ALASKA STATE LEGISLATURE  HOUSE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE  April 13, 2021 3:08 p.m. MEMBERS PRESENT Representative Liz Snyder, Co-Chair Representative Tiffany Zulkosky, Co-Chair Representative Ivy Spohnholz Representative Zack Fields Representative Ken McCarty Representative Mike Prax Representative Christopher Kurka MEMBERS ABSENT  All members present COMMITTEE CALENDAR  HOUSE BILL NO. 168 "An Act requiring the Department of Health and Social Services to provide and allow submission of an electronic application for certain state benefits; and providing for an effective date." - HEARD & HELD HOUSE BILL NO. 103 "An Act relating to house rules for assisted living homes." - HEARD & HELD SENATE BILL NO. 21 "An Act relating to mobile intensive care paramedics; relating to duties of the State Medical Board and the Department of Health and Social Services; and providing for an effective date." - HEARD & HELD   PREVIOUS COMMITTEE ACTION  BILL: HB 168 SHORT TITLE: ELECTRONIC APPLICATION FOR STATE BENEFITS SPONSOR(s): REPRESENTATIVE(s) SNYDER 04/09/21 (H) READ THE FIRST TIME - REFERRALS 04/09/21 (H) HSS, FIN 04/13/21 (H) HSS AT 3:00 PM DAVIS 106 BILL: HB 103 SHORT TITLE: ASSISTED LIVING HOMES: HOUSE RULES SPONSOR(s): RULES BY REQUEST OF THE GOVERNOR 02/18/21 (H) READ THE FIRST TIME - REFERRALS 02/18/21 (H) STA, HSS 03/18/21 (H) STA AT 3:00 PM GRUENBERG 120 03/18/21 (H) Heard & Held 03/18/21 (H) MINUTE(STA) 03/25/21 (H) STA AT 3:00 PM GRUENBERG 120 03/25/21 (H) -- MEETING CANCELED -- 04/01/21 (H) STA AT 3:00 PM GRUENBERG 120 04/01/21 (H) Moved HB 103 Out of Committee 04/01/21 (H) MINUTE(STA) 04/05/21 (H) STA RPT 6DP 04/05/21 (H) DP: CLAMAN, STORY, KAUFMAN, VANCE, TARR, KREISS-TOMKINS 04/08/21 (H) STA AT 3:00 PM GRUENBERG 120 04/08/21 (H) 04/13/21 (H) HSS AT 3:00 PM DAVIS 106 BILL: SB 21 SHORT TITLE: LICENSE MOBILE INTENSIVE CARE PARAMEDICS SPONSOR(s): REVAK 01/22/21 (S) PREFILE RELEASED 1/8/21 01/22/21 (S) READ THE FIRST TIME - REFERRALS 01/22/21 (S) HSS, L&C 03/02/21 (S) HSS AT 1:30 PM BUTROVICH 205 03/02/21 (S) Heard & Held 03/02/21 (S) MINUTE(HSS) 03/04/21 (S) HSS AT 1:30 PM BUTROVICH 205 03/04/21 (S) Moved SB 21 Out of Committee 03/04/21 (S) MINUTE(HSS) 03/05/21 (S) HSS RPT 3DP 1NR 03/05/21 (S) DP: WILSON, COSTELLO, HUGHES 03/05/21 (S) NR: BEGICH 03/15/21 (S) L&C AT 1:30 PM BELTZ 105 (TSBldg) 03/15/21 (S) Moved SB 21 Out of Committee 03/15/21 (S) MINUTE(L&C) 03/17/21 (S) L&C RPT 4DP 03/17/21 (S) DP: STEVENS, GRAY-JACKSON, REVAK, HOLLAND 03/22/21 (S) TRANSMITTED TO (H) 03/22/21 (S) VERSION: SB 21 03/24/21 (H) READ THE FIRST TIME - REFERRALS 03/24/21 (H) HSS, L&C 04/13/21 (H) HSS AT 3:00 PM DAVIS 106 WITNESS REGISTER  ARIELLE WIGGIN, Staff Representative Liz Snyder Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Provided a sectional analysis for HB 168 on behalf of Representative Snyder, prime sponsor. ROBBI MIXON, Executive Director Alaska Farmers Market Association Executive Director Alaska Food Policy Council Homer, Alaska POSITION STATEMENT: Provided invited testimony in support of HB 168. CARA DURR, Director of Public Engagement Food Bank of Alaska Anchorage, Alaska POSITION STATEMENT: Provided invited testimony in support of HB 168. SHAWNDA O'BRIEN, Director Division of Public Assistance Department of Health and Social Services Juneau, Alaska POSITION STATEMENT: During the hearing of HB 168, answered questions related to the bill. JOHN LEE, Director Division of Senior and Disability Services Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Presented HB 103 on behalf the House Rules Standing Committee, sponsor, by request of the governor. CRAIG BAXTER, Program Manager Residential Licensing Section Division of Health Care Services Department of Health and Social Services (DHSS) Anchorage, Alaska POSITION STATEMENT: During the hearing of HB 103, answered questions on behalf of the House Rules Standing Committee by request of the governor. LYNNE KEILMAN-CRUZ, Chief of Quality Division of Senior and Disabilities Services Department of Health and Social Services (DHSS) Anchorage, Alaska POSITION STATEMENT: During the hearing of HB 103, answered questions on behalf of the House Rules Standing Committee, sponsor, by request of the governor. MICHAEL GARVEY, Advocacy Director American Civil Liberties Union of Alaska Anchorage, Alaska POSITION STATEMENT: Testified in support of HB 103. SENATOR JOSH REVAK Alaska State Legislature Juneau, Alaska POSITION STATEMENT: As the prime sponsor, presented SB 21. SETH DUGGAN, Staff Representative Josh Revak Alaska State Legislature Juneau, Alaska POSITION STATEMENT: Provided the sectional analysis for SB 21 on behalf of Senator Revak, prime sponsor. BRIAN WEBB, Emergency Medical Services Officer Division of Public Health Department of Health and Social Services Anchorage, Alaska POSITION STATEMENT: Answered questions during the hearing on SB 21. SARA CHAMBERS, Director Division of Corporation, Business, and Professional Licensing Department of Commerce, Community, and Economic Development Juneau, Alaska POSITION STATEMENT: During the hearing of SB 21, answered questions. WILMA VINTON Fairbanks, Alaska POSITION STATEMENT: Testified in support of SB 21. ACTION NARRATIVE 3:08:27 PM CO-CHAIR LIZ SNYDER called the House Health and Social Services Standing Committee meeting to order at 3:08 p.m. Representatives Spohnholz, McCarty, Prax, Kurka, Zulkosky, and Snyder were present at the call to order. Representative Fields arrived as the meeting was in progress. HB 168-ELECTRONIC APPLICATION FOR STATE BENEFITS  3:09:56 PM   CO-CHAIR SNYDER announced that the first order of business would be HOUSE BILL NO. 168, "An Act requiring the Department of Health and Social Services to provide and allow submission of an electronic application for certain state benefits; and providing for an effective date." 3:10:20 PM CO-CHAIR SNYDER took a brief at-ease to pass the gavel to Co- Chair Zulkosky. 3:11:16 PM CO-CHAIR SNYDER, as prime sponsor, presented HB 168. She explained the bill would require the addition of an online submission option for public assistance applications through the state's internet site, but nothing in the bill would change current options for applying for public assistance. Current options include mailing, faxing, dropping off in person, and in some instances downloading, completing, and sending the application as an email attachment. She noted that during a budget subcommittee meeting, the Division of Public Assistance (DPA), Department of Health and Social Services (DHSS), stated that it is working to get the online submission option up and running. Thus, HB 168 would put the division's work into statute, thereby protecting it into the future. CO-CHAIR SNYDER related that HB 168 would apply to a variety of public assistance programs, including Medicaid for chronic and acute medical assistance; supplemental nutrition assistance through the Supplemental Nutrition Assistance Program (SNAP); adult public assistance; senior benefits program; heating assistance; Women, Infants, and Children (WIC) Program; and the Commodity Supplemental Food Program that is for seniors over 60 who need access to supplemental food; along with renewals and recertifications. 3:13:58 PM CO-CHAIR SNYDER discussed the three primary points of motivation for adding an online application submission as an option for these programs. She said the first motivation is that it modernizes the process to reflect typical current practices. For example, the United State Department of Agriculture (USDA), which administers SNAP, has been providing guidance to states on best practices for online SNAP applications since at least 2006. Alaska is one of a small number of states that does not yet have the online application option. Even before the COVID-19 pandemic, adding online submission options has been the trend because it addresses the other two motivations of HB 168. CO-CHAIR SNYDER related that the second motivation is to remove barriers to access. She explained that the purpose of public assistance programs is to help Alaskans get through a challenging time in their lives, and the fewer barriers put in front of that path the faster folks can achieve positive outcomes. While some barriers may not seem large, they can be a big deal. For example, having a printer is necessary when a signature on the application is required and cannot be done online. In Alaska's rural areas there may be issues with the frequency and consistency of postal service, adding excess time to the submission of an application. CO-CHAIR SNYDER conveyed that the third motivation is improved efficiency for the division through online applications. She said paper processing is slow and takes up much staff time, contributing to backlogs and long review times. The governor's budget, in anticipation of efficiencies that will be provided by online applications, included cuts of nearly $1 million in reduced needs for postage and supplies and the elimination of dozens of positions that would be unnecessary with online applications. She said a fiscal note has not yet been received but will be shared as soon as it is available. CO-CHAIR SNYDER summarized that HB 168 would put the division's current modernization work into statute and the addition of an online submission option for public assistance would remove barriers to access and improve processing efficiencies, saving money and time for the state. 3:18:07 PM ARIELLE WIGGIN, Staff, Representative Liz Snyder, Alaska State Legislature, provided a sectional analysis for HB 168 on behalf of Representative Snyder, prime sponsor. She paraphrased from the written sectional analysis titled, "SECTIONAL ANALYSIS, HB 168: ELECTRONIC APPLICATION FOR STATE BENEFITS, Ver. W," which read [original punctuation with some formatting changes]: Sec. 1: Adds a new subsection (19) to AS 47.05.010 Duties of Department requiring the Department of Health and Social Services to create and provide an entirely online application process for individuals applying for public assistance and defines an online application. It does not mandate applicants apply online or remove the written option. Sec. 2: Amends AS 47.08.150(b) Assistance For Chronic or Acute Medical Conditions by adding language requiring the Department of Health and Social Services to establish an entirely online application process for individuals applying for the Chronic and Acute Medical Assistance program. Sec. 3: Adds a new subsection (6) to AS 47.25.001(a) Powers and Duties that requires the department establish an entirely online application process and allows applicants to apply in any form required by state and federal law. Sec. 4: Adds a new section (7) to AS 47.25.071(e) Child Care Grant Program that requires the department establish an entirely online application process for assistance under the Child Care Grant Program. Sec. 5: Amends AS 47.25.095 Definitions For Day Care Assistance and Child Care Grant Programs to define electronic application. Sec. 6: Amends AS 47.25.150 Application For Assistance by adding language requiring the Department of Public Assistance to establish an entirely online application process for individuals applying for assistance from the department and defines an online application. Sec. 7: Amends AS 47.25.440 Application For Assistance by adding language requiring the Department of Health and Social Services to establish an entirely online application process for individuals applying to receive Adult Public Assistance and defines an online application. Sec. 8: Adds a new subsection (4) to AS 47.25.622 Alaska Affordable Heating Program requiring the Department of Health and Social Services to create and provide an entirely online application process for individuals applying for the Alaska Affordable Heating Program and defines an online application. Sec. 9: Adds a new subsection (4) to AS 47.25.980(a) Duties of Department requiring the Department of Public Assistance to create and provide an entirely online application process for individuals applying for the Supplemental Nutrition Assistance Program and defines an online application. Sec. 10: Amends AS 47.27.020(a) Application Requirements by adding language requiring the Department of Public Assistance to establish an entirely online application process for individuals applying for the Alaska Temporary Assistance Program. Defines online application. Sec. 11: Amends AS 47.45.302(a) Cash Assistance Benefits by adding language requiring the Department of Health and Social Services to establish an entirely online application process for individuals applying for the cash assistance program. Defines online application. Sec. 12: Adds a new section to the uncodified law of the State of Alaska allowing the Department of Health and Social Services to adopt regulations needed to create and implement online applications. Sec. 13: Requires Section 12 to take effect immediately under AS 01.10.070(c). Sec. 14: Provides an effective date of July 1, 2022. 3:19:26 PM CO-CHAIR ZULKOSKY opened invited testimony. 3:19:48 PM ROBBI MIXON, Executive Director, Alaska Farmers Market Association, Executive Director, Alaska Food Policy Council, provided invited testimony in support of HB 168. She stated that electronic public assistance applications would create greater government efficiencies and expand the number of people able to access these benefits. These benefits are a vehicle for accessing healthy food and allow for making healthier food choices. It also provides funds for local produce and quality proteins that are often outside of some people's budgets, providing more equity in accessing healthy foods. MS. MIXON noted that programs like SNAP increase recipients' purchasing power and allows them to access local foods or programs like farmers market SNAP and doubling programs. Bolstering opportunities like this for local farmers is in direct alignment with Governor Dunleavy's declared interest in expanding Alaska's agricultural industry. Increasing access to public food assistance benefits would also support Alaska's growing food sectors, increasing sales for Alaska's farmers and food producers. Every dollar spent in SNAP generates about $1.80 in economic activity for local economies. MS. MIXON added that allowing for electronic applications would go a long way in creating greater food security in Alaska, which is important given one in six Alaskan children go to bed each night food insecure. The bill holds many potential benefits with very low costs, she stated in conclusion. 3:22:34 PM CARA DURR, Director of Public Engagement, Food Bank of Alaska, provided invited testimony in support of HB 168. She related that the Food Bank hopes the bill will ensure that the division has the support and resources needed to achieve its goal of providing an online application. She said she oversees the Food Bank's SNAP Outreach Program, a federally funded program done in partnership with the state. Broadly, her program's charge is to provide education, outreach, application assistance, and case status updates for current and potential SNAP clients. MS. DURR noted that Alaska has a lower participation index for SNAP, about 76 percent, which speaks to the number of people who are eligible and able to access the program. According to the USDA, she continued, about 25 percent of the people in Alaska who are eligible are not accessing the program. Some of the reasons for this can be addressed and some cannot. One barrier is access and the lack of options on how to apply, and an online application would improve this. The current paper application requires a "wet" or "pen-to-paper" signature. The division is working on some alternative signature options, like an e- signature or a telephonic signature. The Food Bank has recently received a waiver from USDA specific to COVID-19 flexibilities, which allows the Food Bank to be an authorized representative and sign on behalf of clients who aren't able to see the Food Bank in person. Since it is tied to COVID-19 it is unknown how long this will last, but these are important flexibilities to continue because the more options the better. MS. DURR stated that given COVID-19, many DPA offices are closed, plus many communities don't have DPA offices; therefore, people don't have a way to get applications. Some clients don't have access to the online PDF document, some don't have printing or mailing capabilities, and some need help with understanding the questions that are asked on the 28-page application. The Food Bank is helping people over the phone by asking questions of the client and filling out the application on the Food Bank's end. If a client doesn't have printing capabilities, the Food Bank then mails the application to the client with a pre-paid return envelope, the client then reviews, signs, and mails back the application. This process can take weeks for clients in rural communities and many times the application doesn't get submitted for one reason or another. She said she knows that if clients had access to the internet and could self-submit, even with guidance from the Food Bank over the phone, it would be a great option for them and would save the mailing time and associated costs. MS. DURR said another benefit of an online application is that it can simplify the application per client. Currently clients can apply for multiple benefits at the same time, but that results in a long application and some of the questions are not always relevant. When helping clients, the Food Bank Outreach Team knows which questions are required and which aren't, which simplifies the daunting process for clients. She suggested making the online application predictive so it could allow clients to just answer the questions that are relevant to the programs they are applying for and could even provide further explanation of the information needed. She concluded by expressing the Food Bank's support for the bill. 3:27:57 PM REPRESENTATIVE KURKA drew attention to Section 5 of the bill and noted that the State of Alaska already has infrastructure for electronic signatures in the myAlaska system, a seemingly natural infrastructure from which to build this. He interpreted the bill's language as directing the department to have the application submitted through the department's website. He asked whether the bill would be building a competitive infrastructure. CO-CHAIR SNYDER replied that the interest is in whatever is necessary to create an efficiency. She said the language in the bill came from talking with the department and Legislative Legal Services. She deferred to the department to further answer the question. 3:30:08 PM SHAWNDA O'BRIEN, Director, Division of Public Assistance (DPA), Department of Health and Social Services (DHSS), responded that DPA has been exploring options to use myAlaska as the platform for validation and verification of an individual's identity given that that platform would be the most efficient and advantageous way to move forward. However, she explained, the division has been unable to get the USDA to allow using the myAlaska single sign-on for the application because it requires the individual to have an email address as a means for contacting them, and that goes against USDA's regulatory oversight. Therefore, DPA will most likely have to pursue another platform for folks to apply for SNAP benefits. The division is continuing to see if there is something else that would still enable taking advantage of myAlaska because that would make more sense. She added that DPA has used the argument that Alaska is unique in that most individuals applying for a permanent fund dividend (PFD) have a myAlaska account, which means that people are familiar with that already. REPRESENTATIVE KURKA asked whether the bill's current language would preclude DPA from using myAlaska if the division is able to make it work through the department's website. MS. O'BRIEN answered that she does not believe the language in the bill would prohibit DPA from doing whatever means it needed to make that happen. She said she reads the bill as giving DPA the flexibility to use any internet type platform as long as the recipients are not in any way excluded from participating. REPRESENTATIVE KURKA inquired about the percentage of Alaskans who use myAlaska versus other options to apply for the PFD. MS. O'BRIEN offered her understanding that more Alaskans use it to apply for their PFD than not, but she doesn't know the number. 3:33:29 PM REPRESENTATIVE SPOHNHOLZ asked whether DPA's work to create an online application process is being done in-house or through contracting. MS. O'BRIEN replied that DPA has been communicating with the vendor that did the PFD application, as well as the document management system, for the Department of Revenue. She stated that this vendor also developed and implemented DPA's document management system, and that DPA has been working with the vendor to ensure that the division's document management system and its workflow management system are aligned to receive all those documents electronically. Right now, she continued, DPA is entering into the initial procurement stages of that project and hopes to have the procurements approved and work underway in the next couple months. The work the vendor has done with the PFD includes the ability of the application to be predictive so that it streamlines and limits the types of questions an individual is made to respond to when applying, for example, for just SNAP. This is advantageous to DPA and will be beneficial for both the user and DPA staff. She pointed out that the USDA funding currently being made available to states is a good opportunity for DPA to maximize its federal funding sources to fund this project. The division is trying to take advantage of that, so it is using less state general funds from its capital projects to accomplish this. REPRESENTATIVE SPOHNHOLZ remarked that it seems the predictive application could be constructive because some people may not understand that they don't need to fill out every page of the application. She noted that people can already apply for Medicaid at myAlaska.gov. She asked whether there are any provisions in the American Rescue Plan Act of 2021 (ARPA) that might be used in addition to the USDA funding. MS. O'BRIEN answered that there is funding under the ARPA to cover 100 percent of the administrative costs, so DPA has been working to identify what documentation is necessary to take advantage of that funding going forward for as long as that funding will be available. She added that the division is getting close to having those answers. 3:37:33 PM REPRESENTATIVE SPOHNHOLZ offered her understanding that an email address is needed on the USDA's SNAP application and that the state could potentially apply for a waiver to the USDA. She inquired whether there are any other programs that would require some special permission from the federal government to do this. MS. O'BRIEN replied that it is the reverse the USDA requirements would not allow DPA to require that an individual provide an email address as a part of the authentication and that is what DPA is has been trying to work through. She stated that because DPA wants to get this going and get something in place sooner than later, the division is proceeding as if it will not be able to take advantage of the myAlaska platform for SNAP benefits. She said there aren't any restrictions in place for the other programs that would be prohibitive that way. REPRESENTATIVE SPOHNHOLZ asked whether DPA is proceeding as if a waiver won't be received for using myAlaska, or whether DPA is assuming that it cannot get a waiver and is not going to try. MS. O'BRIEN responded that in this case there is not an option for DPA to apply for a waiver. She related that she has put in writing to USDA the argument that many of the recipients in Alaska are already using myAlaska for applying for the PFD. Using that logic she was hoping to persuade USDA to give DPA permission to use the myAlaska platform and still have options for folks who don't have an email address to use some other platform. 3:40:21 PM REPRESENTATIVE MCCARTY asked whether the USDA is giving DPA any solutions for not being able to use myAlaska or when people don't have an email address. MS. O'BRIEN answered that the USDA requires a mailing address for communicating with recipients, so DPA would have an option for folks to elect to communicate with the division; however, DPA cannot require folks to have an email and that is where the difference is. She said myAlaska requires individuals to have an email address as a means for communication or identification, but DPA cannot use that for the purposes of the application for SNAP; DPA has to have the mailing address as the primary means of communication and notification. Responding further to Representative McCarty, she confirmed that DPA must require a mailing address but cannot require an email address. REPRESENTATIVE MCCARTY inquired about checks and balances for fraud given that multiple people may use the same mailing address. MS. O'BRIEN confirmed that multiple individuals may share a single mailing address. She stated that for purposes of the program, validation of the residence or the mailing address being used on record is something DPA's fraud unit would look into if there were reasons to suspect that an individual was fraudulently using the system. Regarding the application, she said many folks may use the same mailing address for various reasons, but she cannot speak to what the requirements are for USDA's purposes in terms of validating an individual based on a mailing address versus an email address. She offered to get additional information to the committee. 3:43:49 PM CO-CHAIR SNYDER stated that the addition of an online application does not affect the possibility of some misuse in addition to what is already possible with the other forms of application, and therefore it is a separate question. She said the level of misuse and abuse is a single digit percentage and that [DPA] has been working over the years to address that, such as using electronic benefit transfer cards. MS. DURR agreed with Co-Chair Snyder's summation. She said SNAP has very low rates of fraud, waste, and abuse, and she doesn't see an online application as inviting more fraud. Fraud is taken seriously, she added, because the program is important and DPA doesn't want to see people misusing it. REPRESENTATIVE MCCARTY stated that he likes making things easier to process but asked what is being done in the electronic system to recognize red flags. CO-CHAIR ZULKOSKY responded that this is a related but separate question that can be discussed when the committee again considers HB 168. She said the bill focuses on creating an online application system, not on conflating the two issues. 3:46:56 PM REPRESENTATIVE PRAX inquired whether this idea could be accomplished without passing a statute. CO-CHAIR SNYDER answered that part of the motivation is to provide statutory support for this work that has begun but has taken quite a long time to achieve. She said procurement is required which has an associated cost, and that has been addressed in the budget. But the number one reason is because if [the state] is going to invest and get this best practice operational in this department, having it in statute protects the online application option from being easily removed by future administrations. As seen with other states that have adopted this, it is a good plan, improves efficiency, saves time, and removes barriers to access these programs, and having it in statute protects that. REPRESENTATIVE PRAX asked whether a fiscal note will be associated with the bill given it is a project with a beginning and an end and a cost somewhere. CO-CHAIR SNYDER replied that a fiscal note is being awaited and will be provided to the committee as soon as it is received. She concurred that a cost is anticipated but said it is expected that the cost will be balanced out with some of the proposed cuts that foresee the savings generated by putting it online. 3:49:13 PM REPRESENTATIVE PRAX noted that the word "needy" is used several times throughout the bill. He maintained that this word is unnecessary and asked whether this language could be cleaned up. CO-CHAIR SNYDER offered her understanding and suggested that it is an amendment the committee could consider. She noted that the bill also references the outdated term "food stamps," which has been brought to the attention of DHSS as a possible change. 3:50:33 PM REPRESENTATIVE KURKA conveyed that 15.16 percent of PFD applications are through paper, 8.07 percent are online paper signature, and 76.77 percent are the online electronic signature process. He stated that procuring and having a mailing address would be more difficult than an email address but qualified that this is not meant as an argument with DHSS. CO-CHAIR ZULKOSKY announced that public testimony on HB 168 will be heard on 4/15/22. [HB 168 was held over.] 3:51:26 PM CO-CHAIR ZULKOSKY took a brief at-ease to return the gavel to Co-Chair Snyder. HB 103-ASSISTED LIVING HOMES: HOUSE RULES  3:51:52 PM CO-CHAIR SNYDER announced that the next order of business would be HOUSE BILL NO. 103, "An Act relating to house rules for assisted living homes." She noted the bill is from the House Rules Standing Committee by request of the governor. 3:53:02 PM JOHN LEE, Director, Division of Senior and Disability Services, Department of Health and Social Services (DHSS), presented HB 103 on behalf of the House Rules Standing Committee, sponsor, by request of the governor. He stated that the bill is needed because Alaska's statutes are not in compliance with federal regulations which require home and community-based services (HCBS) providers to give people who are on waivers the same access to the community as people who are not on waivers. The term waiver, he explained, refers to the federal programs that allow people who would otherwise be in an institution at a much higher cost the opportunity to live in non-institutional settings such as an assisted living facility. MR. LEE said [Alaska] state law allows that assisted living homes may establish house rules that address residents' right to have visitors. While [Alaska] statute says the rules may not be unusually restrictive the federal regulations are much more explicit, stating that individuals on waivers and in such settings are able to have visitors of their choosing at any time. Although Alaska received initial approval from the federal government for its plan to bring its settings into compliance, this approval was contingent on the state revising its statutes to reflect this federal statute. Ongoing financial participation in the state's waiver programs by the federal government is reliant on services being provided in compliant settings. Without this amendment to state statutes, the federal government's match is jeopardized. MR. LEE explained that HB 103 addresses this need by proposing a simple insertion of language into the assisted living home statute that would bring the state into compliance with the Centers for Medicare and Medicaid Services (CMS) home and community-based setting requirement, protecting Alaska's federal share of Medicaid payments for home and community-based waiver services. The bill would ensure that recipients of residential waiver services will be able to live under conditions that are as much like the person's home as possible. MR. LEE stated that HB 103 would impact Alaska's approximately 700 assisted living homes, which would be required to abide by the conditions defined in the bill. The new statutory language would afford all residents living in an assisted living home the same rights regardless of whether the home accepts Medicaid as payment or not. Over 650 of the homes are already compliant with the conditions set forth in this legislation because they have been certified to operate home and community-based waiver services under these conditions. MR. LEE noted that there is a timeline - all states are required by the federal government to be compliant by March 2023. He further noted that there is zero fiscal impact for the bill. 3:56:12 PM MR. LEE provided the sectional analysis for HB 103. He stated that Section 1 would amend Alaska Statute (AS) 47.33.060, House Rules for Assisted Living Homes, to explicitly require consistency with federal regulation when house rules are established. He explained that Section 2 would add a new section for assisted living homes to make explicit that assisted living homes that provide waiver services may not adopt house rules inconsistent with federal regulations. He said Section 3 carries the statutory amendments proposed in Section 1 and Section 2 of the bill to AS 47.33.300(a) regarding a resident's rights to have visitors. 3:57:10 PM REPRESENTATIVE KURKA asked whether these new requirements would have to be followed by an assisted living home or private home that is outside of state or federal government assistance. MR. LEE replied that of the 700 homes operating in Alaska and licensed by the state, only about 50 do not currently accept waiver payments funds. He pointed out that all facilities must be compliant with federal statutes, and HB 103 would ask those 50 facilities that are not participating in waiver programs to also be compliant. REPRESENTATIVE KURKA referred to Section 2 and asked why these "strings" should apply to homes that do not receive funding. MR. LEE responded that it is for consistency and to not have separate requirements depending on who is the payer, and that all individuals be treated with the same dignity and respect. He deferred to Mr. Craig Baxter to further answer the question. 3:59:56 PM CRAIG BAXTER, Program Manager, Residential Licensing Section, Division of Health Care Services, Department of Health and Social Services (DHSS), answered the question on behalf of the House Rules Standing Committee by request of the governor. He concurred with Mr. Lee's answer. He said many of the residents are private pay and not participating in the home and community- based waiver program. In addition, many of the 50 facilities that are not currently waiver certified will become waiver certified in the future as many of them are in their provisional year of licensure and have not completed the certification process. It is to have facilities consistent, he continued, so that the expectation is the same for visitation regardless of where a person lives if he or she is in an assisted living home. Residents can receive visitors of their choosing when they choose in whatever facility they live, just like people who live in their personal residences. 4:00:55 PM REPRESENTATIVE MCCARTY asked whether federal investigations are conducted on homes that are not consistent. He further inquired about what is going on that Alaska is paying back money to the federal government for noncompliance. MR. LEE replied that HB 103 does not directly address fraud and abuse. He deferred to Mr. Baxter and Ms. Lynne Keilman-Cruz to talk about the department's programs that ensure fraud and abuse are eliminated wherever found. 4:01:48 PM LYNNE KEILMAN-CRUZ, Chief of Quality, Division of Senior and Disabilities Services, Department of Health and Social Services (DHSS), answered the question on behalf of the House Rules Standing Committee, sponsor, by request of the governor. She said the department is required by the federal government to comply with the settings rule for Alaska's home and community- based waivers. In conjunction with the Residential Licensing Section the [Division of Senior and Disabilities Services] conducts the settings evaluations to make sure folks are complying. All the current residential homes have gone through a settings evaluation and found in compliance with the rules as they are stated now. She said she assumes the same would apply for folks who are coming into [the division's] services or becoming certified. For those private homes that are not certified, the federal rule doesn't apply, but if it were to become a law and a regulation then the state's rules would apply for that as well. REPRESENTATIVE MCCARTY inquired whether homes that do not have waivered individuals would have to comply with something anyway. MS. KEILMAN-CRUZ responded that it is to be consistent with licensing rules and it also a very basic human element for folks to be able to have visitors of their choosing in the home. So, it is a federal settings rule, but it is an important human decency rule. REPRESENTATIVE MCCARTY acknowledged the respect of someone to bring anyone or groups of people into their home 24/7, but said he is thinking of a senior "John Belushi Animal House." He asked how it plays out when the choices of one person are intruding on the choices of others. MS. KEILMAN-CRUZ deferred to the Residential Licensing Section to respond to the question. 4:05:02 PM MR. BAXTER answered that this new rule would not prohibit a facility from having reasonable expectations that visitors and guests are not disruptive. For example, the expectation that they would follow any specified quiet hours in the home, and that they are not up late being loud, disruptive, violent, or verbally abusive. Any of those things could still be restricted by the facility. If a resident continued to have disruptive people over, those individuals could be asked to leave if there is a documented pattern of disruption. Or, if the people coming over were unsafe, [the resident's] treatment team and guardian or care coordinator could work with the facility on having restricted visits. This would be addressed within [the resident's] care plan and there would have to be some sort of documentation that the individuals are disruptive, unsafe, and impacting other people in the facility. It would be no different than a facility asking a parent who comes to visit with an unruly child to refrain from bringing the child. The division would not look at that as being an unreasonable restriction to place on that visitation. 4:06:47 PM REPRESENTATIVE SPOHNHOLZ pointed out that most group homes in Alaska are private regardless of whether they accept Medicaid funding. But, she continued, the people living in those homes have the same rights to liberty as people who live independently and therefore they should have the right to have their friends and loved ones visit them when they like, and that the resident doesn't become a hostage just because he or she lives in a group home. She concurred that there is a balancing act and a party at 3:00 a.m. is not a liberty but rather oppression of others in the household. Representative Spohnholz referenced the recommendations made in the annual report of Alaska's Office of Long Term Care Ombudsman for 10/1/20199/30/2020. The recommendations, she related, include the right to access to the internet, the right to receive information in a language that the resident understands, the right to receive meals that are culturally preferred, and the right to live without fear of reprisal or retaliation. She asked whether any of these were considered when drafting HB 103 and, if not, why not. MR. LEE replied that adding additional requirements was debated. However, he continued, ensuring that the requirements outlined in the Code of Federal Regulations (C.F.R.) was wanted, along with not overly complicating the bill given its critical importance to ensuring that the state continues to be eligible to receive the funding through its waiver programs. The foremost priority was to ensure that [the state's] settings rules were compliant with 42 CFR and so that was the strategy chosen. REPRESENTATIVE SPOHNHOLZ inquired whether the department has any objection to adding some of those recommendations. MR. LEE responded that the department would be happy for any friendly amendments. 4:10:10 PM CO-CHAIR SNYDER opened public testimony on HB 103. 4:10:25 PM MICHAEL GARVEY, Advocacy Director, American Civil Liberties Union (ACLU) of Alaska, testified in support of HB 103. He stated that ACLU of Alaska is committed to furthering the rights and dignity of people with disabilities who live in assisted living facilities. He said his organization supports HB 103 because it will bring the state into compliance with the federal government's home and community-based services settings rule. One of the rule's core goals, he continued, is to ensure that federal funding for home and community-based services flows to settings that promote true community integration for people with disabilities and elder Americans. Institutional settings pose a great risk to the physical and mental well-being of residents, limit their autonomy, and isolate them from broader society. MR. GARVEY said ACLU of Alaska is expressing its support because people with disabilities deserve the same right to make choices, access the broader community, and interact with the world as anyone else. Through a simple statutory fix, HB 103 would help ensure that residents of any assisted living facility are living in conditions that uphold their privacy, dignity, respect, agency, and visitation. He added that ACLU of Alaska endorses the recommendations provided by Alaska's Office of Long Term Care Ombudsman, which would further promote the dignity of assisted living facility residents and ensure that they are connected to the community. 4:12:19 PM CO-CHAIR SNYDER closed public testimony after ascertaining no one else wished to testify. CO-CHAIR SNYDER stated that HB 103 was held over. SB 21-LICENSE MOBILE INTENSIVE CARE PARAMEDICS  4:12:37 PM CO-CHAIR SNYDER announced that the final order of business would be SENATE BILL NO. 21, "An Act relating to mobile intensive care paramedics; relating to duties of the State Medical Board and the Department of Health and Social Services; and providing for an effective date." 4:13:17 PM SENATOR JOSH REVAK, Alaska State Legislature, as the prime sponsor, presented SB 21. He reported that licensure oversight of Alaska's approximately 600 licensed paramedics is currently split between two separate agencies - the State Medical Board under the Department of Commerce, Community, and Economic Development (DCCED), and the Emergency Medical Services Office under the Department of Health and Social Services (DHSS). He stated that the purpose of SB 21 is to help Alaska's paramedics by consolidating the emergency medical service system under a single agency, DHSS, to improve peer and professional oversight. Unanimously supported by the State Medical Board, it also has broad support from first responders and paramedics around the state. SENATOR REVAK explained that SB 21 would transfer all paramedic licensure to the Emergency Medical Services Office. He noted that, currently, paramedics are the only one of their kind under DCCED, all other emergency medical services are already under DHSS, which is responsible for certifying all emergency medical technicians (EMTs) and intensive care paramedics. The bill would not change the scope of practice, the licensure requirements, or the fee structure. The medical direction would be provided by the existing DHSS Chief Medical Officer and the EMS Medical Directors Committee. He further noted that the bill would have zero fiscal impact and that DHSS's existing data systems are already able to incorporate paramedic licensure, making the move a seamless transition. Aligning all EMS services under a single agency would promote public health and safety, he continued, while also providing efficiencies through peer and professional oversight. The bill has bipartisan support and passed unanimously on the Senate floor. 4:15:25 PM SETH DUGGAN, Staff, Representative Josh Revak, Alaska State Legislature, provided the sectional analysis for SB 21 on behalf of Senator Revak, prime sponsor. He paraphrased from the written document titled, "SECTIONAL ANALYSIS, Senate Bill 21," which read [original punctuation provided except for some minor formatting changes]: Sec. 1 amends 08.64.107, State Medical Board/ Regulation of physician assistants and intensive care paramedics, to remove regulation of paramedic licensure from the Medical Board. (See also Sec. 8.) Sec. 2 amends 08.64.170(a), License to practice medicine, podiatry, or osteopathy, allowing paramedics to practice medicine to render emergency lifesaving service under "another law" instead of under the Medical Board's authority. (See also Sec. 6) Sec. 3 amends 08.64.360, Penalty for practicing without a license or in violation of chapter, to remove paramedics. (See also Sec. 10) Sec. 4 amends 08.64.369(d), Health care professionals to report certain injuries, to change paramedics licensed under the Medical Board to those licensed under DHSS, for health care providers who must report certain injuries to the Department of Public Safety. Sec. 5 amends 12.55.185(11), Sentencing and Probation, to change paramedics licensed under the Medical Board to those licensed under DHSS. Sec. 6 amends 18.08.075, Authority of emergency medical technician, to allow paramedics to provide emergency medical care. (See also Sec. 2.) Sec. 7 amends 18.08.080, Emergency Medical Services/ Regulation, to require DHSS to adopt regulations establishing standards for paramedic licenses. Sec. 8 adds a new paragraph 18.08.082(a)(5), Issuance of certificates; designations, to add regulation of paramedic licensure to DHSS. (See also Sec. 1.) Sec. 9 amends 18.08.082(b), Issuance of certificates; designations, to clarify that DHSS is the central certifying and licensing agency for emergency medical services. Sec. 10 amends 18.08.084(a), Certificate required, to prohibit a person from practicing as a paramedic without a license. (See also Sec. 3.) Sec. 11 amends 18.08.086(a), Immunity from liability, Adding the term license. Provides civil immunity to licensed or certified emergency medical providers who are providing emergency medical service. They are not liable for civil damages unless [it's] gross negligence. Sec. 12 18.08.089(a) is amended to clarify a paramedic is allowed to pronounce someone dead in certain circumstances. Sec. 13 adds a new paragraph (14) to 18.08.200, Emergency Medical Services/Definitions, to add the definition of "mobile intensive care paramedic". (See also Sec. 14.) Sec. 14 Amends 29.45.050(r) to include mobile intensive care paramedics in a municipal property tax exemption. Sec. 15 amends 37.05.146(c)(77)(F), Definition of program receipts and non-general fund program receipts, to add fees for licensure of paramedics to the list of fees collected by DHSS. Sec. 16 repeals 08.64.366, Liability for services rendered by a mobile intensive care paramedic (See Sec. 11, 18.08.086, Immunity from liability, under DHSS). Repeals 08.64.380, Medicine/Definitions to remove (3) "emergency lifesaving service" and (4) "mobile intensive care paramedic" (See also Sec. 13). Sec. 17 amends the uncodified law to provide transitional authorities: (a) A current paramedic license issued before January 1, 2022 remains valid until it expires under the Medical Board, is suspended or revoked, or is converted to a license under DHSS. (b) The Department of Commerce, Community and Economic Development and the Medical Board will transfer to DHSS on January 1, 2022, files of all pending paramedic-related records and proceedings, applications, and disciplinary actions. (c) Authority for DHSS to adopt regulations which shall include the conversion of unexpired paramedic licenses issued under the Medical Board. Sec. 18 provides an immediate effective date for DHSS to adopt regulations. Sec. 19 provides an effective date of January 1, 2022. 4:18:45 PM REPRESENTATIVE SPOHNHOLZ noted that most of the licensing for health care professionals is done in DCCED. She remarked that there seems to be an exception here, wherein SB 21 is seeking to consolidate licensure for EMTs and paramedics into one spot. She asked why [the sponsor] chose to go with DHSS rather than, for example, staying with DCCED and creating a new board. SENATOR REVAK answered that all the EMS services are already housed under one roof within DHSS. The split between the two occurred at the time when intensive care mobile paramedics were created, and [this split] has caused some significant challenges to licensure. So, [consolidating EMTs and paramedics] is a cleanup measure. REPRESENTATIVE SPOHNHOLZ said she understands the rationale for moving paramedics from under the Medical Board. It used to be that everything was under the Medical Board, she continued, but now it has been realized that health care providers who have different expertise can regulate and manage their own licensure, and paramedics should be allowed to do that. However, she pointed out, most licensure in the state of Alaska is done in DCCED and the choice is being made here to move paramedics under DHSS as opposed to moving EMTs under DCCED. She inquired about the rationale for doing that. SENATOR REVAK deferred to the agency to answer the question. 4:21:58 PM BRIAN WEBB, Emergency Medical Services Officer, Division of Public Health, Department of Health and Social Services (DHSS), noted he is one of a remaining few who were on the ground at the time this whole thing was started. He stated that there are no emergency medicine or paramedical subject matter experts in DCCED, plus emergency medicine and paramedical professionals do not have much input into changing regulations for their craft. So, paramedics always seem to be left behind. However, the Emergency Medical Services Office, with all its in-house paramedics, would have the ability to develop and change regulations and keep up to date with new procedures in the craft. Changes to education requirements, standards, and procedures are easily done within the Emergency Medical Services Office, yet it is exceedingly hard to do for the Medical Board. [Paramedics] have tried for years to have a seat on the Medical Board because there are over 655 paramedics in Alaska. However, [paramedics] have been repeatedly told they will not have a seat on the Medical Board because that would mean somebody else would have to give up a seat. One reason why [paramedics] have requested this, Mr. Webb continued, is to have some control over their craft and their future. Another impetus comes from the 2014 National Highway Transportation Safety Administration's (NHTSA's) reassessment of emergency medical services in Alaska, which recommended that the Alaska State Legislature transfer the licensing of paramedics from the State Medical Board to DHSS. A footnote to this recommendation, he added, is that only four states have a similar regulatory split; most states have their personnel under their semblance of an Emergency Medical Services Office. REPRESENTATIVE SPOHNHOLZ said she understands the issue of wanting to move out from underneath the State Medical Board it doesn't make any sense that paramedics be licensed and decisions about licensing for paramedics be done by the State Medical Board, particularly if there isn't space for paramedics to sit on that board. But, she continued, most of the other health care practitioners have their own boards that are made up of peers of their own choosing and they make the regulations and licensing standards, and they sit under DCCED's Division of Corporation, Business, and Professional Licensing. All other health care items, health care licensing and facility licensing, sit at DHSS, but the practitioners themselves are governed, licensed, and managed under DCCED. She asked whether consideration was given to creating a board of paramedics that was made up of paramedics and which would be responsible for managing licensure under the DCCED. 4:26:07 PM SARA CHAMBERS, Director, Division of Corporation, Business, and Professional Licensing, Department of Commerce, Community, and Economic Development (DCCED), replied that the bill was originally, and continues to be, presented not as a "let's solve a problem with a variety of options;" rather, this is the proposal. She stated that the division did not explore deeply the idea of creating a new board, or proposing that the legislature create a new board, because DHSS is already so well resourced and already has all the staff and the programming set up for emergency services that it didn't make sense from an efficiency standard to try to recreate that or something similar on DCCED's side. She said DCCED's model of governance through a board is very different than the EMS management model with paramedics already on staff who are working to govern those regulations through the public process. Of these two processes, DHSS is far better resourced than DCCED to provide the value to paramedics and consistency with the [Emergency Medical Services Office]. REPRESENTATIVE SPOHNHOLZ asked whether paramedics are governed, regulated, and licensed this same way in other states or whether paramedics tend to sit in the same department as nurses, physician assistants, doctors, and other health care providers. MR. WEBB responded that four states have this same split and are currently trying to solve that as well. Therefore, the majority are through their semblance of a state EMS office. In further response, he agreed to provide written details. 4:29:27 PM CO-CHAIR SNYDER opened public testimony on SB 21. 4:29:48 PM WILMA VINTON, testified in support of SB 21. She related that she is the assistant chief of EMS for the state's volunteer fire department, which is responsible for ensuring that folks are certified, and she is also an instructor for the State of Alaska and teaches many EMTs throughout the Interior. She said she assists EMTs and Mobile Intensive Care Paramedics (MICPs) with acquiring and maintaining their certifications and licensure. She stated she has personally gone through both processes, first becoming certified as an EMT in Alaska from Montana in 1979 and then becoming an MICP in 2007, and it is her opinion that moving from the State Medical Board to the Emergency Medical Services Office in DHSS is an excellent way to streamline the licensing and certification process. MS. VINTON pointed out that EMTs and MICPs work side by side, yet certification and recertification requires working with two different agencies and two different processes. She said the Emergency Medical Services Office currently certifies EMTs within 7-20 days of testing, and she doesn't see a problem with MICPs being licensed in the same timeline. Currently, the MICP licensing process under the State Medical Board can take several months because the board only meets quarterly to approve licenses, causing a backup in receiving certifications and licenses. The Emergency Medical Services Office, however, has staff whose daily job is to provide licensing and certification. They have honed the process and will be as thorough as the State Medical Board's process, albeit in a shorter amount of time. This shortened timeframe is important to someone who is trying to get a paramedic job in Alaska. Ms. Vinton offered her strong belief that it would be a seamless move and would align the MICPs with EMS like in many other states. She concluded by urging the committee to support SB 21. 4:33:01 PM CO-CHAIR ZULKOSKY offered her understanding that SB 21 would create an intensive care paramedic in addition to an EMT. SENATOR REVAK replied that it doesn't create a new one, it moves the paramedics from DCCED over to DHSS with the rest of EMS. SENATOR REVAK returned to an earlier question by Representative Spohnholz and explained that when initially looking at this problem this seemed to be the easiest path that made the most sense since EMS is already running seamlessly under DHSS. 4:34:15 PM CO-CHAIR SNYDER closed public testimony on SB 21. CO-CHAIR ZULKOSKY asked whether adopting this legislation would have any downstream impacts for people who are currently paramedics in Alaska. SENATOR REVAK responded that SB 21 should not affect the scope of service in any way. MS. CHAMBERS responded that DCCED has pledged to DHSS that it would be a seamless transition and there are no proposed or anticipated changes other than to potentially receive augmented services through the new department. She said DCCED is working behind the scenes to make this as coordinated as possible. REPRESENTATIVE MCCARTY expressed his support for SB 21. [SB 21 was held over.] 4:38:15 PM ADJOURNMENT  There being no further business before the committee, the House Health and Social Services Standing Committee meeting was adjourned at 4:38 p.m.