The Committee on Health and Human Services was called to order at 1:40 p.m., on Wednesday, February 17, 1999. Chairman Vivian Freeman presided in Room 3138 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All Exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

COMMITTEE MEMBERS PRESENT:

Mrs. Vivian Freeman, Chairman

Mrs. Ellen Koivisto, Vice Chairman

Ms. Sharron Angle

Ms. Merle Berman

Ms. Barbara Buckley

Ms. Dawn Gibbons

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Kathy McClain

Mr. Kelly Thomas

Ms. Kathy Von Tobel

Mr. Wendell Williams

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Following roll call, Chairman Freeman opened the work session on A.B. 139.

Paul Gowins representing the Disability Forum had spoken previously before the Interim Committee on Health Care. He believed passage of the bill would allow people with disabilities to work and maintain their health insurance. Its concept was similar to U.S. Senate Bill 331 that had addressed those issues. In addition to what A.B. 139 would implement in Nevada, S.B. 331 would allow even greater flexibility at the federal level through Medicaid. In studies done to promote S.B. 331 it was found a small percentage increase in utilizing the targeted disabled population could save the Federal Government $3.5 billion over the lifetime of the individuals. Even though health care might be provided in certain instances, it did not pay for things such as attendant care. Passage of A.B. 139 would be taking a step forward.

Jon Sasser representing Washoe Legal Services and three other civil legal services programs, testified in support of A.B. 139. He had served as a lay member on the Interim Committee on Health Care and on the subcommittee for the disabled and elderly, chaired by former Assemblyman Jack Close. A.B. 139 had been a recommendation of the subcommittee which had subsequently been adopted by the full committee. In order to receive matching federal Medicaid funds, Nevada was required to provide Medicaid coverage to certain groups who were called "categorically eligible" for the program. Nevada, in addition had the option of covering other categories with matching federal dollars.

A.B. 139 proposed Nevada cover the optional group of disabled individuals with earnings up to 250 percent of the federal poverty level. That new option had been adopted by Congress in August 1997.

Mr. Sasser, in his written testimony (Exhibit C) stated, in Nevada disabled individuals could obtain Medicaid coverage in only three ways:

1. As recipients of Social Security Disability Insurance (SSDI) disability benefits: "Categorically eligible," meant an individual living independently whose income did not exceed $500 per month. The maximum SSDI payment was also $500 monthly. Persons in group care homes could have higher incomes and the maximum payment was higher.
2. As residents of long-term care facilities: That optional group could have incomes up to 300 percent of the SSDI payment level ($1,500 monthly).
3. As recipients of Medicaid "waiver" services: That optional group could have incomes up to 300 percent of the SSDI payment level. They had to be certified as needing nursing home care but be able to live independently in their own homes with certain services. The number of recipients was capped and there was a waiting list for services.

He added, disabled individuals living independently in the community often must totally rely on Medicaid for their independence. Recipients of either SSI or Medicaid waiver services may receive assistance of private care assistants, home health aides, and so on, without which nursing home care would be necessary. Private insurance covering those services was generally unavailable or unaffordable.

With in-home services some disabled individuals would be able to work; some full-time, others only part-time. Some others might need vocational rehabilitation before returning to work. If too much was earned, Medicaid eligibility could be lost. Without the services provided by Medicaid, however, disabled individuals could not continue to work. A.B. 139 would remedy that situation. Mr. Sasser stated it was good public policy. It encouraged disabled individuals to re-enter the workforce, improved their quality of life, enriched society by that individual's contribution, and the generated income increased our tax base.

Chairman Freeman stated she had been receiving correspondence from individuals in need of vocational training and wondered if there had been significant cut-backs in funding for vocational training. Mr. Sasser admitted he had not analyzed that as yet.

Janice Wright, identified herself as representing the Division of Health Care Financing and Policy, and stated A.B. 139 would be an expansion to the existing Medicaid program but was not contained within the executive budget.

One concern about the Medicaid program was if eligibility in providing services was raised, it could not later be lowered. Once created as part of the entitlement program, it would become an ongoing obligation of the state. She reiterated the bill would encourage those disabled "working poor" individuals who were able to work to continue with the knowledge they had access to medical coverage via Medicaid.

The current federal poverty level of $671 was for one person; the eligibility for the disabled was proposed to be raised to 250 percent of the federal poverty level, to $1,677.50. Under current Health Care Financing Administration (HCFA) provisions, however, the increase must be up to 250 percent or nothing. HCFA would not allow any incremental increases. Coverage for the working disabled became available even if insurance coverage was not available through their current employment. The potential for substantial additional cost to the state in covering the new eligibility group was significant.

Additional costs would be incurred with respect to programming costs for the Nevada Operations Multi Automated Data Systems (NOMADS) program, plus eligibility and program staff. Ms. Wright explained there were potential significant increases to the amount of general funds that would have to be placed in the Medicaid budget to support it. The disabled community served by the Medicaid program was one of the highest cost groups in the existing program. Those were costs that would be matchable with federal funds under Title XIX. Approximately 49,804 individuals would be a monthly average eligible for coverage for the first year of the biennium. For the second year of the biennium, approximately 52,600 per month would be eligible. The cost would be approximately $615 per individual per month, thus it would be a considerable impact. The total cost could be in the area of $276 million for the first year, and $379 million for the second year. Half of that was matchable through Title XIX. Therefore, $138 million would be assessed to the general fund the first year and $189 million in the second year of the biennium.

Chairman Freeman said that was not good news.

Assemblywoman Leslie asked how many other states were already covering the disabled at that level. Ms. Wright did not have that information but offered to research the answer. Ms. Leslie said she would like to have the information because she understood Nevada was at the bottom of the states in terms of how much money was spent on those services and she wanted to compare. Ms. Wright said she would provide the information on what other states were doing.

Lawrence Matheis identified himself as Executive Director, Nevada State Medical Association, and was also a member of the Interim Committee on Health Care. The subcommittee which investigated the issue had not been apprised of the figures presented by Ms. Wright, and felt the number of disabled persons who would qualify was very large. In a session where budget problems existed the easiest way to kill legislation which approached difficult issues was to put an unreasonable fiscal note on it, especially in a shortened session. By the time it could be determined whether the premise on which the estimate was based was valid, it would be too late. He recommended the numbers needed to be examined before being influenced to kill legislation.

A.B. 139 was a good idea, Mr. Matheis said, because in Nevada the years had been allowed to slip by without facing the problems of indigent care and what it did to the infrastructure of the state's health care system, as well as to the financing of public services. Nevada was one of only 11 states without a medically-needy portion of its Medicaid program. It created a burden on the counties to take care of a large number of indigents who would in 39 other states be a part of the Medicaid program. He added the day would come when Clark County commissioners would discover they had a huge deficit in their budget for indigent care they were unable to fill, or one of the rural counties would see not only its hospitals but its financial system bankrupted. The way the state's Medicaid program had been structured needed to be examined: had Nevada been making maximum use of federal money. The money county taxpayers paid for indigent care was not matched by federal money; Medicaid was matched. It created an entitlement, an obligation to continue the program but, contrary to what Ms. Wright stated, if the state committed to trying to cover the poor disabled under Medicaid, and it did not work out, the program could be eliminated in the future. Would it be politically difficult to give up something, he wondered. It had not been difficult in the past. The state had given up a lot in those areas when it became financially untenable. The bill addressed one aspect of the medically needy who could be added to the Medicaid program.

The Interim Committee on Health Care had debated the advisability of trying to bring in all medically needy, or looking at categories where there was high need, high use of services, and where the state should acknowledge its obligation and could maximize federal funds. It appeared as though the disabled, in the category between the current level of Medicaid level and 250 percent of poverty, had not been an unreasonable extension of the program. Mr. Matheis emphatically did not believe it would cost Nevada $130 million additional in the first year. Ms. Wright believed it and had numbers to support it. In his experience, however, he could not take at face value a number made available at the last minute and during an 18 month series of hearings had not been mentioned. Particularly since the administrator of Ms. Wright's agency had been on the interim committee. If the numbers had been available, presumably he would have had them.

For those reasons, Mr. Matheis said NSMA supported A.B. 139, and recommended it be moved to the Committee on Ways and Means for fiscal analysis. Finally, the time had come to look at how Nevada faced the Medicaid program, how Nevada and its counties faced indigent care, the problem of special groups, and where they fell in the cracks.

Chairman Freeman stated she had made similar comments in the past, in connection with a bill sponsored by Assemblyman David Goldwater. It was time the state faced up to its responsibilities. She suggested Mr. Matheis speak with Mr. Goldwater and try to work with him on the issue.

Mrs. Freeman asked Ms. Wright to provide the committee with justification of her numbers, because the time had come to access federal dollars to treat Nevada's citizens.

Assemblywoman Berman asked why there was such disparity between the numbers Ms. Wright had given, 49,000 people entitled to coverage under the bill, and those Mr. Matheis felt would be entitled. Mr. Matheis answered in the discussions before the interim committee and subcommittee, that number had not been mentioned. He added he would work with Marla Williams to obtain the number. In fact, he did not believe any number had been mentioned during those meetings. Chairman Freeman said she would obtain the minutes of those meetings for review.

Paul Gowins, Disability Forum, said he believed the numbers as presented had been misconstrued. The federal intent behind the similar bill had been for people who were returning to work, would be on Medicaid, and who would have the incentive to remove themselves from the rolls of Medicaid should they be able to maintain their medical insurance. The overall number presented represented a total increase of Medicaid eligibility to 250 percent for all people who would be eligible. The concept presented to the committee supported by the disabled community was: people without medical coverage would not be going back to work; if they had coverage they could return to work. The number presented, he said, had been extremely exaggerated over the estimates presented to the interim committee. He recommended doing a 250 percent "across the board" increase. In view of the fiscal restraints it might not be possible in the 1999 session, however, he asked the committee to look at the people returning to work who would normally already be on the SSDI rolls. That needed to be very clear and distinct in any discussion to move the bill forward.

Chairman Freeman asked Ms. Wright how an eligible month compared to recipients. Ms. Wright said they had tried to measure the number of people having a service on a monthly basis. For the total year, some of those people would have had services several of the months but not every month. She had calculated it to show an unduplicated count for number of services, or number of people eligible for a given month. The figure had been 49,000. Mr. Sasser had information she had not been given. She asked for the opportunity to work with Mr. Sasser and Mr. Matheis and get the information presented to the interim committee and perhaps recalculate the amounts using those figures to refine the numbers.

Chairman Freeman recommended they work together and the committee would hold the bill pending receipt of those figures, before referring to the Committee on Ways and Means.

Jan Gilbert, representing the Progressive Leadership Alliance of Nevada (PLAN), expressed strong support for A.B. 139.

Brian Lahren, Executive Director of Washoe Association for Retarded Citizens (WARC), also appeared on behalf of Truckee Meadows Human Services Association (TMHSA). He urged support of maximizing Medicaid funding for any program possible in the state. He referred to a publication entitled State of the States in Development Disabilities (Exhibit D), a summary of a study of Medicaid utilization across the United States. Table 12, on page 27, Fiscal Effort Rankings indicated a range of years in which Nevada had been ranked 51, the very worst in the nation behind Mississippi and the District of Columbia in accessing federally supported programs. Other states had established models for providing levels of care that were reasonable while Nevada had always been unable to provide care. Part of the reason was that the state had not accessed the money it could have, therefore, spent state dollars for services that could have been matched and doubled the services or increased the richness of them.

Table 7, Exhibit D, described federal home and community-based waiver spending. Waivers were a way of allowing Medicaid money to be spent on pro-active community-based services that supported individuals and maintained them in their natural environments. In that area, Nevada again, had been behind the District of Columbia and Mississippi. Since then, Mississippi had received a huge tobacco settlement which had been applied to human services. Dr. Lahren hypothesized what might happen if some of the money from the tobacco settlement was used as match money against Medicaid. It would double the services for every single dollar taken from the tobacco settlement. The money, theoretically targeted for health and human service activities, could be leveraged. It would not be a one-time expenditure but would continue to pay dividends over an extended period of time.

In 1996 Nevada's per capita expenditures on home and community-based waivers had been $1.48. Vermont that year spent $47.00; Texas spent $277.

Dr. Lahren described the types of services that could be funded by waivers:

• Case management
• Homemaker assistance
• Home health aides
• Personal care
• Residential habilitation
• Day habilitation
• Respite care
• Transportation
• Supported employment
• Adapted equipment
• Home modification
• Occupational speech
• Physical therapy
• Behavior therapists

All could be used to provide programs that offset the costs of long-term care in institutional settings where rates ranged from $80 to $185 a day.

Dr. Lahren further stated existing state dollar expenditures on child and adolescent mental health services were abysmally inadequate. The state dollars spent in the absence of waivers could be used as a match against waivers on programs that desperately needed to be expanded.

To the extent Nevada expanded its role in Medicaid, it could take advantage of the very specific tracking requirements Medicaid had for who was being served, where they were being served, and what kinds of services were received. Medicaid funding would pick up the cost of doing the data tracking needed to organize and orchestrate better service for people in the state.

In summation, Dr. Lahren stated social policy demanded the state maximize Medicaid wherever it possibly could.

Chairman Freeman asked if the money available for data tracking was allocated for hardware or software, and could the state decide how to use that money.

Dr. Lahren responded there was considerable latitude within the administrative components enabling the state to decide where the dollars would be spent, up to a certain limit. There was sufficient money available in that area to enable the kind of active treatment in tracking that Medicaid insisted states provide.

The dollar amount was based on the state dollars matched against Medicaid.

Mary Jean Thomsen identified herself as Community Advocacy Coordinator for Northern Nevada Center for Independent Living. Disabled individuals came to her seeking employment; they wanted to work full-time in order to be productive but were unable to. She had to explain to them how to keep their income low so they did not lose benefits, because benefits were the most important thing to them. She felt as if she were cheating the system as well as helping the consumer cheat the system. They were in a "Catch 22" situation. She voiced support and passage of A.B. 139, so she could help her consumers better manage the system.

Chairman Freeman closed the work session on A.B. 139. She stated A.B. 146 would be delayed until a later date. She opened the work session on A.C.R. 7.

Myla Florence, Administrator, Welfare Division, Department of Human Resources, stated the important issue was a result of "delinking" cash assistance and Medicaid eligibility. She provided written testimony (Exhibit E) which stated, in part, the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA), aka "welfare reform," had repealed the old Aid to Families with Dependent Children (AFDC) and replaced it with a block grant program known as Temporary Assistance for Needy Families (TANF). With TANF, there was no longer an automatic link between cash assistance and Medicaid eligibility. States had broad flexibility to design TANF programs with emphasis on work.

States could choose very restrictive eligibility criteria for TANF that discouraged families from accessing Medicaid. Nevada decided not to delink TANF and Medicaid, a very important point. In designing the TANF program, the Welfare Division had received input from the Health and Human Services Committee and others to liberalize eligibility requirements to ensure recipients continued Medicaid eligibility and ensured frontline workers would not have to make separate eligibility determinations. In essence, the Welfare Division had crafted a TANF program focused on work but more generous in its eligibility requirements.

The Welfare Division had not wanted to separate TANF and Medicaid because that would require another separate eligibility determination. The Balanced Budget Act provided funding of $500 million nationally because of concern with states who had delinked Medicaid and TANF. It was believed there would be a decline in Medicaid enrollment. And, in fact, according to a December 21, 1998, report from the Center on Budget and Policy Priorities, that had happened, in part because of "changes in TANF program rules and procedures."

However, in Nevada that had not been the case. Nevada's Medicaid population had increased significantly since the passage of PRWORA, almost to the extent of the decline in overall TANF decrease. In other words, there had been a commensurate increase in Medicaid to the decline in TANF. That spoke well for Nevada and the efforts made to ensure Medicaid coverage was not overlooked.

Ms. Florence went on to say Nevada's allocation for enhanced federal matching funds would amount to $3.2 million. However, that funding had to be attributed to the delinkage and outreach efforts that might be the result of those factors. There were some issues to be reviewed in terms of accessing a portion of those funds but, Ms. Florence stated, she did not believe the entire amount would be eligible for federal participation. There might be some opportunity to tie Nevada Check-Up to Medicaid, and some programming changes made once the TANF conversion had been fully implemented to ensure people who might otherwise be eligible for Medicaid would retain the ability to access the program.

Ms. Florence pointed out, in Exhibit E, A.C.R. 7 suggested on page 2, lines 12 to 13, community-based organizations were "making Medicaid eligibility determinations." They might assist in gathering eligibility information and conduct outreach, however, state staff had to determine Medicaid eligibility.

Finally, Ms. Florence reported the $3.2 million available to Nevada was appropriated through year 2000, although the President's federal fiscal year 2000 proposed budget appeared to extend beyond that date. The Welfare Division, through its financial analysis team, was assessing potential allowable activities which could be claimed under that fund. However, matching funds were not budgeted and would have to be determined.

Assemblywoman Leslie asked if Ms. Florence supported using community-based organizations, like Family Resource Centers, or other frontline community groups, receiving funds to help people through outreach to access Medicaid and other services. Ms. Florence stated she felt it was an appropriate role for those organizations. She felt however, there appeared to be a generalization the money could be used for any outreach effort. That was not the case. It was only outreach as it related to the delinkage of Medicaid and TANF, and that had not been the situation in Nevada.

Ms. Leslie asked how large was the problem of people leaving TANF. Ms. Florence said she did not have the numbers, however, there were people who refused to cooperate with TANF requirements who then were contacted to continue Medicaid eligibility and for whatever reason had not followed through. She did not feel it was a big problem; those people who had decided not to follow through were also eligible for Children's Hospital Assurance Plan (CHAP) and the CHAP caseload was increasing. The correlation of the numbers—the decline and the increase—gave some comfort, she added.

Chairman Freeman closed the work session on A.C.R. 7 and opened the work session on A.C.R. 8.

Myla Florence, Administrator of the Welfare Division, stated A.C.R. 8 urged the Department of Human Resources (DHR) to provide staff at all federally-qualified health centers to determine Medicaid eligibility for pregnant women and children; also, to make eligibility determinations for other state medical assistance programs. The Welfare Division had been outstationing staff at various facilities over the years including federally-qualified health centers, University Medical Center, and Washoe Medical Center. The issues with federally-qualified health centers had to do with demand and cost effectiveness of outstationing staff on either a full or part-time basis.

In written testimony (Exhibit F), Ms. Florence described federally-qualified health centers located in Las Vegas, Mesquite, Jackpot, Carson City, Hawthorne, and Reno, Nevada.

The Reno office had attempted to acquire the necessary data processing equipment without success. The Las Vegas office used to station a worker 3 mornings a week, until she had been told the center did not have room for a worker and one was not needed. It had been agreed applicants would thereafter be sent to the district office located a couple of buildings away from the health center. The operations director at the Jackpot federally-qualified health center office had requested someone from the Elko office visit Jackpot monthly to help enroll welfare applicants. However, the 124 mile one-way drive and minimal number of applicants did not warrant having staff there on a regular basis. Instead, they made other arrangements including having the Elko office manager train the Jackpot staff in processing potential applicants for the various programs. If additional information were needed, Elko would contact applicants directly. The Hawthorne office kept in close contact with the Fallon health center by telephone to assist and answer questions. The health center referred CHAP applicants to Hawthorne. The Belrose office was positioned to assist the Mesquite office, as the Carson City office was ready to assist the Nevada Rural Health Centers in Carson City, when the need arose.

In summation, Ms. Florence stated the need to consider the cost effectiveness of outstationing staff at all federally-qualified health centers. The need appeared to be minimal in most centers and could be accommodated by training, telephone, and on-call assistance when necessary.

Chairman Freeman stated in reviewing the minutes, what had been requested was workers to be trained, and she understood from Ms. Florence's testimony they were doing that. Ms. Florence said they had offered to train individuals at community health centers to take applications, if they desired. It depended upon what the level of demand was at a particular time. The Welfare Division was ready and willing.

Assemblywoman Von Tobel asked if adoption of A.C.R. 8 would require additional staff and were those positions in the budget. Ms. Florence stated it really depended upon the kind of arrangements that could be worked out. If they were required to outstation workers at every hospital and federally-qualified health center regardless of demand, it would definitely have a budgetary impact. Generally they had been able to assign someone on an itinerant basis 1 day a week, or half-days, and absorb that with existing staff. It depended on how far the legislature urged the Welfare Division to go.

Chairman Freeman closed the work session on A.C.R. 8 and opened the work session on A.C.R. 9.

Mary Jean Thompson, Community Advocacy Coordinator, Northern Nevada Center for Independent Living, stated there had been a number of problems consumers faced. Those problems, detailed in her written testimony (Exhibit G), were in part, as follows:

1. There were four different opportunities for personal care assistant (PCA) services: Namely, Medicaid, Medicaid personal care assistant-disabled (PCA-D), home health agencies, and the Office of Community Based Services contracting with ASI, Inc. She stated it was difficult for any consumer to figure out where they should go for services. They did not know how to access the system, how they would qualify, or what the eligibility criteria was.
2. In the PCA-D program, there was no backup system for the consumer. Backup could only come from a certified PCA who had provided services for the consumer. If the other PCAs who had worked for the consumer were unavailable, the consumer had no resource to find another person to cover. The secondary problem involved payment; there were not many PCAs willing to pay the up-front and monthly fee just to be a back-up when they might not be called. The alternative for the consumer without family support to cover was to go to the emergency room, which was costly, or to return to the long-term care facility.
3. Recruiting, which allowed greater independence for the individual, was a barrier to those without the skills for hiring or firing. An individual being released from the hospital in need of the service could not choose that option because of the extensive recruitment for hiring needed prior to discharge.
4. The wages for all the programs were too low, which only compounded the problem. The rate was $9.25 hourly, less deduction for taxes and monthly fees, reduced that rate to around $7 an hour. Also, medical coverage had not been available for part time employees.
5. Insufficient hours allocated to individuals for PCA services. An average of 4 hours a day was allowed. There were exceptions, however, finding the right Medicaid person to approve that exception was difficult. Most consumers said the minimum hours they could get by with was 5 to 6.

Ms. Thomsen recommended solutions to those problems, detailed in Exhibit G, which in part were as follows:

1. Merge all the programs into one. Make it consistent and easily accessible for any consumer.
2. Contract programs. Have Medicaid contract with a service provider so that some type of back-up would be available to the consumer.
3. Increase wages for PCAs.
4. Allocate more hours of PCA care to individuals with disabilities.

Chairman Freeman asked for someone from the HCFP to respond.

Janice Wright, Division of Health Care Financing and Policy (HCFP), identified herself and introduced April Townley, Deputy Administrator, HCFP. Ms. Wright stated Nevada Medicaid recognized the importance the PCA services currently provided. Many of the issues addressed by Ms. Thomsen were correct and valid. It was critical for many of the individuals to have that care in their homes. The situation came down to a fiscal impact and once again, the solution was not easy.

PCA services provided through the Medicaid program were optional services, but the state had determined that was an appropriate use of its revenue. Money would be saved in the long run when the alternative, institutionalized long-term care, was considered. PCA programs were available to any Medicaid-eligible client who met program criteria, but when PCAs were not available there were home health agencies contracted with the Medicaid program to provide those services. There was no waiting list, however, there had been a set amount of hours available and that caused some difficulty. It was of concern when individual clients had needs that exceeded the amount of hours allocated. Needs had to be addressed on a case-by-case basis.

Ms. Wright stated the PCAs were independent contractors not state employees. They were reimbursed at a rate of $9.25 hourly, a low amount when compared to the homemaker services provided through Budget Account 3250 and to the reimbursement paid by other state agencies. The industrial insurance premiums had been a barrier to recruitment of PCAs, and was addressed in A.C.R. 9. There was a labor shortage made more difficult by the low reimbursement rate.

When no PCA care was available, services were provided through whatever available means, such as a home health agency. The executive budget did not contain resources to fund reimbursement rate increases for PCAs.

April Townley, Deputy Administrator, HCFP, stated they had a Medicaid policy in which there was no coverage for the cost of home care above what it cost for a person to stay in a nursing facility. In terms of granting an exception, it had been done on a case-by-case basis, and must also meet certain criteria before an exception could be made. Many of those decisions had been made based on budgetary concerns. With regard to individuals in the PCA-D program, where the consumer must govern his own care, Ms. Townley stated HCFP had been following state law which stated the PCA must be certified by a health professional. HCFP continued to refine policy to the extent they could without adding a budgetary concern to it to make it more accessible and were willing to continue working with advocacy groups on that basis. HCFP was also conducting a study to see if it could utilize money currently used for home health care (more expensive than PCA services) to move into an arrangement with an employer-based PCA program. That would take care of two major concerns: the Employers Insurance Company of Nevada (EICN; formerly SIIS) issue, and also getting PCAs available for a backup system.

Chairman Freeman stated in the interim between sessions, a meeting had been called with Speaker Dini, Senator Jacobson, Assemblyman Humke and herself, where the issue had been discussed. Mrs. Freeman said some of those present at that meeting were still on the Committee on Ways and Means and suggested A.C.R. 9 be rereferred to that committee to see if something could be done. She asked for clarification of the law governing the certification of PCAs. Ms. Townley stated PCA's did not have to be certified, but PCA-Ds did according to state law.

Assemblywoman Gibbons asked who decided the reimbursement rate for PCAs. Ms. Wright replied it was a function of the budget. A module included in the budget for Medicaid—an E-130 rate module—established what the rate would be. In the past it had been subject to about a 2.5 percent increase for the various providers, however, there was no built-in increase in the rate structure for the upcoming biennium.

Assemblywoman Leslie asked for comment on Ms. Thomsen's proposed solution of merging some of the programs for easier access. Ms. Townley responded of the four programs mentioned, three were Medicaid and one was a separate program which she understood was for people who were not Medicaid eligible. There were two ways consumers could access the Medicaid programs (PCA, PCA-D, and Home Health Agency); by doctor-referral which then went through an authorization process, and second was by contacting the HCFP office, at which time both the PCA and PCA-D programs were explained.

Ms. Townley was not certain how those programs could be merged more than they currently were. What she felt was needed was for programs to be better publicized outside the agency, perhaps to staff people at various centers. Also perhaps HCFP needed to prepare better written material.

Ms. Leslie encouraged HCFP to undertake that publicity.

Rick Cline, a disabled consumer, expressed appreciation for the focus on that issue. There were some complicated deficiencies in the care aide administration buyer, Medicaid, and a lot of them were needless. Continued discussion about the problems and effort would yield results. With regard to the money issue for some extremely disabled people who required more care than the 4 hour limitation, he stated it was erroneous that allotting more than 4 hours would be more expensive than rest home or institutionalization. "Please don't believe that," Mr. Cline said. It was not a fair representation.

Chairman Freeman said A.C.R. 9 would be rereferred to the Committee on Ways and Means, and asked Ms. Townley to keep her informed if there was anything further the Committee on Health and Human Services could do.

ASSEMBLYWOMAN GIBBONS MOVED TO REFER TO THE COMMITTEE ON WAYS AND MEANS AND INCLUDE A LETTER OF INTENT FROM THE COMMITTEE.

ASSEMBLYMAN MANENDO SECONDED THE MOTION.

MOTION CARRIED UNANIMOUSLY.

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Chairman Freeman opened the work session on A.C.R. 12.

Winthrop Cashdollar identified himself as Executive Director, Nevada Health Care Association and they recognized the desire and need for the intent of the legislation. He urged the committee to seriously consider the provision on page 2 of A.C.R 12, regarding Medicaid reimbursement to an unlicensed facility. The provision indicated Medicaid reimbursement would be provided to the extent authorized by Health Care Financing Administration (HCFA), and asked consideration be given to reimbursing unlicensed facilities under the resolution.

Chairman Freeman closed the work session on A.C.R. 12 and stated it would be discussed further at a workshop on Wednesday, February 24, 1999.

Discussion ensued about the number of introductions the committee had been assigned. Chairman Freeman said another introduction was needed in connection with A.B. 155 (1997), dealing with criminal background checks for people who worked in nursing homes. U.S. Senator Reid was proposing a federal bill on it.

Mrs. Freeman said there had been some problems and asked Mr. Panelli to address the issue, the concept, and the proposed amendment language.

Richard Panelli identified himself as Chief, Bureau of Licensure and Certification, Health Division, Department of Human Resources. He stated the concepts they wanted to present involved some issues raised over the past 2 years. One, all facilities had not been included in the original legislation, only specific ones such as skilled nursing facilities and residential facilities for groups. They had issues with some providers of health care who had problems in the past, had criminal records, and probably should be included in the legislation. The potential existed for someone to take advantage or commit crimes similar to those for which they had been convicted previously. Mr. Panelli's intent was to make the legislation equal through all health care facilities. There was a specific statutory exemption for facilities for alcohol and drug abuse which were not included.

The second issue was employees of the facility only were addressed by the legislation. The facilities could look at that and say they had no "employees. Everyone who works in this facility is a contractor." Thus eliminating all the people who worked in the facility from the intent of the legislation. It was probably something simply not seen in the original legislation Assemblyman Close had introduced last session.

Mr. Panelli asked that the language which said "skilled nursing facility, etc." be replaced with "medical facility and medical facility for the dependent," which were already defined in statute. Mr. Panelli said they had tried to come up with a definition for "employee" which was discussed with the attorney general's office. Additionally, there had been no provision for any type of followup activity. Once a background check had been made, years could pass without a re-check. If a crime had been committed after the initial check, it would never be discovered. Therefore, he stated they had modeled the wording after legislation that currently existed in the State of California requiring a re-check at least every 5 years.

Chairman Freeman asked for a motion to request bill draft to amend NRS 449.173, et seq., concerning background checks for employees and licensees of facilities that provide care to persons who are dependent.

VICE-CHAIRMAN KOIVISTO SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

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Chairman Freeman asked Assemblywoman Berman to discuss her proposal on which she wanted the committee to request a resolution.

Assemblywoman Berman asked for a resolution to be drawn to commend Dr. Daniel Peterson of Incline Village for his work on behalf of persons with chronic fatigue syndrome. He had done a great deal of work on the cutting edge for the disease and because the study was being done in our state, it would be nice to recognize him.

Chairman Freeman asked for a motion.

ASSEMBLYWOMAN BERMAN MOTIONED TO REQUEST A RESOLUTION TO COMMEND DR. PETERSON.

ASSEMBLYWOMAN GIBBONS SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

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Chairman Freeman discussed drafting a resolution to Congress to rectify inequities in ERISA regulated health care plans. Specifically, Congress should implement standards that required ERISA plans to establish internal appeals processes. Mrs. Freeman said she and Assemblywoman Buckley each had introduced a bill to establish external appeals so something had been done at the state level, but it would be a good idea if Congress followed suit.

VICE-CHAIRMAN KOIVISTO MOVED TO REQUEST A RESOLUTION BE DRAFTED CONCERNING ERISA INEQUITIES.

With no further business before the committee, Chairman Freeman adjourned the meeting at 3:10 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

DATE: