HOUSE BILL 459 "An Act establishing new eligibility for medical assistance for certain disabled persons and giving their eligibility for services the highest priority among optional services and groups under the medical assistance program; amending the definition of 'personal care services in a recipient's home' as used in the medical assistance program; moving midwife services from being the first to being the seventh service eliminated under the medical assistance program when there is insufficient funding; adjusting the priority of optional services and optional eligible groups under the medical assistance program in order to reflect the new priorities given to the newly-eligible disabled persons and to midwife services but without otherwise changing the relative order of the other optional services and optional groups; relating to catastrophic illness assistance; establishing a medical assistance program for chronic and acute medical conditions; and providing for an effective date." Co-chair Sharp provided history of the bill in committee, including concerns about the midwife section. He noted that the sponsor was indifferent to whether the section was in the legislation or not. Senator Phillips MOVED Amendment 1. ROBERT BRIGGS, ATTORNEY, DISABILITY LAW CENTER OF ALASKA, informed the committee that the center was neutral on the position of whether the midwives section should be changed. He opined that the midwifery provisions of the bill should be deleted if the committee was inclined to not act on the bill because of the mix of the two different subjects in the bill. Mr. Briggs maintained that the bill was very important to the disability community and that the proposed amendment would accomplish what was needed. Senator Pearce OBJECTED to the amendment. Senator Donley commented that the amendment would change the title of the bill. There was a discussion about procedure related to changing the title. Senator Donley stated that there had been compelling testimony the day before about the position of the Health, Education, and Social Services Committee related to midwife services; there could be a large potential savings for the program, which would free up funds to provide the services listed. Co-chair Sharp queried whether the amount of Medicaid appropriated by the state had failed to reach the whole list. NANCY WELLER, CHIEF MEDICAL ASSISTANT, DIVISION OF MEDICAL ASSISTANCE, DEPARTMENT OF HEALTH AND SOCIAL SERVICES (DHSS), responded that the first five services on the list were not covered (midwives, clinical social workers, psychologists, chiropractors, and advanced nurse practitioners). She added that there were three types of advanced nurse practitioners that were mandatory under federal law and covered under the Medicaid program: nurse midwives, pediatric nurse practitioners, and family practice nurse practitioners. Senator Phillips questioned coverage for chiropractors. Ms. Weller responded that chiropractors were only funded for children. Co-chair Sharp asked whether a fiscal note had been prepared by DHSS that at least projected the savings. He noted the additional cost for disabled premiums. Ms. Weller replied that when the amendment was proposed in the House Finance Committee, DHSS reported that it did not have experience with certified direct-entry midwives, though it anticipated there could be some cost savings. There were very few such midwives in Alaska. However, DHSS supported the inclusion of direct-entry midwives in the Medicaid program and had proposed a different way of including direct-entry midwives in the program in the governor's child health insurance program bill, but the change was acceptable to the department. Co-chair Sharp noted that he had kept hearing that there would be savings using the midwives rather than doctors. He asked whether the amounts could be estimated or projected on a per-person basis. He wanted to see the numbers on a fiscal note. Ms. Weller replied that it was possible there could be savings; the department had not received information from the midwives association of how many clients it projected seeing. She stated the issue was more about access to the types of services the clients wanted for maternity and delivery care. She added that certified direct-entry midwives could provide home deliveries. Senator Parnell thought the department should be able to get numbers related to the projected savings. He wanted DHSS to estimate the possible savings. Co-chair Sharp agreed and wanted to see something in writing, at least an estimate in the narrative. He wanted a fiscal note backing up a claim for savings. Senator Parnell asked whether the department could provide the information if the bill moved out of committee. Ms. Weller replied that she would do her best. Co-chair Sharp spoke to expected meetings and possible delays. He requested that a fiscal note be supplied to the committee with projected estimates of how many people would be affected so that the committee could have something to base a decision on. He was concerned that people who would be moved down the list would be upset. Senator Donley agreed that the department should provide the information. He noted that birthing services would be an alternative to doctor services; he did not think expenses would increase, but only decrease. Co-chair Sharp also wanted the total amount paid out to adult dental services, which would be dropped off the list. Senator Parnell thought that would miss the point because people who were eligible could go to a doctor and get reimbursed under the list already for pregnancy-related services; they would go to a midwife instead and get the service provided at less expense. He thought those were the numbers needed from the department. He hoped the department could also say that no other services would be lost as a result of the savings. Co-chair Sharp wanted to see the total cost paid out for adult dental with a comparison with total anticipated savings. He was concerned that people would be upset because they did not qualify for adult dental expenses because the list was changed; he wanted to be able to say that DHSS had assured the committee in a fiscal note. Ms. Weller pointed out that the projected number for adult dental was $4 million per year, limited to emergency treatment of pain and acute infection. She anticipated the services would continue. She recalled intent language in the budget the year prior to restore services 6 through 19; the services were restored with program savings October 12, 1997. Co-chair Sharp suggested moving midwives to position 6 instead of 15, if there was money available. Senator Donley thought the suggestion might be reasonable; however, the title specifically said 1 to 14; the other suggestion would require a title amendment as well. Co-chair Sharp assumed a simple title change could be approved as long as the schedule was adjusted to qualify. He did not think midwife services had gone up to $4 million (the cost of the adult dental). Co-chair Sharp SET ASIDE HB 459 until later in the meeting (pending receipt of the new fiscal note by DHSS).