Legislature(2015 - 2016)CAPITOL 106

02/02/2016 03:00 PM House HEALTH & SOCIAL SERVICES

Note: the audio and video recordings are distinct records and are obtained from different sources. As such there may be key differences between the two. The audio recordings are captured by our records offices as the official record of the meeting and will have more accurate timestamps. Use the icons to switch between them.

Download Mp3. <- Right click and save file as

Audio Topic
03:03:21 PM Start
03:03:50 PM HB227
05:02:34 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
-- Testimony <Invitation Only> --
+ Bills Previously Heard/Scheduled TELECONFERENCED
                HB 227-MEDICAL ASSISTANCE REFORM                                                                            
3:03:50 PM                                                                                                                    
CHAIR SEATON announced that the  first order of business would be                                                               
HOUSE  BILL  NO. 227,  "An  Act  relating to  medical  assistance                                                               
reform  measures; relating  to  administrative  appeals of  civil                                                               
penalties  for  medical  assistance providers;  relating  to  the                                                               
duties of the Department of  Health and Social Services; relating                                                               
to audits  and civil penalties for  medical assistance providers;                                                               
relating to  medical assistance cost containment  measures by the                                                               
Department  of Health  and Social  Services; relating  to medical                                                               
assistance coverage  of clinic  and rehabilitative  services; and                                                               
providing for an effective date."                                                                                               
CHAIR  SEATON  explained  that  these  reform  efforts  had  been                                                               
introduced last year in a  bill combined with Medicaid Expansion,                                                               
and were now being presented separate from Medicaid Expansion.                                                                  
3:04:42 PM                                                                                                                    
TANEEKA HANSEN,  Staff, Representative Paul Seaton,  Alaska State                                                               
Legislature, explained  that the  proposed bill was  comprised of                                                               
reform components, with  a goal to renew  the conversation around                                                               
Medicaid  reform,  especially  important in  the  current  budget                                                               
climate for  sustainability and efficiency  in all  the programs.                                                               
These reforms had  all been discussed in the last  year, and many                                                               
of  the reforms  would  require approval  by  the legislature  in                                                               
order  to  give Department  of  Health  and Social  Services  the                                                               
authority to move forward.                                                                                                      
MS.  HANSEN  stated  that  proposed   HB  227  encompassed  three                                                               
categories:   administrative and  procedural changes to  help the                                                               
department  administer  the  program,  pursue  overpayments,  and                                                               
lessen  the   burden  on  providers;   offer  direction   to  the                                                               
department in  application for waivers  to implement  cost reform                                                               
options,  pursue demonstration  and pilot  projects, and  execute                                                               
other   system  wide   reforms  for   improvement  to   care  and                                                               
efficiency;   require  reports which  maintain accountability  to                                                               
the Alaska  State Legislature.   She reported that, based  on the                                                               
quantifiable  reforms, the  initial  estimated  savings was  more                                                               
than  $300  million,  which  had  since  been  updated  with  new                                                               
information from Department  of Health and Social  Services.  She                                                               
added  that additional  savings  could be  recognized from  other                                                               
reforms  in  the  proposed   bill,  including  the  demonstration                                                               
projects and super utilizer managed care.                                                                                       
3:08:32 PM                                                                                                                    
CHAIR SEATON clarified that the  proposed bill would not be moved                                                               
today, and would be held over for further consideration.                                                                        
MS.  HANSEN declared  that  health  care reform  needed  to be  a                                                               
continuous process of  ways to improve on the  current system and                                                               
search for better care.                                                                                                         
3:09:17 PM                                                                                                                    
MS. HANSEN paraphrased from the Sectional Analysis, which read:                                                                 
     Section  1 Page  1-2 Legislative  intent language  that                                                                  
     asserts   that   the   current  Medicaid   Program   is                                                                    
     unsustainable.  The  department  of Health  and  Social                                                                    
     Services  should take  the steps  necessary to  capture                                                                    
     additional federal  revenue, obtain waivers  for tribal                                                                    
     partnerships  and   alternative  service   models,  and                                                                    
     establish  prevention of  disease  a  primary model  of                                                                    
     health care.                                                                                                               
     Section 2 Page 2  Adds civil penalties assessed against                                                                  
     Medicaid  providers   to  the  procedures   covered  by                                                                    
     administrative adjudication under AS 44.62.330.                                                                            
     Section  3 Page  2-4 Directs  the Department  of Health                                                                  
     and  Social service  to  assist  Medicaid providers  in                                                                    
     developing health care  models that encourage nutrition                                                                    
     and disease prevention  by adding to the  duties of the                                                                    
     department under AS 47.05.010.                                                                                             
MS. HANSEN pointed out that  the background information [Included                                                               
in members' packets] presented a  summary of the projected health                                                               
care savings  related to Vitamin D  sufficiency, which summarized                                                               
the  findings of  two studies  reviewing the  economic burden  of                                                               
Vitamin  D  deficiency   in  Canada  and  Germany.     If  Alaska                                                               
recognized  similar  results as  Canada,  there  could be  a  6.9                                                               
percent reduction in economic burden,  a savings of $28.5 million                                                               
in annual savings  based on the preceding year costs.   She noted                                                               
that this  was one of  the aforementioned reforms that  would not                                                               
reflect directly in the fiscal notes.                                                                                           
3:11:55 PM                                                                                                                    
MS. HANSEN moved on and paraphrased from Section 4, which read:                                                                 
     Section 4  Page 4-5  Amends AS 47.05.200(a)  to clarify                                                                  
     the minimum  number of audits that  DHSS should conduct                                                                    
     each  year and  that DHSS  should minimize  duplicative                                                                    
     state and federal audits for  Medicaid providers to the                                                                    
     extent possible.                                                                                                           
     Section  5 Page  5-6  Amends AS  47.05.200(b) to  allow                                                                  
     DHSS  to   impose  interest  penalties   on  identified                                                                    
     overpayments using the post judgment statutory rate.                                                                       
MS.   HANSEN  shared   that  the   intention  was   for  adequate                                                               
notification  and   a  grace  period,  and   would  provide  some                                                               
incentive for  providers once  overpayments had  been identified,                                                               
to repay the department in a timely manner.                                                                                     
3:13:19 PM                                                                                                                    
MS. HANSEN paraphrased from Section 6, which read:                                                                              
     Section 6  Page 6 Adopts AS  47.05.250 which authorizes                                                                  
     DHSS to  develop provider  fines though  regulation for                                                                    
     violations  of  AS  47.05,   AS  47.07  or  regulations                                                                    
     adopted  under those  chapters,  in  addition to  other                                                                    
     remedies  allowed   under  the  chapter.   Allows  that                                                                    
     Medicaid providers  may appeal civil fines  through the                                                                    
     office of Administrative Hearings.                                                                                         
MS. HANSEN explained that the intent was to create a medium                                                                     
enforcement opportunity, in lieu of an audit.  She moved on to                                                                  
the next sections, which read:                                                                                                  
     Section 7  and 8  Page 6-8  Amends AS  47.07.020(g) and                                                                  
     (m) to clarify  when DHSS may impose  transfer of asset                                                                    
     penalties  when determining  eligibility for  Medicaid.                                                                    
     Clarifies  under  (g)  that  the  department  may  only                                                                    
     consider information that is  verified through a source                                                                    
     other than the claimant.                                                                                                   
3:16:20 PM                                                                                                                    
MS. HANSEN reported on Section 9, which read:                                                                                   
     Section 9  Page 7  Amends AS  47.07.030(d) to  make the                                                                  
     establishment  of a  primary care  case management  for                                                                    
     identified super-utilizers a  mandatory service for the                                                                    
3:17:01 PM                                                                                                                    
REPRESENTATIVE  TARR referenced  an  earlier  pilot program,  and                                                               
asked if this would instead address "anything going forward."                                                                   
MS. HANSEN, in  response, offered her belief that  this would not                                                               
3:17:47 PM                                                                                                                    
MS.  HANSEN directed  attention back  to the  Sectional Analysis,                                                               
which read:                                                                                                                     
     Section 10  Page 7 Requires  the department  to include                                                                  
     in an  annual report  to the legislature  a description                                                                    
     of  state costs  for  optional  and mandatory  Medicaid                                                                    
CHAIR  SEATON  clarified  that  previously  there  had  been  two                                                               
different  ideas:    provide  optional  services  as  opposed  to                                                               
mandatory services,  as the optional  services were  cheaper; or,                                                               
we  provide a  vast array  of services  more than  required, only                                                               
because these optional services were  available.  Stating that it                                                               
was difficult to separate  these philosophical approaches without                                                               
a report,  this section  of the proposed  bill required  a report                                                               
detailing the two sets of proposed services.                                                                                    
REPRESENTATIVE  TARR presented  an example  which she  opined was                                                               
necessary to  better understand the optional  services, surmising                                                               
that these were  often less expensive as  they offered prevention                                                               
to more costly long term chronic health problems.                                                                               
CHAIR SEATON  suggested that representatives from  the Department                                                               
of Health  and Social  Services (DHSS)  should be  questioned for                                                               
further clarification regarding this section.                                                                                   
3:20:37 PM                                                                                                                    
MS. HANSEN discussed the next two sections, which read:                                                                         
     Section  11 and  12 Page  7 Amends  AS 47.07.036(b)  to                                                                  
     remove  conflicting language  and adds  AS 47.07.036(d)                                                                    
     to  outline  cost  reform   measures  that  DHSS  shall                                                                    
     undertake,  including  demonstration waivers,  applying                                                                    
     for  the  1915  (i)  and  (k)  options,  and  improving                                                                    
     telemedicine  for   Medicaid  recipient.   Directs  the                                                                    
     department  to  implement  at least  one  demonstration                                                                    
     project using  a global payment project  and allows for                                                                    
     other similar projects.                                                                                                    
MS. HANSEN suggested that discussion  could center on the Centers                                                               
for Medicare  & Medicaid Services  (CMS) recommendations  and how                                                               
these could bolster  the aforementioned waivers.   She noted that                                                               
defining the  criteria for the aforementioned  options could also                                                               
shift some costs to federal funds.                                                                                              
REPRESENTATIVE  TARR  asked  to  review the  global  payment  fee                                                               
MS.  HANSEN deferred  to  DHSS  and to  Ms.  Hultberg during  her                                                               
presentation later in the committee  meeting, offering her belief                                                               
that this was a version of provider coordinated care.                                                                           
MS.  HANSEN  pointed  out that  the  definition  of  telemedicine                                                               
included visual,  and that the committee  supported its expansion                                                               
in appropriate ways.                                                                                                            
3:26:55 PM                                                                                                                    
MS. HANSEN discussed the next sections, which read:                                                                             
     Section 13  and 14  Page 9  Amends AS  47.07.900(4) and                                                                  
     (17) to  remove the requirement that  behavioral health                                                                    
     providers be a grantee of  the state of Alaska in order                                                                    
     to bill Medicaid.                                                                                                          
MS. HANSEN explained  that the intention was to  expand access to                                                               
behavioral health services, which  were important to the Medicaid                                                               
population, by removing the grantee  language to allow enrollment                                                               
for smaller  providers and  allow for medium  level care  to help                                                               
prevent more intensive care needs.                                                                                              
3:28:09 PM                                                                                                                    
MS. HANSEN reported on the next section, which read:                                                                            
     Section 15 Page 9 Directs  the department to design and                                                                  
     implement    a    demonstration    project    utilizing                                                                    
     nutritional counselling  and supplementation  to reduce                                                                    
     preterm birth rates among  pregnancies eligible for the                                                                    
     Denali Kid Care program.                                                                                                   
MS. HANSEN explained  that a project currently  underway in South                                                               
Carolina,   "Protect   our   Children  Now,"   was   working   in                                                               
collaboration with  Select Health,  a managed  care organization.                                                               
She pointed out  that the educational resources  and data systems                                                               
already existed under  this model, and she  directed attention to                                                               
the summary  of the  model, which included  its cost  and savings                                                               
[Included  in  members' packets].    She  reported that  $450,000                                                               
could be  spent for the  education, supplementation,  and testing                                                               
of  500 pregnancies  under this  model, noting  that the  average                                                               
cost of a  pre-term birth was $55,000.  She  shared that research                                                               
studies had shown a decrease of  50 percent in the pre-term birth                                                               
rate, which would reflect a substantial savings.                                                                                
REPRESENTATIVE  WOOL,  noting that  the  pre-term  birth rate  in                                                               
Alaska was 8.5  percent, asked about this rate  in South Carolina                                                               
and its corresponding results.                                                                                                  
MS. HANSEN opined that, although  the background material did not                                                               
list the  South Carolina  pre-term birth rates,  it was  about 13                                                               
percent, higher than  that in Alaska.  She reported  that the two                                                               
research  studies on  which  the  aforementioned project  focused                                                               
found a reduction  of more than 50 percent in  the pre-term birth                                                               
rate,   with  the   corresponding  substantial   savings.     She                                                               
acknowledged that there could be some differences in Alaska.                                                                    
REPRESENTATIVE TARR asked what components,  other than Vitamin D,                                                               
were included in "Protect our Children Now."                                                                                    
MS. HANSEN offered  to share the handout from  the South Carolina                                                               
program,  which  described  the  project.    She  declared  that,                                                               
although the focus was on  Vitamin D, there was other nutritional                                                               
counseling in the  program.  She noted that  the research project                                                               
was in low income community  health centers in ethnic areas which                                                               
had higher  rates of  Vitamin D deficiency  due to  skin pigment,                                                               
even though the state was in a more southerly latitude.                                                                         
CHAIR  SEATON  added that  the  South  Carolina model  was  being                                                               
replicated  in either  Montana  or Idaho,  and  funded by  Select                                                               
Health,  the local  insurance  provider, in  order  to study  the                                                               
savings.   He noted that  nutritional counseling  and non-smoking                                                               
counseling were  part of this  established pre-term  birth model.                                                               
He reported  that it  included at least  one post-partum  test on                                                               
Vitamin D status.   He pointed out that there  was a $1.5 million                                                               
savings on  a $450,000 investment  plus the health benefits.   He                                                               
asked whether the  state wanted to contract  with an organization                                                               
or  have DHSS  "start from  scratch and  develop something."   He                                                               
declared that there was a  pre-term birth problem in Alaska, with                                                               
some areas reporting 14 percent  pre-term births.  He stated that                                                               
the  goal of  the pilot  project was  "to find  out if  something                                                               
works for Alaska  the way it works for other  areas of the United                                                               
3:35:15 PM                                                                                                                    
MS. HANSEN moved on to discuss the next section, which read:                                                                    
     Section 16  Page 10 Requires  the Department  of Health                                                                  
     and Social  Services to establish  a primary  care case                                                                    
     management  system for  super-utilizers  and deliver  a                                                                    
     report on the project by January 1, 2017.                                                                                  
MS. HANSEN shared that the intention  was to make the terms broad                                                               
enough  to  include  the current  DHSS  projects  addressing  the                                                               
super-utilizer  issues, and  to require  a report  to the  Alaska                                                               
State Legislature.   She  added that  this section  also required                                                               
the  department to  provide a  report to  the legislature  on the                                                               
Medicaid redesign  and expansion  technical assistance  study, on                                                               
the current  cost sharing measures,  and on the progress  on cost                                                               
savings of  the waivers  under Section 12  of the  proposed bill.                                                               
She stated that the language  had been slightly modified relevant                                                               
to  the  Medicaid  Redesign  report.    She  explained  that  the                                                               
intention  behind the  report summarizing  cost sharing  measures                                                               
implemented  prior to  October 1,  2015, mentioned  in subsection                                                               
(b), was  to list the  current status of cost  sharing, including                                                               
co-pays,  to give  a better  understanding for  any consideration                                                               
for change.                                                                                                                     
3:39:22 PM                                                                                                                    
MS. HANSEN  moved on to  discuss the remaining  sections, dealing                                                               
with conditional effects, which read:                                                                                           
     Section 17  Page 10 Requires  the Department  of Health                                                                  
     and  Social  Services  to provide  to  the  legislature                                                                    
     reports   on  the   Medicaid  Redesign   and  Expansion                                                                    
     Technical   Assistance   study,  current   cost-sharing                                                                    
     measures in  the Medicaid program, and  on the progress                                                                    
     and  cost savings  of the  waivers and  options applied                                                                    
     for under section 12 of this legislation.                                                                                  
     Section  18 Page  11 Informs  the  revisor of  statutes                                                                  
     that  the  Department  of Health  and  Social  Services                                                                    
     shall  apply for  federal approval  for the  state plan                                                                    
     amendments necessary  under section  9, 12, 15,  and 16                                                                    
     of this Act.                                                                                                               
     Section  19 Page  12 Permits  the Department  of Health                                                                  
     and Social Services to  adopt the regulations necessary                                                                    
     to implement  this act, not  before the  effective date                                                                    
     of the relevant provisions.                                                                                                
     Section 20  Page 12 Instructs  the revisor  of statutes                                                                  
     to  make  technical  amendments  to  the  title  of  AS                                                                    
     47.07.036 to conform with the changes in this Act.                                                                         
     Section 21  Page 12 Clarifies  that changes  enacted in                                                                  
     sections  9, 12,  15, and  16 only  take effect  if the                                                                    
     Department of  Health and Social Services  receives the                                                                    
     necessary federal approval by  the deadlines created in                                                                    
     this Act.                                                                                                                  
     Section   22-25   Page   13-14  States   that   if   AS                                                                  
     47.07.0309(d) as  amended by section 9  and section 16,                                                                    
     section 12(e),  section 12(f),  and section  15 receive                                                                    
     federal  approval, each  section will  take effect  the                                                                    
     day  after  the date  the  commissioner  of health  and                                                                    
     social  services notifies  the revisor  of statutes  in                                                                    
     writing, as required by sections 18 and 21.                                                                                
     Section 26  Page 13 Provides  that sections  17(a), 18,                                                                  
     19 and 21 take effect immediately.                                                                                         
3:40:52 PM                                                                                                                    
REPRESENTATIVE  VAZQUEZ  directed attention  to  page  11 of  the                                                               
proposed bill,  and asked whether  there was a report  on options                                                               
1915(i) and (k).                                                                                                                
MS. HANSEN  replied that a  current requirement under  Section 17                                                               
required a  DHSS report  to the legislature  on February  1, 2019                                                               
regarding these and other waivers.                                                                                              
REPRESENTATIVE VAZQUEZ suggested that  there was some information                                                               
and experience  from other  states which  indicated that  some of                                                               
these   actions   would   increase   the   number   of   Medicaid                                                               
beneficiaries.  She  asked if there had been any  studies for the                                                               
number of new enrollees as a result of these two options.                                                                       
MS.  HANSEN deferred  to DHSS,  and  she opined  that this  would                                                               
depend on the definitions of the eligibility criteria.                                                                          
3:44:20 PM                                                                                                                    
VALERIE  DAVIDSON,  Commissioner,  Office  of  the  Commissioner,                                                               
Department  of Health  and Social  Services  (DHSS), offered  her                                                               
general comments on  the proposed bill.  She  reiterated that the                                                               
administration  was  very  committed  to  Medicaid  reform,  that                                                               
reform was  a constant for  those states that  did it well.   She                                                               
highlighted that,  over the last several  weeks, numerous reports                                                               
had  been released  on reform  opportunities.   She offered  that                                                               
those  reports may  provide additional  reform opportunities  for                                                               
the committee to consider.                                                                                                      
JON  SHERWOOD,  Deputy  Commissioner, Medicaid  and  Health  Care                                                               
Policy,  Office of  the Commissioner,  Department  of Health  and                                                               
Social Services,  in response  to Representative  Vazquez, listed                                                               
his areas of responsibility, which  included the Medicaid program                                                               
as well as four divisions,  the Division of Alaska Pioneer Homes,                                                               
Division of Public Assistance, Division  of Health Care Services,                                                               
and Division of Senior and Disabilities Services.                                                                               
CHAIR  SEATON asked  for discussion  on the  11 fiscal  notes for                                                               
proposed HB 227.                                                                                                                
MR.  SHERWOOD  pointed out  that  the  11  fiscal notes  did  not                                                               
necessarily "tie neatly  to a section of bill," as  there were "a                                                               
lot of  moving parts in  each fiscal  note."  He  summarized that                                                               
the net  impact was to reduce  costs or shift from  state general                                                               
funds  to  federal  funds  or  another source  of  revenue.    He                                                               
reported that the  total of all the fiscal notes  would result in                                                               
a net  reduction to the general  fund of $2,889,000 in  FY17.  He                                                               
shared that it would also reflect  a change in tribal policy with                                                               
a  projected  reduction  of  $12,350,000.     The  savings  would                                                               
continue to  accrue as  other programs  were implemented,  as not                                                               
all the programs in  the proposed bill would start on  Day 1.  He                                                               
shared that these  savings would grow and, for  FY2022, there was                                                               
a  projected  reduction in  general  funds  of $88,431,000.    He                                                               
opined that  the cumulative savings  were more than  $300 million                                                               
over the next six years.                                                                                                        
3:51:14 PM                                                                                                                    
MR. SHERWOOD  directed attention to  the first fiscal  note which                                                               
reflected the administrative costs  at the Division of Behavioral                                                               
Health,  labelled  OMB  Component  Number  2665,  which  revolved                                                               
around implementation  of Section  12 of the  proposed bill.   He                                                               
reported  that  this  included   coverage  of  behavioral  health                                                               
services administration  under the  1115 demonstration  waiver to                                                               
restructure the services.   He explained that  this would include                                                               
the  addition of  one  full  time staff  person  to  work on  the                                                               
development and  administration of a demonstration  waiver, at an                                                               
annual cost  of $127,800 in  FY 17,  with an additional  one time                                                               
cost  of $8100.   He  pointed out  that these  were paid  with 50                                                               
percent each of general funds and federal funds.                                                                                
REPRESENTATIVE STUTES  asked how  long the federal  funding would                                                               
MR. SHERWOOD  replied that  this was a  50 percent  federal match                                                               
funding,   a  standard   administrative   activities  match   for                                                               
Medicaid, which had  existed since the inception  of the Medicaid                                                               
program,  and it  would require  congressional  action to  change                                                               
those federal match rates.                                                                                                      
REPRESENTATIVE STUTES declared that  she was skeptical, and asked                                                               
if there was any assurance for this reimbursement.                                                                              
COMMISSIONER  DAVIDSON,  in  response to  Representative  Stutes,                                                               
said that the guarantee was  that federal law mandated this rate,                                                               
and it would  require a change in federal law  and the consent of                                                               
both bodies of Congress and the president.                                                                                      
REPRESENTATIVE  VAZQUEZ   said  that  her  research   found  that                                                               
Congress had  changed the  federal match  several times,  and she                                                               
offered her belief that it would  again be changed in the future.                                                               
She asked how often that had been changed.                                                                                      
CHAIR SEATON  asked for  clarification that  the request  was for                                                               
any changes to federal match,  pointing out that the response had                                                               
been specifically for the administrative fee.                                                                                   
REPRESENTATIVE VAZQUEZ  replied that  she wanted  to know  of any                                                               
changes, including the administrative fees.                                                                                     
COMMISSIONER DAVIDSON  expressed her agreement that  Congress had                                                               
occasionally changed  the Federal Medical  Assistance Percentages                                                               
(FMAP),  pointing   out  that  most   recently  there   had  been                                                               
enhancements  to  increase the  federal  match  and decrease  the                                                               
match requirement  for states.   She acknowledged that  there had                                                               
been a time when the normal  calculation for FMAP had indicated a                                                               
50 percent match  for Alaska, however, then  Senator Ted Stevens,                                                               
Chair of  the Appropriations committee,  had provided a  rider to                                                               
increase the  Alaska FMAP  beyond the 50  percent.   She reported                                                               
that it had since been returned to the original rate.                                                                           
REPRESENTATIVE  VAZQUEZ asked  if Commissioner  Davidson's recent                                                               
testimony to  no change had  changed, stating "maybe  your memory                                                               
was jogged."                                                                                                                    
COMMISSIONER DAVIDSON  replied that she  had not stated  that the                                                               
FMAP had not changed, and,  responding to Representative Vazquez,                                                               
she asked "was that in this committee?"                                                                                         
REPRESENTATIVE VAZQUEZ  replied that  either the  commissioner or                                                               
Mr. Sherwood had stated that the FMAP had never changed.                                                                        
COMMISSIONER  DAVIDSON   offered  her  belief  that   the  Deputy                                                               
Commissioner  had  stated that  the  administrative  match of  50                                                               
percent had not changed.                                                                                                        
MR. SHERWOOD,  in response  to Representative  Vazquez, explained                                                               
that he had stated that, to  the best of his knowledge, there had                                                               
never  been a  change to  the  basic administrative  match of  50                                                               
percent, although  some other activities had  been identified for                                                               
enhanced match.                                                                                                                 
4:01:35 PM                                                                                                                    
REPRESENTATIVE TALERICO  asked if the intention  for this section                                                               
of the proposed bill was to increase the efficiency.                                                                            
MR. SHERWOOD  replied that this  was for effectiveness,  "to make                                                               
behavioral  health  services more  effective  in  how we  deliver                                                               
services."   He  opined  that  an expectation  would  be to  gain                                                               
REPRESENTATIVE VAZQUEZ asked  for the amount of  grants issued to                                                               
date in FY16 to behavioral health providers.                                                                                    
COMMISSIONER  DAVIDSON   offered  to  provide   the  information,                                                               
pointing  out that  this was  not  reflected in  the fiscal  note                                                               
being discussed.                                                                                                                
REPRESENTATIVE VAZQUEZ  requested the same information  for FY15.                                                               
She asked  if the department posted  the list of grantees  on its                                                               
MR. SHERWOOD replied that he would find out.                                                                                    
REPRESENTATIVE  VAZQUEZ, in  response to  Chair Seaton,  asked to                                                               
receive the list from FY15 and FY16.                                                                                            
4:04:29 PM                                                                                                                    
MR. SHERWOOD  directed attention to  the fiscal note  for Medical                                                               
Assistance Administration  costs to  the Division of  Health Care                                                               
Services,  OMB Component  Number 242.   He  said that  this would                                                               
consist of  one long  term, 24  month, non-permanent  position to                                                               
handle the increased  volume of appeals for civil  fines, with an                                                               
annualized cost  of $54,000  and an  additional one-time  cost of                                                               
$7600.  He  said that, from Section 12 of  the proposed bill, one                                                               
additional  full time  position would  be needed  to oversee  the                                                               
tribal claims, with  an annual cost of $86,500  beginning in FY17                                                               
and a  one-time cost of $7600.   He pointed out  that the federal                                                               
match  for these  administrative positions  was 50  percent.   He                                                               
pointed  out   that  this   would  decline   over  time   as  the                                                               
aforementioned non-permanent position phased out.                                                                               
CHAIR SEATON asked about the increase in FY18 to $97,300.                                                                       
MR. SHERWOOD  replied that the  temporary position would  only be                                                               
necessary  for six  months in  FY17, noting  that experience  had                                                               
shown that  implementation of  a new program  brought a  spike in                                                               
the  volume  of   appeals  until,  as  the   process  was  better                                                               
understood, the volume would decrease.                                                                                          
CHAIR  SEATON  asked about  any  anticipated  revenue from  those                                                               
MR. SHERWOOD said  there had not been a  calculation for recovery                                                               
to expense, although there was  some information for expectations                                                               
to recovery in an additional fiscal note.                                                                                       
4:08:27 PM                                                                                                                    
REPRESENTATIVE VAZQUEZ asked if  this proposed position was being                                                               
established to  address the corrective  action plan  necessary to                                                               
submit to CMS as a result of the recent audit.                                                                                  
MR. SHERWOOD  replied that this  position was not related  to the                                                               
corrective  action  plan  addressed  in the  recent  audit,  but,                                                               
instead,  addressed the  provisions  in the  proposed  bill.   He                                                               
stated that  the provisions of  the proposed bill did  not relate                                                               
to the recent audit.                                                                                                            
REPRESENTATIVE  VAZQUEZ  asked  for  clarification  what  in  the                                                               
proposed bill would require this additional resource.                                                                           
MR.  SHERWOOD  explained that  the  implementation  of the  civil                                                               
penalties  provision,  with  the  authority to  impose  fines  in                                                               
Section 6, necessitated  this.  He noted that  new federal policy                                                               
on  tribal  claiming  could lead  to  expectations  for  enhanced                                                               
claiming  from  tribal  health providers,  and  would  need  some                                                               
degree of oversight and monitoring for eligibility.                                                                             
4:11:32 PM                                                                                                                    
REPRESENTATIVE VAZQUEZ,  referencing page  6, lines  13 -  16, of                                                               
the  proposed  bill,  which discussed  the  assessment  of  civil                                                               
penalties,   asked  how   this  interfaced   with  the   criminal                                                               
prosecution of  Medicaid providers by the  Medicaid Fraud Control                                                               
4:13:05 PM                                                                                                                    
STACIE  KRALY,   Chief  Assistant  Attorney   General,  Statewide                                                               
Section  Supervisor,  Human   Services  Section,  Civil  Division                                                               
(Juneau),  Department  of  Law,  in  response  to  Representative                                                               
Vazquez,   stated  that   there  were   two  separate   processes                                                               
contemplated within  the proposed  bill, whereby DHSS  would have                                                               
the  ability  to impose  civil  fines  in  the context  of  civil                                                               
actions  related  to  overpayments or  sanctions  issued  against                                                               
Medicaid providers.  She stated  that these would be separate and                                                               
distinct from  Medicaid fraud prosecution, which  could also have                                                               
an associated  criminal fine  or penalty.   She pointed  out that                                                               
criminal  conduct  was  not  addressed in  the  context  of  this                                                               
proposed bill.                                                                                                                  
REPRESENTATIVE VAZQUEZ  asked who made the  decision for criminal                                                               
or civil prosecution.                                                                                                           
MS. KRALY  explained that  the decision for  a criminal  case was                                                               
determined by the  Medicaid Fraud Control Unit.  If  there was an                                                               
allegation of improper billing or  activity, DHSS would meet with                                                               
Department of Law  and the Medicaid Fraud Control  Unit to decide                                                               
what to do.   Even if a  criminal action was taken,  this did not                                                               
limit a civil review by DHSS  of inappropriate action.  She noted                                                               
that  sometimes there  were concurrent  processes,  but that  the                                                               
primary  decision  for who  acted  was  with the  Medicaid  Fraud                                                               
Control Unit.                                                                                                                   
REPRESENTATIVE  VAZQUEZ  asked  who  made  the  referral  to  the                                                               
Medicaid Fraud Control Unit.                                                                                                    
MS. KRALY  replied that this  could be  made by anyone  to either                                                               
DHSS or the Medicaid Fraud Control Unit.                                                                                        
REPRESENTATIVE VAZQUEZ  stated that  she liked  Section 6  of the                                                               
proposed bill.                                                                                                                  
4:17:24 PM                                                                                                                    
REPRESENTATIVE VAZQUEZ  directed attention to  page 5, lines  1 -                                                               
31, and page 6, lines 1 -3 of  the proposed bill.  She pointed to                                                               
page 5,  lines 5 -  10, which  statutorily reduced the  number of                                                               
audits, and  she opined  that reducing the  number of  audits was                                                               
not  a  good  idea  as   it  reduced  the  accountability.    She                                                               
acknowledged that, page 5, lines  18 - 20, explicitly stated that                                                               
DHSS  should "attempt  to minimize  concurrent  state or  federal                                                               
audits,"   and  she   expressed  her   agreement,  although   she                                                               
"strenuously" objected to the reduction of audits.                                                                              
COMMISSIONER DAVIDSON,  in response, stated that  as the national                                                               
Medicaid program  had further developed, there  was an increasing                                                               
number  of federal  audits imposed  on  providers.   In order  to                                                               
minimize  the concurrent  state  or federal  audits mentioned  on                                                               
page 5, lines 18 - 20, of  the proposed bill, it was necessary to                                                               
reduce the number  of audits, as stated  on page 5, line  5.  She                                                               
declared that,  even with  this provision,  the number  of audits                                                               
required by the provider community had increased over time.                                                                     
4:21:38 PM                                                                                                                    
MR. SHERWOOD,  in response to  Chair Seaton, asked that,  as DHSS                                                               
counted enrolled  providers in different  ways, he  would respond                                                               
later to  ensure that his  answer matched the definition  used in                                                               
the provision.                                                                                                                  
CHAIR SEATON  reflected that the  minimum number of  audits could                                                               
be in the hundreds depending on  the required 0.75 percent of all                                                               
providers, and  he mused whether  there was any relevance  to the                                                               
not less than number.                                                                                                           
MR. SHERWOOD  relayed that the  range of  audits was close  to 75                                                               
during an annual cycle.                                                                                                         
REPRESENTATIVE  VAZQUEZ   pointed  out  that  the   auditor  used                                                               
analytics to  look at high  risk provider profiles.   She offered                                                               
her belief  that there  were about  3000 Medicaid  providers, and                                                               
that  historically, the  department  had chosen  to undertake  75                                                               
audits, which she deemed was not "outrageously high."                                                                           
MR. SHERWOOD replied that he would  send the current count to the                                                               
committee, and he expressed appreciation  for the point that DHSS                                                               
did not  have random  targeting for  audits.   He noted  that the                                                               
pool  of  high  risk  providers was  substantially  smaller,  and                                                               
shared that DHSS did not want  to burden the low risk, low volume                                                               
providers simply to make a number.                                                                                              
REPRESENTATIVE  VAZQUEZ acknowledged  that  DHSS  worked hand  in                                                               
hand with  the audit  contractor to help  identify the  high risk                                                               
MR. SHERWOOD,  in response to  Representative Vazquez,  said that                                                               
MMIS  (Medicaid Management  Information  Systems)  was a  generic                                                               
term  for   the  claims  processing  system   under  the  federal                                                               
definition.   He clarified  that Enterprise  was what  the vendor                                                               
called  its specific  product.   He explained  that "capture  the                                                               
income  contingent   cost  sharing  rules  set   in  new  federal                                                               
regulations"  on  the  last  line  of  page  2,  fiscal  note  2,                                                               
referenced a federal regulation  which limited total cost sharing                                                               
to 5 percent of household income for some Medicaid recipients.                                                                  
REPRESENTATIVE  VAZQUEZ asked  for the  citation to  that federal                                                               
MR. SHERWOOD said that he would forward that to the committee.                                                                  
4:28:16 PM                                                                                                                    
MR. SHERWOOD  moved on to  fiscal note 3, labelled  OMB Component                                                               
Number 2696,  from the Office of  Rate Review in the  Division of                                                               
Health Care Services.  This  office established rates for many of                                                               
the  provider  payments.   Directing  attention  to the  proposed                                                               
bill, Section  12, subsections (e)  and (f), he pointed  out that                                                               
these  outlined the  requirement  for one  or more  demonstration                                                               
projects  focused  on  innovative  payments  including  one  that                                                               
includes  a  global payment  fee  structure.   He  reported  that                                                               
fiscal note 3 included one-time  costs for hiring a contractor to                                                               
analyze and implement  a new payment model at a  cost of $500,000                                                               
in  FY17, with  the  assumption for  on-going  actuarial work  in                                                               
subsequent  years  associated  with   the  calculation  of  those                                                               
payments,  at a  cost of  $100,000 per  year.   He noted  that as                                                               
these  were general  administrative costs,  the state  would only                                                               
have to pay 50 percent.                                                                                                         
REPRESENTATIVE  VAZQUEZ asked  if an  RFP (request  for proposal)                                                               
for a contractor had been issued.                                                                                               
MR. SHERWOOD replied there had not been any action just yet.                                                                    
REPRESENTATIVE VAZQUEZ  expressed her  assumption that  the money                                                               
would be distributed  through the Office of Rate  Review, and was                                                               
solely devoted to the 1115 demonstration waiver.                                                                                
MR.  SHERWOOD  replied  that  it   was  for  the  global  payment                                                               
demonstration mentioned in the proposed bill.                                                                                   
REPRESENTATIVE  VAZQUEZ asked  if  the  global demonstration  was                                                               
also the 1115 demonstration waiver.                                                                                             
MR. SHERWOOD offered his belief  that the proposed bill specified                                                               
the 1115 demonstration waiver.                                                                                                  
REPRESENTATIVE  VAZQUEZ  asked  if implementation  of  this  1115                                                               
waiver would add new beneficiaries.                                                                                             
MR.  SHERWOOD replied  that it  was not  envisioned for  the 1115                                                               
waiver for global  payment to add new beneficiaries,  as it would                                                               
simply change  the method  of payment  for services  delivered to                                                               
current beneficiaries.                                                                                                          
CHAIR SEATON  pointed out  that this  was a  change from  fee for                                                               
service   for   value   toward  the   HMO   (health   maintenance                                                               
organization) model.                                                                                                            
4:32:55 PM                                                                                                                    
REPRESENTATIVE  VAZQUEZ asked  about  the  FMAP (federal  medical                                                               
assistance percentages)  for the  1115 waiver if  the beneficiary                                                               
goes to a non-tribal facility.                                                                                                  
COMMISSIONER  DAVIDSON explained  that U.S.  Secretary of  Health                                                               
and Human  Services Burwell  had announced  a policy  change that                                                               
would allow  Alaska and 34  other states with  significant tribal                                                               
membership  to be  reimbursed at  100 percent  federal match  for                                                               
medically  necessary accommodations  and travel,  as well  as for                                                               
services  referred   through  an  IHS  (Indian   Health  Service)                                                               
facility   to  a   non-tribal  facility.     She   reported  that                                                               
negotiation for this was ongoing with  CMS, as well as with other                                                               
states, as  it was a  significant national policy change  for IHS                                                               
CHAIR SEATON asked to relate this to the global payment model.                                                                  
MR. SHERWOOD explained that the  1115 demonstration waiver had to                                                               
be  cost  neutral.   He  explained  that  the federal  match  was                                                               
negotiated based  on what you intend  to do, and "how  far afield                                                               
it is  of regular Medicaid."   It would  be negotiated to  a rate                                                               
that  kept  it cost  neutral  for  the federal  government,  with                                                               
anticipation that the  purpose was for savings  across the board,                                                               
and  not to  add anything  extraordinary that  was not  typically                                                               
covered, so that  the match rates would be  for services provided                                                               
as they applied.  He stated  that those eligible for tribal match                                                               
would be at the 100 percent  match rate, family planning would be                                                               
90  percent match  rate, and  the  base match  rate for  services                                                               
would  be 50  percent.   He  pointed out  that  signing the  1115                                                               
waiver  was  technically  an  agreement for  just  how  much  the                                                               
federal government would support the  project.  He clarified that                                                               
this was the global payment feature.                                                                                            
REPRESENTATIVE TARR  requested further detail on  global payment,                                                               
asking  if this  negotiated  FMAP with  tribal  partners was  one                                                               
MR. SHERWOOD  explained that  the change in  tribal policy  was a                                                               
separate waiver, and the global  payment waiver was not dependent                                                               
on that  change.  He stated  that global payment was  a move away                                                               
from fee for service, looking,  instead, for consolidated payment                                                               
such as a shared savings agreement to provider groups.                                                                          
REPRESENTATIVE TARR  asked whether provider groups  might include                                                               
the state  health coverage through  Aetna rather  than individual                                                               
fee for service.                                                                                                                
MR. SHERWOOD  replied that  he did not  envision this  through an                                                               
insurance  company,  although  an   insurance  company  could  be                                                               
involved as  a third party  administrator managing the  money and                                                               
cash flow.   He stated  that typically these  were organizations,                                                               
and offered  an example  of a community  where the  hospital, the                                                               
primary  care   doctors,  the  clinics,  the   behavioral  health                                                               
providers all  get together  and agree  to certain  practices and                                                               
relationships  to deliver  care  more effectively  and share  and                                                               
distribute  the  savings or  assume  the  risk.   He  offered  an                                                               
example of an innovative hospital  project in Ketchikan to better                                                               
manage chronic care.  Under  the previous fee for service system,                                                               
the benefits  did not accrue  directly to the hospital,  but this                                                               
innovation would allow for some  redistribution of those benefits                                                               
to offset some of the revenue loss.                                                                                             
REPRESENTATIVE TARR asked if, under  this scenario, the state was                                                               
not the payment manager.                                                                                                        
COMMISSIONER  DAVIDSON,  in   response  to  Representative  Tarr,                                                               
shared  that a  recommendation from  the Agnew::Beck  Consulting,                                                               
LLC  report  on  Medicaid  Redesign  and  Expansion  was  for  an                                                               
accountable   care  organization,   for  example,   an  insurance                                                               
company,  an  administrative  services  company, or  a  group  of                                                               
providers  who came  together.   She  explained that  this was  a                                                               
demonstration that  would move  away from fee  for service.   She                                                               
declared that payment reform  established disincentives to repeat                                                               
occurrences,  creating,  instead,  an incentive  for  prevention,                                                               
wellness activities, and providing more effective care.                                                                         
4:44:32 PM                                                                                                                    
REPRESENTATIVE  WOOL asked  to clarify  that  global payment  was                                                               
managed care, a health cost  savings measure, and that Alaska was                                                               
investigating these programs.                                                                                                   
COMMISSIONER DAVIDSON replied that she  had described one type of                                                               
care management.   She pointed  out that  there was also  a legal                                                               
entity  called a  Managed Care  Organization, which  was its  own                                                               
special structure.  She reported  that there were many models for                                                               
care   management  opportunities,   and   that  the   Agnew::Beck                                                               
Consulting  group  had  spent considerable  time  discussing  the                                                               
various options to managing the  care for Medicaid beneficiaries,                                                               
as well as analysis for which models made sense for Alaska.                                                                     
REPRESENTATIVE  TARR asked  if this  was a  demonstration project                                                               
only for Medicaid recipients.                                                                                                   
COMMISSIONER  DAVIDSON replied  that this  particular section  of                                                               
the proposed bill was for Medicaid beneficiaries.                                                                               
CHAIR SEATON opined  that an entity using a  global payment model                                                               
at the  same time  with other insurers  was a  separate question,                                                               
but was not part of the state Medicaid population.                                                                              
REPRESENTATIVE  VAZQUEZ asked  for a  list of  the various  FMAPs                                                               
applicable to this 1115 waiver.                                                                                                 
CHAIR SEATON  reminded the  committee that  it was  still unknown                                                               
whether there would  be a tribal component.  He  surmised that it                                                               
would  be very  difficult to  accurately predict  all components,                                                               
because we could  have some FMAP rates but we  don't know how big                                                               
or small each recipient type will be.                                                                                           
4:49:32 PM                                                                                                                    
BECKY HULTBERG, President/CEO, Alaska  State Hospital and Nursing                                                               
Home Association, stated that there  was no easy button in health                                                               
care reform, and  that, although it was really hard  work and was                                                               
expensive and time consuming, it  was worth doing as it concerned                                                               
both the fiscal impact to the State  of Alaska and to the care to                                                               
every  patient.   She stated  that health  care was  undergoing a                                                               
period  of rapid  transformation.   During  this  time of  budget                                                               
difficulties, it  was necessary to  look ahead and create  a road                                                               
map for  how health  care would be  transformed from  its current                                                               
system,  which  needed  to  change,  to  something  ahead.    The                                                               
transformation needed  to make economic  sense for the  state and                                                               
for  patients  and communities,  and  needed  to be  sustainable,                                                               
patient centered,  and meet  the needs of  the communities.   She                                                               
reported that many pieces needed  to be reviewed, including short                                                               
term  cost containment  to better  manage cost  for the  next few                                                               
years.     She   suggested  a   hospital  based   emergency  room                                                               
initiative, which  was one of  the recommendations from  both the                                                               
Agnew::Beck  report and  the  hospitals.   She  shared that  this                                                               
would  almost  immediately  reduce  emergency  room  utilization,                                                               
emergency  room   costs,  and   opioid  prescriptions   from  the                                                               
emergency room.   She  suggested the  coordination of  care among                                                               
frequently hospitalized Medicaid recipients.   She declared that,                                                               
although both  of these would  reduce hospital  revenue, managing                                                               
utilization was  the right way  to approach cost  containment and                                                               
make the transition  from volume based to value based  care.  She                                                               
moved  on  to discuss  the  foundational  elements of  long  term                                                               
health  care reform,  what  needed  to be  done  now  to set  the                                                               
infrastructure in  place.  She  stated that an enhanced  role for                                                               
primary care  was very  important, opining  that the  concept for                                                               
this was  embedded in  proposed HB  227.   She declared  that the                                                               
Medicaid  system  needed   to  focus  on  primary   care  as  the                                                               
gatekeeper  for  services.   She  moved  on  to state  that  data                                                               
analytics,  a robust  data system,  was  necessary to  understand                                                               
where the Medicaid  patients were going, how were  they using the                                                               
services and what  patterns were observed, and how  this could be                                                               
managed based on these observations.   She acknowledged that this                                                               
could cost  money now, but the  return was in the  long term from                                                               
better  management  with  better  data.   Lastly,  she  addressed                                                               
payment reform,  the move  from compensation  based on  volume to                                                               
compensation based on  outcome.  She pointed out that  this was a                                                               
huge  change in  health care  that would  not be  made overnight.                                                               
She declared  support for  proposed HB 227,  as it  offered pilot                                                               
programs with provider groups and  communities to advance payment                                                               
reform.   She stated that there  was not the infrastructure  on a                                                               
global  scale to  "go all  in on  one type  of payment  reform or                                                               
another."   She offered her  belief that innovation  would emerge                                                               
through  these  pilot  programs   which  could  then  be  broadly                                                               
adopted.  She encouraged a  pilot approach for the payment reform                                                               
4:55:08 PM                                                                                                                    
REPRESENTATIVE WOOL asked if this  move away from fee for service                                                               
had to be system wide or just for Medicaid.                                                                                     
MS.  HULTBERG replied  that her  counterparts  across the  United                                                               
States  had agreed  that the  entire system  needed to  move away                                                               
from fee  for service,  even though  it would  take a  long time.                                                               
She  stated  that,  as  Medicare  was a  significant  part  of  a                                                               
hospital payer mix, and, as Medicare  had stated it would move to                                                               
value, this change could happen more quickly in hospitals.                                                                      
MS.  HULTBERG  stated  that availability  of  data  for  decision                                                               
making  was  really  important,  as   was  the  capacity  of  the                                                               
Department of  Health and Social  Services to manage  the change.                                                               
Although  this was  a time  of fiscal  challenge, it  would still                                                               
take  time  and investment  and  people  to  do  the work.    She                                                               
suggested that  it was  necessary to  assess what  the department                                                               
could realistically accomplish  and in what time  frame, and then                                                               
either resource them to do it, or phase it so it was manageable.                                                                
MS.  HULTBERG, commenting  on  Section 9  of  the proposed  bill,                                                               
endorsed  the  concept  of  coordinated  care  for  primary  case                                                               
management, as  it was a  foundational building block  for health                                                               
care  reform.    She  expressed concern  over  the  managed  care                                                               
organization (MCO)  model as  it was  predicated on  high volume,                                                               
and Alaska  was a low volume  state.  She suggested  that this be                                                               
an optional  aspect, as  primary care  case management  should be                                                               
the  focus.     She  referenced  the   Agnew::Beck  report  which                                                               
indicated  that the  MCO model  would  not bring  any savings  to                                                               
Alaska.  She declared support  for expansion of behavioral health                                                               
services, Sections  13 and 14 of  the proposed bill.   She stated                                                               
that behavioral  health needs were  equally important  to address                                                               
as  medical needs.   She  pointed  to data  which supported  that                                                               
behavioral health needs  often included high medical  needs.  She                                                               
said that ASHNA was still  reviewing and evaluating the fraud and                                                               
abuse sections of the proposed bill.   She noted that ASHNA was a                                                               
low risk  provider group, but  she pointed out that  audits added                                                               
significant administrative time and  cost.  She expressed concern                                                               
with over regulation and applauded  the efforts to streamline the                                                               
audit function.   She shared  that a significant  complaint about                                                               
audits was  for the time and  cost of compliance to  both federal                                                               
and state audits.                                                                                                               
REPRESENTATIVE  TARR  relayed that  one  of  her constituents,  a                                                               
small provider,  reported spending  tens of thousands  on audits,                                                               
and  she  expressed a  desire  to  align  the state  and  federal                                                               
audits.   She stated that  there was already  a lot of  data, and                                                               
asked if the need was for  more real time data to better evaluate                                                               
the patterns.                                                                                                                   
MS.  HULTBERG  said that  it  was  a  need  for a  more  advanced                                                               
analytics capability,  and not for  raw data, in order  to better                                                               
target interventions.                                                                                                           
5:01:42 PM                                                                                                                    
MS.  HULTBERG  commented  that  most of  the  components  of  the                                                               
proposed  bill  were  directionally  correct,  and  that  it  was                                                               
necessary  and important  work.   She declared  that overall  the                                                               
Alaska State  Hospital and Nursing  Home Association  was pleased                                                               
with the  bill, that  it was "a  really good next  step as  we go                                                               
down this journey to reform."                                                                                                   
[HB 227 was held over.]                                                                                                         

Document Name Date/Time Subjects
HB 227 version A.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Sponsor Statement_1.18.2016.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Sectional Analysis.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Background_HB148 cost savings with full expansion_DHSS.pdf HHSS 2/2/2016 3:00:00 PM
HB 148
HB 227
HB 227 Background_vitamin D savings.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Background_preterm birth project.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Background _Medicaid_Comparison_Table_(c) (i) & (k)_DHSS.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Background_(i) & (k) FAQs_DHSS.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-MAA-1-30-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-RR-1-29-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-SCBG-1-30-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-SDMS-1-30-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-SDSA-1-30-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_WCFH-1-29-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-BHA-1-29-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-BHMS-1-29-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-CDDG-1-30-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-GRTAL-1-30-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227
HB 227 Fiscal Note_DHSS-HCMS-1-30-16.pdf HHSS 2/2/2016 3:00:00 PM
HB 227