SB 98-ADULT HOME CARE; ADULT ADOPTION  3:10:32 PM CO-CHAIR ZULKOSKY announced that the first order of business would be SENATE BILL NO. 98, "An Act relating to medical assistance for recipients of adult foster care services; establishing an adult foster care home license and procedures; and providing for the transition of individuals from foster care to adult foster care homes." [Before the committee was CSSB 98(FIN), reported out of the Senate Finance Committee on April 12, 2022.] 3:11:09 PM JOHN LEE, Director, Division of Senior and Disabilities Services, Department of Health and Social Services (DHSS), on behalf of the bill sponsor, Senate Rules by request of the governor, explained the changes to CSSB 98(FIN) made by the Senate Finance Committee. He stated that the bill was amended to widen its reach and strengthen the home- and community-based support for Alaska's vulnerable populations. He said that the changes were inspired by one central idea - whether adult foster care services could be extended to more people than just those aging out of the foster care system. When this question was asked to stakeholders, he reported, the response was "an enthusiastic 'yes.'" He explained that the change would mean more opportunities for community-based care, create options less expensive than group homes, have less demanding staffing requirements, and allow care to be provided in a home-like setting. He added that the intention would be to have the regulations mirror child foster parent and home expectations. He stated that these changes would allow more seniors to receive care within their communities instead of having to move to urban areas where senior living facilities were more available. He posited that there could also be an economic benefit. He said that there would be some additional staff required for monitoring this new type of care setting, but otherwise providing the service would be cost neutral to the state. CO-CHAIR ZULKOSKY asked for a review of the sectional analysis. 3:14:32 PM TONY NEWMAN, Deputy Director, Division of Senior and Disability Services, Department of Health and Social Services, on behalf of the bill sponsor, Senate Rules by request of the governor, gave the sectional analysis for CSSB 98(FIN) [included in the committee packet], which read as follows [original punctuation provided]: Section 1: Amends AS 25.23, Who May Adopt, to allow for the adoption of an adult by only one member of a married couple as long as the spouse consents to the adoption. Section 2: Adds a new section to AS 47.07, Medicaid Assistance for Needy Persons, to create a new program- adult home care services for individuals. Adult home care services will be available for individuals at least 18 years of age or older who are enrolled in a home and community-base[d] waiver. The Department of Health will develop regulations establishing the standards and rates of the program and providing an efficient process to allow existing foster homes to transition into the new adult home care license. Section 3: Amends AS 47.32.010(b) to add a new setting, "adult home care homes," that shall be subject to the centralized licensing functions of the Department of Health. Section 4: Adds a new section to AS 47.32 that defines the conditions under which the department may license an adult home care home. A person may be licensed to operate such a home for up to two persons age[d] 18 or older who are enrolled in home and community-based waiver services. This section requires the department to streamline the application process necessary for the person to be approved as an adult home care home provider and requires that the department approve variances of building code requirements to the extent permitted by state, local, or federal law. Section 5: Amends uncodified law by adding a new section that requires the Department of Health to submit for approval by the United States Department of Health and Human Services an amendment to the state medical assistance plan, waivers, or an 1115 demonstration waiver as necessary to allow eligible individuals to receive adult come care services and other long-term care services that are not duplicative. Section 6: Amends uncodified law adding a new section related to the conditional effect of section 4 and the required state plan amendments submitted to the United States Department of Health and Social Services. Requires the department to notify the revisor of statutes of the approval of state plan amendments. Section 7: Effective date related to the requirement for the department to provide notification of the revisor of statutes of approval of state plan amendments. Section 8: Provides for a July 1, 2022 effective date to align with the effective date of Executive Order 121 and the change of the applicable department to the Department of Health. 3:17:33 PM REPRESENTATIVE FIELDS referred to language on page 4 of the bill which would require DHSS to give instruction to adult foster- care applicants on acquiring a variance for their application if their home does not meet building code requirements. He posited that the new setting envisioned in CSSB 98(FIN) would include family homes and asked why the department would advise a variance rather than requiring the applicant to improve the home to meet safety standards. 3:18:19 PM CRAIG BAXTER, Program Manager, Residential Life, Division of Health Care Services, Department of Health and Social Services, explained that meeting many of the building codes for traditional care facilities would require changes which could be cost prohibitive for families providing the care, such as installing a sprinkler system. He stated that the new setting would be residential homes and voiced the understanding that there are no codes currently in effect for residential care in these new facilities. However, if building codes change in the future, he explained that this provision of the bill would allow DHSS to direct adult foster-care applicants to obtain a variance; this is included to showcase the department's willingness to help applicants go through the process if needed. He reiterated that current residential-care building codes require more updates only if the household is caring for three or more people; therefore, most of the people targeted by this bill would not be asked to comply. REPRESENTATIVE FIELDS asked how many people per home the bill would address. MR. BAXTER explained that CSSB 98(FIN) would create a new license for homes providing care for two or fewer individuals, in comparison to facilities which care for three or more. He explained that current building codes effect only home care settings serving three or more people. REPRESENTATIVE FIELDS expressed the understanding that fire codes would not be an issue for the new applicants. 3:21:44 PM REPRESENTATIVE MCCARTY noted that the proposed bill would limit each home providing adult home care services to two or fewer individuals. He questioned the inclusion of language which would allow this number to be increased at the discretion of DHSS. MR. LEE replied that the intent is for two or fewer and explained that there are possible scenarios where the state would want to grant an exception. He stated that being able to keep families together is the intent behind this language. REPRESENTATIVE MCCARTY questioned the frequency of multiple family members with adult foster care needs who would request waivers. MR. LEE explained that it is not common but does occur, and he referred to a current case where three family members are being served on waivers. REPRESENTATIVE MCCARTY expressed the belief that the language which would address this is "wide open" and questioned whether it should be fine-tuned to be more specific to family-based exceptions. MR. LEE explained that the regulations would be made to manage exceptions. 3:24:45 PM REPRESENTATIVE SPOHNHOLZ shared her experience with having her own home licensed for foster care and explained the coding requirements. She expressed concern that treating adult foster care homes as a subset of assisted living homes could introduce a building code work-around for assisted living homes. She asked why the adult foster-care licensing process is not being conducted the same way as child foster care licensing. 3:26:18 PM MR. BAXTER explained that for adult care facilities, local and state fire codes would not differentiate between the type of residence, rather the consideration would be the number of adults being served. He stated that municipalities enforce these codes based on the thresholds within the code and not on how the service is labeled. He restated that the intent is for DHSS to assist applicants who exceed the code thresholds, as there are currently no fire codes within Alaska which require the installation of a sprinkler system for homes serving two or fewer adults. REPRESENTATIVE SPOHNHOLZ noted that the proposed bill would allow the licensing of adult foster care homes as foster care, but they would be treated as assisted living homes. She asked whether a new standard could be created for adult foster homes to differentiate them from assisted living homes. She explained that if the bill is truly "creating a whole new category" of licensing for adult foster care, then the license should not be subject to standards for a different type of care. She suggested that the language of the bill be "tidied up" to prevent the mixing of regulations. 3:29:47 PM MR. NEWMAN explained that the intent of the bill is to "thread the needle" to create a setting between foster care and assisted living, and this aligns with the needs of stakeholders. He explained that the language would be a safety net to allow variances if needed later. REPRESENTATIVE SPOHNHOLZ suggested that she may draft an amendment to specify when variances could be made to increase the limit of adults. 3:30:44 PM REPRESENTATIVE FIELDS expressed opposition to including variances, citing the possibility of a single caregiver being unable to manage three adults with disabilities in the event of an emergency like a fire. He argued that the department should not be encouraging variances, and the language should be stricken from the bill entirely. He continued that, if the proposed legislation does not pass, those affected may not receive appropriate care. He pointed out the difference between staying at home or moving into an assisted living facility. MR. LEE confirmed that most of the individuals affected would be served with in-home support or with assisted living, and the intent of the bill is to create a new option. He clarified that the intent is not to divert clients from other options, but instead to lower the barriers of providing care to create more options across the state and increase access to care in places where it would not otherwise exist. He shared that stakeholder feedback supported creating another choice, as this would be valuable for those wanting to remain in their communities or not wanting to live in a group home. REPRESENTATIVE FIELDS pointed to the higher cost associated with the proposed setting as compared to receiving services through a personal care attendant (PCA) and inquired about the differences in workload between the two options. MR. LEE explained that there are many ways in which people can receive care and services from the state; however, this depends on the individual's condition, and CSSB 98(FIN) would open "certain avenues of support" for individuals to receive these services. He deferred to Mr. Newman for further detail. 3:35:04 PM MR. NEWMAN confirmed that the department's vision for the new adult home care license is to target the needs of patients, specifically the elderly, who are just starting to need at-home assistance a few hours a week. He explained that, under current practice, those people can receive services only within an assisted living setting, and he posited that the proposed bill would allow these people to continue living in a family home setting and receive services, even as the services increase over time. He described the proposed setting as a place one could "stop at during the journey of your life." REPRESENTATIVE FIELDS questioned the stakeholder input and whether the money allocated through the new setting would be enough to provide proper care. MR. LEE explained that the reimbursement rate for adult home care would need to be established and, because each person requires a different level of service, the plans are "person- centered," with the cost depending on the individual. He noted that the costs spoken about during the presentation were all example figures; the actual costs would vary based on each person's needs. 3:37:16 PM REPRESENTATIVE SPOHNHOLZ posited that the creation of the adult home care setting could function as a workaround to assisted living care by allowing compensation for similar care at a lower rate. MR. LEE reiterated that the goal is to create a care option which is less restrictive and easier to procure licensure. He pointed out that other states with similar policies have proven to have valuable and viable care settings. He explained that a new setting type must be established for the new license type to be created. MR. NEWMAN added that the main difference between the proposed setting type and an assisted living home is the habilitation requirements associated with the medical plan model of assisted living facilities. He reported that many stakeholders have expressed the desire to have a care option without habilitation goals. He explained that the new setting for an adult home care license would allow for service delivery without the habilitation goals. 3:39:55 PM REPRESENTATIVE MCCARTY reiterated the understanding that some minors in foster care "age out" but still require care for a mental or physical disability, and the proposed legislation would allow them to stay with the foster family, with whom they have a relationship, and continue to receive services. After listening to testimony, he expressed the understanding that the bill would be focused on allowing elderly people to move into a home care situation without a prior relationship with their caregiver, and this would allow other licensed facilities to be bypassed. He questioned the situation the bill would be addressing. MR. LEE explained that the bill started with a focus on those aging out of foster care; however, after hearing from stakeholders and community members, it was rewritten to be inclusive of other care recipients. REPRESENTATIVE MCCARTY asked whether the new category in this bill would allow for an elderly person to move in with an extended family member [who gets the new license type] and have the state pay for the services. MR. LEE replied that the intent of the bill is to allow people to choose a setting which best fits their needs. He explained that people who have the space within their home and the desire to provide services would be allowed to apply for the license, and this would become an option for people receiving care. He provided the scenario where an elderly person wished to remain in his/her current home with a family member, who already resided in the home. This family member would need the required license to give the needed care. He pointed out that this scenario would need to be addressed through regulation, as it was not the original intention of the bill. REPRESENTATIVE MCCARTY referenced the service waivers for people with developmental disabilities and shared his concern that the pool of eligible recipients would be widened too much by the proposed legislation. He sought clarification on who would be eligible to receive services. MR. LEE explained that in order to receive services in the proposed setting, an individual would have to already be on a waiver. 3:45:25 PM REPRESENTATIVE SPOHNHOLZ recollected that, for individuals who need care past the age of 18, the House companion bill of CSSB 98(FIN) would only allow for the continuation of foster-care services with the same family. She voiced support for the House's version of the legislation. She shared her appreciation of the intent to move away from the medical model of care for people with intrinsic disabilities or needs which will never "go away;" however, she voiced concern that the senior and disabilities services waiver qualification would be mixing two disparate groups. She suggested that expanding a bill intended for extending foster care to also include senior care within a new setting could lead to the creation of substandard assisted living homes. She expressed discomfort in mixing foster care and assisted living policy because they are two different levels of service which are treated differently in eligibility determination and licensing standards. She opined that the new setting and licensure pathway the bill proposes is not the same as a continuation of a family-like living model. She expressed opposition to mixing the two. MR. LEE referenced other states' plans which have created more options for the aging population. These plans, along with listening to feedback from stakeholders, informed the decision to create a new service type for the benefit of older Alaskans. He reiterated that the proposed setting would allow for more care opportunities in rural areas where establishing assisted living facilities would be much harder. REPRESENTATIVE SPOHNHOLZ asked how eligibility and access would be determined for the new setting and how this would be different from the existing waiver system. She expressed the opinion that there is more demand for [waiver] services than the state can meet. She questioned whether the proposed legislation would increase the demand for services and whether the criteria for waiver eligibility would be changed. MR. LEE explained that new regulations would need to be put into place, but that the eligibility criteria would not change. He stated that, once a person has been determined eligible, the new setting would be an additional option for receiving services. 3:51:24 PM REPRESENTATIVE PRAX referred to a list of levels of available care examples in the summary of CSSB 98(FIN) provided to the committee, which read as follows [original punctuation provided]: • Live at home and receive personal care services and waiver services. Daily Cost - $284 • Live in an Assisted Living Home and receive Group Home Services and other waiver services. Daily Cost - $416 Live in a Nursing Home and receive no waiver services. Daily Cost - $771 REPRESENTATIVE PRAX asked whether the level of care for the proposed setting would be between the levels detailed in the first and second bullets. MR. LEE responded in the affirmative. 3:52:11 PM CO-CHAIR ZULKOSKY opened public testimony on SB 98. 3:52:38 PM STEPHANIE WHEELER, Long-Term Care Ombudsman, Department of Revenue, expressed support for SB 98. She explained that the proposed legislation would give seniors alternatives to the existing services and living environments. As part of her work ensuring quality care for Alaska's seniors, she explained that she conducts unannounced visits to assisted living facilities. She reported that many elders within these facilities express the desire to receive care closer to their communities and families. She opined that SB 98 would help elders meet their care needs in the community of their preference. 3:54:05 PM MICHELE GIRAULT, Executive Director, Hope Community Resources, testified in favor of the concept of SB 98, citing a need for greater flexibility for providers of youth with intellectual and developmental disabilities. She reported that many families currently providing foster care to children with disabilities have resisted transitioning to an adult assisted living license because of the complexities and additional facility needs associated with this licensure. This has caused individuals with disabilities to be removed from the care of families, with whom they have formed relationships. The individuals are then placed in assisted living facilities, even though they often need youth transition support well into their twenties. She acknowledged some of the complications of the new service setting but opined that the proposed legislation would simplify the transition process for young adults with disabilities, allowing them a continued sense of normalcy and sense of family, and she reiterated support for SB 98. 3:56:11 PM LIZETTE STIEHR, Executive Director, Alaska Association on Developmental Disabilities (AADD), testifying on SB 98, explained that the AADD is the trade association for care providers who work with individuals with intellectual and developmental disabilities and expressed that AADD is "thrilled" by the proposed addition of a new service setting. She expressed the opinion that adding more options for service settings would allow recipients to live "meaningful" lives with more choices. She spoke about the complexity of the regulations concerning assisted living homes and stated that this has been a barrier to families providing care. She continued that the adult foster care license would be beneficial to many people within the system. She explained that the bill would provide broader options and lower costs for care. She posited that many of the questions brought up by the committee would be answered through regulation. 3:58:26 PM CO-CHAIR ZULKOSKY, after ascertaining that there was no one else who wished to testify, closed public testimony on SB 98. 3:58:34 PM CO-CHAIR ZULKOSKY announced that SB 98 was held over.