Legislature(2017 - 2018)ADAMS ROOM 519

04/12/2018 09:00 AM FINANCE

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CS FOR SENATE BILL NO. 105(FIN)                                                                                               
     "An  Act  relating  to the  licensure  of  marital  and                                                                    
     family therapists;  relating to medical  assistance for                                                                    
     marital and family therapy  services; and providing for                                                                    
     an effective date."                                                                                                        
9:26:22 AM                                                                                                                    
Co-Chair Foster indicated  that Representative Ivy Spohnholz                                                                    
carried the companion bill, HB  353 Marital & Family Therapy                                                                    
Lic. & Services.                                                                                                                
REPRESENTATIVE  IVY  SPOHNHOLZ,   explained  that  the  bill                                                                    
updated  and clarified  the supervisory  requirements for  a                                                                    
licensed Marital  and Family  Therapist (LMFT).  The updated                                                                    
requirements would  allow the therapists to  become eligible                                                                    
for Medicaid reimbursement.  The purpose of the  bill was to                                                                    
increase  the  access  to   behavioral  health  care,  which                                                                    
currently  the  state  had  a  shortage  of  providers.  She                                                                    
indicated  that  the  fiscal note  was  "modest"  and  would                                                                    
reduce  costs over  the "mid-term"  by allowing  more people                                                                    
struggling with  behavioral health  issues access  to health                                                                    
care before the condition was  acute. She qualified that the                                                                    
bill was  not an expansion  of Medicaid  and was a  "step in                                                                    
the  right  direction"  to  increase  access  to  behavioral                                                                    
health care.                                                                                                                    
9:28:35 AM                                                                                                                    
SENATOR DAVID WILSON, SPONSOR, spoke  to the legislation. He                                                                    
explained   that   the   bill  involved   the   professional                                                                    
application  of assessments,  treatments, and  psychotherapy                                                                    
services  to  individuals,  families, and  couples  for  the                                                                    
purposes  of treating  and diagnosing  emotional and  mental                                                                    
disorders.  Currently, LMFTs  were only  allowed to  provide                                                                    
services  in community  health clinics  or physician  mental                                                                    
health  clinics,   which  limited  the  number   of  willing                                                                    
providers.  The  legislation   expanded  medical  assistance                                                                    
reimbursement  services  to  cover those  services  provided                                                                    
directly and  independently by LMFTs. He  delineated that SB
105 specifically defined the  supervision training hours and                                                                    
requirements for  an Associate  Marital &  Family Therapist,                                                                    
expanded the list of  approved healthcare professionals that                                                                    
can  provide group  supervision  of an  Associate Marital  &                                                                    
Family  Therapist  and,  added   Marital  &  Family  Therapy                                                                    
services as eligible to render  and bill for Medicaid-funded                                                                    
services as  independent practitioners under  Alaska Statute                                                                    
47.07.030 (b).  He furthered that  SB 105  "dovetailed" with                                                                    
SB  169  (Medicaid:  Behavioral  Health  Coverage)  [Senator                                                                    
Giessel -  Adopted Both Bodies  05/04/2018] which removed 30                                                                  
percent of  onsite requirement for supervision  and provided                                                                    
for a  telecommunication device option.  He voiced  that the                                                                    
bill  dealt  with the  shortage  of  behavioral health  care                                                                    
professionals  that   was  addressed  in  SB   74  (Medicaid                                                                    
Reform;Telemedicine;Drug  Databas)[CHAPTER   25  SLA   16  -                                                                    
06/21/2016] but  was accidentally omitted  during regulation                                                                    
drafting  by the  Department of  Health and  Social Services                                                                    
(DHSS). The  department also  discovered that  the necessary                                                                    
statute that would  allow the regulations did  not exist and                                                                    
the  bill  also  provided  "clean-up" language  for  SB  74.                                                                    
Finally,  the bill  also fit  together with  the departments                                                                    
federal  1115  waiver  [Allowed   a  state  to  use  federal                                                                    
Medicaid  funds in  ways that  are  not otherwise  allowed.]                                                                    
that authorized expansion of  behavioral health services. He                                                                    
related  that  DHSS's  experienced challenges  in  extending                                                                    
behavioral health  services throughout the state  due to the                                                                    
geographic   nature  of   the   state   and  problems   with                                                                    
recruitment and  retention of a behavioral  health care work                                                                    
force.  He  spoke  to  the cost  of  recruiting  a  licensed                                                                    
clinical social  worker of up  to $100 thousand,  which took                                                                    
up to  6 months to fill  versus recruiting a LMFT  at a cost                                                                    
of up  to $40 thousand.  The LMFTs were equally  trained and                                                                    
more plentiful.                                                                                                                 
9:31:57 AM                                                                                                                    
GARY  ZEPP,  STAFF,  SENATOR   DAVID  WILSON,  reviewed  the                                                                    
PowerPoint    presentation   titled    "CCSB   105(FIN)    -                                                                    
Marital/Family Therapy"  (copy on file).   He reviewed items                                                                    
on slide 1:                                                                                                                     
What is Behavioral Health?                                                                                                      
     The  term  "behavioral  health" is  the  umbrella  that                                                                    
     encompasses  all  contributions   to  mental  wellness,                                                                    
     including substance  abuse, behavior  health disorders,                                                                    
     schizophrenia,  bipolar  disorder,   and  other  mental                                                                    
     health concerns.                                                                                                           
     Behavioral health promotes  well-being by preventing or                                                                    
     intervening in  mental illness,  such as  depression or                                                                    
     anxiety,  but  also aims  to  prevent  or intervene  in                                                                    
     substance abuse or other addictions.                                                                                       
     One in  four Americans  experience a mental  illness or                                                                    
     substance use  disorder each year, and  the majority of                                                                    
     these people  also have a co-occurring  physical health                                                                    
     condition,   according   to   the   American   Hospital                                                                    
     National Behavioral Health Needs:                                                                                          
          20%  of inmates  in  jails suffer  from a  serious                                                                    
     mental illness;                                                                                                            
          60%  of   inmates  suffer  from   substance  abuse                                                                    
          80% of  people who suffer from  mental illness are                                                                    
          26% of all homeless  shelter residents suffer from                                                                    
     severe mental illness;                                                                                                     
          34%   of  homeless   people   also  have   chronic                                                                    
     substance abuse issues.                                                                                                    
     Source:  US   National  Library   of  Medicine/National                                                                    
     Institutes  of Health;  National  Association of  State                                                                    
     Mental Health Program Directors                                                                                            
Mr.  Zepp  believed  that early  intervention  prevented  an                                                                    
emergency    room    (ER)   crisis,    incarceration,    and                                                                    
institutionalizing  and  individual with  behavioral  health                                                                    
issues. He noted that ER  visits costs were much higher than                                                                    
therapy sessions.  He moved to slide 2:                                                                                         
Alaska's Behavioral Health Needs:                                                                                               
          Alaska's suicide rate is  21.8 per 100,000 people,                                                                    
     the national rate is 11.5 per 100,000 people;                                                                              
          Approximately  145,790  Alaskans need  mental  and                                                                    
     behavioral health services; Of  those, only 19% receive                                                                    
     behavioral health services;                                                                                                
          It's  estimated  that   65%  of  Alaska  prisoners                                                                    
     suffer from some  form of mental health  issues and 80%                                                                    
     have drug or alcohol addictions;                                                                                           
          In 2016, the  Mat-Su Regional Emergency Department                                                                    
     spent  $43.8  million   for  patients  with  behavioral                                                                    
     health diagnoses for 3,443 patients;                                                                                       
          This  does not  include additional  costs for  law                                                                    
     enforcement, dispatch, and ambulance services.                                                                             
Source: Arctic Mental Health Working Group; Alaska                                                                              
Behavioral Health Systems Assessment Final                                                                                      
Report; Alaska Dispatch News; Treatment Advocacy Center                                                                         
Alaska's Behavioral Health Care Shortages - Psychiatrists:                                                                      
          Alaska   needs    approximately   106   additional                                                                    
     psychiatrists  to  meet   the  national  standard,  per                                                                    
     100,000 adults;                                                                                                            
          Alaska is 20%  - 54% below the  estimated need for                                                                    
     psychiatrists  in  Alaska,   as  compared  to  national                                                                    
          2.9  years =  average  retention  time for  mental                                                                    
     health care providers in Alaska;                                                                                           
          The  ratio   of  vacant  mental   health  provider                                                                    
     positions in  rural Alaska is 1  in 5 as compared  to 1                                                                    
     in 10 in urban Alaska.                                                                                                     
Source:  Arctic Mental Health Working Group                                                                                     
9:35:43 AM                                                                                                                    
Mr. Zepp adressed slide 3:                                                                                                      
What is CSSB 105(FIN)?                                                                                                          
     If   enacted,  the   proposed  legislation   would  add                                                                    
     licensed Marital  and Family Therapists to  the list of                                                                    
     independent  practitioners to  address the  shortage of                                                                    
     Medicaid-eligible  behavioral health  providers in  the                                                                    
     state,  afford  more  options  for  beneficiaries,  and                                                                    
     increase access to behavioral health care.                                                                                 
     Currently, licensed  Marital and Family  Therapists are                                                                    
     only allowed  to provide  services in  community health                                                                    
     clinics  or  physician  mental  health  clinics,  which                                                                    
     limits the  number of willing providers.  CSSB 105(FIN)                                                                    
     expands  medical assistance  reimbursement services  to                                                                    
     cover  those  services provided  directly/independently                                                                    
     by licensed marital & family therapists.                                                                                   
Specifically, CSSB 105(FIN):                                                                                                    
     Defines    the   supervision    training   hours    and                                                                    
     requirements   for  an   Associate  Marital   &  Family                                                                    
     Therapists. This  will create  a path for  an associate                                                                    
     to become a fully licensed marital & family therapist.                                                                     
     This  in turn  creates  more fully  licensed marital  &                                                                    
     family  therapists   and  increases  the   capacity  of                                                                    
     behavioral health services in our state!                                                                                   
     Expands the list of  approved health care professionals                                                                    
     that  can provide  group  supervision  of an  Associate                                                                    
     Marital &  Family Therapist; and Adds  Marital & Family                                                                    
     Therapy  services as  eligible to  render and  bill for                                                                    
     Medicaid funded  services as  independent practitioners                                                                    
     under AS 47.07.030(b).                                                                                                     
 9:37:43 AM                                                                                                                   
Mr. Zepp  specified that  the bill  mandated 1,700  hours of                                                                    
clinical  contact   and  of  that  amount   100  hours  were                                                                    
individual supervision  and 100 hours of  group supervision.                                                                    
He delineated  that Section 2,  page 3, lines 5  through 13,                                                                    
of the  bill expanded the  list of providers to  6 different                                                                    
mental  health  care  providers   who  could  deliver  group                                                                    
supervision to  the associates who were  attempting to reach                                                                    
the level of LMFT. He added that currently all supervisors                                                                      
had to meet board approval. He moved to slide 4:                                                                                
Benefits of CSSB 105(FIN) and how does it help Alaskans?                                                                        
          By   expanding  Medicaid   optional  services   to                                                                    
     include licensed marital &  family therapy, it provides                                                                    
     an opportunity to intervene early  to help Alaskans, so                                                                    
     they  don't  end  up in  an  expensive  emergency  room                                                                    
     setting or in a costly institutional setting;                                                                              
          Example:  Private clinical hourly  cost = $150 per                                                                    
     hour vs.  $4,370   average   one-time  emergency   room                                                                    
     behavioral health                                                                                                          
          By   increasing   the   number  of   health   care                                                                    
     professionals available  to provide services  for those                                                                    
     who  cannot  currently receive  services  or  are on  a                                                                    
     waiting list  for behavioral  health services,  both in                                                                    
     urban and rural areas of our state;                                                                                        
          Improve   behavioral  health   care  services   to                                                                    
     Alaskans  improves their  health  outcomes and  reduces                                                                    
     spending on physical health issues;                                                                                        
          Add  additional health  care professionals  to the                                                                    
     group supervision  of an  associate licensed  marital &                                                                    
     family  therapist  should  enable  more  associates  to                                                                    
     become a fully licensed marital & family therapy;                                                                          
          Better access  to behavioral health care  leads to                                                                    
     positive   outcomes   and   likely   avoids   expensive                                                                    
     emergency  room  care, correctional  incarceration,  or                                                                    
     psychiatric institutionalization.                                                                                          
9:39:35 AM                                                                                                                    
Mr. Zepp concluded on slide 5:                                                                                                  
     Acknowledgment and Thanks!                                                                                                 
     Thank you for your support of CSSB 105(FIN)                                                                                
     "An  Act  relating  to the  licensure  of  marital  and                                                                    
     family therapists;  relating to medical  assistance for                                                                    
     marital and family therapy  services; and providing for                                                                    
     an effective date."                                                                                                        
     CSSB 105(FIN) is supported by:                                                                                             
          Alaska Board of Marital & Family Therapy;                                                                             
          American Association for Marriage and Family                                                                          
          Mat-Su Health Foundation;                                                                                             
          American College of Emergency Physicians/Alaska                                                                       
          Alaska Emergency Room Physicians                                                                                      
Representative  Guttenberg  understood   the  need  for  the                                                                    
legislation. He asked  who set the standards  for the hours.                                                                    
He  wondered  where the  requirements  came  from. Mr.  Zepp                                                                    
replied  the hours  had  been established  by  the Board  of                                                                    
Marital  and  Family Therapists.  Representative  Guttenberg                                                                    
asked if  there had  been any  feedback from  licensees. Mr.                                                                    
Zepp  deferred  the answer  to  the  past president  of  the                                                                    
KEN  MCCARTY, PAST  PRESIDENT, BOARD  OF MARITAL  AND FAMILY                                                                    
THERAPISTS,  EAGLE RIVER  (via teleconference),  voiced that                                                                    
he was on the regulatory board  for 6 years. He replied that                                                                    
the  language  clarified  the standard  of  1,500  hours  of                                                                    
clinical time  with 200 hours  of supervised  clinical time;                                                                    
100  hours  for  individual  and 100  hours  for  group.  He                                                                    
reported  that  the way  the  statue  currently read  caused                                                                    
confusion.  He furthered  that the  provision broadened  the                                                                    
supervisory role and  was included due to  the difficulty of                                                                    
finding a  licensed LMFT  supervisor in  areas of  the state                                                                    
like Utqiaqvik,  Nome, Kotzebue, and even  Seward. The board                                                                    
noted that the supervisory  shortage caused LMFT trainees to                                                                    
pursue   a  different   career.  Other   professionals  lead                                                                    
clinical   groups  in   the  areas   noted  therefore,   the                                                                    
opportunity   was  available   for   others   to  gain   the                                                                    
certification  by  allowing  other  behavioral  health  care                                                                    
professionals to supervise LMFT trainees.                                                                                       
9:44:37 AM                                                                                                                    
Representative   Guttenberg  wanted   to  ensure   potential                                                                    
licensees did not  consider that the hours were  too high or                                                                    
a  barrier to  entry.  Mr.  McCarty replied  that  he was  a                                                                    
licensed supervisor and  had the ability to  provide the 100                                                                    
hours of  individual supervision through an  associate under                                                                    
contract agreements  in places like Utqiaqvik  but could not                                                                    
do a group in the same  manner. The bill allowed the trainee                                                                    
from a place like Utqiaqvik to capture the supervision.                                                                         
Representative  Spohnholz clarified  that the  bill did  not                                                                    
change  the  hours  it  took  to become  a  LMFT.  The  bill                                                                    
clarified   the  requirement   statute   and  also   allowed                                                                    
supervisors from  other professions to  provide supervision.                                                                    
She  believed the  provision would  increase  the number  of                                                                    
qualified  LMFTs and  had not  heard  any negative  feedback                                                                    
relating to the change.                                                                                                         
Representative  Tilton welcomed  the students,  parents, and                                                                    
teachers  from  Academy  Charter School  in  the  Matanuska-                                                                    
Susitna Borough in the audience.                                                                                                
Co-Chair Foster also welcomed the students.                                                                                     
9:48:11 AM                                                                                                                    
Representative  Wilson remarked  that  the  bill was  adding                                                                    
another optional service. She pointed  to Section 3, page 3,                                                                    
of the  bill and  read the following  "? the  department may                                                                    
offer only the following  optional services?" and listed the                                                                    
LMFT  category. Representative  Spohnholz replied  that they                                                                    
were not  adding an  optional service.  The bill  only added                                                                    
LMFTs  to  the  range   of  options.  Representative  Wilson                                                                    
believed it was an option.                                                                                                      
Senator Wilson clarified that SB  105 merely added the LMFTs                                                                    
to the  list of  professionals who had  the ability  to bill                                                                    
individually for optional  Medicaid services. Otherwise, the                                                                    
LMFT would only  be able to provide the services  as part of                                                                    
a  community  mental  health clinic.  Representative  Wilson                                                                    
stated  that   without  the  language  they   would  not  be                                                                    
authorized to  bill Medicaid  and thought  it was  the whole                                                                    
reason  for the  bill.  She expressed  concern  over the  $1                                                                    
million  fiscal note  [FN4 (DHS)].  She  noted that  federal                                                                    
receipts  were in  the amount  of $660.5  million [thousand]                                                                    
and  the  GF  match  was  $340.3  thousand  [FY  2020].  She                                                                    
referred to  the analysis on  page 2 and read  the following                                                                    
"$1,581  annual  per  recipient cost  times  633  recipients                                                                    
equaled $1,000,773."  She wondered  where the number  of 633                                                                    
recipients had come from.                                                                                                       
Mr. Zepp deferred to DHSS for the answer.                                                                                       
MARGARET   BRODIE,  DIRECTOR,   DIVISION   OF  HEALTH   CARE                                                                    
SERVICES,  DEPARTMENT OF  HEALTH  AND  SOCIAL SERVICES  (via                                                                    
teleconference),  answered that  the Division  of Behavioral                                                                    
Heath prepared the fiscal note.                                                                                                 
Co-Chair Seaton  asked whether Ms.  Brodie could  answer the                                                                    
question of whether  the bill added an  optional service and                                                                    
the explain  the difference  between mandatory  and optional                                                                    
services. Ms.  Brodie replied that  the service  was already                                                                    
covered  under  the  duly  eligible  recipients,  which  was                                                                    
covered  under  Medicaid  and Medicare.  The  bill  added  a                                                                    
provider to a currently covered service.                                                                                        
9:52:42 AM                                                                                                                    
Representative  Wilson did  not understand  the answer.  She                                                                    
wondered why  it had to be  added to AS 47.07.030  (b) if it                                                                    
was not adding to the optional services list.                                                                                   
Senator Wilson deferred the answer to Mr. Calcote.                                                                              
RICK CALCOTE, CHIEF, RISK  AND RESEARCH MANAGEMENT, DIVISION                                                                    
OF  BEHAVIORAL  HEALTH,  DEPARTMENT  OF  HEALTH  AND  SOCIAL                                                                    
SERVICES (via  teleconference), replied that SB  74 expanded                                                                    
the  list  of licensed  providers  who  could bill  Medicaid                                                                    
independently  for  Medicaid  services. Under  the  statute,                                                                    
LMFTs were  not included  on the list  and the  bill allowed                                                                    
LMFTs   to  become   independent   providers  for   Medicaid                                                                    
9:55:17 AM                                                                                                                    
Representative  Wilson stated  it had  been her  exact point                                                                    
that  the bill  added to  the list  of providers.  She asked                                                                    
whether  the   633  individuals  were   currently  receiving                                                                    
services  in  a  clinical  setting and  would  switch  to  a                                                                    
private  setting and  for the  current  number of  providers                                                                    
that  would  be  able  to bill  Medicaid  individually.  She                                                                    
stated that Medicaid "was one  of the fastest growing areas"                                                                    
and the  bill was adding  services, which was  concerning to                                                                    
her.  Mr. Calcote  responded that  the  fiscal note  assumed                                                                    
that a number of individuals  were currently in the Medicaid                                                                    
system  and  were   receiving  behavioral  health  treatment                                                                    
through   physicians'  offices,   mental  health   physician                                                                    
clinics,  and   community  behavioral  health   centers.  He                                                                    
delineated  that by  expanding the  number of  providers the                                                                    
division assumed that individuals  not currently  being seen                                                                    
within  the Medicaid  system would  be served.  The division                                                                    
based  the fiscal  note on  projected  figures derived  from                                                                    
Medicaid prevalence data that  indicated there were a number                                                                    
of unserved  recipients who were  eligible but did  not seek                                                                    
services.  In  addition,  the  division  used  the  national                                                                    
average   number    of   unserved   recipients    that   was                                                                    
approximately   10  percent.   The  division   employed  the                                                                    
greatest  number  of  participants that  could  possibly  be                                                                    
served  (633)   by  expanding  the  new   provider  set.  He                                                                    
indicated that  most likely the  number would be  fewer than                                                                    
633.  Representative Wilson  asked how  many providers  were                                                                    
currently unable  to bill Medicaid.  Mr. Calcote  was unable                                                                    
to  answer  the question  accurately.  He  detailed that  he                                                                    
lacked the necessary data.                                                                                                      
9:59:02 AM                                                                                                                    
Representative  Wilson asked  how  many  providers it  would                                                                    
take to service 633 participants.                                                                                               
Senator Wilson replied that currently  there were roughly 85                                                                    
LMFTs  in  the state.  The  numbers  were currently  unknown                                                                    
because  the choice  to  become a  LMFT  was personal.  Some                                                                    
businesses  like  the  Federally  Qualified  Health  Centers                                                                    
would more likely  pursue LMFTs to be able  to bill Medicaid                                                                    
for them. He emphasized that  the bill was not "necessarily"                                                                    
adding   recipients  to   Medicaid,   the  recipients   were                                                                    
underserved, and the  bill would "open the  door" to provide                                                                    
more  access to  mental health  services. He  suggested that                                                                    
current LMFTs  providing testimony  could better  answer the                                                                    
question. Representative  Wilson stated that she  would wait                                                                    
for public testimony to provide the answer.                                                                                     
Vice-Chair  Gara  remarked   that  leaving  family  problems                                                                    
untreated was  not "free". He  noted that the state  had the                                                                    
highest  rate of  repeat child  abuse and  drug and  alcohol                                                                    
abuse, which affected children and  families. He voiced that                                                                    
fiscal  notes  do  not report  the  amount  of  expenditures                                                                    
avoided as  a result of  expanding services and  thought the                                                                    
information would be useful. He  believed that not expanding                                                                    
the services would cost the state more.                                                                                         
10:02:40 AM                                                                                                                   
Representative  Kawasaki mentioned  that currently  clinical                                                                    
social  work services  was  part of  the  provider list.  He                                                                    
asked whether  clinical social workers provided  marital and                                                                    
family advice  for a patient.  Senator Wilson was  unsure of                                                                    
the numbers  and deferred the answer  to providers. However,                                                                    
he acknowledged  that the number of  clinical social workers                                                                    
were  much  fewer  and  cost  more  to  hire  because  their                                                                    
services were  in demand for  other practices  and services.                                                                    
Representative Kawasaki returned to  the question of whether                                                                    
the bill was adding an  optional service. He referred to the                                                                    
fiscal note analysis on page 2 and read the following:                                                                          
     This  fiscal  note  reflects  the  fact  that  licensed                                                                    
     marriage and family therapist  services have been added                                                                    
     to the AS 47.07.030  list of Medicaid optional services                                                                    
     for which the State will reimburse.                                                                                        
Representative Kawasaki alluded  to the conflicted testimony                                                                    
regarding  the  optional service  and  felt  that it  was  a                                                                    
policy decision. He wanted  a definitive statement regarding                                                                    
whether the legislation was  adding another optional service                                                                    
that could potentially cost the state more in the future.                                                                       
10:05:45 AM                                                                                                                   
Mr.  Calcote  responded  that  the   addition  of  the  LMFT                                                                    
provider  in  statute would  certainly  allow  them to  bill                                                                    
Medicaid services  directly. The  providers would  no longer                                                                    
have  to  bill  through  a community  or  behavioral  health                                                                    
clinic. He assumed  that a small percentage  of the Medicaid                                                                    
population  might seek  the services  of a  LMFT independent                                                                    
practitioner  for extended  treatment.  He  was unclear  how                                                                    
much the  Medicaid bill would  be affected. The  fiscal note                                                                    
was the  division's best  estimate and  was in  the "outside                                                                    
range" of probability. The department  would know more after                                                                    
the bill  took effect.  Representative Kawasaki  stated that                                                                    
the current number of LMFTs were  known and thought it was a                                                                    
yes or  no answer. He stressed  that the bill offered  a new                                                                    
optional service to  LMFTs who otherwise was  unable to bill                                                                    
Medicaid "prior  to the bill  passing". He asked  whether he                                                                    
was  correct. Mr.  Calcote replied  in  the affirmative.  He                                                                    
deferred to the sponsor for further answers.                                                                                    
Mr. Zepp  replied that  it was  also his  understanding that                                                                    
LMFTs   were  currently   eligible   through  community   or                                                                    
physicians' behavioral  health clinics billing and  the bill                                                                    
authorized coverage  for LMFTs  to bill directly  through an                                                                    
independent practice.                                                                                                           
Co-Chair  Seaton wanted  to  gain clarity  on  the bill.  He                                                                    
asked if  the bill  was a "two-way  street". The  LMFT could                                                                    
bill for  a service  listed under  the Medicaid  optional or                                                                    
mandatory services  and anyone  who is qualified  could bill                                                                    
for marital  and family therapy  services. He  asked whether                                                                    
he   was  correct.   Mr.  Calcote   clarified  that   family                                                                    
psychotherapy  was  already  an existing  Medicaid  billable                                                                    
service and anyone  qualified to provide the  service may do                                                                    
so.  He  restated that  by  changing  the statute  the  bill                                                                    
merely allowed LMFT to bill  for Medicaid services. Co-Chair                                                                    
Seaton asked  if anyone else  qualified could also  bill for                                                                    
marital and family therapy services.                                                                                            
10:12:42 AM                                                                                                                   
Mr. Calcote  replied in the affirmative.  Anyone licensed in                                                                    
the state and  was a qualified Medicaid  provider of marital                                                                    
and family therapy could provide the service.                                                                                   
Representative Thompson cited  the presentation and surmised                                                                    
that there  was a  severe shortage  of family  therapists in                                                                    
the  state.  He deduced  that  the  bill was  attempting  to                                                                    
increase  the number  of providers  covered under  Medicaid.                                                                    
He thought  the untreated  individuals could  end up  in the                                                                    
emergency room (ER) or incarcerated.  He viewed the bill "as                                                                    
a cost avoidance  in some fashion." He asked  whether he was                                                                    
correct. Senator Wilson answered in the affirmative.                                                                            
Mr.  Zepp interjected  that  the costs  of  ER services  was                                                                    
"astronomically  higher"   than  treatment  in   a  clinical                                                                    
setting.  He  reported that  according  to  DHSS 2016  data,                                                                    
$621 million was  spent in ER billing and  53.9 percent were                                                                    
Medicaid clients. He determined  that the state already bore                                                                    
the costs  because the first 23  hours in an ER  was covered                                                                    
by Medicaid and after that the hospital assumed the costs.                                                                      
Representative  Kawasaki supported  the bill.  He knew  that                                                                    
LMFTs  would like  the ability  to bill  Medicaid. He  spoke                                                                    
about arguments in  other sectors of the  medical field that                                                                    
felt  expanding  services  "cut  into  the  market"  of  the                                                                    
established licensees. He wondered  if any behavioral health                                                                    
care providers  that currently billed Medicaid  were opposed                                                                    
to the bill. Senator Wilson replied in the negative.                                                                            
Representative  Guttenberg asked  Ms.  Brodie  if there  had                                                                    
ever been  reports done  on avoidance  costs. He  thought it                                                                    
would  be   interesting  to   see  the   difference  between                                                                    
individuals getting  expanded coverage  versus going  to the                                                                    
ER and if any previous data existed.                                                                                            
10:17:43 AM                                                                                                                   
Ms. Brodie  responded in the  negative. She  elaborated that                                                                    
the  issue spread  across other  departments and  divisions.                                                                    
She exemplified the costs related  to the Office of Children                                                                    
Services  (OCS)  removing children  from  the  home and  the                                                                    
state paying for therapy that  was required to allow them to                                                                    
return  home  coupled  with the  Department  of  Corrections                                                                    
(DOC) involvement and  the costs related to the  use of ERs.                                                                    
Representative  Guttenberg recognized  that  costs were  far                                                                    
reaching  to other  agencies and  institutions  as well.  He                                                                    
would do some research on the national level.                                                                                   
Senator  Wilson  replied that  an  all  claims database  was                                                                    
necessary  to gather  the data.  Lacking the  data base,  it                                                                    
would be  difficult to extrapolate the  data; the department                                                                    
did not have the capability to perform the study.                                                                               
Co-Chair  Seaton referenced  the fiscal  note from  DHSS. He                                                                    
read  the following  from the  last paragraph  on page  2                                                                       
some of  those professionals  are already billing  for their                                                                    
services  under the  umbrella of  a mental  health physician                                                                    
clinic."  He   inquired  whether  mental   health  physician                                                                    
clinics  were   currently  providing  marriage   and  family                                                                    
therapist services  and were able  to bill for  the services                                                                    
without the service listed as  an optional service or if the                                                                    
clinics billed  under another service such  as psychological                                                                    
10:20:07 AM                                                                                                                   
Ms.  Brodie answered  that  all  behavioral health  services                                                                    
were  optional  services.  Co-Chair  Seaton  was  trying  to                                                                    
determine the  current system. He  asked whether  some other                                                                    
behavioral health  providers were  billing for  marriage and                                                                    
family therapist  services under  a different  category. Ms.                                                                    
Brodie deferred to Mr. Calcote.                                                                                                 
Mr.  Calcote  replied  that  Co-Chair  Seaton  was  correct.                                                                    
Currently  community behavioral  health  centers and  mental                                                                    
health physician  clinics were  able to bill  any behavioral                                                                    
health  Medicaid clinic  service  that included  individual,                                                                    
group,  or  family  psychotherapy.  He  expounded  that  any                                                                    
qualified  providers working  in the  provider agencies  who                                                                    
were able to  deliver the services billed  Medicaid with the                                                                    
psychiatrist  provider  identification billing  number.  Co-                                                                    
Chair  Seaton  asked  if  the bill  would  require  a  "plan                                                                    
amendment"  and  whether it  was  in  the fiscal  note.  Mr.                                                                    
Calcote  understood that  the expansion  did  not require  a                                                                    
state plan amendment.                                                                                                           
Representative Wilson pointed to the  following on page 2 of                                                                    
the fiscal note:                                                                                                                
     FY2019 General  Fund Match in the  Services Line: $50.0                                                                    
     for  development  of  business rules  in  the  Medicaid                                                                    
     Management  Information System  [(MMIS)] detailing  the                                                                    
     parameters for services/reimbursement.                                                                                     
Representative Wilson  thought the $50,000 cost  seemed high                                                                    
and inquired how  the cost was derived.  Ms. Brodie answered                                                                    
that  the  expenditure  was  for   the  development  of  the                                                                    
business  rules. She  elaborated that  currently the  system                                                                    
was  only able  to accept  claims from  Medicare and  had to                                                                    
accept Medicaid only claims as  well. The system development                                                                    
for the MMIS was  extremely expensive. Representative Wilson                                                                    
was very uncomfortable  with the fiscal note and  how it was                                                                    
developed. She agreed  with the services the  bill wanted to                                                                    
provide  and  she  thought most  recipients  were  currently                                                                    
receiving  the services.  She was  not certain  amending the                                                                    
bill  would  help with  the  fiscal  note. She  thought  the                                                                    
fiscal note was "one-sided" and  she wanted to see the "cost                                                                    
shifting advantages."                                                                                                           
10:24:18 AM                                                                                                                   
Co-Chair Foster noted there was  a forthcoming amendment and                                                                    
the  bill  would not  report  out  of committee  during  the                                                                    
current meeting. He asked the  department to further examine                                                                    
the fiscal note.                                                                                                                
Vice-Chair  Gara asked  whether Mr.  Calcote considered  two                                                                    
countervailing  factors when  writing  the  fiscal note.  He                                                                    
deduced that the number of  recipients receiving the service                                                                    
from more expensive  providers who would switch  to the LMFT                                                                    
would reduce  costs, but the state  recession was increasing                                                                    
Medicaid   enrollment.  Mr.   Calcote  answered   that  many                                                                    
variables could  not be  completely quantified.  The precise                                                                    
number  of  LMFTs  who would  provide  service  to  Medicaid                                                                    
clients  was unknown.  The national  10 percent  underserved                                                                    
figure matched the states historic  data. He elaborated that                                                                    
even  though  the  state  may   have  633  new  people  seek                                                                    
services,  the  division  did  not  know  how  many  of  the                                                                    
individuals   would  seek   services  from   an  independent                                                                    
provider  versus  a  clinic  and   did  not  know  how  many                                                                    
individuals  would  terminate  services  within  a  calendar                                                                    
10:27:01 AM                                                                                                                   
Vice-Chair Gara  ascertained that Mr. Calote  stated factors                                                                    
that  may  lower  the  fiscal  note  yet  other  issues  may                                                                    
increase  the fiscal  note, like  a prolonged  recession. He                                                                    
guessed  that the  department had  developed  a fiscal  note                                                                    
based  on all  factors "to  the  best of  its ability".  Mr.                                                                    
Calcote replied in the affirmative.                                                                                             
Co-Chair Foster asked to hear from invited testimony.                                                                           
Mr. McCarty  testified in support  of the bill.  He stressed                                                                    
that  the  state  did  not have  enough  providers.  He  had                                                                    
conducted  a survey  in  2013  and had  found  that over  35                                                                    
percent  of the  providers  were working  for agencies  that                                                                    
already billed  for their services. He  discovered that only                                                                    
8 percent of LMFTs wanted  to bill Medicaid directly, but at                                                                    
least  8  percent  more providers  would  be  available.  He                                                                    
indicated that  regarding addiction, morphine  treatment was                                                                    
only  effective with  psychotherapy. He  had been  concerned                                                                    
over  the fiscal  note  and in  2013 when  SB  74 was  being                                                                    
deliberated he  examined what happened in  other states when                                                                    
they included LMFTs as providers.  He had found there was no                                                                    
increase to the budget in  other states and they experienced                                                                    
reductions  due  to decreased  visits  to  places like  ERs,                                                                    
mental  institutions, or  other intrusive  interventions due                                                                    
to early treatment.                                                                                                             
Representative Kawasaki  asked Mr.  McCarty for  the typical                                                                    
hourly rate for LFMT services.  Mr. McCarty replied that the                                                                    
hourly rate and what the  insurance would pay was different.                                                                    
The hourly  rate was  $215 and  typically insurance  paid 80                                                                    
percent of the rate.                                                                                                            
10:32:54 AM                                                                                                                   
Representative Kawasaki asked whether  Mr. McCarty was aware                                                                    
of the  audit and billing  requirements for Medicaid  and if                                                                    
would  he offer  the  service for  Medicaid recipients.  Mr.                                                                    
McCarty  answered   that  he  had  already   done  what  was                                                                    
necessary to  become a Medicaid provider  including spending                                                                    
"tens  of  thousands of  dollars."  He  expected that  other                                                                    
behavioral health  "agencies" would demonstrate they  were a                                                                    
"trustworthy entity" and want to bill Medicaid.                                                                                 
10:33:50 AM                                                                                                                   
DR. MELISSA KEMBERLING, DIRECTOR  OF PROGRAMS, MAT-SU HEALTH                                                                    
FOUNDATION, MATANUSKA-SUSITNA  BOROUGH (via teleconference),                                                                    
spoke  in  support   of  the  bill.  She   shared  that  the                                                                    
foundation  shared  ownership  in  Mat-Su  Regional  Medical                                                                    
Center.  She elaborated  that the  foundation  was "very  in                                                                    
touch"  with Mat-Su  residents. The  foundation conducted  a                                                                    
community  health needs  assessment every  three years.  The                                                                    
top challenges  were related  to behavioral  health; alcohol                                                                    
and  substance  abuse,   childhood  trauma,  depression  and                                                                    
suicide, domestic  violence and sexual assault,  and lack of                                                                    
access  to  behavioral  health care.  The  bill  would  help                                                                    
increase the  number of providers available  to clients. She                                                                    
related that  school nurses had  conveyed to  the foundation                                                                    
that  lack of  access  to behavioral  health  service was  a                                                                    
challenge due to  a 4 to 8 months wait  list for individuals                                                                    
and families to  see a counselor who  accepted Medicaid. The                                                                    
borough only  had one behavioral  health provider  for every                                                                    
860 residents versus one provider  to every 330 residents in                                                                    
other  communities   in  the   country.  She   informed  the                                                                    
committee  that the  Mat-Su Regional  Medical Center  had no                                                                    
behavioral  health treatment  so an  individual who  went to                                                                    
the ER with  a behavioral health crisis  would be stabilized                                                                    
for a cost of $4,370. and  most of those individuals went to                                                                    
the ER 5 or more times  per year. She indicated that in Mat-                                                                    
Su roughly 300 individuals  had behavioral health needs. She                                                                    
offered that  LMFT visits  cost $150  per visit.  She voiced                                                                    
that  the opioid  crisis increased  the need  for behavioral                                                                    
health  and  the  foundation  was   attempting  to  build  a                                                                    
behavioral  health continuum  of  care  staffed with  caring                                                                    
professionals   through   investing   in   non-profits   and                                                                    
providing  scholarships  to   train  new  behavioral  health                                                                    
providers. The  effort was aimed at  keeping individuals out                                                                    
of institutional and  ER care and was  providing local jobs.                                                                    
She  believed   that  SB  105  would   help  the  foundation                                                                    
accomplish building its continuum of care.                                                                                      
Co-Chair  Seaton was  not finding  that the  bill authorized                                                                    
marital  and family  therapists to  do anything.  He thought                                                                    
that the bill provided  for any qualified professional could                                                                    
provide marital and family therapy  services. He wondered if                                                                    
there was  another category of  behavioral health or  if the                                                                    
idea  of  the  bill  was that  marital  and  family  therapy                                                                    
services  was  not   sufficiently  covered.  Ms.  Kemberling                                                                    
observed  that in  the Mat-Su  a "handful  of agencies"  had                                                                    
counselors including LMFTs that  were able to bill Medicaid,                                                                    
but  individual  providers   were  prohibited  from  billing                                                                    
Medicaid. The clinics and agencies  that billed Medicaid had                                                                    
a  significant  shortage of  staff.  She  concluded that  if                                                                    
private  providers  could  bill Medicaid  the  result  would                                                                    
provide more  access to  families needing  behavioral health                                                                    
10:41:03 AM                                                                                                                   
Co-Chair Seaton  asked whether LMFTs  would only be  able to                                                                    
bill  Medicaid  for  marriage and  family  therapy  services                                                                    
under the bill.  Ms. Kemberling answered that  what the bill                                                                    
allowed independent LMFTs to  bill Medicaid. Co-Chair Seaton                                                                    
asked for  what services. He  wondered if it was  limited to                                                                    
marital and family therapy.                                                                                                     
Senator  Wilson  interjected  that   a  marital  and  family                                                                    
therapist  was a  designated  licensure  that was  qualified                                                                    
through  educational   experience  and  going   through  the                                                                    
licensure process  that made the  licensee eligible  to bill                                                                    
for a  myriad of  therapies. He added  that the  therapy was                                                                    
not  limited  to marriage  and  family  issues per  say  but                                                                    
included psychotherapy services and treating and diagnosing                                                                     
mental disorders.  Co-Chair Seaton  asked Senator  Wilson to                                                                    
follow up with the definitions.                                                                                                 
Representative   Wilson   ascertained  that   currently   an                                                                    
independent LMFT  could not  bill Medicaid  but if  the bill                                                                    
passed  a  LMFT  could  bill  for  all  services  under  the                                                                    
parameters   of   the    professional   qualifications   and                                                                    
licensure.   She asked  if she  was correct.  Senator Wilson                                                                    
replied in the affirmative.                                                                                                     
10:44:36 AM                                                                                                                   
AMY SPARGO, ASSISTANT  SUPERINTENDENT, MAT-SU BOROUGH SCHOOL                                                                    
DISTRICT, PALMER  (via teleconference), spoke in  support of                                                                    
the bill.  She shared  that her focus  was on  school safety                                                                    
and  advocated for  increasing access  to behavioral  health                                                                    
services for students in crisis  and preventative health for                                                                    
students who  were experiencing trauma. The  school district                                                                    
engaged  in   a  pilot  program   with  the   Mat-Su  Health                                                                    
Foundation.   Five  of   the  district's   schools,  through                                                                    
behavioral health wellness  grants, partnered with community                                                                    
providers to work  part-time in the schools  and address the                                                                    
behavioral  health needs  of the  students and  families. In                                                                    
order to provide the services,  the program  needed Medicaid                                                                    
eligible  providers to  give equal  access to  all families.                                                                    
She discovered that there were  not enough Medicaid eligible                                                                    
providers  in the  borough. The  bill  allowed more  private                                                                    
providers to be eligible under  the plan. She referenced the                                                                    
conversation about  how to  quantify preventative  work. She                                                                    
related a 2015 study by  the Center for Benefit Cost Studies                                                                    
in Education  from Columbia University that  determined each                                                                    
dollar spent  on prevention returned  the equivalent  of $11                                                                    
to  students and  society later.  She  noted the  connection                                                                    
between   social  and   emotional  learning   and  increased                                                                    
academic performance.                                                                                                           
10:47:48 AM                                                                                                                   
Co-Chair Foster OPENED public testimony.                                                                                        
BEN   SHELTON,  PRESIDENT,   ALASKA   AMERICAN  COLLEGE   OF                                                                    
EMERGENCY PHYSICIANS, ANCHORAGE  (via teleconference), spoke                                                                    
in support of  the bill. He related that as  an ER physician                                                                    
he cared for patients daily  that were in crisis with mental                                                                    
health  conditions  who  were  not  able  to  access  timely                                                                    
outpatient care, which lead to  the crisis. He believed that                                                                    
timely outpatient care could  have prevented their condition                                                                    
from deteriorating  into a crisis.  He restated  his support                                                                    
for the bill.                                                                                                                   
LAURA  EVANS,  STATE  GOVERNMENT AFFAIRS  MANAGER,  AMERICAN                                                                    
ASSOCIATION FOR  MARRIAGE AND FAMILY THERAPY,  VIRGINIA (via                                                                    
teleconference),  spoke   in  support   of  the   bill.  The                                                                    
organization  represented approximately  62 thousand  LMFTs.                                                                    
She believed  that the  bill would  expand access  to mental                                                                    
health services  that were already covered  and simply allow                                                                    
more  provider choice.  She offered  that a  study showed  a                                                                    
decrease  of  about  21.5 percent  ER  utilization  after  6                                                                    
months of   marrital  and family  therapy and  that patients                                                                    
were  taking   better  care   of  their   health  generally.                                                                    
Regarding the fiscal  note, she believed the  costs would be                                                                    
minimal  because  the  services were  already  covered,  but                                                                    
simply  offered an  additional provider  to  address the  10                                                                    
percent increase  in recipients.  She indicated that  the 10                                                                    
percent  increase would  happen whether  or not  marital and                                                                    
family therapy was part of  the program because Medicaid was                                                                    
an entitlement  program. She noted  that Alaskan  LMFTs were                                                                    
clinical providers and licensees  could diagnose and provide                                                                    
treatment  for mental  and  behavioral  disorders. The  LMFT                                                                    
therapy differed from other methods  by employing a holistic                                                                    
or systemic perspective and believed  that the needs did not                                                                    
occur in a vacuum  and the individual's relationship dynamic                                                                    
affected a person's mental  or behavioral disorder. However,                                                                    
the  services provided  were  all clinical  and  able to  be                                                                    
billed  via Medicaid.  She stressed  that the  bill was  not                                                                    
providing for other services or  non-clinical services to be                                                                    
added to Medicaid reimbursement.                                                                                                
Vice-Chair Gara  asked if the  definition of  family therapy                                                                    
included treatment  of a child  or one  parent individually.                                                                    
Ms. Evans  replied that LMFTs  saw individuals  and families                                                                    
and  thought  the scenario  merely  related  to the  billing                                                                    
10:55:38 AM                                                                                                                   
JON  ZASADA,  POLICY  INTEGRATION DIRECTOR,  ALASKA  PRIMARY                                                                    
CARE ASSOCIATION, ANCHORAGE  (via teleconference), testified                                                                    
in  support of  the bill.  He related  that the  association                                                                    
represented  Alaska's  federally  qualified  health  centers                                                                    
that  provided   behavioral  health  care   integrated  with                                                                    
medical  services.  The  centers  operated  outside  of  the                                                                    
community behavioral health centers  and could not currently                                                                    
bill  for  services  provided  by   LMFTs.  He  voiced  that                                                                    
expanding the  Medicaid billable labor force  was the number                                                                    
one priority for the association  and it supported the bill.                                                                    
He emphasized  the chronic and serious  shortage of billable                                                                    
providers and  some positions in  the centers were  open for                                                                    
up to one year. Adding LMFTs  to the list of providers would                                                                    
enable the centers  to serve a wide variety  of patients. He                                                                    
would submit additional written testimony.                                                                                      
Co-Chair Foster set an amendment  deadline for the following                                                                    
day at  9:00 a.m. He  intended to  hear the bill  on Friday,                                                                    
April 13, 2018.                                                                                                                 
SB 105 was HEARD and HELD in committee for further                                                                              
Co-Chair Foster reviewed the schedule for the following                                                                         

Document Name Date/Time Subjects
SB126 Sectional Analysis ver J 3.19.18.pdf HFIN 4/12/2018 9:00:00 AM
SB 126
SB126 Supporting Documents-Suport Letters 3.19.18.pdf HFIN 4/12/2018 9:00:00 AM
SB 126
SB126 Sponsor Statement 3.19.18.pdf HFIN 4/12/2018 9:00:00 AM
SB 126
CSSB 105(FIN) Arctic Mental Health Working Group - Alaska's Mental Health Needs 4.5.18.pdf HFIN 4/12/2018 9:00:00 AM
SB 105
CSSB 105(FIN) Consolidated LOS 4.5.18.pdf HFIN 4/12/2018 9:00:00 AM
SB 105
CSSB 105(FIN) Nat'l Assoc State Mental Health Program Directors_Fact Sheets on Behavioral Health 4.5.18.pdf HFIN 4/12/2018 9:00:00 AM
SB 105
CSSB 105(FIN) Sectional Analysis 4.5.18.pdf HFIN 4/12/2018 9:00:00 AM
SB 105
CSSB 105(FIN) Sponsor Statement 4.5.18.pdf HFIN 4/12/2018 9:00:00 AM
SB 105
CSSB 105(FIN) Summary of Changes 4.5.18.pdf HFIN 4/12/2018 9:00:00 AM
SB 105
CSSB 105(FIN) – LMFT PP.pdf HFIN 4/12/2018 9:00:00 AM
SB 105