The Committee on Health and Human Services was called to order at 1:40 p.m. on Wednesday, March 10, 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

GUEST LEGISLATORS PRESENT:

Assemblyman David Goldwater, Assembly District 10

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Assemblyman David Goldwater representing Assembly District 10 identified himself and stated he had not received the amendment to his bill, A.B. 69, and asked to have the hearing rescheduled.

Chairman Freeman opened the work session on A.B. 178.

Marla Williams identified herself as committee policy analyst and referred to the work session document, EXHIBIT C, which contained amendments on the bills to be heard.

A.B. 178, requested by Assemblywoman Sheila Leslie, was discussed under Tab A of EXHIBIT C. Two recommendations had been made by the subcommittee after hearing additional testimony. There was general support for the bill however it appeared the language broadened the scope beyond children, which was the reason the bill was drafted. To limit the fiscal cost the subcommittee recommended to: Amend the measure to specify that marriage and family therapists and licensed clinical social workers may act as direct providers of mental health services for children under 19 years of age who are not required to enroll in managed care programs administered by the Department of Human Resources.

Assemblywoman Leslie, representing District 27, identified herself. She had chaired the subcommittee on which Assemblywomen Gibbons and Berman were members. Excellent testimony had been presented giving reasons why the provisions of the bill were needed to extend beyond age 19, specifically, testimony from the elderly population. The more people included, however, the higher the cost. The bill would not add a new service, it merely proposed adding providers to existing services. But, because A.B. 178 came about out of concern for children on a waiting list for services, the subcommittee agreed to limit the bill's scope to children under 19 years of age.

Janice Wright, Deputy Administrator, Health Care Financing and Policy (HCFP), stated there would be a fiscal impact. HCFP would be providing revised figures to the committee. There was no funding for the bill in the executive budget and therefore would have to proceed through the Committee on Ways and Means.

ASSEMBLYWOMAN LESLIE MOVED TO AMEND AND REREFER A.B. 178 TO THE COMMITTEE ON WAYS AND MEANS.

ASSEMBLYWOMAN GIBBONS SECONDED THE MOTION.

THE MOTION CARRIED.

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Chairman Freeman opened the work session on A.B. 238.

Marla Williams discussed the amendment (Tab B, EXHIBIT C) provided by Dr. Mary Guinan, State Health Officer, which stated in part:

• The term "poor reproductive outcomes" was changed to "adverse birth outcomes."

• The measure applied only to medical facilities as defined in Nevada Revised Statutes (NRS) 449.012 and NRS 449.0155. Those facilities were (1) hospitals; and (2) obstetric centers, which were not part of hospitals and provided services for normal, uncomplicated births.

• The reference to "International Classification of Diseases, 9^th Edition, Clinical Modification," was deleted (Section 8, page 2, lines 31 through 33).

• A suggested language change, recommended by Assemblywoman Gibbons, to ease privacy concerns, would add the term "and authorized" on page 3, line 12.

• The term "maternity home" was replaced by "obstetric center" on page 4, line 4.

Patricia Glenn, President of Nevada Right to Life, presented written testimony in opposition to A.B. 238. Her testimony, EXHIBIT D, expressed concerns regarding:

• Confidentiality and privacy.
• Governmental intrusion and control of testing and medical diagnosis.
• Genetic testing which would encourage abortion and/or experimentation.

Assemblywoman Jan Evans, Assembly District 30, identified herself and stated the amendment for A.B. 238 had been heard and she had nothing further to add.

Assemblywoman Buckley said she would support the bill; however, there had been considerable testimony regarding erosion of privacy rights or dissemination of information to perhaps be used by others to take adverse action against individuals with birth defects. However, after speaking to the bill's sponsor and reviewing testimony, she felt comfortable the information would be protected and its collection would seek to improve public health not hurt it. With additional legal safeguards, such as the law prohibiting insurance companies from discriminating on the basis of genetic information, there was enough protection to ensure it would not be misused.

Assemblywoman Berman also supported A.B. 238 but reiterated Ms. Buckley's concerns and wanted on the record that she, too, had been extremely concerned about privacy and the improper dissemination of information.

Chairman Freeman asked for a motion.

VICE CHAIRMAN KOIVISTO MOVED TO AMEND AND DO PASS A.B. 238.

ASSEMBLYWOMAN GIBBONS SECONDED THE MOTION.

THE MOTION CARRIED WITH ASSEMBLYWOMEN ANGLE AND VON TOBEL OPPOSED.

Chairman Freeman opened the work session on A.B. 249.

provided by Myla Florence, Administrator, State Welfare Department, and stated in part:

• The agency would have the ability to collect from the "undivided estate of a Medicaid recipient" the amount of incorrectly paid benefits.

• Conformed to the optional federal definition of "estate" and clarified the ability of the division to seek recovery from property owned by the recipient immediately prior to death or at time of death. Included property held in joint tenancy or other arrangements where title normally passed upon death of recipient.

• In Section 3, included "undivided estate" instead of "estate." Change also provided notice the Medicaid Estate Recovery Program would not seek recovery for benefits paid prior to October 1, 1993.

Assemblywoman Gibbons asked for a definition of "undivided estate." Kathryn Bliss Holt, identified herself as a deputy attorney general, and responded. Undivided estate was an estate of an individual who held property in joint tenancy or held a portion of an interest but not the entire interest, and their interest was not divided as to what percentage belonged to them."

Ms. Gibbons expressed concern about an individual who might be part of a trust and not know it and might not be able to claim benefits or access the money. Ms. Holt said there were federal provisions that dealt specifically with trusts and the beneficiary's interest in the trust. Certain provisions in the federal guidelines would require Medicaid to recover a portion of monies paid.

Ms. Holt provided written support (EXHIBIT E) for A.B. 249.

Ed Fend, Chairman, State Legislative Committee, American Association of Retired Persons (AARP), asked if monies could be collected from an undivided estate before the second partner had died. Myla Florence, Administrator, State Welfare Division, responded, "No." The important issue to be kept in mind had to do with the collection of Medicaid reimbursement for services rendered after the spouse had died or there was no other dependent, which conformed to federal requirements. The second issue was notification to the Welfare Division at the time of death so the Welfare Division could be an interested party in any proceeding.

Assemblywoman Buckley asked that A.B. 249 be held until the next work session to allow review of several items including: (1) would the bill cover all Medicaid recipients, not just those financing long-term care (2) the "undivided estate" definition, and (3) the new statute of limitations, which had been an attempt to reverse an administrative law judge's decision.

Chairman Freeman agreed. She closed the hearing on A.B. 249, and opened the work session on A.B. 250.

Marla Williams referred to the proposed amendment discussed at Tab D, EXHIBIT C, provided by the Department of Human Resources, Division for Aging Services. The purpose of the amendment was to reduce the incidence of elderly persons expecting legal assistance from the division because the specialists for the elderly were not attorneys. Accordingly, the proposed change stated that the specialist: "Provide advocacy and education relating to the rights of elderly persons and shall assist in the development of legal services to assist elderly persons in securing and maintaining their legal rights."

Kathryn Bliss Holt, Deputy Attorney General, provided written testimony (EXHIBIT F) in support of A.B. 250.

ASSEMBLYWOMAN BUCKLEY MOVED TO AMEND AND DO PASS

A.B. 250.

ASSEMBLYWOMAN GIBBONS SECONDED THE MOTION.

THE MOTION CARRIED.

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

Marla Williams stated A.C.R. 12 was a measure that resulted from the Legislative Committee on Health Care and at the time of the hearing, Winthrop Cashdollar, Executive Director of the Nevada Health Care Association, had been the only person present that addressed the measure. He had suggested an amendment which had been included, as described at Tab E, EXHIBIT C, which addressed his concern that reimbursement might be made to facilities that were not regulated. The amendment proposed would delete lines 6 through 11 of page 2.

Susan Haase identified herself as representing the Nevada Health Care Association and appeared for Winthrop Cashdollar. She expressed support for A.C.R. 12 in its amended form.

Wendy Simons identified herself as Administrator, Park Place Assisted Living, and voiced support for A.C.R. 12 and reimbursement only for regulated facilities.

Janice Wright, Deputy Administrator, Health Care Financing and Policy (HCFP), stated the measure would be an expansion of the Medicaid program which had not been funded in the executive budget. The measure would provide Medicaid reimbursement to assisted living facilities that were non-medical facilities. That was not currently done. It would require HCFP to do an 11.15 Demonstration Waiver to obtain assurances from Health Care Financing Administration that HCFP would be allowed to make the reimbursement.

The measure would allow individuals the option of choosing to move to an assisted living facility and have the state pay for a majority of the cost of care. It would require the state to pay for their medical expenses as they would now be eligible for full Medicaid coverage, whereas previously they might not have been eligible due to income levels. HCFP's concerns were:

• The potential for significant cost increases within the existing Medicaid program. Persons residing in assisted living facilities were only eligible for Medicaid if they received Social Security Income (SSI).

• The assisted living facility cost was not currently allowable.

• In Nevada, assisted living facilities were limited and had individual supervision, but the licensure issue previously addressed was of concern.

• Nevada Medicaid program provided for reimbursement for cost of living in facilities licensed by the state only if approved by the 11.15 Demonstration Waiver.

• Due to the low reimbursement rate few facilities participated and because of the medical and financial eligibility criteria a limited number of residents actually qualified for the waiver program.

HCFP urged the continued requirements for the state licensure as a means of ensuring the quality of care; however, the Division's concern was that the measure was not part of the executive budget.

Assemblywoman Buckley pointed out A.C.R. 12 was a resolution that stated institutional long term care was not always in the best interests of the senior citizen. The least restrictive place should be considered to allow the senior additional housing options. For those reasons, the Assembly urged the plan be amended to provide reimbursement for more humane settings in appropriate circumstances. If there was not money in the executive budget for that, it would be expected that HCFP would factor it in and determine when the measure might be considered. In essence, Ms. Buckley wondered how efficient it was to spend three pages of testimony opposing a resolution that was merely trying to urge consideration of the needs of senior citizens.

Ms. Wright said it was important for HCFP to inform the committee prior to passage what that impact would be. She understood there was no fiscal impact for a resolution but wanted to make sure the committee had the information.

Assemblywoman Von Tobel expressed frustration at the number of bills considered that ended up with fiscal notes. She felt it was a dubious task to resolve to support a certain group of individuals to be able to live in an assisted living facility when the state did not have the money in the budget. It gave false hope. Legislators could support almost anything but without the money in the budget it was not fair. She added she opposed the resolution not on merit but on principle.

Assemblywoman Leslie agreed with the frustration of trying to get the plan amended, no one seemed to know what to do or how to do it, but the resolution was a very small thing the committee could do. Passage was essentially meaningless, except that it did shine some light on an obvious problem on multiple levels.

Assemblywoman Buckley stated she had served on the Health Care Committee for the first time with Chairman Freeman who had served many times. Much testimony was given by senior citizens and AARP about the state of services provided in the long-term care arena. Legislators had not done a very good job. The reason the Health Care Committee had not put in a bill draft to appropriate more money was in recognition of the fiscal problems. However, committee members felt it was only fair to all of the senior citizens who came out to support it to at least put a resolution in that said "when appropriate" the legislature would seek to provide better services to our senior citizens. For that reason and in light of all that testimony, Ms. Buckley had not felt the resolution was useless but considered responsive to their concerns.

Chairman Freeman agreed legislators needed to take a position on those matters. She was indeed frustrated, as a member of the Committee on Taxation, to see how services were funded in the state, and when something like A.C.R. 12 came up that was desired, not enough money was generated to provide those services.

Assemblywoman Gibbons felt in voting for A.C.R. 12 the committee told those in the state who could put money in the budget the issue was a priority.

Assemblywoman Berman asked Janice Wright if grants would be a possibility to at least start the funding. Janice Wright said the division always looked for alternative ways to provide additional services; however, she was not aware of any grants for assisted living currently available. The possibility would be pursued and the division would work hard to find a way to appropriately fund such matters.

Chairman Freeman said all comments were appreciated. If more money could be put into the Medicaid budget it would certainly help. She asked if Ms. Wright had heard anything about the Economic Forum's projections. Ms. Wright said the information she heard had not been positive enough to fill the holes in the Medicaid budget.

ASSEMBLYWOMAN BUCKLEY MOVED TO AMEND AND ADOPT

A.C.R. 12 WITH THE AMENDMENT BEING TO DELETE LINES 6 THROUGH 11 ON PAGE 2.

THE MOTION WAS SECONDED BY ASSEMBLYWOMAN BERMAN.

THE MOTION CARRIED WITH ASSEMBLYWOMAN VON TOBEL OPPOSED.

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Marla Williams advised three measures had been pending in committee and required action.

The first measure, A.B. 7, Chairman Freeman advised the proponent, Winthrop Cashdollar, had been working with Myla Florence and the Welfare Division and they felt the legislation was not needed at that time.

VICE CHAIRMAN KOIVISTO MOVED TO INDEFINITELY POSTPONE

A.B. 7

ASSEMBLYMAN MANENDO SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

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Marla Williams advised the second measure, A.C.R. 7, had come out of the Health Care Committee. From earlier testimony it appeared the division was actively pursuing the objectives in the measure.

ASSEMBLYWOMAN BUCKLEY MOVED TO INDEFINITELY POSTPONE A.C.R. 7.

ASSEMBLYWOMAN ANGLE SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

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Marla Williams said the final measure was A.C.R. 8, a recommendation of the Health Care Committee. In hearings the administrator of the Welfare Division indicated the division was actively pursuing the objectives contained in the measure.

VICE-CHAIRMAN KOIVISTO MOVED TO INDEFINITELY POSTPONE A.C.R. 8.

THE MOTION WAS SECONDED BY ASSEMBLYMAN WILLIAMS.

THE MOTION CARRIED UNANIMOUSLY.

With no further business before the committee, Chairman Freeman adjourned the meeting at 2:25 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

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