HB 58-ADULT HOME CARE; MED ASSISTANCE  3:36:40 PM CHAIR PRAX announced that the final order of business would be HOUSE BILL NO. 58, "An Act relating to medical assistance for recipients of Medicaid waivers; establishing an adult care home license and procedures; providing for the transition of individuals from foster care to adult home care settings; and providing for an effective date." 3:37:27 PM TONY NEWMAN, Acting Director, Division of Senior and Disability Services, Department of Health, presented HB 58 on behalf of the sponsor, House Rules by request of the governor. He began a PowerPoint [hard copy included in the committee packet] and directed attention to slide 2, "Senior and Disabilities Services - Medicaid Home and Community Based Waivers," which read as follows [original punctuation provided]: Senior and Disabilities Services Medicaid Home and Community Based Waivers • Allow people with disabilities and seniors to remain in their homes or local community settings when they would otherwise need institutional care • Home and Community Based Waivers receive a 50% Federal and 50% General Fund Match • Alaska provides five home and community-based waivers: • Intellectual and Developmental Disabilities waiver (serving about 2,000 people) • Alaskans Living Independently waiver (2,200 people) • Children with Complex Medical Conditions waiver (225 people) • Adults with Physical & Developmental Disabilities waiver (144 people) • Individualized Supports waiver (500 people) MR. NEWMAN gave an example of someone who might be on the Alaskans Living Independently waiver as a senior who had a stroke, has limited use of their arms and legs, and has had to move into an assisted living home. An example of someone on the Intellectual and Developmental Disabilities waiver might be someone with cerebral palsy or Down's Syndrome, but with enough support is able to stay at home or in a group home. He said the waiver provides people not only with more independence and personal choice but also saves the state significant amounts of money that would otherwise be spent on more expensive institutional care. MR. NEWMAN moved on to slide 3, "Services available under Alaska's Medicaid Home and Community-Based Waivers," which lists the services, as follows [original punctuation provided]: • Residential Habilitation (Group Home, Family Home Habilitation) • In-Home Supports • Supported Living • Day Habilitation • Adult Day Services • Respite • Supported Employment • Transportation Environmental Modifications • Meals • Specialized Medical Equipment • Nursing Oversight • Intensive Active Treatment • Specialized Private Duty Nursing ...and Care Coordination MR. NEWMAN explained that not all the services are available to every waiver. The one thing all people on waivers have in common is that they rely on caregiver coordinators to set up support plans and help recipients take the best advantage of the resources in their communities. He expressed gratitude for all those serving as care coordinators. He said they are not state employes; they work for non-profit organizations or are self- employed. He said HB 58 seeks to provide people on waivers with a new service option called, "Adult Home Care," which would be offered in a new residential setting an "Adult Care Home." He said the vision is that both the service and setting will have reduced administrative burdens compared with the assisted living home option, while still ensuring the care and safety of the individuals residing in them. MR. NEWMAN said the idea for HB 58 was brought to the governor's attention by constituents who were serving as foster parents for children with severe disabilities who were "aging out" of the foster care system, and there were no easy ways to continue to offer care to these foster children as they became adults. The only option available to them was to turn their home into an assisted living home, with all the licensure and other requirements that would entail. He said HB 58 would extend the possibility of home care to other individuals with disabilities, including seniors who qualify under the Medicaid Home and Community Based Waiver program. MR. NEWMAN covered slide 4, "Options for 24/7 residential care for people on Medicaid home & community-based waivers," which compares the assisted living home with the proposed adult care home. The assisted living home is available for three waivers, and the adult care home would be available for four waivers. He said regulations would need to be worked out to cover the types of training needed, the space expectations, and rates of payment. He said the division would invite input from its partners and those with disabilities. The proposed legislation provides the conceptual framework to get all that started, he advised. The bill is needed because of the lack of care options, the growth of the senior population, and workforce shortages. He stated, "We are hopeful that adult home care will grow in popularity and ultimately be an attractive alternative, helping make Alaska the best place it can be for neighbors and friends to live and grow older together." 3:43:59 PM MR. NEWMAN presented the sectional analysis for HB 58, which read as follows [original punctuation provided]: Section 1. Adds a new section in AS 47.07, Medicaid Assistance for Needy Persons, declaring that the state shall pay for adult home care services for an individual at a daily rate set by the department in regulation for individuals on Medicaid who are at least 18; enrolled in a home and community-based waiver under AS 47.07.045; if the individual's support plan is approved for adult home care services; and if they person providing the services to the individual holds an adult care home license issued under AS 47.32. This section also allows individuals to receive habilitative and rehabilitative care in addition to adult home care services and directs the department to adopt regulations setting a rate for the service, establish standards for operating an adult care home, and establish a procedure for transitioning an individual from a licensed foster care home to a licensed adult care home. This section also directs the department to establish a simple and efficient process to allow a foster parent who holds a foster home license issued under AS 47.32 to transition from the foster home license to an adult care home license for purposes of maintaining the placement of and services provided to an individual who is transitioning out of foster care, enrolled in a waiver, and at least 18 years of age. Section 2. Amends AS 47.32.010(b) to add a new entity, "adult care homes," that shall be subject to the centralized licensing functions of the department. Section 3. Adds a new section to AS 47.33 that defines the conditions under which the department may license an adult care home. A person may be licensed to operate such a home for an individual who is at least 18 years of age and enrolled in Medicaid and home and community-based waiver services. An adult care home may provide 24-hour oversight and care for up to two adults for compensation or reimbursement under the adult home care service, allows the department to establish standards in regulation to authorize care for up to three individuals based on unusual circumstances; and defines "care" as providing for the physical, mental, and social needs of an individual. Section 4. Amends AS 47.32.900(2) to add adult care homes to the list of settings that are not defined as assisted living homes. Section 5. Amends AS 47.32.900 to add a definition of adult care home, meaning a licensed home, not a business site, in which the adult head of household resides and provides 24-hour care on a continuing basis for eligible individuals. SECTIONAL ANALYSIS House Bill 58: Adult Home Care Services Prepared on February 1, 2023 Page 2 of 2 Section 6. 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 home care services and other long-term care services that are not duplicative. Section 7. Amends uncodified law by adding a new Conditional Effect Notification section specifying that Section 1 takes affect if the United States Department of Health and Human Services approves amendments to the state plan submitted under Section 6 by July 1, 2027 and adds requires the commissioner of health to notify the revisor of statutes in writing within 30 days that those amendments were approved. Section 8. Provides for an effective date for any portion of section 1 as the day after the revisor of statutes receives notice from the commissioner of health, per Section 7. 3:47:29 PM REPRESENTATIVE SUMNER offered his understanding that Medicaid expansion is 90 percent federal and 10 percent state, and he asked whether, under HB 58, people eligible for Medicaid expansion would be declassified, thus increasing the amount of state matching funds required. MR. NEWMAN responded that the services provided under the Home Community Based Waiver are provided at a 50/50 rate. He added that the individuals who are eligible for the division's services must be Medicaid eligible. 3:48:28 PM REPRESENTATIVE SADDLER asked if the provisions under HB 58 would be "implementing a federally authorized level of service." MR. NEWMAN replied that Alaska would be developing this service in collaboration with the Centers for Medicare and Medicaid Services. He said other states offer similar services, but with variations that make it difficult to compare state to state. Unique to Alaska is that all of its services currently offered not in a home setting require licensure in an assisted living home setting. In response to another question, he said there are approximately 50 children on a home and community based waiver who are also in foster care; five or fewer a year are graduations from foster care into adulthood and remaining on the waiver. There are approximately 2,200 seniors on the Alaska Living Independently waiver. 3:50:59 PM REPRESENTATIVE FIELDS asked for information as to the funding. MR. NEWMAN responded that the fiscal note includes staff to oversee residential licensing. He added that the division certifies the service, and both the Division of Health Care Services and the Division of Senior and Disability Services do the monitoring. REPRESENTATIVE FIELDS asked about frequency of visits. MR. NEWMAN deferred the question to Mr. Robert Nave. 3:52:36 PM ROBERT "BOBBY" NAVE, Assisted Living Home Manager, Division of Healthcare Services, Department of Health, answered that the division visits the assisted living homes biannually to inspect them for the purpose of licensing. Additionally, it conducts unannounced investigations. 3:53:14 PM REPRESENTATIVE SADDLER asked a question about two foster children in a home, where one is aging out but wants to stay in the home, and whether the home could operate under two licensures: adult care and foster care. MR. NEWMAN said that is a situation that arises now, and he deferred to Mr. Nave to describe how that is handled. 3:54:05 PM MR. NAVE confirmed that currently the division has dually licensed homes, and the division coordinates with the Office of Children's Services to make plans that meet regulations and care for the clients. 3:54:53 PM MR. NEWMAN, at the invitation of Chair Prax, reviewed the two fiscal notes to HB 58 [included in the committee packet]. Referring to fiscal note 1, with the Division of Health Care Services appropriation, he paraphrased a part of the analysis section, which read as follows: One full-time Community Care Licensing Specialist 1 (including benefits): Range 16, Anchorage: $105.0 in FY2024 and beginning in FY2029 and beyond two Community Care Licensing Specialists will be needed at a cost of $210.0 annually. Travel: $10.0 annually for each position to license and recertify providers. Years one through five $10.0 annually and year six $20.0 annually. Services: Office space, phone, reimbursable service agreements for position support: $10.0 annually for each position. Years one through five $14.0 annually and year six $28.0 annually. Commodities: Office Supplies $1.0 annually for each position. Years one through five $1.0 annually and year six $2.0 annually. One-Time Commodities Cost: Computer, software, and office equipment: $3.0 in the first year and $3.0 in year six with the addition of one more position. MR. NEWMAN then referred to fiscal note 2, with the Division of Senior and Disabilities Services appropriation, and he paraphrased a portion of the analysis, which read as follows: The division's provider certification and compliance unit would require one additional permanent full-time Health Program Manager 2, Range 19, in Anchorage, to manage the work of certifying and monitoring these providers for compliance with service rules and requirements. Cost for a Health Program Manager 2, Range 19, would be $119.1 with a 50% Federal/50% General Fund Match. Annual position costs include: Travel: $2.3; Services: $14.0; Commodities: $3.0. This position would be hired to begin July 1, 2024. Regulations would be needed to define the expectations for qualifications and service delivery for these providers. 3:56:23 PM REPRESENTATIVE MINA prefaced her question by sharing she grew up in assisted living homes; her family ran assisted living homes. She pointed to fiscal note 1 and offered her understanding that it indicates there would be 40 new providers licensed in the first two years, and she asked where that number is derived. MR. NEWMAN proffered it is "a fair best estimate," and then he deferred to Mr. Nave. 3:58:08 PM MR. NAVE responded that this was a "best estimate" based on applications and percentages. In response to a follow-up question, he touched upon the average caseload per provider. 4:00:10 PM REPRESENTATIVE FIELDS asked how HB 58 would provide for a situation in which a live-in care giver gets sick and must hire a caregiver that is not live-in. MR. NEWMAN answered that those are details that would be "ironed out" through regulation. 4:01:19 PM REPRESENTATIVE SADDLER asked if there is any risk that if HB 58 passed, consequently there would be a change in funding. MR. NEWMAN emphasized the good report and communication the division has had with the Centers for Medicaid and Medicare Service. He added, "We've not had them change course that dramatically in any way, (indisc.)." 4:02:21 PM REPRESENTATIVE RUFFRIDGE offered his understanding of how HB 58 would work, with a scenario of a family offering foster care and a child aging out, at which point the parents apply to have their home licensed as an adult care home and receive some kind of monthly financial support. He asked, "Is that what that $408 is that's mentioned in the summary of HB 58?" MR. NEWMAN answered that it is the cost to the state and would be inclusive of the daily rate, as well as other services for which the person would be eligible. He added that the daily rates are figured by the Office of Rate Review. 4:04:50 PM REPRESENTATIVE MINA, regarding the fiscal notes, asked whether there may be a need for increased capacity to do inspections if there is an increase in providers. MR. NEWMAN responded yes. He said the folks at the Residential Licensing Section are "more actively out and visiting facilities." He noted, "Our fiscal note is lower, because we don't anticipate needing a second person in the out years." 4:06:08 PM REPRESENTATIVE FIELDS expressed concern that wages that at least meet minimum state wage requirements would be considered when considering outsourcing. 4:07:13 PM CHAIR PRAX announced that HB 58 was held over.