Legislature(2019 - 2020)BUTROVICH 205
02/19/2020 01:30 PM Senate HEALTH & SOCIAL SERVICES
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| Audio | Topic |
|---|---|
| Start | |
| HB29 | |
| Presentation: Department of Health and Social Services Update | |
| Adjourn |
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
| + | TELECONFERENCED | ||
| + | TELECONFERENCED | ||
| += | HB 29 | TELECONFERENCED | |
ALASKA STATE LEGISLATURE
SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE
February 19, 2020
1:31 p.m.
MEMBERS PRESENT
Senator David Wilson, Chair
Senator Natasha von Imhof, Vice Chair
Senator Cathy Giessel
Senator Mike Shower
Senator Tom Begich
MEMBERS ABSENT
All members present
COMMITTEE CALENDAR
PRESENTATION: DEPARTMENT OF HEALTH AND SOCIAL SERVICES UPDATE
- HEARD
HOUSE BILL NO. 29
"An Act relating to insurance coverage for benefits provided
through telehealth; and providing for an effective date."
- MOVED SCS HB 29(HSS) OUT OF COMMITTEE
PREVIOUS COMMITTEE ACTION
BILL: HB 29
SHORT TITLE: INSURANCE COVERAGE FOR TELEHEALTH
SPONSOR(s): REPRESENTATIVE(s) SPOHNHOLZ
02/20/19 (H) PREFILE RELEASED 1/11/19
02/20/19 (H) READ THE FIRST TIME - REFERRALS
02/20/19 (H) HSS, L&C
03/26/19 (H) HSS AT 3:00 PM CAPITOL 106
03/26/19 (H) Heard & Held
03/26/19 (H) MINUTE(HSS)
03/28/19 (H) HSS AT 3:00 PM CAPITOL 106
03/28/19 (H) Moved HB 29 Out of Committee
03/28/19 (H) MINUTE(HSS)
03/29/19 (H) HSS RPT 3DP 1NR
03/29/19 (H) DP: CLAMAN, DRUMMOND, SPOHNHOLZ
03/29/19 (H) NR: PRUITT
04/12/19 (H) L&C AT 3:15 PM BARNES 124
04/12/19 (H) -- MEETING CANCELED --
04/15/19 (H) L&C AT 3:15 PM BARNES 124
04/15/19 (H) Scheduled but Not Heard
04/24/19 (H) L&C AT 3:15 PM BARNES 124
04/24/19 (H) Heard & Held
04/24/19 (H) MINUTE(L&C)
04/26/19 (H) L&C AT 3:15 PM BARNES 124
04/26/19 (H) <Bill Hearing Canceled>
04/29/19 (H) L&C AT 3:15 PM BARNES 124
04/29/19 (H) Moved HB 29 Out of Committee
04/29/19 (H) MINUTE(L&C)
04/30/19 (H) L&C RPT 5DP 2NR
04/30/19 (H) DP: HANNAN, STUTES, FIELDS, WOOL,
LEDOUX
04/30/19 (H) NR: REVAK, TALERICO
05/07/19 (H) TRANSMITTED TO (S)
05/07/19 (H) VERSION: HB 29
05/08/19 (S) READ THE FIRST TIME - REFERRALS
05/08/19 (S) HSS
02/14/20 (S) HSS AT 1:30 PM BUTROVICH 205
02/14/20 (S) Heard & Held
02/14/20 (S) MINUTE(HSS)
02/19/20 (S) HSS AT 1:30 PM BUTROVICH 205
WITNESS REGISTER
LORI WING-HEIER, Director
Division of Insurance
Department of Commerce, Community and Economic Development
(DCCED)
Anchorage, Alaska
POSITION STATEMENT: Answered questions about HB 29.
REPRESENTATIVE IVY SPOHNHOLZ
Alaska State Legislature
Juneau, Alaska
POSITION STATEMENT: Spoke as sponsor of HB 29.
ADAM CRUM, Commissioner
Department of Health and Social Services (DHSS)
Anchorage, Alaska
POSITION STATEMENT: Presented an update on the Department of
Health and Social Services (DHSS).
ALBERT WALL, Deputy Commissioner
Medicaid & Health Care Policy
Anchorage, Alaska
POSITION STATEMENT: Presented an update on the Department of
Health and Social Services (DHSS).
ACTION NARRATIVE
1:31:09 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 von Imhof, Giessel, and Chair
Wilson. Senators Begich and Shower arrived as the meeting was in
progress.
HB 29-INSURANCE COVERAGE FOR TELEHEALTH
1:31:31 PM
CHAIR WILSON announced the consideration of HOUSE BILL NO. 29,
"An Act relating to insurance coverage for benefits provided
through telehealth; and providing for an effective date."
He noted there had been a discussion about an amendment on
parity pay but that was deemed unnecessary. He invited
Representative Spohnholz and Lori Wing-Heier to speak to the
issue of pay parity.
1:32:51 PM
LORI WING-HEIER, Director, Division of Insurance, Department of
Commerce, Community and Economic Development (DCCED), Anchorage,
Alaska, stated that this bill was heard numerous times last year
and the issue of pay parity never come up. She had not seen
concern about parity from the providers until last week. Most
providers have negotiated agreements that would take care of the
concern of parity.
1:33:28 PM
REPRESENTATIVE IVY SPOHNHOLZ, Alaska State Legislature, Juneau,
Alaska, said that based on Director Wing-Heier's recommendation
and after consultations with insurers and providers, she decided
not to ask for an amendment to address parity because that
allows the market flexibility to be able to negotiate on a case-
by-case basis around rates. That will allow for collaboration
and innovation on ways to reduce health care costs. Later on, if
there are problems with parity, the legislature can address it.
CHAIR WILSON noted that the Division of Insurance recommended an
effective date change. He solicited a motion.
1:34:37 PM
SENATOR VON IMHOF moved to adopt Amendment 1, A.3:
31-LS0274\A.3
Marx
2/18/20
AMENDMENT 1
OFFERED IN THE SENATE BY SENATOR VON IMHOF
TO: HB 29
Page 2, line 15:
Delete "July 1, 2020"
Insert "January 1, 2021"
1:34:42 PM
CHAIR WILSON objected for purposes of discussion and for an
explanation of the change.
MS. WING-HEIER said her division discussed with the sponsor's
office the need for an extended effective date because of the
forms and filings that have to be made. Under the ACA
(Affordable Care Act), the division cannot amend the forms
midyear. Forms are filed in the spring for an effective date the
following January. The timeframe for when insurers could make
this effective needs to be reasonable. The individual market is
very strict about when the forms are filed and the effective
date.
1:35:41 PM
CHAIR WILSON removed his objection and there being no further
objection, Amendment 1 was adopted.
1:35:58 PM
CHAIR WILSON solicited a motion.
1:36:03 PM
SENATOR VON IMHOF moved to report HB 29, as amended, from
committee with individual recommendations and updated fiscal
notes.
1:36:18 PM
CHAIR WILSON found no objection and SCS HB 29(HSS) was reported
from the Senate Health and Social Services Standing Committee.
1:36:29 PM
At ease
^Presentation: Department of Health and Social Services Update
Presentation: Department of Health and Social Services Update
1:36:35 PM
CHAIR WILSON reconvened the meeting and announced the
presentation: Department of Health and Social Services (DHSS)
Update. He called Commissioner Adam Crum and Deputy Commissioner
Albert Wall to the table.
1:38:28 PM
ADAM CRUM, Commissioner, Department of Health and Social
Services (DHSS), Anchorage, Alaska, began a PowerPoint on the
Department of Health and Social Services. He read the
department's mission on slide 1, "To promote and protect the
health and well-being of Alaskans." He turned to slide 2, DHSS
Three-year Vision:
• Systems Alignment and Change
• Focus on IT Systems
• Behavioral Health Continuum of Care
• Emergency Readiness and Response
COMMISSIONER CRUM explained that systems alignment and change
involves helping families climb the economic ladder by
addressing the benefits cliff. This topic is of great interest
to Governor Dunleavy. The benefits cliff is when program
participants lose more in benefits than these employees receive
through employment. This issue has been raised at recent federal
conferences and the U.S. Department of Health and Human Services
(HHS) is taking the lead on this nationally. HHS is the lead
agency in the development of the new federal Council on Economic
Mobility, which will focus on cross-cutting issues that cannot
be accomplished by a single agency.
COMMISSIONER CRUM said this will include other federal agencies
such as the U.S. Department of Agriculture (USDA), Education,
Housing and Urban Development, and the U.S. Department of Labor.
The Administration for Children and Families, under HSS, is
encouraging states to share best practices to support parents in
achieving greater gains and economic stability. Examples of
short-term solutions are phasing out benefits slowly, extending
certification periods or using sliding fee schedules, raising
eligibility limits, or allowing a longer stay on benefits while
working to accompany the change in loss of eligibility
standards. These options came from an Administration for
Children and Families working group. The administration is
encouraging other states and regions to review how this will
work with other federal programs.
1:40:37 PM
COMMISSIONER CRUM said long-term strategies are to increase
educational and work support through job training and skills
development initiatives to provide employer supports to
encourage the hiring of these early stage workers. These
strategies are being approached through the Division of Public
Assistance (DPA) and Work Services. Work Services is the TANF
(Temporary Assistance for Needy Families) work program. This
program is for all participants who are not otherwise exempt
from participation in work or job search activity. DPA is
looking to integrate services and provide funding streams
between the TANF program and the Workforce Innovation and
Opportunity Act (WIOA) program in the Department of Labor.
COMMISSIONER CRUM said the Administration for Children and
Families hosted summits to demonstrate how states can take
advantage of braiding funding streams to maximize the outcomes
through these services. DPA is acting on increased employer
supports programs through more formalized incentives for
employers and job seekers. DPA also is addressing an expected
increase in the SNAP [the Supplemental Nutrition Assistance
Program] by switching to a provider agreement rather than an
operating grant program. This will allow more flexibility in
onboarding new providers throughout the year.
COMMISSIONER CRUM said another part of the systems and alignment
change is that Medicaid has been integrated on one platform.
Behavioral health with Deputy Commissioner Wall has been moved
to the Medicaid area. The Division of Public Assistance, Senior
and Disabilities Services, the Division of Health Care Services,
and the Division of Behavioral Health all have important
missions that overlap. This allows better program alignment to
better serve the Medicaid population.
COMMISSIONER CRUM said that DHSS works with sister agencies in
the Department of Administration's Division of Retirement and
Benefits and the Department of Commerce, Community and Economic
Development (DCCED)'s, Division of Insurance to find ways to
work together for economies of scale and gain efficiencies in
technology or service delivery.
1:42:34 PM
SENATOR BEGICH said governors can apply for SNAP waivers for
areas of chronic, high unemployment. The Anchorage and Mat-Su
communities were excluded from the waiver, but those areas now
meet the unemployment criteria. He asked if there is any
intention of including those two areas in the governor's waiver
request. He expressed concern both because of the reduction of
resources that will be coming into the state and because a
substantial number of Alaskans could experience food insecurity.
COMMISSIONER CRUM clarified that Senator Begich was referring to
the Food and Nutrition Service (FNS) ABAWD (able-bodied adult
without dependents) rule for SNAP. That proposed rule goes into
effect in April. This rule allows for different definitions for
labor market areas. For years Alaska worked under a blanket
exemption from the work requirements, but there are now closely
defined areas. FNS has provided several options, one strict and
the other more lenient. The governor chose the second, which
allows more Alaskans in tougher areas to be exempt from the work
requirements. Advocacy groups reached out to DHSS about changing
it. DHSS is working with the USDA and FNS to see if this
exemption is permitted under the intent of the rule. The state
has been given additional time to submit the waiver.
SENATOR BEGICH expressed hope that the commissioner will provide
the committee with updates as those talks proceed. He encouraged
the state not to leave federal dollars on the table since these
funds can feed Alaskans. Everyone wants to see more jobs so that
Alaska falls below the unemployment level for the waiver, but
the state has not yet accomplished that goal.
1:46:28 PM
COMMISSIONER CRUM replied DHSS would provide updates regarding
whether an individual outside of a [labor market] area can be
exempt from the work requirement. He offered to provide
information to food coalition groups on exemptions for work
requirements. He said that the department anticipates hearing
from FNS within the next few weeks so that DHSS can amend the
waiver and be ready to go.
COMMISSIONER CRUM said DHSS collects tremendous amounts of data
that must be analyzed before it can be used. In the last year,
the DHSS has made progress to improve and upgrade its IT
systems, including implementing an electronic document
management system. This step provides a single application
interface for all assistance programs and helps the department
be more responsive to Alaskans in their time of need. In
collaboration with the Department of Administration (DOA), DHSS
has made progress to update its software on a HIPAA (Health
Insurance Portability and Accountability Act) compliant system
for mobile devices. This means the Office of Children's Services
(OCS) employees will have secure phones document and transmit
data securely while in the field. Currently, because DHSS in
order to have HIPAA-complaint messaging, employees must log into
a separate direct service mail protocol, which is burdensome for
staff.
COMMISSIONER CRUM highlighted the project to implement a viable
information exchange to meet the needs of providers and the
state. He said DHSS is focused on an addressing the need of an
HIE (health information exchange) with its chief data officer
and chief medical officer. Upcoming IT projects that will be
implemented by the end of the calendar year are the electronic
visit verification for the personal care attendants, which is a
mandatory compliance issue from CMS (Centers for Medicare and
Medicaid Services) for the home and community-based waiver
population, and the eligibility verification system for DPA. SB
74 encouraged DHSS to pursue that and it is also part of federal
compliance. Both of these systems will help maintain program
integrity so resources are available to serve those who are
truly eligible and in need. DHSS will work to continue to
implement innovative IT solutions so that it can be agile enough
to respond to health care providers and recipients and broadly
utilize data analytics to combat fraud, waste, and abuse.
1:49:54 PM
SENATOR GIESSEL shared that it causes her great concern when she
hears DHSS talk about innovation in IT systems. She asked if
DHSS ever got certification of its Medicaid Management
Information System (MMIS).
COMMISSIONER CRUM answered yes; it is the fiscal agent
responsible for Medicaid. The DHSS is IT trying to be
innovative. The IT system was archaic. FBI agents shared with
the security staff that hackers in other countries used Alaska
as a testing ground for their protocols to deploy in the rest of
the country. The IT staff has done a fantastic job over the last
few years improving that. DHSS recently had a death-to-the-
dinosaur party because all Windows 7 programs, which are no
longer supported by Microsoft, throughout the entire department
were removed. DHSS collects data for the state, and many people
request that data. DHSS needs to respond faster so people can
have live information.
1:51:56 PM
SENATOR SHOWER joined the committee.
COMMISSIONER CRUM said one of the goals of the department is to
continually improve and make it a better running, faster
machine.
SENATOR GIESSEL said she hopes things go well.
CHAIR WILSON said he also shares that concern, and not just for
this department. At the beginning of last year, there were over
34 upgrades to different IT systems in the state, all using
different contractors and programming that did not communicate
with each other. He noted that Senator Shower had joined the
committee.
COMMISSIONER CRUM responded that the federal process has gotten
much more prescriptive when looking at large IT systems. DHSS
has to get program advanced planning documents (PAPD). During
the planning stage the feds look at everything including the way
the Request for Proposals is written and the goals and
timelines. The federal agency can approve, based on the
thresholds DHSS meets, even more advanced federal match to pay
for these IT systems. Once those are approved, DHSS gets the
IAPD (Implementation Advanced Planning Document), which is the
guidance document. The job of the chief data officer is to
coordinate these projects through federal partners and across
divisions to meet each one of these prescriptive thresholds.
1:54:02 PM
SENATOR VON IMHOF said she was pleased to hear that DHSS is
bringing on a chief data officer. She is seeing that more and
more in different entities. This has become a new job
description to make sure that the large, overarching accounting
software, as well as small systems, match and talk to each
other. One example of a small system is the use of debit cards
for Medicaid recipients to purchase medical supplies. Electronic
purchases are uploaded automatically into a system and purchases
can be tracked. Then no one has to do data entry for that
information. She asked if the commissioner was considering those
options.
COMMISSIONER CRUM said that was brought to the attention of DHSS
by the Key Coalition and the Governor's Council on Disabilities
and Special Education. DHSS is trying to navigate that and
recognizes the utility of it. DHSS is working to see if it can
be justified with the federal partners.
SENATOR VON IMHOF noted that Commissioner Crum sits with her on
the executive committee of the Health Care Transformation
Council. She and Representative Spohnholz have a bill on an all-
payer claims database. Along with the health information
exchange, the council seeks to eventually lower the cost of
health care by understanding where health care dollars are
spent. She asked him to comment on the ability to use HIPPA-
compliant data, whether it is through this particular bill or
any other platform, to run reports on Medicaid data to show
where health care dollars are being spent regionally and for
what ailments, etc.
COMMISSIONER CRUM said any time that DHSS can knock down
barriers for data in an appropriate way, it is better for the
consumer. As DHSS works with the Division of Insurance and
Retirement and Benefits, a formal agreement could be beneficial.
DHSS has had internal working groups to address that particular
bill to find out what are some department suggestions and what
would benefit the state. The first goal the governor gave him
when he became commissioner was to address the cost of health
care to the state of Alaska with the Medicaid program and to
address the cost of health care costs for all Alaskans.
Information about the 30 to 35 percent of the population on
Medicaid, along with state employees and retirees, could be used
to help health care costs in Alaska.
1:58:12 PM
COMMISSIONER CRUM pointed out, moving to emergency readiness and
response, that many states have counties that perform public
health services. Alaska has the benefit of centralized public
health at the state level with the Division of Public Health.
That allows Alaska to have a rapid crisis response. The public
health and emergency response issues have changed, from the
creation of the OSMAP (Office of Substance Misuse and Addiction
Prevention) to deal with the opioid issue to sexually
transmitted diseases, alcohol abuse, and tobacco cessation. Now
there are greatly increased fire seasons and earthquakes and new
viruses. The importance of public health has never been greater.
COMMISSIONER CRUM said he is immensely proud and humble that
Chief Medical Officer Dr. Zink wanted to work with him as the
administration addresses these complex issues and to continue
efforts to modernize the Division of Public Health. He quoted
from the 1993 publication. "A History of Health and Social
Services in Alaska":
Public health in Alaska started in 1893 with the
arrival of the first professional nurse in Bethel,
three years before the first doctor arrived and 23
years before the first hospital was built in the area.
For many, the traveling nurse was the only source of
health care. They incorporated health education and
disease prevention into their primary health care
practices. Today public health nurses continue that
mission by being on the front lines in communities to
address local issues.
COMMISSINER CRUM said the Division of Public Health is
responsible for health emergency operations and response, crisis
communications, strategy, data building and information sharing.
Dr. Anne Zink mentioned two weeks ago that the division's goal
was to activate the emergency operations center and respond to
issues before there are outbreaks. A prime example is a
confirmed case of measles last summer that was isolated and
contained to that single case. As emergencies occur, this team
coordinates with local municipalities, health facilities, and
responders to ensure that health care systems have the support
and needed supplies to remain open. An example of this was the
earthquake of 2018. The team worked not only with hospitals but
with small assisted living homes to make sure residents had
proper medical supplies when the roads were shut down.
2:00:57 PM
COMMISSIONER CRUM said Public Health has been running the
emergency operations center to monitor the situation with COVID-
19. Public Health has weekly if not daily calls with federal
partners and fellow state agencies to make sure it is fully
prepared to respond.
COMMISSIONER CRUM said the Division of Public Health is working
on chronic health conditions and preventative measures. The MESA
(Medicaid Enrollment and Spending in Alaska) report identified
that chronic conditions are the main cost drivers of the
Medicaid program. Getting in front of that with prevention is a
key aspect. Division of Public Health Director Hedberg is part
of the weekly Medicaid director meetings to integrate efforts
regarding education programs and processes.
CHAIR WILSON asked, regarding the MESA report, whether the state
is looking at a managed care system to help manage those chronic
conditions. The report shows that these cases represent a small
percentage who live in Anchorage, Mat-Su, and Kenai.
COMMISSIONER CRUM replied that DHSS identified those chronic
conditions in the MESA report. One, end state renal disease, was
addressed last year through regulation. DHSS found cost savings
of $1 million a year by dropping it to Medicare rates instead of
cost base rate. DHSS has lots of different projects in play.
Senate Bill 74 included other authorities like exploring bundled
payments for innovations and incentives to providers for
savings. Commissioner Crum described various initiatives such as
employee engagement, PLAAY Summit, alcohol, and tobacco
education in schools. DHSS does the CDC (Centers for Disease
Control and Prevention) Youth Risk Behavior Survey every two
years to use for policy decisions. The Petersburg School
District has removed sugary drinks from its vending machines and
cafeteria and put water bottle fillers in schools. Public Health
is working on little investments like that in education that can
have generational effects.
SENATOR GIESSEL noted that diabetes is a common chronic
condition. It is often challenging for people to find
comprehensive care for diabetes. A nurse practitioner who
specializes in that is in the committee room today. Nurse
practitioners are only reimbursed at 85 percent of the physician
rate, but often can provide better care. Sometimes those
financial things make all the difference in combating a chronic
condition that ultimately results in renal disease.
COMMISSIONER CRUM replied that the governor has encouraged DHSS
to consider not only the initial cost but long term savings. He
said that is always part of the discussion when DHSS pursues
different regulatory packages or other actions.
2:06:06 PM
SENATOR BEGICH said looking beyond the governmental expense was
not the message from the administration last year. The
implications are not just for the state budget but impact the
health care cost in Alaska to the average person or to the
provider. He agreed with Commissioner that there are other
things that need to be considered besides the budget, such as if
a policy in the long run will benefit society.
COMMISSIONER CRUM addressed the last topic of the DHSS three-
year vision, the behavioral health continuum of care. Because of
legislative efforts in prior years, his predecessors, and
dedicated stakeholders, the state has had great progress in
breaking down the stigma of behavioral health. Behavioral health
issues affect many. Because of the diminishing stigma, the stage
is set to focus on the buildup of a behavioral health continuum
of care. There has been progress in community-level investment
over the last two years. The Fairbanks Memorial Hospital brought
online a dedicated behavioral treatment unit and designated
evaluation and treatment center in January 2019. Mat-Su Regional
recently unveiled its behavioral health treatment and designated
evaluation and treatment center. This community investment is
necessary to provide acute behavioral health services in
community. DHSS is grateful these community organizations are
stepping up and building capacity.
COMMISSIONER CRUM said a key piece has been the 1115 Behavioral
Health Medicaid Waiver for mental health and substance use
disorders. It is a multi-year effort with parties from all
across the state. With the 1115 waiver, two dozen new service
types have been added that can bill Medicaid and provide
services sooner at a more appropriate level of care that is more
localized than before. The goal is to keep individuals working
and families together by getting them the crucial help and
necessary treatment before much more expensive interventions are
required. The 1115 waiver opens up a possible funding mechanism
for behavioral health crisis stabilization.
COMMISSIONER CRUM said, moving into addressing the divisions of
DHSS, Alaska Pioneer Homes did receive approval for construction
of a dementia floor at the Anchorage Pioneer Home. It has taken
time to work on zoning issues with the municipality. This had
been a hole in the system of behavioral health. The Pioneer
Homes Division is exploring the addition of 22 beds for the
higher Veterans Affairs (VA) per diem rate at the Palmer Pioneer
Home. Fourteen beds have been transitioned. That has to be done
in complete units. There are certain protocols that must be
followed, but it does bring in additional VA revenue.
2:10:10 PM
SENATOR BEGICH said the committee heard that the Pioneer Homes
could qualify for higher reimbursement rates if buildings were
brought up to code. He asked if there were any efforts to bring
up the homes up to the nursing home standard.
COMMISSIONER CRUM answered that Pioneer Homes are licensed as
assisted living homes. To be a skilled nursing facility or a
nursing home is a completely different license type. Some of the
Pioneer Homes may provide nursing home level of care. He can get
information on whether that is something the division will
pursue.
SENATOR BEGICH referred to the bottom line issue discussed
earlier. The Senate and House might consider the capital expense
if it allowed the Pioneer Homes to provide a greater level of
care and a greater level of reimbursement that could pay off in
the long run.
2:12:21 PM
ALBERT WALL, Deputy Commissioner, Medicaid & Health Care Policy,
Anchorage, Alaska, replied that capital expenditures to bring
buildings up to code is one of several considerations. A skilled
nursing facility has other requirements that have to do with
staffing and training and the type of services provided. He
offered to provide that information to the committee.
COMMISSIONER CRUM said the mission of the Division of Behavioral
Health is to manage an integrated and comprehensive behavioral
health system based on sound policy, effective practices, and
open partnerships. Partners are the Alaska Mental Health Trust,
community-based hospitals, the Alaska Behavioral Health
Association, the Alaska Psychiatric Association, and others to
build the full continuum of care needed in Alaska. The question
is how to provide services sooner and closer to home at a more
appropriate level.
MR. WALL reviewed slide 5, 1115 Behavioral Health Medicaid
Waiver:
The 1115 Behavioral Health Medicaid Waiver
demonstration project focuses on establishing an
enhanced set of benefits for three target populations
of Medicaid recipients:
• Children, adolescents, and their parents or caretakers
with or at risk of mental health and/or substance-
use disorders.
• Individuals with acute mental health needs.
• Individuals with substance-use disorders.
More detailed information about the waiver
demonstration's goals and objectives for each of these
target populations is found on the 1115 webpage:
http://dhss.alaska.gov/dbh/Pages/1115/
MR. WALL said this was implemented under Senate Bill 74.
Commissioner Crum spoke earlier about the behavioral health
continuum of care. One challenge that DHSS faces is the funding
mechanism for behavioral health services in the state. Services
were grant-funded with UGF [unrestricted general funds] and
Medicaid since Medicaid did not quite pay for the services. The
second challenge was that services were not covered under the
old Medicaid system for behavioral health, so gaps in the
continuum of service were created. The 1115 waiver is designed
to remedy that by allowing new billable services under Medicaid,
which will reduce the need for UGF grants.
MR. WALL reviewed slide 6, 1115 Behavioral Health Waiver:
• Substance Misuse Disorder Treatment Component
• Approved in November 2018
• Became effective January 1, 2019
• Behavioral Health Component
• Approved September 2019
• Will be implemented by June 30, 2020
• Administrative Services Organization
• Contracted with Optum Health in November 2019
• Went live on February 1, 2020
MR. WALL said CMS asked the state to break the 1115 Behavioral
Health Waiver into the above two components. He explained the
CMS structure will not allow states to bill for Medicaid
services in an Institute for Mental Diseases (IMD) that has over
16 beds. He said this provision has a long federal history. This
has limited the state's ability to pay for substance abuse and
serious mental illness in institutes with over 16 beds. The 1115
behavioral health waiver allows service providers to currently
bill Medicaid for more than 16 beds for substance use treatment.
MR. WALL said the behavioral health component covers the mental
health portion, those with serious mental illnesses or children
with serious emotional disturbances. That also addresses the
IMD. If that is fully approved, implementation will allow
billing for inpatient psychiatry in institutes of over 16 beds.
That would also include the Alaska Psychiatric Institute.
2:17:41 PM
SENATOR VON IMHOF said she toured the facilities at Fairbanks
Memorial Hospital this fall. She acknowledged Mr. Wall was
alluding to the fact that funding is potentially in jeopardy.
She stated that the hospital has a $2 million Disproportionate
Share Hospital (DSH) grant. She asked what will happen to this
great program that fills a gap in the mental health continuum of
care in Fairbanks if the DSH funding goes away.
MR. WALL replied it is a very complex issue. For example,
different sections and services of Medicaid are paid at
different rates. Some sections relate to age, others to
diagnoses or types of treatment. Typically, under Medicaid,
services are billed under the titles, federal authority given to
that particular portion of Medicaid. For example, Title 19 is
for adults and Title 21 is for Denali KidCare services for
children and pregnant women. The behavioral health services
provided in the past under Medicaid were billed under clinic
services and rehab, not how physicians or hospitals or any other
service would bill. The 1115 waiver takes those clinic services
and rehab and "outdates" them, replacing them typically with
bundled payments. Under the old system, billing for behavioral
health interventions was in small increments, perhaps 15
minutes. Under the 1115 waiver, billings can be billed at a
bundled rate of up to 23 hours of stabilization for a variety of
services. The 1115 waiver allows more services and the
administrative overhead is much less than under the old system.
MR. WALL explained that the issue of inpatient psychiatric care
is a little different. The 1115 waiver allows Medicaid billing
for over 16 beds for inpatient psychiatric care. However, that
care is still billed under hospital services for Medicaid.
Senator von Imhof was referring to Disproportionate Share for
Hospitals, which is divided into "two buckets" for the state.
One is an allocation from the federal government that allows for
Disproportionate Share to go to hospitals that are providing
care for people who do not have coverage. A large portion of
that goes to API because the state is not allowed to bill
Medicaid for API patients because it has more than 16 beds. A
second allocation of DSH funding was made available by the
legislature that gave DHSS more federal authority, which
requires a general fund match. That federal authority will end
on June 30, 2020.
2:22:16 PM
COMMISSIONER CRUM added that the $4.5 million general fund and
matching $4.5 million in federal funds for DHS is part of a 90-
day plan to satisfy a pending court case [that was filed in 2018
by the Disability Law Center of Alaska (DLC) and heard by Alaska
Superior Court Judge William Morse]. This recognizes the
importance of designated evaluation and treatment centers. DHSS
is working to finalize the plan with Judge W. Morse and
plaintiff. This funding was put forward in the department's
amended budget for FY 2021.
SENATOR VON IMHOF noted that Fairbanks is under a Morse plan,
and will get DHS funds this year to continue this program.
COMMISSIONER CRUM replied that Fairbanks is one of the intended
recipients of that program.
CHAIR WILSON said the prior administration indicated that
Medicaid expansion would lessen the need for state grants
because there would be billable services. The influx never came
through to a lot of behavioral health grantees. Others asked for
the data to show that the amount of billable services was
offsetting the cost of grants, but that data never came through.
The Alaska Native Health Board wrote a white paper that showed
the funds did not come. With the additional billing under the
1115 waiver, he asked if providers are billing for Medicaid to
make up for grant services. If so, is the state going to see
further reductions in grant services to those behavioral health
providers.
COMMISSIONER CRUM replied that grant recipients that are large
providers of substance use disorders services, through this
initial billing phase, have been made more than whole with
Medicaid funding for any decrease in grants. That was the way
the process was supposed to work because these providers see a
higher proportion of the Medicaid expansion population at the
higher 90 percent federal match. DHSS has not proposed
behavioral health grants for this coming year because DHSS wants
to maintain stability through the system for this year while
DHSS gets the rest of the providers signed up with the
Administrative Service Organization to become 1115 Medicaid
providers. Technical assistance and guidance to make sure
providers are up and running can be provided by the
Administrative Service Organization and the department. Then
DHSS can evaluate and put forward further grant reductions if
necessary.
2:25:40 PM
CHAIR WILSON asked whether the federal match rate for the 1115
waiver is at 90 percent instead of 50 percent.
MR. WALL answered that it is based on the eligibility type.
COMMISSIONER CRUM turned to the tables in slides 7,8, and that
show the different services in the mental health continuum of
care for children and adolescents, for individuals 18 and over,
and the substance use disorder continuum of care for individuals
12 and older. The services are color coded to show which were
added under the 1115 waiver.
CHAIR WILSON asked if the state has enough providers that can
currently bill and if 12 new provider types were enough.
MR. WALL replied it is a mixed bag at this point. For example,
the state has no crisis stabilization centers, which is a
facility-based service. The state would have to build the
licensure type, provide staff, and stand them up as a separate
provider type. Some of the other provider types are licensed and
up and running. Some will be licensed and bring in more
providers and others will not.
SENATOR GIESSEL observed that the law was changed a couple years
ago to remove psychiatrist supervision. So, now, a physician can
supervise clinical social workers, clinical counselors, and
family therapists. She asked if that been implemented and if
more services were available.
COMMISSIONER CRUM replied the regulatory package is completed
and waiting for a signature from the lieutenant governor's
office.
SENATOR GIESSEL noted that that bill was passed two years ago.
CHAIR WILSON asked if statutory or regulatory change is needed
to add providers and if so when that will occur.
MR. WALL answered that it depends on the provider type and
licensure. Both types of changes will be needed, but some will
require no change.
2:29:20 PM
SENATOR BEGICH asked if the legislature will be getting
guidance. If a statutory change is needed on top of regulatory
change, it could take four or five years to pass.
MR. WALL acknowledged his frustration, noting he has been
working on this for many years. For example, a psychiatrist
having to provide 30 percent supervision of behavioral health
providers has been an ongoing frustration for many years. Under
the old state plan for behavioral health, there were only three
defined provider groups that could provide behavioral health
services. A clinic with a psychiatrist to provide oversight was
one. Psychologist and LCSW (licensed clinical social worker)
could only provide limited services. He said that DHSS is
developing a plan to [provide more services]. The biggest
partners DHSS has in this process are associations and groups in
the [Alaska Mental Health] Trust Authority (AMHTA). DHSS is
working closely with the Alaska Behavioral Health Association.
The AMHTA has been the driving force behind the movement for
crisis stabilization. DHSS has held discussions with the Alaska
Primary Care Association, the Hospital Association, Alaska
Association of Homes for Children, about the 1115 waiver and
what needs to be in place to ensure its delivery of services.
MR. WALL said the first phase was substance abuse. The state has
all the license types and service lines for implementation.
Moving forward, the road map is being developed. DHSS is
grateful for the Trust's involvement in that. The Trust has a
vendor who has put together a report that can be shared with the
committee.
2:31:43 PM
SENATOR VON IMHOF recapped that the blue on slides 7, 8, and 9
are for the new services. She asked what the fiscal note will be
with the varying demands of all the blue services and the
various matching rates. She said she understands there may be a
transition from traditional behavioral health grants. The grants
will be decreased and the match will be ramped up. She offered
her belief that it will not be net zero. Although he does not
need to answer today, he should just know that the subcommittee
process starts tomorrow.
COMMISSIONER CRUM replied DHSS will provide that information.
The 1115 waiver process must be cost neutral or provide a
savings to the federal government over time. Each waiver is a
five-year process. DHSS had to pay for an actuarial analysis of
its plan to make sure that was the case.
SENATOR VON IMHOF asked about it being cost neutral to the
state.
2:33:25 PM
COMMISSIONER CRUM replied the DHSS plan for expanded services
would have cost savings for the state because it is a buildup of
the continuum. The idea is to get individuals services more
quickly so these patients do not end up in the emergency
departments. There would be anticipated savings for that. DHSS
has specific tracking mechanisms to report back to CMS.
MR. WALL added that a good portion of this is already in the
operational budget for this year. It is already included in the
next Medicaid budget. The fiscal notes have already been
accomplished.
MR. WALL said he is excited about behavioral health crisis
stabilization because he thinks it solves a lot of problems in
the state around behavioral health. The state is rapidly moving
toward a behavioral health crisis stabilization approach, which
some organizations and some states have. DHSS has had technical
assistance trips to the state of Arizona because Alaska's 1115
waiver is most closely similar to Arizona's. Arizona's system of
care is built around this idea of behavioral health crisis
stabilization which has four pillars.
He reviewed slide 10, Behavioral Health Crisis Stabilization:
The four "pillars":
1. Call In Center
2. Crisis Response Teams
3. Crisis Stabilization Centers
4. A robust behavioral health continuum of care
He said that in Anchorage when someone has a behavioral health
crisis, that person is picked up by an ambulance or a police
officer on some charge. That person goes either to an emergency
room or jail. Sometimes that person sits there for a long period
of time waiting for services. Under the crisis stabilization
approach, it is turned upside down. That person does not go to
jail or an emergency room.
2:35:43 PM
MR. WALL described how the situation would be handled with the
four pillars of crisis stabilization. The call in center is
designated to handle all crisis calls and deescalate. All calls
come to a central location, including suicidal threats or a
behavioral health disturbance on a street. In 75 percent of the
cases ,the call center is able to de-escalate the crisis without
any further intervention.
MR. WALL said if the call center cannot stabilize someone on the
phone, it launches a crisis response team made up of two people,
a mental health professional and a peer. Many times, those two
individuals are able to de-escalate on site without any further
intervention. If the team cannot do so or the person needs
further help, the individual is taken to a crisis stabilization
center, which is a facility. The center receives individuals
brought by police officers, EMT vehicles, and crisis response
teams. The primary goal of the center is not the diagnosis and
treatment received in an emergency room. The goal of the crisis
center is to stabilize. The center wants to de-escalate the
problem and connect the individual with ongoing services.
MR. WALL said Alaska currently does not have a robust behavioral
health continuum of care, the fourth pillar of behavioral health
crisis stabilization. It will be built. This really changes the
approach of a social response to behavioral health. Rather than
having an individual who is acting out in an emergency room with
police officers waiting for hours to hand that person off to
medical staff, in Arizona the handoff is done in three to five
minutes and the police officers return to public safety work. He
appreciates the involvement of many legislators who have gone to
Arizona on those trips, including Senator Wilson, Senator
Micciche, Representative Spohnholz, and Representative Johnston.
CHAIR WILSON added that this is not done with huge government
involvement. It is done by a lot of community members. Alaska
has many of these pieces in place. It requires better
coordination of the resources the state already has to pull this
together with limited government growth in terms of
administration.
2:39:08 PM
SENATOR BEGICH asked how this would work in rural Alaska where
there is no law enforcement and no capacity for a crisis team.
He acknowledged that it is a good idea for urban Alaska.
MR. WALL replied DHSS has had a robust discussion around that.
On one trip, the Alaska group had a question-and-answer time
with a tribal liaison. Like Alaska, Arizona has unique
challenges also. Arizona has a tribal village at the bottom of
the Grand Canyon that is only accessible by mule. The system is
built to be flexible. CMS is working with tribes on how to make
it work with them. In one village, all able-bodied adults are
trained to be the crisis response team and the team handles the
phone calls in shifts. CMS has taken some innovative approaches
with this. In Arizona, transportation by horseback is a
Medicaid-reimbursable service. CMS is willing to do innovations
around this issue. This approach is proven to bring down costs,
provide better care and long-term stability, and change the face
of the culture. He was very impressed with what he saw in
Arizona and he is very hopeful for what it can do in Alaska.
SENATOR BEGICH said he looks forward to seeing those innovations
written up.
CHAIR WILSON shared that he was very hopeful.
2:41:11 PM
COMMISSIONER CRUM reviewed slide 11, Alaska Psychiatric
Institute:
To provide emergency and court-ordered inpatient
psychiatric services in a safe environment using
culturally-sensitive, effective, person-centered
treatment followed by a referral to an appropriate
level of care and support for recovery from mental
illness
He said it is important to know that API is a hospital and DHSS
is trying to manage it like a hospital with an active governance
board. The board has 26 members from the public and private
sector who take an active role. The board is going through the
process of hiring a permanent CEO at API. It has been a good
process to get that level of involvement. Last spring API was in
an emergency situation with almost 400 cases of violations from
its certifying and accrediting bodies. There was a real threat
of being shut down and losing federal dollars. DHSS brought in
Wellpath to help manage API. Wellpath brought stability and
national training standards. API has corrected 92 percent of the
violations. Most of the plans of correction were written with
Wellpath's guidance. Wellpath also helped to recruit employees
because of its national reach and the overall image of the
facility improved. API has a completely different feel than in
years past. DHSS is looking forward to growing and stabilizing
API further.
COMMISSIONER CRUM read the new mission statement for the Office
of Children's Services (OCS) on slide 13.
Ensuring the safety, permanency and well-being of
children by strengthening families, engaging
communities, and partnering with tribes.
He said OCS deals with families and kids at their most
vulnerable time. DHSS tries to provide support to families so
these families can develop resiliency tools to stay together.
OCS has worked on innovative recruitment and retention efforts.
Turnover has been reduced from 51 percent to 43 percent.
Although, hat is still not where DHSS wants to be, but it is an
improvement.
DHSS is working to relieve front-line staff of administrative
functions. The number of children placed with relatives has
increased thanks to tribal compacting and family and relative
searches. More youth are exiting foster care to enter college or
vocational programs than in the past. The independent living
program takes an innovative approach to make sure kids aging out
of the foster care system have an active path for their futures.
This stems from a partnership that has expanded to include all
at-risk youth. The Department of Labor hired a coordinator to
coordinate funds from the Workforce Innovation and Opportunity
Act (WIOA) program and Division of Vocational Rehabilitation to
work with foster kids and kids leaving juvenile justice because
these youth may not have family supports when these youth are
out on their own.
SENATOR VON IMHOF said the legislature passed [House Bill 151]
for OCS that added more money for case managers with provisions
to allow siblings staying together or teens as young as 14 being
able to participate in their care plan. One provision required
an annual report for three years about how it was going. She
asked if the legislature would be getting a report in the next
six months or so.
COMMISSIONER CRUM responded that DHSS would be doing an updated
report.
2:46:06 PM
COMMISSIONER CRUM reviewed slide 13, Division of Juvenile
Justice:
To hold juvenile offenders accountable for their
behavior, promote the safety and restoration of
victims and communities, and assist offenders and
their families in developing skills to prevent crime.
He said the Division of Juvenile Justice (DJJ) had a reduction
in recidivism for youth released from DJJ secure treatment from
a high of 71 percent in FY 2012 to 35.9 percent in FY 2019. That
is a massive achievement to give youth the support, care, and
tools needed to return and thrive back in the community. DJJ has
expanded its trauma-informed response practices. DJJ is
training to help staff work with youth to address behavioral
health issues and multiple projects have expanded services for
youth substance abuse and mental health.
SENATOR BEGICH asked if the recidivism measures were the same in
FY 2012 as FY 2019. In 2012 recidivism was measured over two
years. He wanted to know if that was still the same.
COMMISSIONER CRUM replied he would confirm the measures used.
SENATOR BEGICH said he previously worked in the division, so he
is very conscious of how to measure recidivism. It is often a
moving target. He asked what the plan is for the Nome facility.
2:47:54 PM
COMMISSIONER CRUM replied DHSS transitioned out of the Nome
Youth Facility over the last year. Kids are now able to use
videoconferencing to connect with their families. Kids are
issued dedicated tablets to call and talk to families. With only
six facilities around the state, it means there are only six
places where kids are local. DHSS wanted to make sure that kids
had access and ties to their communities.
CHAIR WILSON said the Mat-Su members have done a wonderful job
with recidivism and implementing programs.
COMMISSIONER CRUM said he has visited most of the Juvenile
Justice facilities. The Juvenile Justice staff speak about the
consistency of staff leadership. He is grateful for that because
he thinks the division is on the right track. Juvenile Justice
is not just the facilities but includes probation, making sure
kids are engaged, and making the right choices when these youth
are released.
CHAIR WILSON pointed out that Commissioner Crum began his
presentation talking about the reorganization of DHSS. The
commissioner's eight predecessors spent about 95 percent of
their time on Medicaid-related issues. The deputy commissioner
for Family and Protective Services has been negated. The other
body defunded that deputy commissioner. He asked Commissioner
Crum to talk about the benefit of an additional deputy
commissioner and the reorganization.
2:51:05 PM
COMMISSIONER CRUM reviewed slide 14, Alaska Department of Health
and Social Services (DHSS). The slide showed the proposed
organization chart that is an item is in the governor's proposed
FY 2021 budget. It would add a new deputy commissioner and
policy staff to oversee the Office of Children's Services, the
Division of Juvenile Justice, and Adult Protective Services to
ensure alignment and mission focus. The two main divisions that
the new deputy commissioner would oversee manage urgent
situations in which families, children, parents, and lives are
frequently at stake. These are some of the most important
decisions state government can make. It includes separating
parents from their children, determining how to handle minors
who have committed serious offenses, and intervening when lives
are in crisis.
COMMISSIONER CRUM said OCS issues are the most frequent reason
why constituents contact the commissioner's office and
legislators. Last year, DHSS recorded over 100 independent
inquiries regarding OCS, most of them from unhappy parents or
confused foster parents. The OCS and DJJ has a staff of almost a
thousand people. The OCS works directly with the public on
stressful, painful issues, which demands an extraordinary amount
of time and attention. This involves debriefing stressful cases,
finding creative solutions for placement for family
preservation, supporting OCS in recruiting and retaining more
frontline social workers, and supporting the director positions
and leadership staff.
COMMISSIONER CRUM explained that decisions from these divisions
must be supported or given final clearance at the level of the
commissioner's office. Jon Sherwood described deputy
commissioners as traffic cops because of the constant pace and
time of decisions. The directors work closely with their
assigned deputy commissioner for policy support and emergency
decisions. Examples are emergency placement of kids with complex
behaviors or medical conditions or approval of emergency
transports. These positions will provide better support to the
divisions to help staff navigate their difficult work. More
importantly, this will allow DHSS to take substantial steps to
change the conditions under which child protection systems and
juvenile justice systems are needed.
COMMISSIONER CRUM said it requires substantial work to enhance
partnerships with tribes, communities, and stakeholders, but the
day-to-day work does not allow that kind of effort. To continue
to work on tribal compacts takes time and leadership. It is too
important an effort to try to fit in a few hours a month.
Growing government is not something people typically associate
with this administration, but the administration views this as
an investment. Everyone has seen the data on Adverse Childhood
Experiences (ACEs) and how higher ACEs scores directly correlate
to increases in chronic conditions like diabetes, hypertension,
and heart attack. Recently in the Senate Finance Committee, an
economist addressed the disproportionate costs of chronic
conditions to the Medicaid program as well as the projected
growth of the program. The cost is calculated to be $5 billion
by 2040. If the state can work on keeping families together by
giving them the tools to thrive so these families don't
contribute to ACEs or trauma, then that is an investment in the
next generation and the state can finally bend the curve on
multigenerational issues that result in child abuse, neglect,
and delinquent behavior.
2:54:32 PM
COMMISSIONER CRUM said the department has several cost drivers
that demand attention from all current leadership. The goal of
the dedicated deputy commissioner and policy team is to work
upstream and focus on systemic changes that will not be siloed
from other divisions. The team will be charged with taking care
of young Alaskans and making families stronger. The DHSS
requested four new positions for the team: a deputy
commissioner, a project coordinator, a special assistant, and a
program coordinator. The project coordinator would be assigned
as an ICWA (Indian Child Welfare Act) or tribal liaison
specialist. The coordinator would represent the department in
building relationships with tribal partners as the tribes build
up their infrastructure to deal with child welfare issues while
the DHSS tries to make sure these services are provided more at
the local level.
CHAIR WILSON asked for any closing comments as well as written
comments about updates with the Divisions of Public Assistance,
Public Health, Senior Disabilities and Services, Health Care
Services, and Medicaid Services.
COMMISSIONER CRUM said he loves the people he works with, the
department's mission, and the citizens that DHSS serves. This is
an opportunity for Alaskans to address some of these difficult
situations for the next 20 years.
2:56:59 PM
There being no further business to come before the committee,
Chair Wilson adjourned the Senate Health and Social Services
Standing Committee at 2:56 p.m.
| Document Name | Date/Time | Subjects |
|---|---|---|
| DHSS Overview Senate HSS 2-19-20.pdf |
SHSS 2/19/2020 1:30:00 PM |
DHSS Departmental Update 2.19.20 |
| HB029 Sponsor Statement 2.25.19.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB029 Supporting Document-Letter of Support 2.25.19.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB029 Fiscal Note DCCED-DOI 3.22.2019.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB029 Letter of Support Moda Health 03.25.2019.pdf |
HHSS 3/26/2019 3:00:00 PM HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB029 Letter of Support ACoA 03.25.2019.pdf |
HHSS 3/28/2019 3:00:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup ADN Article.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup Letters of Support.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Bill Version A.PDF |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Fiscal Note.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Presentation.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Sectional.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Sponsor.pdf |
HL&C 4/15/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Sponsor.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup Letters of Support.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup ADN Article.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Bill Version A.PDF |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Fiscal Note.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Presentation.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Sectional.pdf |
HL&C 4/24/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup Letter of Support AARP.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup ADN Article.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Backup Letters of Support.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Bill Version A.PDF |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Fiscal Note.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB29 Dr. Evans Letter of Support 2.14.20.pdf |
SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29 Premera Letter of Support 2.14.20.pdf |
SHSS 2/19/2020 1:30:00 PM |
HB 29 |
| HB 29.Sponsor.pdf |
HL&C 4/29/2019 3:15:00 PM SHSS 2/14/2020 1:30:00 PM SHSS 2/19/2020 1:30:00 PM |
HB 29 |