Legislature(2019 - 2020)SENATE FINANCE 532

03/16/2020 09:00 AM Senate FINANCE

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09:05:14 AM Start
09:05:44 AM SB134
10:26:58 AM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
-- Public Testimony --
Bills Previously Heard/Scheduled
**Please Note: All Public Testimony Will be via
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From Juneau: 586-9085, Anchorage: 563-9085
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Written Testimony Will be Accepted at:
                 SENATE FINANCE COMMITTEE                                                                                       
                      March 16, 2020                                                                                            
                         9:05 a.m.                                                                                              
9:05:14 AM                                                                                                                    
CALL TO ORDER                                                                                                                 
Co-Chair  von  Imhof  called the  Senate  Finance  Committee                                                                    
meeting to order at 9:05 a.m.                                                                                                   
MEMBERS PRESENT                                                                                                               
Senator Natasha von Imhof, Co-Chair                                                                                             
Senator Bert Stedman, Co-Chair                                                                                                  
Senator Click Bishop                                                                                                            
Senator Lyman Hoffman                                                                                                           
Senator Donny Olson                                                                                                             
Senator Bill Wielechowski                                                                                                       
Senator David Wilson                                                                                                            
MEMBERS ABSENT                                                                                                                
ALSO PRESENT                                                                                                                  
Senator  David Wilson,  Sponsor; Gary  Zepp, Staff,  Senator                                                                    
David Wilson.                                                                                                                   
PRESENT VIA TELECONFERENCE                                                                                                    
Albert Wall,  Deputy Commissioner, Department of  Health and                                                                    
Social  Services; Jared  Kosin,  President  and CEO,  Alaska                                                                    
State Hospital and Nursing  Home Association, Anchorage; Jon                                                                    
Zasada,  Policy Director,  Alaska Primary  Care Association,                                                                    
Hope;  Jocelyn  Pemberton,  CEO, Alaska  Hospitalist  Group,                                                                    
Anchorage;  Prentiss  Pemberton,   Counseling  Solutions  of                                                                    
Alaska,  Anchorage; Jennifer  Morton, Licensed  Professional                                                                    
Counselor,  Nome;  Vikki  Jo Kennedy,  Self,  Juneau;  Laura                                                                    
Porter, Self, Palmer.                                                                                                           
SB 134    MEDICAID COVERAGE OF LIC. COUNSELORS                                                                                  
          SB 134 was HEARD and HELD in committee for                                                                            
          further consideration.                                                                                                
SENATE BILL NO. 134                                                                                                           
     "An  Act relating  to medical  assistance reimbursement                                                                    
     for the  services of licensed  professional counselors;                                                                    
     and providing for an effective date."                                                                                      
9:05:44 AM                                                                                                                    
Co-Chair von Imhof discussed housekeeping and read the                                                                          
title of the bill.                                                                                                              
9:06:12 AM                                                                                                                    
SENATOR DAVID WILSON, SPONSOR, read from the sponsor                                                                            
statement (copy on file):                                                                                                       
     "An  Act relating  to medical  assistance reimbursement                                                                    
     for the  services of licensed  professional counselors;                                                                    
     and providing for an effective date."                                                                                      
     If  enacted, SB  134  would  add licensed  professional                                                                    
     counselors   to  the   list  of   independent  licensed                                                                    
     practitioners  to  address  the shortage  of  Medicaid-                                                                    
     eligible  behavioral  health  providers in  the  state,                                                                    
     afford  more options  for  beneficiaries, and  increase                                                                    
     access to behavioral health care.                                                                                          
     Currently, licensed professional  counselors (LPCs) are                                                                    
     only allowed  to provide  services in  community health                                                                    
     clinics  or  physician  mental  health  clinics,  which                                                                    
     limits the number of willing  providers. SB 134 expands                                                                    
     medical  assistance  reimbursement  services  to  cover                                                                    
     those   services  provided   directly/independently  by                                                                    
     Specifically, SB 134:                                                                                                      
     ? Adds Professional Counseling services  to the list of                                                                    
     Medicaid optional services under AS                                                                                        
     ?   Defines   Professional  Counseling   services   and                                                                    
     licensing under AS 08.29;                                                                                                  
     ?   Authorizes  Professional   Counselor  services   as                                                                    
     eligible  to  render  and   bill  for  Medicaid  funded                                                                    
     services  as  independent  practitioners  under  Alaska                                                                    
     Statute 47.07.030 (b).                                                                                                     
     ? Requests  the Department of Health  & Social Services                                                                    
     to  amend   the  state  plan  for   medical  assistance                                                                    
   coverage under Title XIX of the Social Security Act;                                                                         
     We respectfully  encourage your support of  Senate Bill                                                                    
9:08:03 AM                                                                                                                    
AT EASE                                                                                                                         
9:11:45 AM                                                                                                                    
GARY  ZEPP,  STAFF,  SENATOR  DAVID  WILSON,  discussed  the                                                                    
presentation "SB 134" (copy on  file). He commented that the                                                                    
bill concept was to add  additional capacity and utilization                                                                    
of  behavioral healthcare  in a  clinical  setting versus  a                                                                    
state  of crisis  in emergency  rooms throughout  the state.                                                                    
The  expansion of  healthcare was  projected to  reduce wait                                                                    
times  and   improve  quality  of  care   by  providing  the                                                                    
appropriate    care    by   the    appropriate    healthcare                                                                    
professional. He  related that the  cost would be  less than                                                                    
the  behavioral healthcare  in  emergency  rooms across  the                                                                    
state.  He said  that  conversations  with stakeholders  had                                                                    
revealed problems with wait times  for services like alcohol                                                                    
and  drug   abuse,  suicide  and  depression,   trauma  from                                                                    
violence and  serious mental illness;  wait times  for these                                                                    
issues  averaged 3  to 6  months for  Medicaid clients.  The                                                                    
wait times  were due to  a workforce shortage  of behavioral                                                                    
health professionals available  to receive Medicaid clients.                                                                    
He  thought  that  examples  of  the  behavioral  healthcare                                                                    
shortage  could   be  witnessed   in  the  daily   lives  of                                                                    
communities throughout the state.                                                                                               
9:13:18 AM                                                                                                                    
Mr. Zepp looked at Slide 2, "SB 134":                                                                                           
     "An  Act relating  to medical  assistance reimbursement                                                                    
     for the  services of licensed  professional counselors;                                                                    
     and providing for an effective date."                                                                                      
     SB 134  would add 717 Licensed  Professional Counselors                                                                    
     to the  Medicaid Optional Services. The  concept of the                                                                    
     bill  is  to  expand  behavioral  health  capacity  and                                                                    
     utilization  for Alaska's  most vulnerable  population,                                                                    
     our  Medicaid population.  If behavioral  health issues                                                                    
     can  be  treated  in a  preventative  manner  within  a                                                                    
     clinical  setting,  rather than  a  crisis  stage at  a                                                                    
     platinum  level, the  costs lesson  and the  quality of                                                                    
     the   healthcare  services   improves.  This   proposed                                                                    
     legislation  is a  piece of  the  puzzle for  providing                                                                    
     behavioral health services to Alaskans.                                                                                    
     his  would  provide  the  "appropriate  care  with  the                                                                    
     appropriate provider."                                                                                                     
Mr. Zepp said that  licensed, professional counselors were a                                                                    
valuable, cost  effective, part of treatment  for behavioral                                                                    
healthcare. He  stated that the  legislation was a  piece of                                                                    
the  behavioral  healthcare  puzzle  that  already  included                                                                    
licensed  social  workers,  PHD  psychologists,  prescribing                                                                    
nurse  practitioners,  marital  and family  therapists,  and                                                                    
medical   doctors  like   psychiatrists  and   primary  care                                                                    
physicians. He  relayed that  there were  approximately 717,                                                                    
licensed, professional counselors currently in the state.                                                                       
9:13:55 AM                                                                                                                    
Mr. Zepp spoke to Slide 3, " Behavioral Health":                                                                                
     Behavioral  health  is  the  scientific  study  of  the                                                                    
     emotions,   behaviors,  and   biology  relating   to  a                                                                    
     person's mental  well-being, their ability  to function                                                                    
     in   everyday  life,   and  their   concept  of   self.                                                                    
     "Behavioral health"  is the  preferred term  to "mental                                                                    
     health."   A  person   struggling  with   his  or   her                                                                    
     behavioral   health   may  face   stress,   depression,                                                                    
     anxiety,   relationship  problems,   grief,  addiction,                                                                    
     attention  deficit/hyperactivity  disorder or  learning                                                                    
     disabilities,  mood disorders,  or other  psychological                                                                    
     Counselors,  therapists,  life coaches,  psychologists,                                                                    
     nurse  practitioners,  or  physicians can  help  manage                                                                    
     behavioral  health  concerns  with treatments  such  as                                                                    
     therapy counseling or medication.                                                                                          
Mr. Zepp related that the  term  mental health  covered many                                                                    
of the same  issues as  behavioral health   but only covered                                                                    
the biological component of the aspect of wellness.                                                                             
9:14:47 AM                                                                                                                    
Mr. Zepp referenced Slide 4,  " Why Medicaid clients and who                                                                    
are they?":                                                                                                                     
     Medicaid  provides health  coverage and  long-term care                                                                    
     services  for   Alaska's  most   vulnerable:  children,                                                                    
     seniors, people with  disabilities, pregnant women, and                                                                    
     very low income or working poor.                                                                                           
     Medicaid  clients have  difficulties finding  access to                                                                    
     behavioral healthcare  and often have to  wait three to                                                                    
     six  months  for appointments.  So  you  can imagine  a                                                                    
     person in crisis who  cannot find behavioral healthcare                                                                    
     access  or are  told it's  available in  three to  four                                                                    
     months, what are their options?                                                                                            
     Alaska's  emergency room  facilities  are  in a  crisis                                                                    
     mode treating behavioral health issues.                                                                                    
Mr.  Zepp  stressed  that  the  legislation  would  directly                                                                    
impact the  lives of the states   most vulnerable population                                                                    
of citizens: the  poor, the young, and  seniors. He lamented                                                                    
that  Alaskas  emergency  rooms  had  been overwhelmed  with                                                                    
volumes of  Medicaid clients in emergency  situations and in                                                                    
need of behavioral  health. He shared that  leading cause of                                                                    
emergency  room  visits  were  related  to  alcohol  related                                                                    
disorders and  the associated ailments of  alcohol abuse. He                                                                    
furthered that  often Medicaid clients  had nowhere  else to                                                                    
go because of  the lack of access and the  lack of capacity,                                                                    
which caused two problems; patients  stay longer in hospital                                                                    
than they should  and if a Medicaid client is  in a stage of                                                                    
crisis without access  to the appropriate care    they leave                                                                    
the facility and the cycle repeats itself.                                                                                      
9:16:24 AM                                                                                                                    
Co-Chair  von  Imhof noted  that  Mr.  Zepp had  brought  up                                                                    
Medicaid because  of the recent  115 waiver and the  need to                                                                    
expand  access  to  health  insurance  for  that  particular                                                                    
population.  She asked if  Mr. Zepp could comment on private                                                                    
insurers and  whether the population  had access to  a wider                                                                    
pool of providers.                                                                                                              
Mr.  Zepp did  not  know specifics  of  coverage by  private                                                                    
insurance for  behavioral health.  He said he  could provide                                                                    
the information to the committee.                                                                                               
Mr. Zepp thought the General  Government Bargaining Unit had                                                                    
an employee assistance program  that covered counselling and                                                                    
other various services.                                                                                                         
9:17:29 AM                                                                                                                    
Senator Wilson  thought one of the  invited testifiers could                                                                    
answer the  question. He thought generally  private insurers                                                                    
covered 10  weeks of  behavioral health  therapy but  the it                                                                    
had to be  pre-approved, depending on the  provider. He said                                                                    
that   health   insurance   for  state   employees   covered                                                                    
behavioral health services.                                                                                                     
9:18:07 AM                                                                                                                    
Mr.  Zepp  turned  to Slide  5,  "Adult  Untreated  Behavior                                                                    
Health Statistics," which showed  a flow chart of statistics                                                                    
related to adult behavioral health:                                                                                             
      In 2017, of the 56.8 million adults ages 18 or older                                                                   
        with a behavioral health condition about 39.7                                                                           
        million (70 percent) did not receive treatment in                                                                       
        the past year.                                                                                                          
      18.7 million with substance use conditions, 17.2                                                                       
        million of those are untreated                                                                                          
      11.2 million with serious mental illness, 3.7                                                                          
        million of those are untreated                                                                                          
      35.4 million with other mental illness, 22.9 million                                                                   
        of those are untreated                                                                                                  
Mr.  Zepp said  that approximately  70 percent  of Americans                                                                    
that  needed  behavioral  health services  did  not  receive                                                                    
treatment. For  substance abuse disorders the  statistic was                                                                    
92  percent; 66  percent of  adults with  serious behavioral                                                                    
health issues  did not receive  treatment. He  lamented that                                                                    
lack  of  treatment  in  a   timely  manner  often  lead  to                                                                    
interactions with law enforcement,  and the court and prison                                                                    
systems.  He  relayed  at according  to  Bureau  of  Justice                                                                    
Statistics approximately  51.4 percent  of prisoners  have a                                                                    
seriously  psychological distress  or  a  history of  mental                                                                    
health  problems,  20  percent   of  which  were  considered                                                                    
severely and persistently mentally ill.                                                                                         
9:19:03 AM                                                                                                                    
Mr.   Zepp  considered   Slide   6,  "Children's   Untreated                                                                    
Behavioral  Health Statistics,"  which  showed  a bar  graph                                                                    
entitled 'Depression, Anxiety,  Behavior Disorders, by Age."                                                                    
He  pointed  out  that children  were  very  susceptible  to                                                                    
behavior health  issues. Common issues  included depression,                                                                    
anxiety, behavioral  disorders, and most  commonly Attention                                                                    
Deficit Hyperactivity Disorder (ADHD).  He said that a child                                                                    
diagnosed with depression had a  74 percent chance of having                                                                    
a co-disorder  like anxiety. He  warned that if  not treated                                                                    
the condition  increased and worsened over  time. He pointed                                                                    
out that boys  were more likely than girls to  have a mental                                                                    
disorder and  children living below  the poverty line  had a                                                                    
22  percent  more likelihood  of  a  mental, behavioral,  or                                                                    
developmental  disorder. He  stressed  that the  legislation                                                                    
could  expand  the  capacity  of  behavioral  healthcare  in                                                                    
schools, communities, and healthcare facilitates.                                                                               
9:20:04 AM                                                                                                                    
Mr.  Zepp  lamented  that mental  disorders  among  children                                                                    
could  cause serious  changes in  ways that  children learn,                                                                    
behave, and  express their emotions, which  can cause stress                                                                    
throughout their day.                                                                                                           
Mr.   Zepp  displayed   Slide  7,   "Alaska  assessment   of                                                                    
behavioral health care needs":                                                                                                  
     Mental  Health  Care  Needs Alaska's  suicide  rate  is                                                                    
     among the  highest in the  nation, with  the prevalence                                                                    
     among  the Alaska  Native  population, particularly  in                                                                    
     the most remote areas of  the state, surpassing that of                                                                    
     the general  Alaskan population1  (Figure 1).  The 2016                                                                    
     Alaska  Behavioral  Health  Systems  Assessment  Report                                                                    
     estimated  that 145,790  adult Alaskansroughly   20% of                                                                    
     the  state's  populationneed    mental  and  behavioral                                                                    
     health  services. One  component  necessary to  address                                                                    
     mental health issues is a  well-trained cadre of mental                                                                    
     health care  providers to provide  preventative support                                                                    
     and treatment.                                                                                                             
     There  are  several  reasons  why  individuals  needing                                                                    
     mental  health services  do not  receive them.  In some                                                                    
     cases,  the   perceived  stigma  associated   with  the                                                                    
     problem  or illness  prevents individuals  from seeking                                                                    
     help.  In   other  cases,   individuals  may   be  more                                                                    
    comfortable seeking help from alternative providers                                                                         
     such as  faith-based, tradition/culture based  or peer-                                                                    
     support  resources  within  their  community.  Finally,                                                                    
     particularly in  remote areas, availability  and access                                                                    
    to mental health care providers are often limited.                                                                          
Mr.  Zepp  relayed  that  Alaska has  the  highest  rate  of                                                                    
suicide, per  capita, of any  state in the country  and that                                                                    
suicide was the number one  cause of death for Alaskans ages                                                                    
10 to  64. He said  that the  states  suicide rate  was 21.8                                                                    
suicides per 100,000  people; for rural Alaska  it was 35.1.                                                                    
He relayed that there was  a 13 percent increase in suicides                                                                    
from  2013  to 2017,  as  compared  to the  previous  5-year                                                                    
period of 2007  to 2011. He related  that toxicology results                                                                    
following  suicides since  2015 showed  70 percent  involved                                                                    
one or  more substances, most frequently  alcohol. He shared                                                                    
that more than 90 percent of  people who die by suicide have                                                                    
depression  or diagnosable,  treatable, mental  or substance                                                                    
abuse disorders.                                                                                                                
9:21:27 AM                                                                                                                    
Mr.  Zepp  highlighted  Slide  8,  "  Alaska  assessment  of                                                                    
behavioral health care needs":                                                                                                  
     How Many Behavioral Health Care Providers Are Needed?                                                                      
     Despite   the  number   of  individuals   in  need   of                                                                    
     behavioral   health  care   services,   the  ratio   of                                                                    
     behavioral  health  care  providers  to  population  is                                                                    
     lower  in  Alaska  than nationally.  Furthermore,  most                                                                    
     providers work  in urban areas,  such that  the state's                                                                    
     remote  areas   have  even   lower  provider/population                                                                    
     ratios.  There  are  many types  of  behavioral  health                                                                    
     providers     in    Alaska     (e.g.,    psychiatrists,                                                                    
     neurologists,  psychologists,  counselors,  clinicians,                                                                    
     technicians,   behavioral   nurse  practitioners,   and                                                                    
     behavioral health  aides), though  as an  example, here                                                                    
     we  consider only  the shortage  of psychiatrists.  Two                                                                    
     studies   estimated  a   need  for   25.96  and   15.37                                                                    
     psychiatrists per  100,000 adults nationally,  with the                                                                    
     authors of the second  study noting that the behavioral                                                                    
     health  care needs  of rural  populations may  not have                                                                    
     been  adequately captured.  National  estimates do  not                                                                    
     account for Alaska's  unique population, geography, and                                                                    
     need but  can serve as  a benchmark for  estimating the                                                                    
     number  of psychiatrists  needed  in  Alaska. Based  on                                                                    
     2010   Census   data,   Alaska   needs   184   or   106                                                                    
     psychiatrists, respectively.                                                                                               
9:22:15 AM                                                                                                                    
Mr.  Zepp   looked  at  Slide  9,   "Alaska  Emergency  Room                                                                    
Department;  Super-Utilizer Facts  -  Total Medicaid  Billed                                                                    
Charges," which showed a bar  graph that reflected the total                                                                    
cost  that  the  state  had  paid  to  emergency  rooms  for                                                                    
Medicaid clients  throughout the  state over the  previous 4                                                                    
Mr.  Zepp continued  to address  Slide 9.  He noted  that in                                                                    
2016, the state  paid over $233 million, which  had risen by                                                                    
$47.1 million,  or 20.1 percent.  He said that in  2019, the                                                                    
top 2.9  percent of super  utilizers (more than 5  ER visits                                                                    
per calendar year)  consumed 16.3 percent of  the charges at                                                                    
$46 million. He  furthered that that was 1301  clients at an                                                                    
average cost  of $35,357  per person.  He furthered  that in                                                                    
2019,  10.03 percent,  or 6,250  Medicaid clients,  cost the                                                                    
state $114  million    40.67 percent  of the  overall annual                                                                    
charges.  He   lamented  that  costs   were  rising   at  an                                                                    
unsustainable rate. Programs needed  to be improved and made                                                                    
more  cost efficient.  He believed  that  outcomes would  be                                                                    
improved by adding more licensed professional counselors.                                                                       
9:23:59 AM                                                                                                                    
Senator  Wielechowski asked  whether  the graph  on Slide  9                                                                    
showed all Medicaid clients or only behavioral health.                                                                          
Mr.  Zepp  replied  that the  chart  included  all  Medicaid                                                                    
Senator  Wielechowski  asked  whether  there was  a  way  to                                                                    
separate  the  behavioral  health   clients  from  the  non-                                                                    
behavioral health clients.                                                                                                      
Mr. Zepp  stated he had  a "super-utilizer" report  (copy on                                                                    
file) that might prove illuminating.                                                                                            
9:24:56 AM                                                                                                                    
Senator Bishop understood  that a  super utilizer   had 5 or                                                                    
more visits to the ER per calendar year.                                                                                        
Mr. Zepp replied in the affirmative.                                                                                            
9:25:11 AM                                                                                                                    
Co-Chair  von  Imhof asked  whether  Mr.  Zepp had  a  slide                                                                    
showing super-utilizers.                                                                                                        
Mr.  Zepp  replied  that  he  did  not  have  a  slide  that                                                                    
specifically showed  the Alaska  Medicaid facts  and figures                                                                    
from DHSS,  but he  had several  graphs that  summarized the                                                                    
9:25:53 AM                                                                                                                    
Senator Wielechowski pointed out  to everyone that the fifth                                                                    
page of  the report  listed that the  health issues  for the                                                                    
top 2.7 percent of patients, with more than 10 visits were:                                                                     
   1. Alcohol abuse with intoxication                                                                                           
   2. Alcohol dependents with withdrawal                                                                                        
   3. Chest pain                                                                                                                
Co-Chair   von  Imhof   relayed  that   the  Department   of                                                                    
Corrections  subcommittee  had  discussed  inebriates  being                                                                    
picked up and held until  they were sobered up. She wondered                                                                    
whether the  state needed more   sleep it off   centers. She                                                                    
wondered   whether  the   sponsor  could   comment  on   the                                                                    
prevalence of alcohol as an outstanding issue.                                                                                  
Senator Wilson  stated that the  bill was trying  to address                                                                    
some  of  the larger  issues,  but  not all  super-utilizers                                                                    
would  be  addressed.  He  cited that  a  large  hospital  I                                                                    
Anchorage had over  220 assessments at their ER  that had to                                                                    
be  billed  at  a  high  rate.  He  discussed  the  provider                                                                    
shortage and  mentioned un-used beds in  the Mat-Su hospital                                                                    
due to lack of the ability  to bill Medicaid for them due to                                                                    
the  provider  shortage.  He wanted  to  allow  entities  to                                                                    
recoup costs related  to the high need  of behavioral health                                                                    
services in the state.                                                                                                          
9:28:29 AM                                                                                                                    
Mr. Zepp  continued to address  Slide 9. He  considered that                                                                    
by  adding  more LPC  counseling  services  the state  could                                                                    
improve outcomes. He  said that the federal  approval of the                                                                    
state's 1115 waiver for  behavioral healthcare services, and                                                                    
by  adding   LPCs  to  the  mix   of  behavioral  healthcare                                                                    
professionals,  would  provide  the  opportunity  to  expand                                                                    
capacity, increase quality of care,  and lower the cost that                                                                    
the state was already paying.                                                                                                   
9:29:14 AM                                                                                                                    
Senator Wielechowski understood that  there was a difference                                                                    
between  behavioral health  and mental  health. He  wondered                                                                    
whether the LPCs  that would be hired would  be dealing with                                                                    
alcohol related issues.                                                                                                         
Mr. Zepp answered in the  affirmative. He noted that SB 105,                                                                    
passed  in  2018,  included   licensed  marital  and  family                                                                    
therapists who could treat substance abuse.                                                                                     
Senator  Wielechowski  spoke  of the  2,531  patient  visits                                                                    
related  to  alcohol abuse  with  intoxication  in 2018.  He                                                                    
thought  that the  2019 numbers  showed  alcohol abuse  with                                                                    
intoxication as the leading cause of patient visits.                                                                            
9:30:26 AM                                                                                                                    
Mr.  Zepp   addressed  Slide  10,  "Alaska   Emergency  Room                                                                    
Department   Super-Utilizer   Facts   Number   of   Medicaid                                                                    
Clients," which showed  a line graph that  depicted that the                                                                    
medical costs,  and not  the number  of Medicaid  clients in                                                                    
ERs, had  increased. He stated  that invited  testimony from                                                                    
DHSS  would comment  on the  statistics. He  reiterated that                                                                    
the  most common  diagnosis for  super  utilizers were  form                                                                    
alcohol related  disorders and associated ailments.  The top                                                                    
2.7 percent  were likely to  be between  20 and 59  years of                                                                    
age; 61 percent were female, and 39 percent were male.                                                                          
9:31:10 AM                                                                                                                    
Mr.  Zepp  turned  to  slide  11,  "Preventative  behavioral                                                                    
health care can reduce costs":                                                                                                  
     Cost of Emergency Room visit  for Medicaid client for a                                                                    
     behavioral  health  assessment  =  $4,360  versus  $200                                                                    
     average per  clinical visit to a  behavioral healthcare                                                                    
     professional  like  a Licensed  Professional  Counselor                                                                    
     The fiscal note from the  Department of Health & Social                                                                    
     Services  reflects that  20%  of  the Medicaid  clients                                                                    
     would receive behavioral health  services from LPCs, if                                                                    
     this bill were passed. Keep  in mind, these are not new                                                                    
     Medicaid clients, they are  current clients. In FY2019,                                                                    
     the total  cost of  emergency room  care in  Alaska for                                                                    
     Medicaid clients totaled $280.0  million. If we use 20%                                                                    
     of  the  Medicaid   client  population  for  comparison                                                                    
     purposes  as  stated in  the  fiscal  note, we  believe                                                                    
     there is  an opportunity for significant  cost savings.                                                                    
     ?  In   2019:  62,284  Medicaid  clients   visited  the                                                                    
     emergency rooms in Alaska:                                                                                                 
     ? 20% X 62,284 clients= 12,457 clients                                                                                     
          ? Current costs of emergency room visits = 12,457                                                                     
          clients X $4,360 = $54,312,250                                                                                        
          ? Current average costs of LPC clinical visit =                                                                       
          12,457 clients X $200 = $2,491,520                                                                                    
     The difference equals = $51,821,120.  We are not saying                                                                    
     this  is  what you'll  save  but  you can  clearly  the                                                                    
     potential  savings of  diverting Medicaid  clients from                                                                    
     the emergency room in a  crisis stage and at a platinum                                                                    
     cost  to   a  preventative  clinical  setting   with  a                                                                    
     Licensed Professional Counselor.                                                                                           
Mr. Zepp commented that the fiscal note from DHSS.                                                                              
Senator Wilson  commented that some  hospitals in  the state                                                                    
would   like  to   hire  an   LPC  to   help  divert   those                                                                    
overutilizing  the ER.  He elaborated  on  the various  ways                                                                    
that this would benefit hospitals.                                                                                              
9:34:58 AM                                                                                                                    
Senator Bishop asked the sponsor about the 12,457 clients                                                                       
listed on Slide 11, and how many of the visits were alcohol                                                                     
Senator Wilson stated that the departmental invited                                                                             
testimony would address the numbers further.                                                                                    
9:35:48 AM                                                                                                                    
Mr. Zepp looked at Slide 12, "SB 134":                                                                                          
     "An  Act relating  to medical  assistance reimbursement                                                                    
     for the  services of licensed  professional counselors;                                                                    
     and providing for an effective date."                                                                                      
     Acknowledgement of support &  our sincere thanks to the                                                                    
     ? Alaska State Hospital and Nursing Home Association                                                                       
     ? Providence Health and Services Alaska                                                                                    
     ? Southeast Alaska Regional Health Consortium                                                                              
     ? Alaska Regional Hospital                                                                                                 
     ? Mat-Su Health Foundation                                                                                                 
     ? Alaska Primary Care Association                                                                                          
     ? Mat-Su Health Services                                                                                                   
     ? Alaska Mental Health Trust Authority                                                                                     
     ? Alaska Department of Health & Social Services                                                                            
     ? Alaska  Department of Commerce, Community  & Economic                                                                    
     ? Discovery Cove Recovery & Wellness Center                                                                                
     ? Recover Alaska                                                                                                           
9:36:34 AM                                                                                                                    
Mr. Zepp addressed a Sectional Analysis (copy on file)"                                                                         
     SB 134 impacts AS  47.07.030(b) "Medical Services to be                                                                    
     Provided" and  AS 47.09.900 "Definitions,"  under title                                                                    
     47,  chapter  5,  "Administration  of  Welfare,  Social                                                                    
     Services, and Institutions."                                                                                               
     Section  1:  "Medical Services  to  be  Provided" -  AS                                                                    
     47.07.030(b) PAGE  1, LINES 4-14  & PAGE 2,  LINES 1-9:                                                                    
     expands  the Medicaid  optional  services by  including                                                                    
     professional  counseling   services  to  the   list  of                                                                    
     optional services  available through the  Department of                                                                    
     Health & Social Services under this subsection.                                                                            
     Section  2: "Definitions"    AS  47.07.900(20) PAGE  2,                                                                    
     LINES  10-14: amends  chapter  07, "Medical  Assistance                                                                    
     for  Needy   Persons"  by  adding  the   definition  of                                                                    
     professional counseling services.                                                                                          
     Section  3:  "Medical Services  to  be  Provided"    AS                                                                    
     47.07.030(b)  PAGE 2,  LINES  15-20: adds  professional                                                                    
     counseling services  to the  list of  optional services                                                                    
     available  through the  Department of  Health &  Social                                                                    
     Services under this subsection.                                                                                            
     Section 4:  "Medicaid State Plan and  Federal Approval"                                                                    
     PAGE  2,  LINES 21-29:  amends  the  uncodified law  to                                                                    
     instruct the  Department of Health and  Social Services                                                                    
     to submit  an amendment to  the state plan  for medical                                                                    
     assistance coverage and seek approval from the U.S.                                                                        
     Department of Health and Human Services.                                                                                   
     Section 5: PAGE 2, LINES 30-31 & PAGE 3, LINE 1:                                                                           
     provides for a contingent effective date.                                                                                  
9:38:58 AM                                                                                                                    
Co-Chair von Imhof  asked invited testimony to  speak to the                                                                    
issues related to the legislation.                                                                                              
ALBERT WALL,  DEPUTY COMMISSIONER, DEPARTMENT OF  HEALTH AND                                                                    
SOCIAL  SERVICES  (via   teleconference),  stated  that  the                                                                    
department  was pleased  to  work with  the  sponsor on  the                                                                    
bill. He  reiterated that it  was possible to  bill Medicaid                                                                    
currently,  but only  under  the auspices  of  working in  a                                                                    
clinic, with supervision from a  medical provider that could                                                                    
sign  off on  their work.  This limited  the number  of LPCs                                                                    
that  were  available  to do  work  with  Medicaid  patients                                                                    
across the  state. He stated  in the department's  view, the                                                                    
bill  would   provide  more  accessibility   for  behavioral                                                                    
healthcare  for Alaskans  and provide  some  relief for  the                                                                    
stress currently placed on the  behavioral health system. He                                                                    
noted that  currently a patient had  to be in crisis  and go                                                                    
to the  ER in  order to  get help.  The provision  of adding                                                                    
LPCs  as  independent  practitioners would  divert  patients                                                                    
from ERs by providing  more mid-level and preventative care.                                                                    
He shared that  private insurance covered LPCs,  to a point.                                                                    
He explained  that LPC coverage  was available  depending on                                                                    
the  individual   care  plan,   such  as   covering  several                                                                    
appointments with prior authorization;  counselors had to be                                                                    
referred and Medicaid did not cover those appointments.                                                                         
9:42:20 AM                                                                                                                    
Mr. Wall commented on the  super-utilizer program, which the                                                                    
department  called the  Care Management  Plan. He  explained                                                                    
that   the  individuals   in  the   plan  had   co-occurring                                                                    
conditions  and the  highest  number of  visits  to ERs.  He                                                                    
mentioned the  1115 Waiver, and thought  the legislation was                                                                    
an importance piece of rolling  out coverage for the waiver.                                                                    
He commented  that there  were a  few pieces  of legislation                                                                    
related  to   the  waiver.  He  discussed   substance  abuse                                                                    
providers, many of whom were LPCs.                                                                                              
Mr. Wall  explained that  the 1115 Waiver  was an  effort to                                                                    
drive the level of acuity down  in order to drive costs down                                                                    
and allow people to be treated in their communities.                                                                            
9:44:02 AM                                                                                                                    
Senator Hoffman  referenced Slide 11, which  was an analysis                                                                    
of potential  savings. He asked  Mr. Wall to comment  on the                                                                    
Mr. Wall  could not see the  slide but recalled he  had seen                                                                    
it previously.  He spoke generally  to the  savings proposed                                                                    
by the  bill. He explained  if more providers  were present,                                                                    
there was  better accessibility, which would  prevent crisis                                                                    
9:45:43 AM                                                                                                                    
Senator  Wielechowski  asked  how  patients  suffering  from                                                                    
alcohol  abuse related  issues were  cared for  in emergency                                                                    
room situations.                                                                                                                
Mr. Wall stated  that many hospitals had  an adjacent sleep-                                                                    
off centers.  He stated that generally  hospitals would give                                                                    
care  to  individuals  experiencing  a  dangerous  level  of                                                                    
intoxication  that  required  medical observation.  He  said                                                                    
that  if a  detox bed  was available,  the patient  would be                                                                    
sent there, but that the beds were limited.                                                                                     
Mr.  Wall  noted that  there  was  a significant  difference                                                                    
between  detoxification and  ongoing  therapy. He  explained                                                                    
that  the   detoxification  process  was  done   by  medical                                                                    
professionals that could administer  drugs if needed. An LPC                                                                    
would see  a patient on  an ongoing  basis in order  to keep                                                                    
the patient sober.  The LPC did the work to  keep people out                                                                    
of the ER in the first place.                                                                                                   
9:48:00 AM                                                                                                                    
Senator Wielechowski  asked whether  the bill  would provide                                                                    
hospitals with the  tools needed to break the  cycle of drug                                                                    
and alcohol abuse.                                                                                                              
Mr. Wall thought the bill was  not a panacea but would help.                                                                    
He thought  the problem  should be addressed  culturally and                                                                    
noted that alcohol killed people  at high rates all over the                                                                    
9:49:17 AM                                                                                                                    
Senator Hoffman asked  how many LPCs would be  needed and if                                                                    
there  were   enough  counsellors  available  to   fill  the                                                                    
positions should the funding become available.                                                                                  
Mr.  Wall thought  there was  700 LPCs  licensed across  the                                                                    
state  and  that  some  were  currently  working  in  health                                                                    
centers. He thought one barrier  that would happen to reduce                                                                    
the  effectiveness of  LPCs was  the administrative  work of                                                                    
billing  Medicaid.  He  did  believe  that  the  bill  would                                                                    
address  the issue  of accessibility.  He thought  that once                                                                    
the 1115 waiver made  different types of services available,                                                                    
the level of acuity in the state would decrease.                                                                                
9:52:18 AM                                                                                                                    
Senator Wielechowski pointed out  that the number one reason                                                                    
people  visited  the  ER was  for  acute  upper  respiratory                                                                    
issues such as  influenza. He asked what  the department was                                                                    
doing to educate the public,  and the Medicaid population in                                                                    
particular, about handwashing and social distancing.                                                                            
Mr. Wall explained  that the public health  did a tremendous                                                                    
job through  signage and advertisement;  including messaging                                                                    
through  radio  and  print. He  noted  that  providers  were                                                                    
trained to interact in a  preventative way with patients. He                                                                    
stressed  that there  was a  multi-level  effort to  address                                                                    
preventative care.                                                                                                              
9:54:16 AM                                                                                                                    
Co-Chair  von Imhof  thought that  cultural shifts  needed a                                                                    
catalyst  and  that Covid-19  could  be  that catalyst.  She                                                                    
considered  other  countries  behavior in  relation  to  the                                                                    
virus  and  noted   that  some  had  bent   the  curve  more                                                                    
successfully  than  others due  to  a  more robust  national                                                                    
response based  on historical knowledge. She  suspected that                                                                    
rather than just  signs in the doctor office  there would be                                                                    
signs everywhere in the ensuing years.                                                                                          
9:56:05 AM                                                                                                                    
JARED KOSIN,  PRESIDENT AND CEO,  ALASKA STATE  HOSPITAL AND                                                                    
NURSING  HOME ASSOCIATION,  ANCHORAGE (via  teleconference),                                                                    
introduced  himself.  He  explained  that  he  had  been  in                                                                    
meetings  all morning  regarding the  COVID-19 response.  He                                                                    
thought the bill should be  a priority. He expressed that if                                                                    
more  counselors  were  willing  and able  to  see  Medicaid                                                                    
patients,  Alaskas   behavioral health  care  will  be in  a                                                                    
better  place. He  emphasized that  hospitals were  the most                                                                    
expensive  point of  care in  the  healthcare continuum.  He                                                                    
stated it  was better for  the patients and  caregivers that                                                                    
people received care at the correct and preventative level.                                                                     
Mr. Kosin  pondered whether the  bill would  allow hospitals                                                                    
the tools to address the  problem. He strongly believed that                                                                    
if  there  was a  sustainable  place  in the  community  for                                                                    
individuals  to receive  long-term  recovery  care it  would                                                                    
allow patients  to receive needed  services at a  much lower                                                                    
cost to all  involved parties. He thought the  bill was very                                                                    
smart  public policy  and very  good fiscal  policy. He  had                                                                    
spoken with  a CEO  of a rural  hospital, who  had expressed                                                                    
that if the bill did not  get passed  all hope was lost.  He                                                                    
reiterated his strong support for the legislation.                                                                              
10:00:43 AM                                                                                                                   
Co-Chair von Imhof OPENED public testimony.                                                                                     
JON   ZASADA,   POLICY   DIRECTOR,   ALASKA   PRIMARY   CARE                                                                    
ASSOCIATION, HOPE (via teleconference),  spoke in support of                                                                    
the bill.  He stated that adding  Medicaid reimbursement for                                                                    
LPCs was a  top priority for his organization,  and had been                                                                    
for  many  years,  to expand  access  to  behavioral  health                                                                    
services. He  noted that  community healthcare  centers were                                                                    
already  using LPCs  in their  practices to  provide school-                                                                    
based services,  individual counselling  services, substance                                                                    
abuse   disorder   treatment,   and   in   supporting   care                                                                    
coordination  and  coaching  for basic  health  and  hygiene                                                                    
issues such  as handwashing. He explained  that the services                                                                    
were  not  reimbursable  and  were  paid  for  with  private                                                                    
grants,  which  was  not   sustainable.  He  furthered  that                                                                    
federally    qualified   health    centers   had    received                                                                    
considerable federal investment  to expand behavioral health                                                                    
services and  substance abuse treatment in  the primary care                                                                    
setting. Those  centers are  required to  provide behavioral                                                                    
healthcare  integrated with  medical, dental,  pharmacy, and                                                                    
other  services.  Adding LPCs  to  the  roster of  available                                                                    
providers  enables  health  centers to  make  their  service                                                                    
expansion sustainable  and was a national  best practice. He                                                                    
stressed that LPCs were a  valuable component to team based,                                                                    
whole person,  primary care. He explained  that whole person                                                                    
primary  care  consisted  of  medical,  dental,  behavioral,                                                                    
pharmacy, and support providers.                                                                                                
10:04:20 AM                                                                                                                   
JOCELYN PEMBERTON, CEO,  ALASKA HOSPITALIST GROUP, ANCHORAGE                                                                    
(via teleconference), testified  regarding her concerns with                                                                    
the  bill.  She  expressed  concern that  the  provision  to                                                                    
require a  medical provider  to oversee an  LPN in  order to                                                                    
provide  therapy would  restrict  access. She  said that  no                                                                    
other  insurance companies  had  the  same requirement.  She                                                                    
believed that many Medicaid recipients  could be referred to                                                                    
either psychiatrists  or nurse practitioners  for behavioral                                                                    
health  medication  prescriptions.  She stressed  that  talk                                                                    
therapy   could  prove   more  beneficial   to  a   persons                                                                     
behavioral health than medication.                                                                                              
10:06:21 AM                                                                                                                   
PRENTISS   PEMBERTON,   COUNSELING  SOLUTIONS   OF   ALASKA,                                                                    
ANCHORAGE  (via teleconference),  voiced  his concerns  with                                                                    
the  legislation.   He  noted  that  his   company  employed                                                                    
therapist  in  Anchorage  and  eagle  River  who  could  not                                                                    
provide  services to  Medicaid recipients  because they  did                                                                    
not  employ  a  psychiatrist.  He  reiterated  the  previous                                                                    
testifiers concerns about accessibility.                                                                                        
10:09:09 AM                                                                                                                   
JENNIFER MORTON, LICENSED  PROFESSIONAL COUNSELOR, NOME (via                                                                    
teleconference),  spoke  in support  of  the  bill. For  the                                                                    
previous eight  years she had  worked in rural parts  of the                                                                    
state  including Dillingham  and  surrounding villages.  She                                                                    
thought the primary issue in  rural Alaska is that there was                                                                    
only  one  option  for care:  the  community  mental  health                                                                    
center. She lamented  that many of the public  did not trust                                                                    
the  care provided  by  the centers  because  it was  short-                                                                    
lived.  This caused  abandonment issues.  She said  that the                                                                    
community  would not  seek services  if they  felt providers                                                                    
were not invested  in the community. She  had specialized in                                                                    
art therapy, which she thought  was culturally relevant. She                                                                    
stated that she  could not bill Medicaid.  She stressed that                                                                    
low-income,  unemployed people  needed  the  most help.  She                                                                    
stressed  the  additional  counselling services  would  help                                                                    
keep people out of the emergency room.                                                                                          
10:13:02 AM                                                                                                                   
VIKKI  JO   KENNEDY,  SELF,  JUNEAU   (via  teleconference),                                                                    
testified  in  support  of  the   bill.  She  discussed  the                                                                    
importance of mental health. She  had spoken with DHSS about                                                                    
the  matter. She  thought there  was a  problem with  people                                                                    
receiving services  and then leaving the  state. She thought                                                                    
mental  health services  and substance  abuse services  were                                                                    
10:14:51 AM                                                                                                                   
LAURA PORTER,  SELF, PALMER  (via teleconference),  spoke in                                                                    
support  of  the bill.  She  was  an  LPC  and worked  as  a                                                                    
subcontractor with  a children's  advocacy center.  She said                                                                    
that she received  weekly calls from people in  need and she                                                                    
had to  turn them away. She  shared that she was  in private                                                                    
practice and was willing to  take on the administrative side                                                                    
to billing Medicaid.                                                                                                            
Senator  Wilson  asked  Ms.  Porter  to  explain  a  child's                                                                    
advocacy center.                                                                                                                
Ms.  Porter  explained  that a  childrens   advocacy  center                                                                    
investigated  Office  of  Childrens   Services  (OCS)  cases                                                                    
involving abuse, neglect, or sexual assault.                                                                                    
10:16:59 AM                                                                                                                   
Co-Chair von Imhof CLOSED public testimony.                                                                                     
Co-Chair  von  Imhof  noted there  were  invited  testifiers                                                                    
available to answer questions.                                                                                                  
10:17:34 AM                                                                                                                   
Senator  Olson   wondered  why  the   fiscal  note   was  so                                                                    
significant for  a bill that  was expected to  save Medicaid                                                                    
Co-Chair  von  Imhof said  that  the  fiscal note  would  be                                                                    
10:18:00 AM                                                                                                                   
Senator Wielechowski  discussed FN 1 from  the Department of                                                                    
Health  and Social  Services, OMB  Component  3234. He  read                                                                    
from the analysis on page 2 of the fiscal note:                                                                                 
     The  bill   allows  licensed   professional  counselors                                                                    
     (LPCs)  to  enroll  and  participate  in  the  Medicaid                                                                    
     program  as individual  billing  providers and  receive                                                                    
     Medicaid   reimbursement    for   medically   necessary                                                                    
     services  provided to  eligible Medicaid  beneficiaries                                                                    
     outside of a clinic setting.                                                                                               
     Total number of registered LPCs in Alaska: 717                                                                             
     Percentage estimated  to accept Medicaid  patients: 20%                                                                    
     Estimated LPCs accepting Medicaid patients: 143                                                                            
     Estimated  number  of patients  seen  per  week by  one                                                                    
     counselor (one hour each): 20                                                                                              
     Percentage  of   patients  estimated  to   be  Medicaid                                                                    
     eligible: 20%                                                                                                              
     Estimated  Medicaid  patients  seen  per  week  by  one                                                                    
     counselor (one hour each): 4                                                                                               
     Current  individual psychotherapy  hourly reimbursement                                                                    
     for LPC: $118.60                                                                                                           
     143 LPCs  x 4 Medicaid patients/week  x $118.60/hr cost                                                                    
     = $67.8 estimated weekly incremental cost                                                                                  
     Estimated annual  incremental cost of LPCs  (48 working                                                                    
     weeks): $3,254.4                                                                                                           
     To  implement  this  bill a  modification  of  Medicaid                                                                    
     Management  Information System  to add  a new  provider                                                                    
     type and  associated business rules would  be required.                                                                    
     The  work  would  take an  estimated  600  modification                                                                    
     hours at a  total cost of $55.9 and  would be completed                                                                    
     by  the system  contractor. Adding  this provider  type                                                                    
     would  not require  additional  staff  to maintain  the                                                                    
     system changes.                                                                                                            
Co-Chair von Imhof asked Senator Wielechowski to review the                                                                     
fund sources.                                                                                                                   
Senator Wielechowski read from Page 1:                                                                                          
     Fund Source (Operating Only)                                                                                             
     1002 Fed Rcpts (Fed) $2,385.1                                                                                              
     1003 GF/Match (UGF) $14.0                                                                                                  
     1037 GF/MH (UGF) $911.2                                                                                                    
     Total: $3,310.3                                                                                                            
     1002 Fed Rcpts (Fed) through FY 26: $2,343.2                                                                               
     1037 GF/MH (UGF) through FY 26: $911.2                                                                                     
Co-Chair von Imhof referenced Senator Olsons question.                                                                          
10:20:46 AM                                                                                                                   
Senator  Wilson stated  that he  had been  working with  the                                                                    
department on the  fiscal note. He thought  it was difficult                                                                    
to disperse  the cost savings.  He discussed  the complexity                                                                    
of the medical billing.                                                                                                         
10:21:52 AM                                                                                                                   
Senator  Olson wondered  whether  the  sponsor expected  the                                                                    
fiscal impact to change.                                                                                                        
Senator  Wilson answered  in the  affirmative. He  said that                                                                    
the goal was  to increase the access at the  lower level and                                                                    
cost of care.                                                                                                                   
Senator Olson thought the plan was optimistic.                                                                                  
Co-Chair von  Imhof thought  the intent of  the bill  was to                                                                    
shift  care   when  appropriate  from  other   medical  care                                                                    
providers to  LPCs. She  thought the  issue was  any savings                                                                    
should  be examined  and considered.  She  thought it  could                                                                    
take several years for the system to come up to speed.                                                                          
Co-Chair  von  Imhof  addressed Senator  Olson's  point  and                                                                    
thought  the department  was  hesitant  to identify  savings                                                                    
until they materialized.                                                                                                        
10:23:31 AM                                                                                                                   
Senator Wielechowski  was curious  about Mr.  Walls  opinion                                                                    
on the matter.                                                                                                                  
Senator Wilson thought  that Gennifer Moreau-Johnson, Acting                                                                    
Director,  Division  of  Behavioral  Health,  Department  of                                                                    
Health and Social Services could speak to the question.                                                                         
10:24:01 AM                                                                                                                   
Ms. Moreau  stated that Senator Wilson  described the matter                                                                    
accurately, and  the fiscal note  reflected an  abundance of                                                                    
caution.   There  were   multiple   initiatives  that   were                                                                    
anticipated to result in a cost savings by reduced use of                                                                       
the emergency room. She detailed the complexity of the                                                                          
Senator Wielechowski queried the savings using the average                                                                      
cost of each ER visit.                                                                                                          
Ms. Moreau believed there had been a report submitted to                                                                        
the sponsor that cited the LPCER savings estimate, which                                                                        
was determined through the department's actuary.                                                                                
10:26:21 AM                                                                                                                   
SB 134 was HEARD and HELD in committee for further                                                                              
Co-Chair von Imhof discussed housekeeping.                                                                                      
10:26:58 AM                                                                                                                   
The meeting was adjourned at 10:26 a.m.                                                                                         

Document Name Date/Time Subjects
SB 134 - Sectional Analysis.pdf SFIN 3/16/2020 9:00:00 AM
SHSS 2/21/2020 1:30:00 PM
SB 134
SB 134 - Sponsor Statement.pdf SFIN 3/16/2020 9:00:00 AM
SHSS 2/21/2020 1:30:00 PM
SB 134
SB134 Letters of Support.pdf SFIN 3/16/2020 9:00:00 AM
SB 134
SB 134 Public Testimony MSHF.pdf SFIN 3/16/2020 9:00:00 AM
SB 134
SB 134 - LPCs to Medicaid Optional Services - Senate Finance Committee - 3.14.20.pdf SFIN 3/16/2020 9:00:00 AM
SB 134
SB 134 Mat-Su HUMS 2018 Q4 Report - Executive Summary.pdf SFIN 3/16/2020 9:00:00 AM
SB 134
SB 134 Providence Alaska Coordinated Care Project Overview.pdf SFIN 3/16/2020 9:00:00 AM
SB 134
SB 134 Public Testimony Pemberton.pdf SFIN 3/16/2020 9:00:00 AM
SB 134
SB 134 Public Testimony Bomalaski.pdf SFIN 3/16/2020 9:00:00 AM
SB 134