Legislature(2007 - 2008)BUTROVICH 205
03/05/2008 01:30 PM Senate HEALTH, EDUCATION & SOCIAL SERVICES
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| Medicaid Behavior Health Presentation | |
| Adjourn |
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ALASKA STATE LEGISLATURE
SENATE HEALTH, EDUCATION AND SOCIAL SERVICES STANDING COMMITTEE
March 5, 2008
1:34 p.m.
MEMBERS PRESENT
Senator Bettye Davis, Chair
Senator Joe Thomas, Vice Chair
Senator John Cowdery
Senator Kim Elton
MEMBERS ABSENT
Senator Fred Dyson
OTHER LEGISLATORS PRESENT
Representative Sharon Cissna
COMMITTEE CALENDAR
Medicaid Behavior Health Presentation
PREVIOUS COMMITTEE ACTION
No previous committee action to be considered
WITNESS REGISTER
WALTER MAJORIS, President
Alaska Behavioral Health Association
Anchorage, AK
POSITION STATEMENT: Introduced Mary Thornton and commented on
the new Medicaid rules.
MARY THORNTON, BSRN, MBA, President and founder
Mary Thornton & Associates, Inc. (MTA)
Boston, MA
POSITION STATEMENT: Gave a presentation on changes to the
federal Medicaid program.
JERRY FULLER, Project Director
Health Care Services, Medicaid Division
Department of Health and Social Services (DHSS)
Juneau, AK
POSITION STATEMENT: Explained how DHSS is preparing for the
Medicaid rule changes.
MELISSA STONE, Director
Division of Behavioral Health
Department of Health and Social Services
Anchorage, AK
POSITION STATEMENT: Commented on the impact of the new Medicaid
rules.
ACTION NARRATIVE
CHAIR BETTYE DAVIS called the Senate Health, Education and
Social Services Standing Committee meeting to order at 1:34:13
PM. Present at the call to order were Senators Elton, Cowdery,
Thomas and Davis.
^Medicaid Behavior Health Presentation
Medicaid Behavior Health Presentation
CHAIR DAVIS announced the Medicaid Behavior Health Presentation.
WALTER MAJORIS, President, Alaska Behavioral Health Association
in combination with the Alaska Associations of Homes for
Children, introduced Mary Thornton, a leading expert in terms of
behavioral health as it relates to the federal Medicaid program.
Chair Davis recognized Representative Sharon Cissna.
1:37:12 PM
MARY THORNTON, BSRN, MBA, President and founder, Mary Thornton &
Associates, Inc. (MTA), thanked Chair Davis and the committee
for the opportunity to speak to them about what was happening at
the federal level with Medicaid, and some of the changes that
were anticipated. She reminded the members that Medicaid is a
shared cost so there are two opinions, the state and the
federal, on the quality and content of services. She said that
the states' and the federal government's opinions on what are
covered and high quality services for behavioral health had
diverged recently. The federal government's focus was so much on
cost savings that, for the first time, the total cost of
Medicaid crossed Medicare. As a result, the center for Medicaid
and Medicare Services and its enforcement and oversight arms
were going in with much narrower definitions of services than in
the past and, after spending quite a bit of time trying to steer
behavioral health into the areas of wellness and recovery, were
really emphasizing a medical model.
The federal frustrations "boiled over" after a number of
government accounting office audits of Medicaid risks including
fraud, abuse, and improper payments. They felt the fraud efforts
were uneven at the state level and were frustrated that they
couldn't have more oversight there. It seemed that the states
were deciding how much emphasis to put on program integrity and
in most cases, investment in the investigative arm at the state
level was inadequate.
They were also frustrated about the fact that the rules were
different on a state-by-state basis. They had a hard time trying
to figure out whether or not differences in practice patterns
and costs had real meaning in terms of quality or just reflected
differences in how the states were managing program integrity.
They felt that what was happening at the state level was the
"Medicaiding" of services, that is, states were taking services
that had formerly been paid for by state grants, changing the
definition of services slightly, and then pushing them under the
Medicaid umbrella. This resulted in a significant rise in the
cost of behavioral health services.
MS. THORNTON presented five areas of change in the federal
government's way of doing things that she believed would have an
impact on behavioral health. The first was new auditors.
1:40:28 PM
New auditors: The Payment Error Rate Measurement (PERM)
initiative, the Deficit Reduction Act (DRA), the Recovery Audit
Contractors (RAC), and all of these sorts of federal audit
functions are quite new. As a result of DRA, they have received
hundreds of millions of dollars to produce savings in the
federal Medicaid program through audits and other oversight
activities. The whole landscape is really changing around audit
functions.
Alaska will undergo its' PERM audit in the next year; the PERM
audit is designed to develop an overall federal error rate for
the Medicaid programs. Error rates greater than 2.5 percent in
any one state will be sent to congress as a kind of "report
card" on the state's ability to manage the integrity of the
Medicaid program. PERM monitors will be in 17 states at a time;
it will be a rolling audit, with a new cycle starting every 3
years.
They have also developed a Medicaid integrity program, which
will have private contractors hired by the federal government
looking at what is going on at the state level and going around
the state directly to providers. This is something new. Usually
the audits coming out of Centers for Medicare & Medicaid
Services (CMS) look at the state's management of providers; the
auditors have not generally audited providers directly.
1:42:37 PM
On the state side, the federal government is pushing the states
to adopt a False Claims Act similar to the federal Act, which
has a lower level of intent and "whistle blower" provisions,
including a provision that whistle blowers will collect a piece
of whatever is recovered by the federal government. This will
provide the Medicaid fraud control units with access to civil as
well as criminal complaints.
The return on investment is expected to be quite high. The
federal government stated that they generally get a 25 to 30
percent return on investment. Total investments as a result of
the DRA have been in excess of $200 million per year, focused
just on Medicaid integrity.
1:43:51 PM
MS. THORNTON identified the second area of change as new rules.
New rules: The New York Times published an article about the
Governor's Association meeting being "up in arms" about new rule
changes proposed by CMS, which they believe will represent a
significant cost shift away from the federal government and back
to the states.
The federal government did pass a new rehabilitation rule that
will shift hundreds of millions of dollars away from the federal
government's Medicaid costs into state funded child welfare
programs. The new rehab rules will reduce the kinds of services
that can be provided to the seriously and persistently mentally
ill, especially adults. The governors obtained a moratorium on
the rule until the end of July 2008, but do not know what will
happen after that time.
1:45:02 PM
Case management rule: The federal government pays a lot in
matching funds for targeted case management and is concerned
about the types of services being provided under case
management. This would not just affect behavioral health;
targeted case management groups include the developmentally
disabled, pregnant women, the elderly and others will be
affected.
Finally, in terms of new rules, SAMSA issued a number of
evidence-based practices with the assumption that Medicaid would
cover the cost of those services. Unfortunately, CMS came out
with an encyclical on the evidence-based practices in mental
health and really restricted the kinds of services within those
practices that Medicaid will cover.
MS. THORNTON said these rule changes will have a huge impact on
the way services can be provided in behavioral health. You can
see the expected outcome from the rehab rule alone was supposed
to be over $2 billion from 2008-2012, and those savings are
going to come primarily from children's services, with a cost
shift into foster care and residential costs that are the
responsibility of the state and away from the costs that
Medicaid has paid to date. In particular, in terms of non-
covered services, they are targeting therapeutic foster care;
regular foster care services; child caring institutions and
other kinds of rehabilitative activities.
1:47:07 PM
In some states that have been under pressure from CMS, they are
seeing the "de-linking" of services from one another in rehab.
The savings are expected to be about $800 million a year on the
case management side, although the governors have really
disputed that figure. They say the federal government's savings
will be a great deal higher, that they underestimated the
additional costs the states will have to cover. Many of these
savings will come from shutting down certain kinds of children's
services. One of the things that the Case Management Rule
emphasizes is that the case managers are there simply to link
people to services, not to provide direct support. The new
definition is quite restrictive; there are only about four
different things people can do. In Massachusetts the state was
told that it has to repay $87 million of $104 million it billed
in Case Management Services because it did not meet the new
definition; so to suggest that the savings are going to be only
$800 million when Massachusetts alone is going to come up with
1/8 of that really underestimates the impact on the states.
1:48:48 PM
The evidence-based practices, in terms of behavioral health,
have really impacted the states' ability to target families as a
treatment entity. Medicaid and Medicare both work from the
position that the services are provided to an identified client
and they must be exclusively directed to that identified client.
So some of the intensive home-based services and other kinds of
service delivery systems that have proven to be a best practice
are going to be impacted by the inability of a provider to
target a family.
Another thing that is important in terms of the evidence-based
practices, Ms. Thornton said, is that, for many in the adult
systems, the targeted recovery outcome is to get the individual
back to work. Medicaid is saying it will not fund any supported
employment activities to help individuals get and keep jobs.
This is often really problematic in behavioral health,
especially with the seriously mentally ill, because the
vocational rehabilitation dollars are very limited in scope and
don't provide the long-term support that many individuals need
to keep a job.
MS. THORNTON advised that the third area of change is the
recreation of SILOs. [Creating Silos: Separating Medicaid from
child welfare, juvenile justice and education systems with
increased pressure on these other systems to pay for
services that have been historically paid by Medicaid.]
1:50:21 PM
1) Payment Issues: Medicaid does not want to be part of an
integrated system; it wants to be able to see its own services.
She cited New Mexico as an example, where a wonderful children's
integrated delivery system was developed whereby all of the
buckets of money went into one place and were doled out as the
child needed them. Medicaid pulled out of the integration at the
last minute and required that it be a braided system so Medicaid
could see exactly how its dollars were being spent. This is one
area in which the federal government has created a SILO.
In the case management rule, for example, the federal government
expects the Title IV-E [Child Welfare federal and state
mandates] money that Alaska gets to pay for all of the case
management services for children in protective custody.
Historically, case workers have had very high caseloads, so a
mental health worker from the mental health system would come in
to provide case management and coordination services for the
seriously emotionally disturbed or the seriously mentally ill.
Under the new rule, that will no longer be possible, so the
state's foster care and child welfare dollars will need to
increase to cover the gap.
A second area is public parole and probation. They said that
public parole and probation and the Criminal Justice System have
their own dollars for health care and Medicaid cannot be used to
supplement those. In Georgia, they literally took apart the
entire children's residential system because it was being
partially paid for by the Juvenile Justice System and partially
paid for by Medicaid. The federal government said that a
resident, whether or not the child volunteered to go into
residential services, was considered to be incarcerated and was
not eligible for any Medicaid at all.
1:52:59 PM
A third area is public guardianship. In many cases, especially
with the adult mentally ill, behavioral health providers are
needed to help people make decisions about their health care.
Medicaid is saying that they will not pay for those services any
more. With special education, Medicaid did allow certain types
of case management activities that were ordered as part of an
Individualized Education Program (IEP) to remain in place, but
they put strict limits on those. They can't include any kind of
administrative work unless the IEP orders a service coordinator,
or the individual family services plan orders a case
coordinator.
The ties that Alaska built with Juvenile Justice in behavioral
health really reduced costs and produced other benefits that
will be lost if those links cannot remain.
4) Reasserting old rules: The federal government is really
focusing on the issue of family treatment, saying that the
family is not an entity as far as Medicaid is concerned and
providers must treat individuals only. It has denied any
training that teaches people how to be parents, saying that the
cost of general parenting training is the responsibility of the
public health or child welfare systems.
1:55:33 PM
On the medical necessity side of things, Medicaid is trying to
implement new rules that will make it more difficult for
providers to engage clients in services because there isn't
enough time for the client and the provider to get to know one
another enough to work together on treatment decisions. For
example, in Texas they have a recovery goals system like the one
Medicaid is now trying to sponsor. What happens is that the
client meets someone for the first time, they do an assessment,
and tell the client, based on that assessment, what the course
of treatment should be. Clients have proven to be disinclined to
follow the recommendation of a perfect stranger, so they are
having a very difficult time getting people into services.
The final issue with regard to reasserting new rules relates to
Institutions of Mental Diseases (IMD). The rules say that an IMD
is any kind of institution with more than 16 beds that is
primarily engaged in providing diagnosis, treatment or care of
individuals with mental diseases, including substance abuse.
They go on to say that if a facility is an IMD, Medicaid will
not pay financial participation for any person between the ages
of 21 and 65, and will pay for inpatient services only for those
who are 21 and under. Children are not covered for medical,
dental or any services other than inpatient psychiatric when
they are in the IMD.
Medicaid has also said it will only pay per diems for services
that are actually level five services, the highest level of
psychiatric treatment. Because of that, states are trying to
figure out what to do with the residential service programs. As
soon as they bring treatment into the residence, Medicaid starts
to question whether it is an IMD and the children are no longer
covered for medical and dental services, resulting in a tug of
war around payment.
What you have in many states including Alaska, is some fairly
substantial campuses that were built when the providers were
providing only child care services, so they were for the
protection and safety of children. At some point in time, some
states realized that these children had serious emotional issues
or mental illness as a result of the abuse they had experienced
so they brought treatment into the facilities. Now Medicaid is
saying if there are more than 16 beds they will cover only a
limited benefit and then only if there are certain medical and
other staff on board, making the services much more expensive.
The residential rate setting is becoming problematic in many
states as they try and figure out how to provide residential
services that are treatment oriented and meaningful but don't
require a level five status in order to get Medicaid
reimbursement.
There have been a number of audits in New York and Virginia. In
one case a New York audit went to the appellate court, which
upheld federal Medicaid's position on IMDs, that the psych under
21 benefit really was only for inpatient services.
Prior to this meeting, Ms. Thornton met with providers to go
through a set of guidelines developed by the state of Georgia
after it had its children's residential programs taken apart by
CMS. They have provided advice to organizations about how to
divide campuses into distinct parts, with distinct licenses and
treatment populations to prevent the government from lumping all
of the beds together and making them IMDs.
Finally, there is the issue of "unbundling".
Medicaid is saying that it no longer wants to pay for per diems,
monthly rates or any kind of case rates. It wants to see each
and every service it is providing. In behavioral health in
Alaska, you have a service called Behavioral Residential Service
(BRS) This is a per diem that providers earn in residential
facilities that allows them to bill multiple services throughout
the day on one claim. Medicaid wants those services unbundled
and documented individually. This increases the administrative
costs significantly without having any impact on the quality of
care.
2:02:14 PM
In the State of Alaska, in behavioral health as well as other
areas where the bundling of services occurs, these will have to
be unbundled in the future. The way that is worded in the Case
Management Rule is "A state cannot employ a methodology or rate
that results in payment for a bundle of services". Medicaid
suggests that a 15 minute unit of service is appropriate, so
they want even 7 day a week, 24 hour per day services laid out
in 15 minute increments, which creates huge problems.
What needs to be done? The awareness at the state level of the
potential impact is incredibly important. This is no time to
wait for things to happen. The legislature, provider community,
and consumers need to work together to look at these programs
and services. There needs to be a lot of support for providers;
new provider manuals that take the new information into account;
technical assistance for providers as they work through the new
rules and other changes. It will be terribly expensive for
providers to work through this on their own; there needs to be a
state-wide effort to make sure it works. There also needs to be
continued legislative advocacy, advising congress that these
rule changes will be devastating to the states.
CHAIR DAVIS asked Ms. Thornton whether there was anyone from the
division [of health care services] present at her meetings
yesterday.
MS. THORNTON replied that there were representatives from the
division attending the meetings both yesterday and today.
CHAIR DAVIS asked when Alaska would have to start unbundling
services.
MS. THORNTON advised that the interim Case Management Rule that
requires unbundling went into effect March 4, 2008, but there
was a lot of work going on at the federal level to create a
moratorium on implementation of that rule until 2009. It is tied
up in a law that President Bush already said he would veto, so
no one really knows what the outcome will be.
CHAIR DAVIS ventured that Alaska was out of compliance if the
moratorium did not go into effect.
MS. THORNTON agreed, but thought states would be given some time
to change their state plans before any punitive measures would
be taken.
MS. THORNTON added that, because this was introduced as an
interim final rule, there was no time for public feedback;
people didn't expect that the Case Management Rule would include
so many extraneous measures, such as unbundling and de-linking.
It was expected to deal only with the definition of services,
because that seemed to be their focus.
MS. THORNTON said the PERM auditors would just be looking at the
Medicaid error rate and would be in Alaska within the next year.
In addition to that there would be the Office of the Inspector
General auditors and the new Medicaid integrity auditors.
CHAIR DAVIS asked if the burden to pay those auditors would fall
on the state or the federal government.
2:07:34 PM
MS. THORNTON advised that the federal government would be paying
for the auditors, but they expect to get it back through the
results of the audits.
CHAIR DAVIS speculated that these rules might be revamped with
the change in administration.
MS. THORNTON clarified that the case management portion was
already in law, but they could make the rules less onerous for
the states. She was not sure how fast the rules could be changed
once they have gone into effect.
SENATOR THOMAS said that, while he is sure many people here in
the state would suggest things be done differently, it doesn't
appear that the goal was just to revamp and improve the system
or make it more efficient. He wondered what the process was that
resulted in these rules and whether they considered any input
from people in the states.
MS. THORNTON said that based on how the rules turned out, she
didn't think they were taking advice from anyone who actually
operates in the behavioral health arena, because some of what
they have suggested is almost operationally impossible. She
added that the audits are often the only information states get
from the federal government about what they like and dislike, so
most providers are watching the audits to determine what is
acceptable.
Rule changes are usually a response to unexpectedly high error
rates. What probably happened is that the costs of rehab
services in mental health were higher than expected around the
country, so they sent in auditors who came back with some bad
findings, which resulted in the rule changes.
CHAIR DAVIS asked Ms. Thornton whether the providers she met
with yesterday talked to her about their state audits.
MS. THORNTON confirmed that they did discuss that and the
providers wondered whether they could rely on these audit
findings in the face of a federal audit; was the state audit
rigorous enough that they could feel comfortable that if they
met the requirements of the state, they would come out alright
on a federal audit. She said that she couldn't respond to that
because she had not seen any of the audits that had been done,
but noted that Alaska is on the cutting edge in that it does
extrapolated audits. Meaning that Alaska does random samples and
extrapolates the results across the entire population, which
seems to be the direction many states are moving toward.
CHAIR DAVIS asked Mr. Majoris what prompted him to bring experts
in to train his workers.
2:14:14 PM
WALTER MAJORIS, President, Alaska Behavioral Health Association,
explained that he was most worried about the audits because
there are so many and because he thinks the goal is big
paybacks, without regard for the quality of service. He was also
very concerned about the reinterpretation of old rules. He gave
an example based on his own organization, Juneau Youth Services.
Under IMD, if a facility offers mental health or substance abuse
services in a residential or institutional setting with more
than 16 beds, it is not reimbursable for federal Medicaid.
Partly because of that rule, all of JYS facilities are less than
16 beds but, as an agency they have 54 beds. CMS has been in
contact with Alaska about this already. On any day, they could
deny all federal participation based on the fact that we have,
in total, more than 16 beds. That would represent millions of
dollars just from his agency.
SENATOR ELTON admitted that her testimony was extremely
disturbing. He asked who they could look to for a good program
or model to review how to deal with the coming tsunami.
MS. THORNTON did not believe there were any models at that time.
She acceded that all of the states were trying to figure out
what to do in the face of this, but suggested they could talk to
Jim Sheehan, Medicaid Inspector General for the state of New
York and a well known health prosecutor. Mr. Sheehan moved from
a federal position to a state job and might be able to help
providers begin to find their way through this. She pointed out
however, that what would also help was just what they did in
their meetings earlier in the day; create a list of priority
items and address them one at a time.
SENATOR ELTON said he anticipated, with all of these new audits,
especially the bounty hunters...
MS. THORNTON interjected that what the federal government had
done with the RAC auditors was quite disturbing! These
contractors come out of the Tax Relief and Welfare Act and have
access to software that can filter huge amounts of data. They
take the publicly available data on the Medicaid program and
look for aberrant practice patterns. For example, they might
find that in West Virginia it only costs $500 per year for
services but in Alaska it costs $10,000, then start looking for
an explanation for the discrepancy. She called them "bounty
hunters" because they can request that the provider make pay
backs. The provider can appeal, but even if he appeals and wins
the RAC auditors get to keep the percentage they earned, so they
have no incentive to ensure that they have a good case. She
pointed out that they work with Medicare only at this point, not
Medicaid.
SENATOR ELTON continued that he assumed, with the RAC Auditors
and all the others, the administrative costs for the association
would skyrocket as they go through audit after audit.
2:21:55 PM
MR. MAJORIS was also concerned about that and about the
difference between the state audits and federal audits. His
agency submitted 11,000 pieces of paper associated with the two
Meyers & Stoffer state audits they went through, and scored 100
percent. In talking to Ms. Thornton however, he learned that if
the federal government finds differently, it will make no
difference whether they complied with all of the state's
regulations and requirements.
MS. THORNTON confirmed that administrative costs are going up
for organizations as a result of these changes.
CHAIR DAVIS proposed that the committee meet with the Medicaid
division after session to find out where they are on all of
this. She thought they had hired a contractor to help them with
some of these problems.
2:25:03 PM
JERRY FULLER Project Director, Health Care Services, Medicaid
Division, Department of Health and Social Services (DHSS), said
this has been on their radar for a couple of years. They have
submitted state plan amendments around rehabilitative services
in the past, only to hit a brick wall with CMS; we pulled back
the state plans rather than reconfigure our system based on
state plan amendments rather than regulations. In addition to
the targeted case management and rehabilitation services, there
are another five regulations that will also have negative
impacts. The Department's focus has been working with Alaska's
delegation to put the kibosh on these regulations. The National
Governors' Association sent a letter to Secretary Levitt and to
Congress advising them that this is too much. When moratorium
language for the Targeted Case Management was added to the
Indian Healthcare Reauthorization bill, the Senate voted for it
unanimously; so there is some momentum back East to stop this.
MR. FULLER said that the [United States] House Subcommittee on
Government Reform and Oversight recently published a survey of
all of the Medicaid programs in the country. CMS in their
testimony to Congress said that these seven regulations were
expected to save the federal government approximately $15
billion, so the committee surveyed all of the states to get an
estimates from the state Medicaid directors. Once it was added
up, the total was closer to $50 billion from the states'
perspective. Whatever the figure, it is all a cost shift to the
state General Fund, at a time when Congress is talking about an
economic slow-down and economic stimulus packages to help the
states out.
He continued that Congress would have to pass a bill before June
th
30 [2008] to deal with Medicare and the fact that Medicare
reimbursement would drop 10 percent if they did not act.
Congress could use that as a vehicle to add language for a
moratorium on the Medicaid rules, so the Department was focusing
on that.
MS. THORNTON added that she wanted to be very clear about the
fact that the rule changes were only one of five big things
going on at the Medicaid level. The fact that there was a
moratorium on the Case Management and Rehabilitation Rule
probably would not diminish the risk to providers by much. She
conceded that the Alaska Department was really "on top of" the
situation compared to other states.
2:30:32 PM
SENATOR ELTON asked Mr. Fuller whether, given what's at risk
just on the component they'd been discussing, he had a team
working with other states to coordinate a message, or attorneys
reviewing the interpretations of old and new rules. If not, he
asked if he needed to assemble a team of people and how much
that would cost. He was concerned that, if they waited, they
might not have time to deal with it.
MR. FULLER reassured him that he had two or three people in the
department focused on this issue and that they were in contact
with many other states to get feedback regarding their audits.
He said he was personally working with the National Association
of State Medicaid Directors and American Public Health Services
Association and NGA [NGA Center for Best Practices] to get it on
the agenda for the upcoming meeting so they can develop a
cohesive approach to approach the next administration. In
addition, he said a lawsuit was filed on Monday [March 3, 2008]
by four states seeking an injunction against implementation of
the targeted case management regulations by the federal Centers
for Medicaid and Medicare Services. That suit was organized by a
Washington DC law firm, Covington & Burling.
SENATOR ELTON asked for copy of the lawsuit and some indication
of the arguments they were using. He commented that a number of
the legislators on the committee belonged to the National
Conference of State Legislatures (NCSL) and that there might be
avenues for them to supplement the department's efforts.
2:34:25 PM
MR. FULLER said he would provide them with whatever information
they would like.
2:35:07 PM
MELISSA STONE, Director, Division of Behavioral Health,
Department of Health and Social Services, said she appreciated
the providers coming together and bringing Ms. Thornton to the
state. She believed it was important to continue to support the
existing system while looking to the future, but was certainly
concerned about the magnitude of the problem facing them. In the
short-term, she felt the challenge was garnering the resources
to protect their systems and to prepare for these changes. She
admonished them not to loose sight of the people they serve and
the quality of those services in their efforts to deal with
funding.
CHAIR DAVIS asked Ms. Stone if there were any money in the
current budget to help them.
MS. STONE replied that there was no money in the 2009 budget for
admin services, but there was money allocated for Medicaid
rates, which would help providers.
SENATOR ELTON thanked Ms. Stone for reminding them of the
clients who would be affected. He thought it might be helpful to
bring someone in to do an assessment of how many clients would
fall out of the system and what the cost of that to the state
would be in the future.
There being no further business to come before the committee,
Chair Davis adjourned the meeting at 2:41:13 PM.
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