Legislature(2017 - 2018)BUTROVICH 205
02/16/2018 01:30 PM Senate HEALTH & SOCIAL SERVICES
Note: the audio ![]()
and video ![]()
recordings are distinct records and are obtained from different sources. As such there may be key differences between the two. The audio recordings are captured by our records offices as the official record of the meeting and will have more accurate timestamps. Use the icons to switch between them.
| Audio | Topic |
|---|---|
| Start | |
| Presentation: Department of Health and Social Services "medicaid Services Waivers" | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
ALASKA STATE LEGISLATURE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
February 16, 2018
1:31 p.m.
MEMBERS PRESENT
Senator David Wilson, Chair
Senator Natasha von Imhof, Vice Chair
Senator Cathy Giessel
Senator Peter Micciche
Senator Tom Begich
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
PRESENTATION: DEPARTMENT OF HEALTH AND SOCIAL SERVICES "MEDICAID
SERVICES WAIVERS"
- HEARD
PREVIOUS COMMITTEE ACTION
No previous action to record
WITNESS REGISTER
JON SHERWOOD, Deputy Commissioner
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Presented on Medicaid Services Waivers.
DUANE MAYES, Director
Division of Senior and Disabilities Services
Department of Health and Social Services (DHSS)
Juneau, Alaska
POSITION STATEMENT: Presented on Medicaid Services Waivers.
ACTION NARRATIVE
1:31:25 PM
CHAIR DAVID WILSON called the Senate Health and Social Services
Standing Committee meeting to order at 1:31 p.m. Present at the
call to order were Senators Begich, von Imhof, Giessel and Chair
Wilson.
^Presentation: Department of Health and Social Services
"Medicaid Services Waivers"
PRESENTATION: DEPARTMENT OF HEALTH AND SOCIAL SERVICES "MEDICAID
SERVICES WAIVERS"
1:31:27 PM
CHAIR WILSON announced the presentation by the Department of
Health and Social Services (DHSS) on "Medicaid Services
Waivers."
JON SHERWOOD, Deputy Commissioner, Department of Health and
Social Services (DHSS), presented on Medicaid Services Waivers.
DUANE MAYES, Director, Division of Senior and Disabilities
Services, Department of Health and Social Services (DHSS),
presented on Medicaid Services Waivers.
1:32:20 PM
MR. MAYES said the presentation would be on waiver optional
services. The first part of the presentation will be on federal
Medicaid law and then go on to show where the state is today
with the optional services. He pointed out that states have the
authority to determine who is eligible for service
Federal law sets broad requirements for the Medicaid
program. States can then make the many operational and
policy decisions that determine
• who is eligible for enrollment,
• which services are covered, and
• how payments are set.
State Medicaid programs must comply with federal
requirements, but states seeking additional
flexibility can apply for formal waivers of some of
these requirements from the Secretary of Health and
Human Services (HHS).
Medicaid waivers can be classified broadly as
demonstration waivers or program waivers.
• Demonstration waivers allow a state to test new
or existing approaches to program financing and
delivery.
• Program waivers, on the other hand, have
generally been designed to expand the array of
defined program options available to a state.
Rather than to provide an avenue of
experimentation with new models.
MR. MAYES said what the state is doing under SB 74 is an example
of a Section 1115 demonstration waiver. A demonstration waiver
is granted for five years, with a possibility of extending up to
three years. "Testing new or existing approaches" is the key
part of a demonstration waiver.
He said program waivers are not an avenue for experimentation.
The majority of the presentation will be about the 1915(c)
program waiver.
1:34:28 PM
SENATOR VON IMHOF asked if a data and reporting requirement
exists for these waivers so their effectiveness can be shown.
She asked where she can find that data collection and analysis.
MR. SHERWOOD said 1115 demonstration waivers do require that
level of evaluation. Part of the waiver application is how to
monitor and evaluate results. To his knowledge, Alaska has only
had one, very small 1115 demonstration waiver several years ago
for children on the portion of Medicaid paid for by CHIP
[Children's Health Insurance Program] that subjected them to a
period of ineligibility if parents dropped health insurance. The
waiver operated five years and was dropped after their
evaluation did not show the desired effects. The topic of
today's presentation, 1915(c) waivers, have reporting
requirements about expenditures and quality assurance. The
financial reports, CMS 372s, are posted on federal websites.
They can provide the CMS quality reports required for waivers if
the committee wants.
1:37:12 PM
SENATOR VON IMHOF said she wants to know if the waiver program
works, "outcome reporting."
1:37:45 PM
MR. SHERWOOD said they don't explicitly report measures of
outcomes, but some of their quality measures include outcome
measures in terms of the health status of the people seeking the
waivers.
1:38:06 PM
MR. MAYES made the following points about Program Waiver:
1915(c):
Enacted in 1981 legislation, ?1915(c) allows states to
waive some Medicaid requirements, in order to offer
home and community-based services (HCBS) to limited
groups
These waivers also allow states to cap the number of
individuals who can receive HCBS.
MR. MAYES pointed out the waivers allow them to offer home and
community-based services (HCBS) to targeted populations as an
alternative to mandatory institutionalized care.
1:38:58 PM
CHAIR WILSON asked if Alaska has caps on services for
individuals.
MR. MAYES said one of the four waivers (which he will break down
later in the presentation), for individuals with [Intellectual
and] Developmental Disabilities (IDD), has a cap. The others do
not.
He explained that individuals must meet institutional level-of-
care requirement to be eligible for these waivers.
To be eligible, individuals must meet level-of-care
requirements-that they would require
institutionalization in the absence of Home and
Community-Based Services (HCBS).
Coverable HCBS, then, are the services needed to avoid
institutionalization; for example, care coordination,
supported employment, adult day, residential
habilitation, respite care.
A separate 1915(c) waiver is generally required for
each eligible population. Alaska currently operates
four waivers under this authority.
Mr. Mayes went over some of the services needed to avoid
institutionalization:
Adult day center (Alaska has 11 adult day care centers
for seniors with dementia.)
Chore services to help with upkeep of the home.
Residential rehabilitation (learning independent
living skills)
Support employment (people with developmental
disabilities may need support in a job, especially at
first)
Respite (providing relief for a caregiver)
1:41:52 PM
MR. MAYES said he has created the Continuum of Care slide for
the past five years. The left side shows the community-based
grants, the lower end of care. To the far right is the facility
care, high-end costs.
SENATOR VON IMHOF asked if she can have slides from the previous
years to see trends in the number of patients served, the cost
per patient, etc.
MR. MAYES said yes. He said the Continuum of Care chart shows
they have realized some reductions through utilization control,
the rewrite of the regulations, what he calls right sizing.
Looking at the 2015 chart will show differences in expenditures.
MR. MAYES directed the committee's attention to the four columns
linked to the Home and Community-Based waivers in the chart. He
noted the presentation is about the four waivers shown there.
Alaskans Living Independently Waiver $37,330 Avg
cost/person
Children w/ Complex Medical Conditions Waiver $48,391
Avg cost/person
Intellectual & Developmental Disabilities Waiver
$89,542 Avg cost/person
Adults w/ Physical & Developmental Disabilities Waiver
$96,083 Avg cost/person
Alaskans Living Independently are primarily seniors and people
with physical disabilities. The FY 17 total for this waiver is
$72 million for 1,933 people. The average cost is $37,000 per
person vs. $164,000 per person in a nursing home.
Children with Complex Medical Conditions is a relatively small
waiver serving 222 children. The FY 17 total is $10.7 million.
For individuals with Intellectual and Developmental Disabilities
(IDD) Waiver, the total is $186 million with 2,085 people
served. All these waivers have a dollar-for-dollar match between
federal and state government.
The Adults with Physical and Developmental Disability Waiver is
very small with 88 people served for a total cost of about $8.5
million.
The total cost for FY 17 for Home and Community-Based Waivers is
$278 million.
1:46:14 PM
SENATOR VON IMHOF said she likes the way the slide provides a
snapshot. One issue from previous DHSS presentations has been
maintenance of effort. When a program has been established, the
level of maintenance of effort seems to go up each year. The bar
keeps going up. She asked how to manage level of effort with
traditional programs and whether it applies to waiver programs.
1:47:01 PM
CHAIR WILSON recognized the presence of Senator Micciche.
1:47:17 PM
MR. SHERWOOD said no explicit maintenance efforts are required
for the HCBS waivers. They are operated at the decision of
states. Every state does have these waivers as they are seen as
cost-effective alternatives. They have not had problems limiting
people served for the Intellectual and Developmental
Disabilities Waiver. Later in the presentation they are going to
talk about case law, the Olmstead decision, which does constrain
the state's ability to remove these waivers, or any kind of
service, for people with disabilities. The most significant
maintenance of effort in the Medicaid program, other than
agreements to provide services to certain mandatory populations,
is around children. As a result of the Affordable Care Act and
extended through reauthorizations of CHIP, states operating
Children Health Insurance Programs have to maintain the level of
eligibility for children on Medicaid through age 18. He thinks
one of the last bills passed pushed that requirement through
2027.
He said there is a maintenance of effort related to Medicaid in
the Adult Public Assistance (APA) program, which is the state
supplement to SSI. It requires the state to maintain payment
levels that were in the place in the 80s or to spend as much
money as the state did in the prior year on the state
supplement, the APA program. The penalty for not meeting that
requirement is the loss of all federal funding for the Medicaid
program. That is the other major maintenance of effort
requirement. They manage that by trying to stay cognizant of
their obligations, but generally speaking those are provisions
in federal law. If the state is going to operate a Medicaid
program, it must meet those provisions.
1:50:31 PM
SENATOR VON IMHOF said a constituent once told her that
maintenance of effort can be addressed by resetting eligibility
requirement to be more of federally average requirements in the
lower 48. For new patients, keeping the same level of payment
and eligibility as for previous patients or for patients already
in the system . . . For example, to pick a year, in 2020, any
new patients are in the new requirements and new services.
Previous patients will be in the exact same levels as before.
So, there will be two groups of patients receiving services, one
that phases out over time and the new group. This person said
that is how the maintenance of effort is reset. It may take a
generation. She asked if that is true.
MR. SHERWOOD said he didn't know of a provision that works like
that. The state must meet some mandatory levels tied to point in
time. Others are tied to the federal poverty level, which cannot
be reset. Some eligibility standards increase each year with
changes in the CPI [Consumer Price Index]. There are some
categories where they can choose not to increase those limits at
that level. At one time, before there was a maintenance of
effort around CHIP, the legislature chose to reduce the
eligibility levels for children and pregnant women and freeze
them at the 2003 standards. Something similar can be done for
pregnant women but not children under the current maintenance of
effort requirement. There are some options to do something like
that. More details are needed for certain scenarios because
there are different categories of eligibility. Some are tied to
federal standards which change every year and some the state
establishes those standards and they may not be subject to
change. They would have to go through the approximately 30
categories of eligibility.
SENATOR MICCICHE said at some point they have to work together
on containing the cost of Medicaid. They have to understand what
escalation looks like. He knows DHSS has a new tool. He will say
it every time he meets with DHSS, he knows how important what
they do is, he knows they care about Alaskans who have the
greatest needs, but at some point, they must contain costs. He
asked for the list of 30 categories.
1:54:51 PM
MR. SHERWOOD said it is about 30 categories of eligibility. Some
are not very different from each other, but federal law requires
them to distinguish.
SENATOR MICCICHE said it is something they need to evaluate in
the subcommittee process. Most categories are around 200 percent
of the federal poverty level. He wondered if removing the top 10
percent--say 190 percent of federal poverty level, would have a
material effect on cost. It still protects the most vulnerable
Alaskans. Perhaps there could be a transition period for people
who would not be covered. He asked if that is something DHSS has
evaluated, or do they think that is the responsibility of the
legislature.
1:56:43 PM
MR. SHERWOOD said they have looked at the impacts of reducing
eligibility standards in 2003. Eventually, they increased them
not all the way back to the original point, but about halfway.
About 2008, 2009. If they reduce the standard some people will
become ineligible and they will save money. To the extent that
the people with the greatest need have the ability to control
their income, they will make sure to maintain coverage if that
is their only option. A ten percent reduction in eligibility
will not result in ten percent reduction in spending. People
with the worst health have a limited ability to make money.
Reducing eligibility would have some impact on spending.
Legislative actions are required to reduce eligibility.
SENATOR MICCICHE said that is the definition of a broken system.
Folks will push themselves to earn less, so they remain
qualified. They need a comprehensive solution, which they are
not talking about today. They could control some of that by
handpicking the eligibility categories so the most in need
health wise will not have the same changes as healthier adults.
It is something they have to look at. They have reduced costs in
every other area except Medicaid eligibility. He openly admits
that DHSS has worked with them for substantial cuts in the last
five to six years. It's hard to get at an answer without
considering the level of eligibility.
2:00:01 PM
At ease.
2:01:09 PM
CHAIR WILSON reconvened the meeting.
SENATOR BEGICH asked if he would read the division mission
statement, if they have one.
MR. MAYES said whenever people ask him what he does, he loses
them in five minutes, so he says, because it is very
complicated, that they are the long-term support services
division, supporting vulnerable populations, people with
disabilities and seniors. They consolidated the mission and have
a very comprehensive vision statement. To simplify, it is to
promote the independence of Alaskan seniors and persons with
physical and developmental disabilities. Supporting them in
their communities, community-based settings, is their primary
focus.
SENATOR MICCICHE said he wanted to make it clear that his goal
is to have adequate funding without a revolution for the most
vulnerable populations. Perhaps at some point they evaluate the
needs of the least needy served by DHSS. Everyone knows where he
stands on seniors and care for those with disabilities. They are
going to continue to fight for those programs. That is the role
of government for folks who have difficulty providing for
themselves because of disabilities or extreme adverse financial
issues related to those problems. He thinks everyone knows that
is his position. Sometimes it is worth saying that on the
record.
MR. MAYES said the division has been accountable for every
penny. Looking at past Continuum of Care slides will show the
division has slowed growth. When he started at the division
about eight years ago, they were growing at $40 to $60 million a
year. That is not happening today. Making sure they have good
regulations, consistent eligibility . . . Whether someone
thinks this is good or bad, it is one of the strictest
eligibilities in the country. Their advocacy organizations may
not like it, but that is what they have had since the beginning
of his time with the division. They have worked to account for
every penny and can provide that evidence.
2:05:17 PM
SENATOR MICCICHE said he had a question on the Continuum of Care
chart. He said he is assuming, considering the percentage of
federal support on the grant programs vs. the 50/50 support of
the waiver programs, that they have maximized or evaluated all
the grant programs for the potential of a 50/50 waiver program.
MR. MAYES said they were flat funded for several years with
their grants. It is a low-cost solution to supporting seniors
and people with disabilities in the community. In May, under SB
74, they are taking the general fund component, referred to as
Community and Developmental Disability grants, $11.6 million of
general funds and moving that over to a Medicaid authority,
putting a cap on it, and creating a wait list so they can manage
its growth. So, they are taking that general fund program and
moving it to a Medicaid authority. Half of that will go away, so
that is the reduction, replaced by the 1915(c) Individualized
Supports waiver. They have been thinking about how to move some
of the general fund grant programs over to a Medicaid authority.
2:07:08 PM
MR. MAYES presented the History of Alaska's Waiver Program.
• 1990--The State Legislature directed the
Department to look at waiver options to serve
Alaskans with Disabilities and Seniors.
• 1993, following legislative approval, the
department began operating 1915(c) Home and
Community-Based Waivers.
• 2018 is the 25th anniversary of Alaska's waivers
• In 2018 a new 1915(c) waiver--Individualized
Supports Waiver will be implemented to refinance
the 100% general fund program, Community and
Developmental Disabilities grant.
MR. MAYES said the Alaska Commission on Aging celebrated the
25th anniversary, something other advocacy groups will also be
celebrating. In May of 2018, they will add a fifth waiver that
he just described, the Individualized Supports Waiver. That is
the refinancing of the general funds grant component, 100
percent general funds program. They are going to move it to a
Medicaid authority, reduce it by half, but a match is required.
Fifty percent will come from CMS and 50 percent from the state.
There are close to 700 individuals that are currently getting
grant dollars. The majority of them will be moved to the new
authority. Based on a thorough analysis, 17.5 or lower is
generally the amount that those who are on grants are receiving.
That cap will be manageable. The other critical piece is the
waitlist. To answer an earlier question, yes, they do have a
cap.
2:09:24 PM
MR. MAYES reviewed Senior and Disabilities Home and Community-
Based Service Options.
1915(c) Waivers
Nursing Facility Level of Care (NFLOC)
• Adults Living Independently
• Adults with Physical and Developmental
Disabilities
• Children with Complex medical
Intermediate Care Facility/Individuals with
Intellectual Disabilities (ICF/IID)
• Persons with Intellectual Disabilities
• Individualized Supports Waiver
MR. MAYES explained people receiving Alaskans Living
Independently Waivers, Adults with Physical and Developmental
Disabilities Waivers, and Children with Complex Medical
Conditions Waivers must meet nursing facility level of care and
then waive that right to remain in the community with wrap-
around supports.
MR. MAYES explained that the other two waivers, Intellectual and
Developmental Disabilities (IDD) Waiver and the new waiver,
Individualized Supports Waiver, fall under the second option,
Intermediate Care Facilities for Individuals with Intellectual
Disabilities (ICF/IID).
2:10:36 PM
SENATOR BEGICH asked if someone denied a waiver can appeal.
MR. MAYES said yes. The initial eligibility is determined by
income eligibility and then a functional assessment. A recipient
has to be reassessed every year to determine eligibility. If
someone does not meet eligibility the second year, there is a
second internal review and if someone is still determined
ineligible, then it goes to a third-party contractor. An appeal
after those levels of review is unlikely to be successful.
SENATOR BEGICH asked whether anyone has successfully appealed.
MR. MAYES said a small percent of appeals have been reversed.
That requires additional medical documentation.
SENATOR BEGICH said it sounds like a thorough and fair process.
CHAIR WILSON asked if people with intellectual disabilities get
help with waiver applications and the appeal process.
2:13:43 PM
MR. MAYES said two entities outside the structure of the state,
Short-Term Assistance & Referral Program (STAR) and the Aging
and Disability Resource Centers, assist people with completing
applications. They are stand-alone agencies and so are not
conflicted. They do not belong to agencies that might benefit.
SENATOR VON IMHOF asked which insurance pays first if someone
has two insurances, Medicaid and something else.
MR. SHERWOOD said under federal law, private insurance and any
other coverage, including VA coverage, pays before Medicaid.
Tribal services is an exception. But for waivers, most insurance
packages do not pay for things such as long term services and
supports that would be paid under the waiver.
SENATOR VON IMHOF asked if IHS [Indian Health Service] insurance
is paid second.
MR. SHERWOOD said his commissioner would want him to clarify
that IHS coverage is not insurance. It is not that full set of
services. It is available to individuals in specific locations
to the extent that the resources are there. Under federal law,
Medicaid pays before IHS. Congress decided several decades ago
that IHS would bill Medicaid for services provided to Medicaid
recipients.
2:17:08 PM
MR. MAYES went through a list of Home and Community-Based
Services provided through waivers.
Care Coordination (ALI, APDD, CCMC, IDD, ISW)
Adult Day
Chore
Meals
Respite
Day Habilitation
Supported Employment
Residential Supportive Living
Residential Habilitation
Intensive Active Treatment (over 21)
Specialized Medical Equipment
Transportation/Escort
Nursing Oversight and Care Management
Specialized Private Duty Nursing
MR. MAYES reviewed the Olmstead Decision.
On June 22, 1999, the United States Supreme Court held
in Olmstead v. L.C. that unjustified segregation of
persons with disabilities constitutes discrimination
in violation of title II of the Americans with
Disabilities Act.
• The Olmstead Decision is not specific to
Medicaid. The decision obligates the state no
matter what type of health care coverage a person
may have.
MR. MAYES recounted how the Olmstead Decision was triggered in
the state of Georgia by two women who went back and forth
between hospitals and their communities.
The Court held that public entities must provide
community-based services to persons with disabilities
when:
(1) such services are appropriate;
(2) the affected persons do not oppose community-based
treatment; and
(3) community-based services can be reasonably
accommodated, taking into account the resources
available to the public entity and the needs of
others who are receiving disability services from
the entity.
2:21:24 PM
MR. MAYES called the Olmstead Decision historic. States shifted
from institutional care to supporting people in their
communities.
MR. MAYES reviewed the Cost of Institutional Care without Home
and Community-Based Service Options.
The top horizonal box has a column for the four Home
and Community-Based Waivers, with a column of the
number served and a column for the average cost per
person. The last column is for total costs, which is
$278 million.
The middle horizontal box is for institutional
placements. There are 16 nursing homes serving 840
individuals with an average cost of $164,234 per
person and a total cost of $138 million. Alaska does
not have intermediate care facilities for individuals
with intellectual disabilities (ICF/IID). Those
facilities have been closed, and all those people have
been integrated in communities.
MR. MAYES said 15 individuals with challenging behaviors are out
of state in Idaho. He has been clear with advocates that the
state should do due diligence to try to bring them back to
Alaska. The cost is over $200,000 per person to have them in
institutions in the lower 48. He believes, and he knows
advocates believe, that there is a place for anyone in the
community with the right kind of services.
He said that eliminating optional services, because mandatory
services are either nursing home or ICF/IID, would grow the
budget. The cost of institutional placements if HCB Waiver
services did not exist would be $506 million. The operating cost
estimate does not include the cost of building more nursing
homes in Alaska, along with intermediate care facilities.
SENATOR MICCICHE said if institutional care is $201,000 per
person in Idaho, how that price could be reduced in Alaska where
it is more expensive than anywhere else.
2:25:52 PM
MR. MAYES said they would bring them home to a community-based
setting, not into an institution. The guardians and those who
are responsible for them want that. They are working on creating
support services for those individuals, so they can return.
CHAIR WILSON said he was trying to understand the increase in
cost. In FY 16 it was about $20 million less. He asked what the
increase for the four waiver services is due to. The budget just
says it was underfunded but does not say what was underfunded in
the 2017 budget.
MR. MAYES said they did not see increases to three of the four
waivers. There were some to the IDD Waiver.
CHAIR WILSON asked if the fifth category will offset that
through the wait list.
2:27:55 PM
MR. MAYES said they are adding the fifth waiver and putting a
cap and wait list in place. As a division director, seeing costs
going up with the IDD Waiver, he reached out to the providers
and said that they need to step back from the landscape of this
particular waiver and recalibrate. One of the ways to try to
manage that is to reduce the number drawn. They were drawing 200
[from the waitlist] and about two years ago they reduced it to
50. That is one way to manage that. Another, whether advocacy
groups agree with this or not, is their ability to look at
certain service categories within that particular waiver that
has significant growth and capping it, making the argument that
if they are at risk of institutionalization, documentation must
be provided to ask for more hours. They are trying to see that
people get what they need and nothing beyond that.
SENATOR VON IMHOF asked if autism was going to be a whole new
category and service program.
2:30:03 PM
MR. SHERWOOD said people with autism do qualify for the waivered
services under the IDD Waiver, but services for autism are
federally mandated services under early periodic screening
diagnosis and treatment provisions of Medicaid or EPSDT. They
are offered under the behavioral health budget of Medicaid.
Those regulations have been adopted and are at the Department of
Law for review. When they become effective, applied behavioral
analysis services they will offered for children with autism. It
is not linked directly to the waiver.
2:31:24 PM
SENATOR VON IMHOF said that would add cost to the budget. She
asked if it were correct that families can qualify regardless of
income levels.
MR. SHERWOOD said there are income limits for most categories
(and EPSDT only applies to children through age 20) in which
children would qualify for Medicaid. The top limit is 208
percent of the federal poverty level. Children who meet the
criteria of a waiver but do not need the specialized services
that are available through a waiver (It is referred to as the
TEFRA category in the budget bill from many years ago.) must
meet an income determination, but the parents' income and assets
are disregarded. They must be determined disabled under the
Social Security standard and they must be determined to meet an
institutional level of care. Some children on the Medicaid
program in Alaska are in that category. Some of them do have a
diagnosis of autism, but it is not the only situation in which
they qualify. Since those children typically are not in a
position to earn income on their own, they would qualify
regardless of the parental income. That category exists because
under the rules of the Social Security Administration, children
can qualify for cash assistance payment if they meet those
standards and are living in an institution. The cash assistance
program, the Supplemental Security Income program, automatically
qualifies them for Medicaid. Parents were faced with the choice
of getting care for their child if placed in an institution, but
if the parents took them out of an institution, the parents'
income would make them ineligible for those services. That
provision was added early in the Reagan administration to avoid
those perverse consequences of how well-intentioned programs
work.
2:34:42 PM
MR. MAYES presented National Information on the Value of HCBS
(Home-and Community-Based Services) Programs.
• Nearly 3.2 million people receive HCBS services
(2014)
• Total Medicaid HCBS spending was $58 Billion
(2014)
• HCBS Medicaid waiver services now exist in all 50
states (2014)
• HCBS 1915(c) waiver accounts for the majority of
enrollment and spending
MR. MAYES said there are states that have 20 to 30 1915(c)
waivers.
All states are reducing the number of individuals in
institutional placements through optional HCBS waivers
• Significant cost savings
• Olmstead decision/ADA
• Person Centered
• The demands on elder community-based care (baby
boomers)
2:37:27 PM
SENATOR BEGICH asked if they are projecting how the aging
population in Alaska is changing.
MR. MAYES said the Commission on Aging is tracking numbers.
Alaska will have 130,000 people over age 65 in the next few
years. As division director, he has been concerned that they
have been flat funded. The state has a waiver specific to the
senior population. The personal care attendant option supports
the senior population. In a presentation he gave, "What's Next,"
he said they should always focus on low cost, no cost solutions.
Some states have implemented the family caregiver model and
shown cost savings by extending seniors' time at home by five to
ten years before placement in nursing homes. In the next year or
two he will want to shore that up and replicate some of these
models that have demonstrated success, such as driving down
nursing home costs.
MR. MAYES said the state should be more aggressive about
existing nursing homes. He met with his counterpart in the state
of Oregon and asked him what he will be most proud of when he's
done with the job. He said they really shored up their ability
of their staff to go into nursing homes to see who wants to
leave and get back in the community. As a result, they have
reduced their costs by millions of dollars. He told Mr. Mayes to
address that issue in the next few years. Keeping a finger on
the pulse of what is happening elsewhere can help them generate
ideas in Alaska going forward. The senior population is going to
explode in Alaska, so National Family Caregiver and
transitioning people out of nursing homes will be two big pieces
going forward.
2:40:30 PM
MR. MAYES presented National Types of HCBS waivers.
A 2012 study looked at 1915(c) waivers provided by the
33 states that had federally recognized tribes at the
time, referred to as "reservation states." The study
found that state waivers mainly covered 4 categories
in 2012:
• Developmental disability (including autism)
• Elderly and disabled
• Medically fragile and palliative care
• Brain injury
2:41:46 PM
MR. MAYES presented a list of Medicaid Waiver Authorities, so
the members could understand what those look like under the
Social Security Act.
1915(a) voluntary managed care program
1915 (b) managed care delivery system:
• (b)(1) Freedom of Choice--restricts Medicaid
enrollees to receive services within the
managed care network
• (b)(2) Enrollment Broker--utilizes a
"central broker"
• (b)(3) Non-Medicaid Services Waiver--uses
cost savings to provide additional services
to beneficiaries
• (b)(4) Selective Contracting Waiver--
restricts the provider from whom the
Medicaid eligible may obtain services
1915(c) Home and Community-Based Waivers
1915(d) State Plan Home and Community-Based Services
for individuals 65 of age or older
1915(e) State Plan Medical Care for Children who
require Hospital or nursing facility level of care
1915(i) State Plan Home and Community-Based Services
for Elderly and Disabled Individuals
1915(j) Self-Directed Personal Assistance Services
Under State Plan
1915(k) State Plan Option to Provide Home and
Community-Based Attendant Services and Supports
MR. MAYES said the state will be implementing 1915(k) in May
with SB 74. Other states have done that to bring more federal
dollars into their states. There is an additional enhanced match
from the federal government. They had considered 1951(i) but
concluded they would not be able to control costs.
2:42:45 PM
SENATOR BEGICH asked, based on the actions of the federal
government this past year and possible future actions, how he
was preparing for the potential loss of federal money.
MR. MAYES said plan b is what they have right now, to be
extremely accountable and provide assurances that they are
stretching dollars to serve as many people as possible.
CHAIR WILSON said he appreciates the presentation about the
value of Medicaid optional waiver services. Something struck him
about the department's ability to expand coverage of Medicaid
through regulations. He asked how the legislature as the
appropriating body help will control costs if the department can
just go through regulation to expand services. He noted that the
supplemental budget this year was a sticker shock.
2:45:43 PM
MR. SHERWOOD said he wanted to give credit to Director Mayes
because the portion of the Medicaid budget that is not driving
the supplemental budget is Senior and Disabilities Services. In
most states this is the most expensive part of the program. It
is, per capita, probably the most expensive population to serve.
The state is able to manage those with the waivers, nursing home
transition, and family caregivers. These are more cost-effective
ways to serve people. They work hard at trying to manage the
costs of health care. The Alaska Medicaid program is not only
the health care payer challenged by that; the challenge of
trying to contain those costs is universal, at least in this
country.
MR. SHERWOOD said all their regulations are constrained by
federal law and state statute. After working with the Medicaid
program for more than 28 years, they give full deference to
state statute with regard to what their obligation is in the
program. Ultimately the legislature wants the department to have
some flexibility in regulation to make adjustments and figure
out better ways of doing things without having to come back to
the legislature every time to ask for permission. Among Medicaid
statutes, Alaska's is proscriptive. Other states' Medicaid
statutes are more permissive. Under Alaska statutes, the
legislature determines what options the department can take,
both in eligibility and the services they provide. A big piece
of it is keeping the communication lines open about what the
department is doing and making sure they all understand how the
program is moving forward.
2:48:45 PM
CHAIR WILSON said he was not just trying to reference the waiver
services. This is something that sort of stuck out as an ominous
issue.
SENATOR BEGICH thanked the presenters saying that he learned
more about Medicaid waivers than he thought he'd ever know.
2:49:12 PM
There being no further business to come before the committee,
Chair Wilson adjourned the Senate Health and Social Services
Standing Committee at 2:49.
| Document Name | Date/Time | Subjects |
|---|---|---|
| SDS HCBS Presentation 2.16.18 final.pdf |
SHSS 2/16/2018 1:30:00 PM |
DHSS Medicaid Services Waiver 2.16.18 FINAL |