CAPITOL 106

01/26/2017 03:00 PM House HEALTH & SOCIAL SERVICES

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Audio Topic
03:34:51 PM Start
03:35:50 PM Overview: Medicaid Redesign Implementation
05:05:54 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Joint with DHS Subcommittee
+ Update: Medicaid Expansion & Reform by Dept. of TELECONFERENCED
Health & Social Services
-- Testimony <Invitation Only> --
                    ALASKA STATE LEGISLATURE                                                                                  
                         JOINT MEETING                                                                                        
      HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                     
    HOUSE FINANCE SUBCOMMITTEE ON HEALTH AND SOCIAL SERVICES                                                                  
                        January 26, 2017                                                                                        
                           3:34 p.m.                                                                                            
MEMBERS PRESENT                                                                                                               
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                             
 Representative Ivy Spohnholz, Chair                                                                                            
 Representative Bryce Edgmon, Vice Chair                                                                                        
 Representative Sam Kito                                                                                                        
 Representative Geran Tarr                                                                                                      
 Representative David Eastman                                                                                                   
 Representative Jennifer Johnston                                                                                               
 Representative Colleen Sullivan-Leonard                                                                                        
HOUSE FINANCE SUBCOMMITTEE ON HEALTH AND SOCIAL SERVICES                                                                        
 Representative Les Gara, Chair                                                                                                 
 Representative Cathy Tilton                                                                                                    
 Representative Ivy Spohnholz                                                                                                   
 Representative Bryce Edgmon                                                                                                    
 Representative Sam Kito                                                                                                        
 Representative Geran Tarr                                                                                                      
 Representative David Eastman                                                                                                   
 Representative Jennifer Johnston                                                                                               
 Representative Colleen Sullivan-Leonard                                                                                        
MEMBERS ABSENT                                                                                                                
HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                             
 Representative Jonathan Kreiss-Tomkins (alternate)                                                                             
OTHER LEGISLATORS PRESENT                                                                                                     
Representative Dan Saddler                                                                                                      
COMMITTEE CALENDAR                                                                                                            
OVERVIEW: MEDICAID REDESIGN IMPLEMENTATION                                                                                      
     - HEARD                                                                                                                    
PREVIOUS COMMITTEE ACTION                                                                                                     
No previous action to record                                                                                                    
WITNESS REGISTER                                                                                                              
VALERIE DAVIDSON, Commissioner                                                                                                  
Office of the Commissioner                                                                                                      
Department of Health and Social Services (DHSS)                                                                                 
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:    Presented a  PowerPoint  overview  titled                                                             
"Medicaid Redesign Implementation."                                                                                             
MONIQUE MARTIN, Health Care Policy Advisor                                                                                      
Office of the Commissioner                                                                                                      
Department of Health and Social Services                                                                                        
Juneau, Alaska                                                                                                                  
POSITION  STATEMENT:    Presented a  PowerPoint  overview  titled                                                             
"Medicaid Redesign Implementation."                                                                                             
ACTION NARRATIVE                                                                                                              
3:34:51 PM                                                                                                                    
CHAIR IVY SPOHNHOLZ  called the House Health  and Social Services                                                             
Standing   Committee    meeting   to    order   at    3:34   p.m.                                                               
Representatives   Spohnholz,   Edgmon,  Kito,   Sullivan-Leonard,                                                               
Johnston, Eastman, Gara,  and Tilton were present at  the call to                                                               
order.    Representative  Tarr  arrived as  the  meeting  was  in                                                               
progress.  Also in attendance was Representative Saddler.                                                                       
^Overview: Medicaid Redesign Implementation                                                                                   
           Overview: Medicaid Redesign Implementation                                                                       
3:35:50 PM                                                                                                                    
CHAIR SPOHNHOLZ announced  that the only order  of business would                                                               
be the overview on Medicaid redesign implementation.                                                                            
[Chair Spohnholz passed the gavel to Chair Gara]                                                                                
3:35:56 PM                                                                                                                    
CHAIR  GARA declared  that the  Department of  Health and  Social                                                               
Services (DHSS)  would address the  large comprehensive  issue of                                                               
Medicaid  Reform and  Medicaid  Expansion, the  results, and  any                                                               
necessary  actions.    He  reiterated his  plan  to  forward  all                                                               
amendments from  this committee for  review by the  House Finance                                                               
3:37:17 PM                                                                                                                    
VALERIE  DAVIDSON,  Commissioner,  Office  of  the  Commissioner,                                                               
Department of  Health and Social Services  (DHSS), explained that                                                               
DHSS   had  worked   with  the   Alaska   State  Legislature   on                                                               
comprehensive Medicaid  Reform which, she declared,  went hand in                                                               
hand with Medicaid  Expansion.  She relayed  that a comprehensive                                                               
Medicaid  Reform bill  had  been passed  during  the 29th  Alaska                                                               
State Legislature.   She stated  that it had "been  an incredible                                                               
process working with Alaskans."   She reported that there were 16                                                               
different  groups working  on this,  and that  DHSS was  only the                                                               
lead on  12 of these groups.   She lauded the  collaboration with                                                               
stakeholders  throughout   Alaska  to  implement   the  necessary                                                               
3:39:40 PM                                                                                                                    
MONIQUE  MARTIN,  Health  Care  Policy  Advisor,  Office  of  the                                                               
Commissioner, Department of Health  and Social Services, directed                                                               
attention   to   the   PowerPoint   titled   "Medicaid   Redesign                                                               
Implementation."  She  relayed that during the  first efforts for                                                               
implementation  of   Senate  Bill  74  there   was  an  immediate                                                               
realization to  the scope of the  reforms and pointed to  slide 3                                                               
which broke out the 16 initiatives of the bill.                                                                                 
MS. MARTIN moved  on to slide 4, "Vision  for Medicaid Redesign."                                                               
She  listed  many of  the  partner  groups which  came  together,                                                               
including  the Alaska  Primary Care  Association  and the  Alaska                                                               
State Hospital  and Nursing Home  Association, to help  DHSS with                                                               
the   Medicaid  Redesign   and  Expansion   Technical  Assistance                                                               
Contract,  and  then  to  implement  the  aforementioned  reforms                                                               
contained  in  Senate  Bill  74.     She  discussed  the  guiding                                                               
principles of the  vision for Medicaid redesign  in Alaska, slide                                                               
4, as  well as  the graphic representation  of the  vision, which                                                               
showed  a  need  for  coordinated   care  both  horizontally  and                                                               
vertically  to ensure  this integration  so  that Alaskans  would                                                               
receive the best health care possible.                                                                                          
3:42:50 PM                                                                                                                    
MS. MARTIN  stated that she  would review the 16  initiatives and                                                               
she directed attention to slide  5, "Primary Care Case Management                                                               
& Health  Homes."  She  reported that  it had been  decided which                                                               
reforms needed to happen first  and which reforms "teed up" other                                                               
reforms.    She  said  that the  coordinated  care  demonstration                                                               
project,  one of  the  two  biggest reforms  in  Senate Bill  74,                                                               
included  primary  care  case management  and  the  health  homes                                                               
initiative  and  was  important  to   have  ramped  up  to  serve                                                               
Alaskans.   She added  that there  was also a  desire to  ramp up                                                               
some temporary case management  services for Medicaid recipients.                                                               
She   reported  that   the  Alaska   Medicaid  Coordinated   Care                                                               
Initiative,  also  known  as   the  super-utilizer  program,  was                                                               
expanded.   She  explained how  the case  management services  to                                                               
those recipients and their family  members receiving Medicaid had                                                               
been  expanded  to  help  with  navigation  of  the  health  care                                                               
delivery system.   She relayed  that the  other part of  the case                                                               
management initiative  was for health  homes, a  specific program                                                               
in  the  Patient Protection  and  Affordable  Care Act,  and  was                                                               
intended to  roll-out in 2018.   She noted  that this had  been a                                                               
long  process  through  the Centers  for  Medicare  and  Medicaid                                                               
Services (CMS) because it included  an enhanced federal match for                                                               
those recipients.  She noted  that most federal matches in Alaska                                                               
were  50 percent,  whereas the  health home  model allowed  for a                                                               
higher   federal  match   for   its  first   eight  quarters   of                                                               
implementation.  She said that there  was a lot of flexibility in                                                               
how to rollout the health home initiative.                                                                                      
3:46:03 PM                                                                                                                    
REPRESENTATIVE SULLIVAN-LEONARD  asked if health homes  were home                                                               
health care.                                                                                                                    
MS.  MARTIN replied  that health  homes could  be a  primary care                                                               
setting,  but could  also  be a  behavioral  health clinic  which                                                               
provided services.   She explained that it was  designed to allow                                                               
flexibility for  the health  care needs of  an individual  and to                                                               
reduce health care costs.                                                                                                       
CHAIR GARA asked  for clarification that the  health home project                                                               
was aimed  at connecting emergency  room over-users  with medical                                                               
care that was cheaper and more appropriate.                                                                                     
MS.  MARTIN expressed  her agreement  that  this was  one way  to                                                               
implement  health homes.   She  said  that it  could be  proposed                                                               
through  providers  for  behavioral health  clients'  health  and                                                               
primary care needs, as it offered  a lot of flexibility to set up                                                               
different programs.   She  pointed out that  this program  had an                                                               
enhanced  federal  match  of  90  percent  for  its  first  eight                                                               
3:48:56 PM                                                                                                                    
REPRESENTATIVE SADDLER  asked if health home  was also considered                                                               
a patient centered medical home.                                                                                                
MS.  MARTIN  replied  that  patient  centered  medical  home  was                                                               
another designation that  did not come with  the enhanced federal                                                               
3:49:31 PM                                                                                                                    
MS. MARTIN  directed attention to slide  6, and said that  one of                                                               
the two biggest  reforms in Senate Bill 74  was Behavioral Health                                                               
System  Reform,  which  she  described  as  "truly  comprehensive                                                               
behavioral health  reform, really looking at  identifying the gap                                                               
in  the continuum  of  care."   She reported  that  there was  an                                                               
important  partnership  with  the   Alaska  Mental  Health  Trust                                                               
Authority, that the  trustees had awarded almost  $10 million for                                                               
the  first three  years of  implementation of  Senate Bill  74 to                                                               
include  stakeholder  engagement, actuarial  consulting  services                                                               
for Section  1115 waiver, and  behavioral health.  She  said that                                                               
one of  the biggest milestones  for this reform was  submitting a                                                               
Section 1115 waiver  to the CMS, as it  would provide flexibility                                                               
in  the ways  to  provide and  pay for  Medicaid  services.   She                                                               
emphasized  this was  a  shift  to paying  for  value instead  of                                                               
volume in the  behavioral health system.  She said  that a waiver                                                               
concept paper  had been  recently submitted  to CMS,  the initial                                                               
step to the  Section 1115 waiver.  She declared  that six public-                                                               
private  teams were  working  on various  aspects  of the  waiver                                                               
application.    She  shared  that this  application  was  a  very                                                               
technical process with  lots of CMS requirements,  and included a                                                               
showing of budget neutrality.                                                                                                   
CHAIR GARA asked for an explanation of the Section 1115 waiver.                                                                 
3:53:07 PM                                                                                                                    
COMMISSIONER DAVIDSON explained that  the Section 1115 waiver was                                                               
a  waiver of  certain requirements  of the  social security  act.                                                               
She explained  that, in  this instance, as  the waiver  needed to                                                               
show budget neutrality, the department  had negotiated terms with                                                               
the  federal   government  for  ways   to  provide   health  care                                                               
differently in Alaska.   She shared that DHSS  was reviewing ways                                                               
to  improve  outcome  measures in  five  different  areas,  which                                                               
included expansion  of treatment capacity and  access to services                                                               
with   better  integration   of  care   in  different   settings,                                                               
integration  of  social  supports  to aid  with  an  individual's                                                               
success,  cost   and  outcomes   reform,  provider   payment  and                                                               
accountability reform, and delivery system reform.                                                                              
CHAIR  GARA asked  if this  would allow  for Medicaid  funding at                                                               
larger facilities than was currently available.                                                                                 
COMMISSIONER  DAVIDSON expressed  her agreement.   She  explained                                                               
that CMS  had a  two-step process to  waive the  institutions for                                                               
mental disease limitation.  She  stated that a facility with more                                                               
than 16  beds could not  bill Medicaid for treatment  services, a                                                               
problem for Alaska  as the state had a  larger treatment facility                                                               
in order  to maximize  economy of  scale and  reduce costs.   She                                                               
pointed out  that, as Alaska  was affected  disproportionately by                                                               
this exclusion, the Section 1115  waiver would allow for a waiver                                                               
of the  exclusion.   She noted  that these waivers  were for  a 5                                                               
year time period, and could be renewed.                                                                                         
CHAIR  GARA  asked   if  the  addition  of   social  supports  to                                                               
transition people out  of the system and back  into the community                                                               
would also be covered by  Medicaid through this waiver, and would                                                               
this be better than a 50 percent match.                                                                                         
COMMISSIONER  DAVIDSON explained  that  the  Section 1115  waiver                                                               
would allow Alaska to be  reimbursed at the appropriate level per                                                               
the individual's  eligibility.  She acknowledged  that this would                                                               
include coverage of the social supports.                                                                                        
3:57:16 PM                                                                                                                    
MS.  MARTIN  relayed  that  DHSS  would  also  contract  with  an                                                               
administrative  services organization  as  support  for this  new                                                               
system being developed with the  Section 1115 waiver.  She listed                                                               
the  next big  steps  to include  the release  of  a request  for                                                               
information  on an  administrative  services organization,  which                                                               
would allow  DHSS to  gauge the interest  for provision  of these                                                               
services, and  to ask  questions to help  flush out  the requests                                                               
for proposals.  She relayed that  this would help the Division of                                                               
Behavioral Health  Services to move from  management of contracts                                                               
with grantees and  providers toward analysis of  data provided by                                                               
the  administrative services  organization  identifying areas  of                                                               
potential gaps  as the new  system of  care was developed.   This                                                               
would allow  movement into policy  development for  the necessary                                                               
services for Alaskans.                                                                                                          
3:58:50 PM                                                                                                                    
MS. MARTIN  directed attention  to slides  7 and  8, "Coordinated                                                               
Care Demonstration Projects."  She  stated that these would allow                                                               
DHSS to test a new delivery  system and payment reform models for                                                               
the Medicaid program.   She listed some of  the specific measures                                                               
which  the   Coordinated  Care  Demonstration  Projects   had  to                                                               
include, including  the release of  a request for  information to                                                               
gauge interest.  She stated  that those responses had ranged from                                                               
regional accountable  care models to statewide  full risk managed                                                               
care, although none of these  responses were required to submit a                                                               
proposal when the  RFP (Request for Proposal) was  released.  She                                                               
relayed  that  DHSS  had found  some  funding  opportunities  for                                                               
technical  assistance, and  had  worked with  the Pacific  Health                                                               
Policy Group in  a review of the current system  of care and what                                                               
should  be  considered.   She  reported  that  the RFP  had  been                                                               
released on  December 30,  2016, as required  by Senate  Bill 74,                                                               
and  that  the  department   anticipated  an  intensive  proposal                                                               
evaluation during the extensive reply process.                                                                                  
CHAIR GARA asked what the project would do once it started.                                                                     
MS.  MARTIN expressed  her agreement  that  the coordinated  care                                                               
demonstration  projects  could  do  about  anything  someone  may                                                               
propose for case management services  to the more costly portions                                                               
of the Medicaid program, and that  they had not yet started.  She                                                               
said they could take on the  delivery of any health care model to                                                               
all  Medicaid  recipients in  a  region  of  the state,  or  even                                                               
statewide, as determined by the regional providers.                                                                             
COMMISSIONER DAVIDSON added that  the department had broad reform                                                               
authority under Senate  Bill 74, which allowed them  to work with                                                               
communities  and  providers  in  the testing  of  new  models  of                                                               
delivery.     She  acknowledged   that  it  had   sometimes  been                                                               
challenging for DHSS to pursue  new models for delivery of health                                                               
care until  they had been  granted this authority.   She reported                                                               
that many  of the proposals  had been very forthright  with their                                                               
information  and modeling.   She  pointed out  that DHSS  had not                                                               
done this  type of work  previously, so they brought  in national                                                               
experts to share  what was within the range  of possibility which                                                               
was being done  by other states.  DHSS was  encouraged to request                                                               
information from groups prior to refining the RFP process.                                                                      
4:05:34 PM                                                                                                                    
CHAIR GARA  asked to focus  more on  the adopted reforms  and the                                                               
cost benefit savings that were  currently happening with Medicaid                                                               
Expansion reform.                                                                                                               
COMMISSIONER  DAVIDSON offered  an  alternative  for sharing  the                                                               
appropriate timelines for expectations of progress.                                                                             
CHAIR GARA expressed his agreement.                                                                                             
4:07:55 PM                                                                                                                    
MS. MARTIN  moved on  to slide  9 "1915(i)  and (k)  Options" and                                                               
addressed implementation of these  options for home and community                                                               
based  services which  were designed  to keep  Alaskans in  their                                                               
homes.  She  stated that these were offered as  an alternative to                                                               
mandatory Medicaid  services for nursing level  of care, pointing                                                               
out that  these were designed to  keep people in their  home at a                                                               
lower  cost.   She  pointed  out that  this  would  allow for  an                                                               
enhanced  federal  match,  and  clarified  that  DHSS  would  not                                                               
implement a program which would  become mandatory.  She said that                                                               
both the  1915(i) and (k)  options were entitlement  programs and                                                               
could  not have  wait  lists  to set  caps  and  ensure DHSS  was                                                               
staying within  budget.  One  of the recommendations was  to move                                                               
forward with  the 1915(k) option  only, at this point,  to ensure                                                               
that DHSS could meet the  requirements for savings as detailed in                                                               
Senate  Bill 74.   She  relayed  that more  information would  be                                                               
forthcoming,  and  there  was  a possibility  for  pursuit  to  a                                                               
different type of waiver.                                                                                                       
CHAIR GARA  asked for  an example of  a state  paid institutional                                                               
level of care, which would  qualify for federal matching funds if                                                               
the waiver was approved.                                                                                                        
COMMISSIONER DAVIDSON  offered an  example of home  and community                                                               
based  services  which  included assistance  with  activities  of                                                               
daily living for which the state  had a 50 percent match, and she                                                               
shared that with  the 1915(k) waiver the state  would now receive                                                               
an enhanced  match of 56  percent.   She reported that  there was                                                               
still  hope to  move forward  with  a 1915(i)  option that  would                                                               
allow certain  behavioral health  services to  be moved  from 100                                                               
percent general fund  payment to a 50 percent  match, although it                                                               
did not appear to be feasible for the state at this time.                                                                       
COMMISSIONER DAVIDSON stated that, as  DHSS moved forward, it had                                                               
been very careful  about making sure "that we drill  down and get                                                               
the  information, due  the actuarial  analysis,  meet with  those                                                               
national experts  who can do a  deep dive on what's  happening in                                                               
Alaska" before making  any adjustments and decisions  for when to                                                               
move forward.   She  reiterated that the  1915(i) option  was not                                                               
currently feasible  for the state,  so DHSS was looking  at other                                                               
options to provide this service.                                                                                                
4:13:10 PM                                                                                                                    
MS. MARTIN  addressed slide 10,  "Criminal Justice Reform  (SB 91                                                               
Integration)," and relayed that there  was a workgroup related to                                                               
Senate Bill  91, implementation and integration  with the ongoing                                                               
efforts for reform in  Senate Bill 74.  She said  that DHSS had a                                                               
large  role in  conjunction  with the  Department of  Corrections                                                               
(DOC),  joining  in   a  monthly  work  group   which  looked  at                                                               
maximizing enrollment  in Medicaid and other  qualifying programs                                                               
for those  about to be  released from a correctional  facility in                                                               
order to ensure success upon release.                                                                                           
4:14:07 PM                                                                                                                    
REPRESENTATIVE  JOHNSTON asked  if both  the Section  1915(i) and                                                               
(k) programs were both longstanding.                                                                                            
COMMISSIONER  DAVIDSON  replied  that Section  1915(k)  was  made                                                               
available  with  the  passage   of  the  Patient  Protection  and                                                               
Affordable Care  Act, and  that Section  1915(i) was  through the                                                               
American Reinvestment and Recovery  Act (ARRA), with enhancements                                                               
through the Patient Protection and Affordable Care Act.                                                                         
COMMISSIONER DAVIDSON,  in response to Representative  Tarr, said                                                               
that  most   released  prisoners   were  eligible   for  Medicaid                                                               
Expansion.  She added that  behavioral health appointments in the                                                               
first week of release, along  with ongoing support had been shown                                                               
to be an  effective recidivism reduction effort  in other states,                                                               
and that DHSS was working with DOC to build healthy Alaskans.                                                                   
4:17:17 PM                                                                                                                    
MS. MARTIN  shared slide 11, "Emergency  Dept. Care Improvement,"                                                               
and  stated  that this  initiative  called  on the  Alaska  State                                                               
Hospital  and  Nursing  Home Association  (ASHNHA)  as  the  lead                                                               
agency,   adding  that   ASHNHA  had   identified  a   real  time                                                               
information exchange  to help those super-utilizers  of emergency                                                               
rooms  connect more  appropriately  with  primary care  services.                                                               
She relayed  that the information exchange  also identified those                                                               
seeking  prescription  drugs.    There were  new  guidelines  for                                                               
prescribing  narcotics  which  were  designed  to  reduce  opioid                                                               
abuse,  and  these  final  guidelines  had  been  distributed  to                                                               
hospitals for sign-off.   She pointed out that  this would reduce                                                               
the  number of  Alaskans inappropriately  using emergency  rooms,                                                               
and connect them with more  appropriate primary care, which could                                                               
reduce the costs.                                                                                                               
REPRESENTATIVE SADDLER asked if the guidelines were binding.                                                                    
COMMISSIONER  DAVIDSON, in  response, relayed  that the  governor                                                               
was  interested in  the  pursuit of  enhancements  to the  opioid                                                               
strategy  based on  the recommendations  from  the opioid  policy                                                               
task  force.    She  opined  that some  of  these  would  require                                                               
legislative changes,  while others could be  implemented in other                                                               
CHAIR  GARA, in  response  to Representative  Saddler, said  that                                                               
this would be discussed at a later meeting.                                                                                     
4:20:54 PM                                                                                                                    
REPRESENTATIVE  JOHNSTON asked  about emergency  room usage,  and                                                               
questioned whether  there was a  way to  track usage in  order to                                                               
see if the reforms were effective.                                                                                              
COMMISSIONER  DAVIDSON  replied  that   one  requirement  of  the                                                               
public-private partnership  was for tracking the  change once the                                                               
program was implemented.                                                                                                        
REPRESENTATIVE JOHNSTON  asked for the statistics  from last year                                                               
and this year.                                                                                                                  
COMMISSIONER  DAVIDSON  replied  that this  specific  project  in                                                               
partnership  with   Alaska  State   Hospital  and   Nursing  Home                                                               
Association was  still in the  planning and  implementation phase                                                               
and had not  yet begun.  However, a voluntary  program looking at                                                               
super-utilizers  and matching  them  with a  care coordinator  to                                                               
find a primary  care appointment was being tracked.   She offered                                                               
to provide the information as it became available.                                                                              
REPRESENTATIVE  TARR  said  that  there  had  been  a  successful                                                               
decrease in super-utilizers in her district.                                                                                    
CHAIR GARA reminded the committee to ask any budget questions.                                                                  
COMMISSIONER DAVIDSON relayed that DHSS  had tried to ensure that                                                               
the  changes  within  different  departments  was  integrated  to                                                               
ensure success.                                                                                                                 
4:25:15 PM                                                                                                                    
CHAIR GARA  asked about  services and  federal funding  now being                                                               
provided that had not been offered prior to Medicaid Expansion.                                                                 
COMMISSIONER  DAVIDSON   stated  that  there  was   a  telehealth                                                               
workgroup for  some of the  already mentioned  programs, although                                                               
with  a focus  on telehealth,  slide 12,  "Telehealth Workgroup."                                                               
She pointed  to the  members on  slide 13,  "Telehealth Workgroup                                                               
Members."  She  acknowledged some gaps in  the health information                                                               
infrastructure, stating that  a company had been  engaged to "get                                                               
where we  need to  be so  that we can  make better  data informed                                                               
decisions, to  make better health  policy decisions as  a state,"                                                               
slide  14, "Health  Information Infrastructure  Plan.   She added                                                               
that these were funded with a 90 percent match.                                                                                 
4:26:57 PM                                                                                                                    
REPRESENTATIVE  SULLIVAN-LEONARD  asked  if  there  had  been  an                                                               
increase in users during development of telehealth.                                                                             
COMMISSIONER  DAVIDSON said  that,  in tribal  health, there  had                                                               
been a significant  increase in the utilization  of telehealth as                                                               
the  equipment and  technology became  more available;  although,                                                               
there was not the same level  of growth in the non-tribal system,                                                               
noting that  there were  some limitations in  state law  that did                                                               
not allow tele-health  to exist at the extent  desired in Alaska.                                                               
She pointed  out that  tele-health allowed  an extended  level of                                                               
care  with a  limited  number of  providers  and specialists  and                                                               
without  an increase  to the  travel costs.   She  said that  the                                                               
tribal health system  had tracked the number  of encounters which                                                               
resulted  in   reduced  travel  and   an  overall   reduction  in                                                               
4:28:58 PM                                                                                                                    
COMMISSIONER  DAVIDSON  addressed   slide  15,  "Tribal  Claiming                                                               
Policy,"  and explained  that CMS  had extended  services through                                                               
tribal  and  non-tribal   partnerships  under  circumstance  when                                                               
certain  requirements were  met.   She relayed  that negotiations                                                               
for care  coordination agreements  and for state  plan amendments                                                               
were ongoing.                                                                                                                   
CHAIR  GARA  asked  whether  the entities  not  yet  approved  as                                                               
recipients had not completed negotiations.                                                                                      
COMMISSIONER  DAVIDSON expressed  her agreement.   She  explained                                                               
that during this  first year most of the effort  had been focused                                                               
on  travel.   She reported  that both  emergency travel  and non-                                                               
emergency,  medically   necessary  travel  was  covered   at  100                                                               
percent.    She  said  that ancillary  travel  and  accommodation                                                               
services were still under discussion,  and that care coordination                                                               
agreements had  to be in  place with  each provider.   She opined                                                               
that this could possibly present  a violation of Health Insurance                                                               
Portability and  Accountability Act (HIPAA).   She explained that                                                               
the  projected savings  in travel  had not  yet been  recognized.                                                               
She  shared  that currently  the  department  was reviewing  high                                                               
dollar, low  volume services,  although it was  not an  easy data                                                               
match for Indian Health Services and Medicaid requirements.                                                                     
4:32:45 PM                                                                                                                    
REPRESENTATIVE  TARR   asked  about   travel  costs   related  to                                                               
cancelled appointments and what was this frequency.                                                                             
COMMISSIONER  DAVIDSON  explained  that Alaska  weather  was  the                                                               
predominant reason for  missed appointments.  She  relayed that a                                                               
benefit  of the  tribal  claiming  policy was  that  a number  of                                                               
tribal  health organizations  had  expressed  interest in  taking                                                               
over this travel piece.                                                                                                         
CHAIR GARA asked for more  information on Medicaid Expansion, the                                                               
costs and the achievements.                                                                                                     
4:36:02 PM                                                                                                                    
MS. MARTIN jumped ahead to  slide 20, "Fraud & Abuse Prevention."                                                               
She  reported  that  Senate  Bill  74  had  created  the  "Alaska                                                               
Medicaid  False  Claim  and Reporting  Act,"  which  allowed  the                                                               
department  to  assess  interest   and  penalties  on  identified                                                               
overpayments, as  well as requiring  self-audits every  two years                                                               
which allowed the provider to  report any errors for overpayments                                                               
with no penalty.  She stated  that the first errors report to the                                                               
legislature was made  on November 15, 2016, and the  first set of                                                               
regulations  related to  audit and  provider record  keeping were                                                               
nearing completion.   She shared  that the  privatization reports                                                               
were due to be released to the legislature the next day.                                                                        
4:38:02 PM                                                                                                                    
COMMISSIONER  DAVIDSON directed  attention to  slide 23,  "Health                                                               
Care Authority," and noted that  the Department of Administration                                                               
was  the  lead  agency  for  this study  on  the  feasibility  of                                                               
creating a Heath  Care Authority and that  the preliminary report                                                               
would be released in February 2017.                                                                                             
COMMISSIONER  DAVIDSON  moved  on   to  slide  25,  "Medicaid  in                                                               
Alaska," and relayed that this  latest monthly report was through                                                               
December 28, 2016  and that it could  be found via a  link on the                                                               
DHSS website.   She explained that the report  showed that 27,415                                                               
Alaskans  were currently  enrolled  in Medicaid  Expansion.   She                                                               
noted that  the top bar  reflected the enrollees by  age category                                                               
and sex.                                                                                                                        
CHAIR GARA  asked if the  $316 million of services  provided were                                                               
covered at the Medicaid Expansion rate.                                                                                         
COMMISSIONER DAVIDSON replied that these  claims had been paid at                                                               
100  percent federal  match,  pointing out  that  these were  new                                                               
federal  revenues into  the Alaska  economy.   She expressed  her                                                               
appreciation that  these Medicaid Expansion revenue  benefits had                                                               
been dispersed  throughout the state  into every  community which                                                               
provided health care.                                                                                                           
CHAIR GARA asked for the parameters to Medicaid expansion.                                                                      
COMMISSIONER DAVIDSON  explained that Medicaid  Expansion covered                                                               
adults between  the ages  of 19 -  64 without  dependent children                                                               
with  incomes of  about  $20,000  for a  single  Alaskan.   Those                                                               
people over  64 were  covered by Medicare  and were  not eligible                                                               
for Medicaid Expansion.   People under 19 years of  age were also                                                               
not  eligible.     She  reported  that   Medicaid  Expansion  was                                                               
reimbursed  through the  Patient Protection  and Affordable  Care                                                               
Act, and  for the first three  hard calendar years, 2014  - 2016,                                                               
there was a 100 percent federal  match.  She clarified that these                                                               
were  not rolling  calendar  years.   Starting  in calendar  year                                                               
2017, the  federal match was  95 percent; in calendar  year 2018,                                                               
the  federal match  was 94  percent; in  calendar year  2019, the                                                               
federal  match was  93 percent;  and  in calendar  year 2020  and                                                               
beyond, the federal match was 90 percent.                                                                                       
4:44:59 PM                                                                                                                    
REPRESENTATIVE  SULLIVAN-LEONARD referenced  slide 18,  and asked                                                               
for  a  quick  overview  of   the  prescription  drug  monitoring                                                               
COMMISSIONER  DAVIDSON  explained   that  the  prescription  drug                                                               
monitoring program was  managed by the Board of  Pharmacy, in the                                                               
Department of  Commerce, Community  & Economic Development.   She                                                               
said that  it required providers  to submit data  that documented                                                               
and  tracked certain  prescription drugs,  including prescription                                                               
opioids.  Providers  had previously only been  required to report                                                               
monthly, but with the passage of  Senate Bill 74, the time period                                                               
was changed  to reporting on  a weekly  basis.  She  allowed that                                                               
there were  some exemptions,  including hospice  and end  of life                                                               
CHAIR GARA noted that this was not part of Medicaid Expansion.                                                                  
REPRESENTATIVE  SADDLER asked  about  the  benefit from  Medicaid                                                               
Expansion to boost  the economy, and its effect  on the recession                                                               
in the state.                                                                                                                   
CHAIR GARA clarified  that there had been almost  7,000 jobs lost                                                               
in  the state,  and  the budget  had  been cut  by  more than  $2                                                               
billion.   He asked what  had been  added to the  economy through                                                               
Medicaid Expansion with relation to jobs.                                                                                       
COMMISSIONER  DAVIDSON replied  that she  would get  back to  the                                                               
committee  with the  exact numbers,  and  referencing the  recent                                                               
economic  report  from  the  Department   of  Labor  &  Workforce                                                               
Development,  she pointed  out that  health care  was the  bright                                                               
spot in the Alaska economy.                                                                                                     
COMMISSIONER  DAVIDSON returned  attention  to the  pie chart  on                                                               
slide 25,  which showed the  percentage of Medicaid  enrollees by                                                               
category,  including  children  and children  with  disabilities,                                                               
parent caretakers,  adults with  disabilities, and seniors.   She                                                               
relayed  that  the   map  on  the  page   showed  the  geographic                                                               
representation  for both  Medicaid  Expansion  enrollees and  all                                                               
CHAIR GARA  asked about  the impact  of behavioral  health parity                                                               
under Medicaid Expansion.                                                                                                       
COMMISSIONER  DAVIDSON said  that  one of  biggest benefits  that                                                               
Medicaid Expansion had  provided in Alaska was  another payer for                                                               
behavioral  health services.   She  offered her  belief that  the                                                               
number of  paid behavioral health  claims was about  $19 million.                                                               
She explained that behavioral health  providers needed to operate                                                               
as  a business,  and  could  "only provide  a  certain amount  of                                                               
charity  care,"  as many  people  were  receiving these  services                                                               
although not being able to pay.   She declared that the state was                                                               
not even  close to  providing the  level of  necessary behavioral                                                               
health  services,  noting that  the  Section  1115 waiver  was  a                                                               
comprehensive way "to better meet our needs."                                                                                   
4:52:33 PM                                                                                                                    
COMMISSIONER  DAVIDSON  directed  attention  to  slide  26,  "ACA                                                               
Repeal and Replace Impacts."                                                                                                    
CHAIR GARA  asked if the  100 percent paid by  Medicaid Expansion                                                               
for  behavioral health  treatment displaced  any money  which the                                                               
state had paid for those services, or did it add services.                                                                      
COMMISSIONER  DAVIDSON  replied  that  the  state  had  saved  on                                                               
catastrophic  coverage for  more  than  450 Alaskans,  previously                                                               
paid through  the general  fund, but which  was now  paid through                                                               
Medicaid Expansion at  100 percent federal match.   She explained                                                               
that,  although an  inmate in  corrections was  not eligible  for                                                               
Medicaid, for  health care provided  on a contract basis  with an                                                               
overnight  stay,  the  inmate was  now  eligible  under  Medicaid                                                               
CHAIR  GARA  asked  if Medicaid  Expansion  displaced  any  state                                                               
expenditures on behavioral health.                                                                                              
COMMISSIONER  DAVIDSON   opined  that  she  could   "answer  that                                                               
question  about 100  different ways."    She asked  if she  could                                                               
provide the committee with a variety  of answers at a later time,                                                               
as there were significant improvements.                                                                                         
REPRESENTATIVE  SADDLER asked  how  the number  of enrollees  and                                                               
cost per claim under Medicaid  Expansion were currently comparing                                                               
to the projections, and if  those projections could change in the                                                               
COMMISSIONER DAVIDSON  replied that in FY2016  it was anticipated                                                               
that Department of  Health and Social Services  would need $145.4                                                               
million,  yet its  expenses  in  FY16 were  $149.5  million.   In                                                               
FY2017, the  projected Medicaid enrollment  had been  23,000, but                                                               
the actual  enrollment was 27,415.   She opined that this  was an                                                               
indication of a  decline in the economy, as more  people were now                                                               
eligible for Medicaid  Expansion than had been  anticipated.  She                                                               
relayed  that  the  projected expenditures  in  FY2017  would  be                                                               
higher than anticipated, some due  to pent-up demand and some due                                                               
to  the utilization  by those  who have  not had  prior coverage.                                                               
She shared that  this had been the experience  with other states,                                                               
noting that eventually it would level off.                                                                                      
4:58:01 PM                                                                                                                    
COMMISSIONER  DAVIDSON  returned  attention   to  slide  26,  and                                                               
reported  that  general  discussions  had included  a  repeal  of                                                               
Medicaid Expansion, although 31  states had expanded Medicaid and                                                               
those governors  were asking what  would replace it.   She shared                                                               
that there was  potential for elimination of  the requirement for                                                               
the individual  mandate for marketplace  plans.  She  stated that                                                               
50,000  Alaskans   had  coverage   through  either   Medicaid  or                                                               
marketplace  plans, and  she  asked what  would  happen to  those                                                               
individuals and  what would be  the economic impact for  the loss                                                               
of  those  resources.    She   pointed  out  that  some  specific                                                               
provisions  in the  Patient Protection  and  Affordable Care  Act                                                               
impacted the  work on health  reform, including health  homes and                                                               
the Section 1332  Waiver through the Division  of Insurance which                                                               
allowed  Alaska to  better help  the high-risk  pool in  order to                                                               
stabilize  the individual  market.   She emphasized  that private                                                               
insurance market place plans and  Medicaid went "hand in hand" as                                                               
better  health  insurance  coverage meant  fewer  people  needing                                                               
Medicaid.    She expressed  concern  with  Medicaid block  grants                                                               
becoming the  way to  shift an annual  allocation to  the states,                                                               
and then shifting the federal  responsibility to the states.  She                                                               
described  states  that  did well  with  Medicaid  block  grants:                                                               
large population,  large concentration  in large  urban settings,                                                               
care  is provided  the  same, travel  is not  an  access to  care                                                               
issue, no  tribal populations,  stable economy,  and low  cost of                                                               
care.   She declared that  Alaska did not  fit into any  of these                                                               
categories, although  if geography was  a factor, "we'd  be set."                                                               
She pointed out  that health care was provided to  meet the needs                                                               
of Alaskans in their settings,  noting that the provision of care                                                               
by tribes in a small community  was very different than the means                                                               
for provision of  care in a large urban setting.   She emphasized                                                               
that  Indian  Health  Service beneficiaries,  Alaska  Natives  or                                                               
American Indians,  were already  covered at 100  percent federal,                                                               
and  therefore,  should   not  be  included  in   a  block  grant                                                               
allocation.  She stated that,  unless this was considered, states                                                               
similar  to Alaska  with  a  large tribal  population  were at  a                                                               
disadvantage.   She reported that  states with a higher  cost for                                                               
providing health  care did not do  as well.  She  shared that, as                                                               
the allocations  were determined early  in the calendar  year and                                                               
did not include  offsets throughout the year,  any downward trend                                                               
during the year created a greater problem.                                                                                      
5:04:17 PM                                                                                                                    
CHAIR GARA  commented that this  would be the  nightmare redesign                                                               
should the law be changed.                                                                                                      
5:04:58 PM                                                                                                                    
COMMISSIONER DAVIDSON  added that a group  of Alaskans, including                                                               
providers,   in   a   recent   conversation   with   the   Alaska                                                               
congressional delegation  had stated  that the "kinds  of savings                                                               
that we are  trying to achieve in Medicaid  Reform through Senate                                                               
Bill 74  will be significantly compromised  if Medicaid Expansion                                                               
goes away."   She declared  that Medicaid Expansion  provided the                                                               
resources to  task the programmatic  changes, and  that expansion                                                               
and reform went hand in hand.                                                                                                   
[Chair Gara returned the gavel to Chair Spohnholz]                                                                              
5:05:54 PM                                                                                                                    
There being no further business before the committee, the House                                                                 
Health and Social Services Standing Committee meeting was                                                                       
adjourned at 5:05 p.m.                                                                                                          

Document Name Date/Time Subjects
DHSS presentation on Medicaid Redesign Implementation.pdf HHSS 1/26/2017 3:00:00 PM
Medicaid Redesign