The Committee on Health and Human Services was called to order at 1:40 p.m., on Wednesday, March 24, 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:

Following roll call, Chairman Freeman announced testimony would be heard on the first four measures on the agenda but during the work session there would be no public testimony.

Mrs. Freeman invited Assemblywoman Berman to discuss A.C.R. 14.

Assemblywoman Merle Berman, representing Assembly District 2, identified herself and explained she had introduced A.J.R. 14 to increase awareness of an important debilitating health condition, chronic fatigue syndrome, or CFS. It was very difficult to diagnose. In 1994 the International CFS Study Group published in Internal Medicine a revision of the criteria that defined CFS and other cases of unexplained prolonged fatigue. The National Institutes of Health reported that despite multiple disciplinary investigations into the cause of CFS its ideology remained unknown.

Historically, CFS had been described in medical journals since the 1930's but cases had been reported for several centuries. The disease affected people of both sexes and a wide range of ages, races, and socio-economic groups. Without objective diagnostic criteria the prevalence of CFS was difficult to measure. The Centers for Disease Control and Prevention estimated the minimum CFS prevalence rate in the U.S. was 4 to 10 per 1,000 people. Rates were lower for adolescents than for adults. The symptoms were discussed in A.J.R. 14 and also described the need for additional scientific study of the disease. Ms. Berman said society could not ignore the disease that prevented a person from living his or her life fully.

The second part of the resolution recognized Dr. Daniel L. Peterson who was a member of the Sierra Internal Medicine in Incline Village. Ms. Berman said she felt honored to know Dr. Peterson and commended him for his work with persons afflicted with CFS. She presented two letters from people she knew; one, Gundrun Fonfa, who was afflicted with CFS, and Judie Brailsford, who's son had CFS. The letters were marked EXHIBIT C. Ms. Berman read a quote from Gudrun Fonfa's letter and asked that it be transcribed in the minutes: "The illness is one of constant relapse and occasional remission. Over the course of the illness each individual will have a multitude of symptoms due to their compromised immune system. It begins as a flu-like disease that never ends. It operates like a virus but affects cognitive functioning. I had a bout of terrifying amnesia. The list of ways chronic fatigue syndrome takes its toll is very long."

Ms. Berman urged the committee to pass A.J.R. 14. She then introduced two guests, Harvey Whittemore and Gerald Crum.

Mr. Whittemore introduced himself as the father of a daughter, Andrea, who was 21 years of age and had been afflicted with CFS for over 9 years. Until they met Dr. Peterson, Andrea had difficulty finding physicians who understood how to provide symptomatic relief to all the different conditions from which she suffered. He said Dr. Peterson was one of the finest physicians in the state who practiced the type of medicine one would hope all residents of the state would be able to receive.

Mr. Whittemore made suggestions for improvements in the wording of A.J.R. 14 as followed:

• Page 1, line 2 – delete the word "nonspecific" because the individuals who suffered from CFS knew there were very specific symptoms.

• Line 7 – change the cause of the disorder to "illness."

• Page 2, line 22 – add the words "including alternative treatments," then "excluding alternative problems" then continue the sentence.

Mr. Whittemore commended Assemblywoman Berman's great work in recognizing the debilitating nature of chronic fatigue syndrome. Senator Bryan, Senator Reid, and Congressman Jim Gibbons had expressed their strong endorsement of recognizing the seriousness of the illness.

Gerald Crum identified himself as a 21 year Carson City resident who had suffered with chronic fatigue syndrome since 1985. His testimony, provided as EXHIBIT D, stated in part:

• He had been a patient of Dr. Peterson's for over 10 years. In speaking to Dr. Peterson about the recognition being bestowed on him by Assemblywoman Berman's resolution, he was very honored.

• Dr. Peterson had persevered in the study and treatment of CFS even when his colleagues scoffed at him and in the 1980's reported an outbreak of chronic fatigue syndrome in Incline Village. He had pioneered research and clinical studies to find out how to treat the disease.

• Mr. Crum's affliction evolved into non-Hodgkin's lymphoma, a cancer, which was now in stage IV and affected nearly every organ in his body

• In 1997, Mr. Crum was appointed by Donna Shalala, the U.S. Secretary of Health, to serve on the Department of Health and Human Services Chronic Fatigue Syndrome Coordinating Committee, chaired by Surgeon General Dr. David Satcher. It was in that position he learned how critical funding for CFS was.

• A.J.R. 14 would be an effective tool when CFS advocates sought more funding from the Federal Government.

Chairman Freeman asked Ms. Berman if she supported the amendments proposed by Mr. Whittemore. Ms. Berman said "Yes." Mrs. Freeman asked for a motion.

ASSEMBLYWOMAN ANGLE MOVED TO AMEND AND DO PASS A.J.R. 14.

ASSEMBLYWOMAN VON TOBEL SECONDED THE MOTION.

MOTION CARRIED UNANIMOUSLY.

Chairman Freeman opened the hearing on A.B. 69 and invited David Goldwater to discuss his bill.

Assemblyman David Goldwater, representing Assembly District 10, introduced himself and presented a memorandum to the committee (EXHIBIT E). He had experienced difficulty drafting an amendment to A.B. 69. He had worked with the Legislative Counsel Bureau research analyst who felt if the committee took positive action on some of the concepts then the amendment could be drafted.

He explained his intent was "to simply see that the money delivered to Nevada via the disproportionate share hospital program (DSH) go to the DSH hospitals with a minimum amount of money taken by our state's Medicaid. In doing so, it is my intention to keep the existing DSH hospitals whole. Nothing in my amendment should take money away from rural hospitals or hospitals currently receiving DSH money. Should my intent be realized it would create more money for DSH. The new money could be claimed by any hospital that meets a DSH definition. That definition could include a private hospital that provided the highest volume of inpatient care to Medicaid patients, indigent patients, or other low income patients in a population exceeding 400,000. The Medicaid utilization rate must be at least 8 percent. Please assure in the amendment that only a share of the new money could be claimed by the above definition."

Assemblywoman Buckley asked if under the proposed conceptual amendment there was new money, how much would go toward the existing recipients of DSH payment, for example, University Medical Center versus the ability for a private hospital to access the funds. Mr. Goldwater could not quote specific amounts but said some things could be assumed from the percentages that were there. A large portion of it would go to University Medical Center.

Bill Hale, CEO of University Medical Center of Southern Nevada, identified himself and presented a spreadsheet (EXHIBIT F) which illustrated the intent of the legislation. The additional DSH payments would total approximately $10.6 million. University Medical Center would receive an additional $6.1 million, Washoe Medical Center would receive $3.5 million, and all the rural hospitals would receive additional monies. There was concern among some people it would hurt the rural hospitals and/or Washoe Medical Center; that was not the intent of the bill.

Mr. Hale asked the committee to move the bill out and he would provide the Legislative Counsel Bureau (LCB) a copy of the spreadsheet so there would be complete understanding about the intent of the bill.

Assemblywoman Buckley asked if it would then be referred to the Committee on Ways and Means, or back to the Committee on Health and Human Services to look at the amended version. Mr. Goldwater communicated to Chairman Freeman a motion to do pass would be fine. He felt the chairman would see the bill on the floor and be alerted to it. If he felt it had a negative impact on the state Medicaid budget he could then pull it in. It needed to be known that was disproportionate hospital share money and if it was going to the Medicaid pot, with which the director disagreed, at least it needed to be stated the policy was not for that to happen. If the fiscal reality was that would happen, then let the Chairman of the Committee on Ways and Means raise the issue.

Ms. Buckley said the community hospital did not receive the support it deserved in treating indigent care and if it was new money and a policy statement was needed to give additional funds, she would be happy to support it. If it was not going to another committee of the assembly, she would like to see the exact language, otherwise there was only a concept. A discussion ensued and Ms. Buckley said she would like to see the bill amended and rereferred back to the committee to make sure it met the intent.

Mr. Goldwater agreed the committee would certainly have to approve of the amendment.

Assemblywoman Leslie shared Ms. Buckley's concern and said she was quite uncomfortable with simply going with the concept, and if the committee agreed to amend and do pass, it might never see the bill again.

Mr. Goldwater said the LCB would not draft an amendment or specific language without definitive committee action. Mrs. Freeman said the committee could move to amend and rerefer back to the committee. She asked Mr. Goldwater to make it very clear in his amendment what his intent was, because they all had a concern about University Medical Center.

Charlotte Crawford, Director of the Department of Human Resources, asked to clarify a statement Mr. Goldwater made. The director had never said the intergovernmental transfer money was not part of the Medicaid budget, it was. There was funding in there, Ms. Crawford added, and wanted to make sure the inaccuracy did not stay on the record.

Mrs. Freeman suggested Ms. Crawford send a memo to Mr. Goldwater, and said those in the audience who wished to speak on the bill would have an opportunity later when the bill came back to committee.

ASSEMBLYWOMAN BERMAN MOVED TO AMEND AND REREFER A.B. 69 BACK TO THE COMMITTEE ON HEALTH AND HUMAN SERVICES.

Mrs. Freeman suspended the hearing briefly to allow Assemblywoman Leslie to make an introduction of a special group.

Ms. Leslie explained she had been selected to represent the Assembly on the Maternal and Child Health Advisory Board. She had presented each committee member with a daisy pin, the national symbol chosen by the Adolescent Pregnant Prevention Awareness. More than 1 million teenage girls became pregnant each year. Nevada had the highest teen pregnancy rate in the nation. To counteract that, the governor's Youth Advisory Council (YAC) had elected to wear the pin and raise awareness about the challenge facing Nevada and the nation.

Yvonne Silva, administrator of the Health Division, reported in 1996 there was no Youth Advisory Council and no focus on teen pregnancy prevention in the state. There had been no statewide initiative and no funding, and no interagency committee to address teen pregnancy prevention in the Department of Human Resources. At the time there was a teen pregnancy rate of 63 per thousand of 15 to 17 year olds. In 1999 there was a focus on teen pregnancy and a statewide initiative. Funding was available from various sources including the Federal Government. There were 33 community action teams located throughout the State of Nevada. It was not the state telling people what to do, but the community identifying the problem areas and seeking solutions. The teen pregnancy rate had dropped to 49 per 1,000. Nevada had met the "Healthy People Year 2000" goal which was 50 per 1,000. The work was not done so long as even 1 teen in the state became pregnant because that teen might not finish high school.

Ms. Silva explained the YAC consisted of young people who traveled to schools in Nevada presenting scenarios to fifth and sixth graders. The YAC members then introduced themselves. They were: Jessica Winters, Las Vegas; Tyson Burton, Reno; Jason Lopez, Reno; Jennifer Lopez, Reno; Amy Juaristi, Elko; Lauren Hayes, Gardnerville; Pete Shaw, Carson City; Shannon Casey, Reno; Lynn Page, Tonopah; Jeff Arthurholtz, Las Vegas; Sam Lemos, Boulder City.

Chairman Freeman opened the hearing on A.C.R.19 and asked Assemblywoman Gibbons to discuss her bill.

Assemblywoman Dawn Gibbons, representing Assembly District 25, explained the purpose of her bill through her guests. First to speak was Jelena Hatfield who said on April 23, 1998, she contracted a rare form of bacterial meningitis and as a result lost her fingers and legs. Before she lost her legs she had needed a graft of cadaver skin in an effort to save them. It took a few days to get the skin, but she then received the skin, a living organ. Passage of A.C.R. 19 would make obtaining living organs much easier and more convenient for the people of Nevada.

Sandy Smith, Sierra Eye and Tissue Donor Service, introduced several persons in the audience from northern Nevada who were waiting for liver transplants Ms. Smith explained that coordinators from Sierra Eye and Tissue Donor Service recovered eyes and tissues from northern Nevada and distributed them to persons waiting in the area. Organ donations were handled in a different manner. Because Nevada shared the local waiting region with northern California, Nevadans were at a disadvantage. There were 65,000 people on the United Network Organ Sharing (UNOS) waiting list for transplants and the number increased greatly every year. The number of people who became donors had remained stagnant and stayed at around 6,000, which equated to about 20,000 organs. So, less than one-third of the 65,000 individuals actually received transplants, the rest continued to wait for years and many died while waiting.

Ms. Smith discussed why directed donation would work well for Nevada. In the entire state 300 people were on the transplant waiting list. In northern Nevada, in the local region that included northern California, over 6,000 were on the waiting list. California always seemed to have more patients waiting who were sicker than Nevada patients. Last year 15 donors from northern Nevada, which had always been a pro-donation community, supplied 64 organs to California and were transplanted into California residents. When Ms. Smith's group spoke to people about organ donation, directed donation gave Nevada another option; they could direct their organ or tissue to someone in need in northern Nevada.

Debbie Pinjuv identified herself and said she had been on the transplant list for over 2-1/2 years. Two months ago she had been flown to Stanford Medical Center in California, due to complications of her end-stage liver disease which caused a build up of poisons and ammonia that the liver was unable to detoxify.

Those poisons and ammonia entered the brain and in the worst case scenario one lapsed into a coma and died. She described the terrible symptoms associated with end-stage liver disease and while hospitalized was prepared for a liver transplant. Before that could happen, two California patients were admitted and she was told they would be receiving transplants instead. The doctors found a drug that stabilized her condition however the dosage was so high it ultimately caused kidney failure and deafness, in which case she would be a candidate for both liver and kidney transplants. Her doctors were trying to find her a liver before deafness occurred.

Ms. Pinjuv said there were 30 people in her liver transplant support group and her story was one of many, all were critically in need of organs. The alternative to receiving a donation was death, but that did not have to be if directed donations became a reality in northern Nevada. She asked the committee to support A.C.R. 19.

Chairman Freeman asked Assemblywoman Gibbons what would be the result of having the resolution passed in regard to public education and how would it be facilitated. Ms. Gibbons said Sandy Smith was setting up a base in Nevada to keep track of organ donors. Ms. Gibbons believed it was a cause that could be celebrated annually and when the legislative session ended she was committed to spending time and raising money to raise awareness. She explained she had not asked for legislation because she felt it would put attention on California and there might be punitive results. The desire behind A.C.R. 19 was to educate Nevadans, to have a donor base in Nevada from which they could draw.

Sandy Smith said her group was working with a living bank in Texas. When people signed up the information would come to the group's office here and a registry would be maintained, ultimately the prospective donors would carry a card stating they were donors. There were also educational seminars in high schools, universities, malls, and so on.

Heidi Smith identified herself as a health insurance agent. She was waiting for a liver transplant. Her condition occurred as a result of contracting hepatitis C after a blood transfusion following a miscarriage in 1980. She was number 1 on the waiting list at Cal-Pacific, and number three on the United Network Organ Sharing (UNOS) list, but had received no call from California stating an organ was available. Someone from California always seemed to need the organ first. She pointed out not everyone who was dying looked like they were, many looked in reasonably good health, but the fact remained that person could die in their sleep; that was often the way it happened. The veins burst and the person bled to death. She said the people waiting did not "want to rile California" but would like to have Nevada take care of its own the same way that California took care of its own.

Assemblywoman Angle said she was concerned about the punitive ramifications of the bill that Ms. Gibbons mentioned, and would that set up an elitist idea that would make other states not want to put Nevadans' names on their lists. Ms. Gibbons said it was already punitive against Nevadans; Californians were receiving the organs. She had brought the resolution forward to draw attention to the issue, there were plans for a much larger campaign in April, which was Donor Month, and included getting Governor Guinn involved. Attorney General Frankie Sue Del Papa sent a letter of support (EXHIBIT G) and was very involved with the organ donor program. The fact remained, if Nevadans in need could not look to Nevada first, she might lose three of her friends who testified today.

Heidi Smith said Nevadans would still be donating to California, however, with passage of A.C.R. 19 people would have the opportunity to say they would like to have their organ go to someone in Nevada. The desire was not to make California angry rather to have Nevada recognized as having a population in need of transplants.

Chairman Freeman recommended A.C.R. 19 be moved out and asked for a motion.

VICE CHAIRMAN KOIVISTO MOVED TO DO ADOPT A.C.R. 19.

ASSEMBLYWOMAN BUCKLEY SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

Chairman Freeman opened the hearing on A.J.R. 15.

Mrs. Freeman explained A.J.R. 15 was a resolution she had requested regarding the Employment Retirement Income Security Act (ERISA). She said often nothing could be done on the state level for people who lived in Nevada. A.J.R. 15 was a resolution that asked Congress to rectify the inequities. Other bills had been introduced during session on that issue and everyone had been waiting for Congress to do something about the inequities, but they never had.

Assemblywoman Buckley said when the ERISA law was passed in 1974 by the Federal Government it was to protect employers from lawsuits concerning health insurance benefits. It had been interpreted that states had no jurisdiction under self-funded insurance plans, so if companies elected to self-insure the state could not regulate the appeals, how they would function, wrongful denials, benefits or many other issues. Often the local managed care organizations opposed legislation saying "you are only covering a third of the market." That was because it was the only power the state had. What A.J.R. 15 would do would be to urge Congress to give the power back to the states. It was a state's rights issue; states should be governing insurance not the Federal Government. The resolution would create a more uniform playing field so all plans would be subject to the same rules, and it would be more equitable to our Nevada insurers. Ms. Buckley believed A.J.R. 15 was a great resolution and one we should pass.

ASSEMBLYWOMAN LESLIE MOVED TO DO PASS A.J.R. 15.

ASSEMBLYWOMAN BUCKLEY SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

Chairman Freeman opened the hearing on A.B. 429.

Janice Wright, deputy administrator, Health Care Financing and Policy (HCFP), explained A.B. 429 deleted the "sunset" provision contained in S.B. 427 of the 1997 Legislative Session. The bill created the Division of Health Care Financing and Policy. It took the Medicaid program out of the Welfare Division and combined it with the Health Care Financial Analysis Unit in the director's office at the Department of Human Resources. The merging created a very strong division that could concentrate its efforts on providing quality health care services to low-income Nevadans and reviewing programs to determine potential federal revenue maximization. The governor's executive budget recommended continuation of the division.

The division had a staff of approximately 295 individuals and a biennial budget of about $1.3 billion. HCFP had been working to improve services to Medicaid recipients and to the Medicaid providers. There were approximately 100,000 Medicaid recipients in the state who needed to be assured of access to quality health care services. HCFP had developed a grievance and hearing process, expanded the maternal obstetrical medical services (MOMS) program by obtaining additional grants, and served over 70 individuals last year in the rehabilitation and case management services (RECAMS) for the physically disabled. The program prevented institutionalization and of the 70 served, 10 were actually discharged from an institution. The remainder had not been institutionalized at the onset. HCFP also established a hospice program and a personal care attendant for the disabled program. For Medicaid providers the division worked to remove barriers to authorizations and payments, established a claims reconciliation and special handling (CRASH) program to review unpaid and stale-dated claims, and focused on training to assist the facilities in getting better service. An electronic payment system for the hospitals was introduced, a reduction in prior authorization turnaround time from a high of 8 weeks to as low as 24 hours, and improvement of the electronic verification of eligibility (EVE) system which was now updated daily.

Additionally, a Medicaid managed care program had gone from voluntary to a comprehensive mandatory program effective December 1, 1998 and established the Nevada Check-Up program that began October 1, 1998, with over 10,904 children who had applied and 5,870 had been approved. 4,804 were enrolled and receiving benefits. Additional details of Ms. Wright's testimony were provided in EXHIBIT H.

Ms. Wright said a change in A.B. 429 was needed. Specifically, to amend section 33.5, line 38 that read: "section 55 through 80.3 inclusive deleted." HCFP did not want to delete two of those sections, sections 78 and 79 of S.B. 427 from the 1997 session. That was the Charge Master program and the executive budget did want that particular portion of the program to be deleted. The one line amendment was provided on page 5 of EXHIBIT H.

Ms. Wright concluded with a comment that Rene Ashelman remarked to her the section that provided for judicial review might shorten the time frame. It was not HCFP's intention to shorten the time frame. Ms. Ashelman would review those statutes and if an extension of time were needed, HCFP would accommodate it in the amendment.

Chairman Freeman said the committee would be meeting again on March 29, 1999, and asked Ms. Wright to bring an amendment forward at that time.

Jim Jepson, Chief Insurance Assistant, Division of Insurance, identified himself and pointed out a provision in A.B. 429 was excluded from application to the Children's Health Insurance Program: page 17, lines 16 and 17, concerned an amendment to Nevada Revised Statutes (NRS) 695C and was the chapter of the insurance code that regulated the activities of health maintenance organizations (HMO). On line 16, provisions of that chapter would not be applicable to the state program for Medicaid managed care and now the Children's Health Insurance Program. Included within those limitations was NRS 695C.185, which was the statute that directed HMOs to approve or deny claims within 30 days, and also established requirements for payment of claims once approved within 30 days. It also included interest on unpaid claims. The Insurance Division had interpreted that provision to include claims for payments by medical providers. If the bill was passed as written the Insurance Division would encourage the administrator of the Division of Health Care Financing and Policy to include a provision in the contract requiring payment of claims within the time frames that were normally applied to HMOs and as specified in NRS 695C.185.

Chairman Freeman asked if Mr. Jepson was asking for an amendment or just to work it out with the administration. Mr. Jepson said he was not asking for an amendment, he just wanted to bring attention to the fact and encourage either a change in the language of the bill or a provision in the contract with any HMO administering that program. Mrs. Freeman asked him to work that out with Ms. Wright.

Assemblywoman Buckley would like to have a debate on whether the change should be made. Timely payment of claims and appeals processes seemed like good public policy and those issues were addressed in the contracts originally, but was there any harm in giving it the force of state law as well. She asked to hear from HCFP as to why it should be excluded.

Janice Wright, HCFP, agreed with Assemblywoman Buckley that those issues were good public policy and it was not HCFP's intention to specifically exempt them. She would be happy to work with Mr. Jepson.

Jon Sasser, Statewide Advocacy Coordinator, Washoe Legal Services, stated he would also like to work with the Division of Health Care Financing and Policy on some potential amendments. A.B. 429 incorporated for the first time into Nevada Statutes the new Children's Health Insurance Program. In speaking with the Attorney General's Office who represented the division there had been a legal opinion that it was not necessary to include hearing notice and judicial review provisions for that new program because it was not an "entitlement" program. However, it did raise a policy question as to whether it was desirable to have such protections in the statute.

Chairman Freeman asked Assemblywoman Buckley if that was something which needed to be discussed in another hearing or could the committee just review the amendments. Ms. Buckley replied that perhaps a work session with the parties present would suffice.

Mrs. Freeman closed the hearing on A.B. 429 and opened the work session on A.B. 167.

Marla Williams, Committee Policy Analyst, provided a work session document, marked as EXHIBIT I, and discussed A.B. 167 and other bills scheduled for the meeting.

The proposed amendment deleted lines 14 through 15 on page 1 and inserted new language that accounted for divisions or programs to be administered by the Department of Human Resources. It would replace the language that was in section D with "a facility funded by any division or program of the Department of Human Resources."

Chairman Freeman expressed some concern that the "facility" in question in section D would not be regulated. Ms. Williams said they were exempt from the Health Division's regulation. Mrs. Freeman then asked to what regulations would they be subjected.

Rick Panelli, Chief, Bureau of Licensure and Certification, came forward to advise the exemption would remove the facility from oversight by any of the health authorities.

Ms. Williams said the statute already applied in existing law and the amendment was simply a cleanup of language that made it more flexible for the Department of Human Resources in the future. Currently there was no oversight for facilities funded by the Department of Human Resources and there were some facilities in Mental Health and Mental Retardation that were funded. She reiterated it did not change existing law.

Mrs. Freeman asked Mr. Panelli if he was comfortable with the amendment. Mr. Panelli said it was an area that had been problematic for his department because there had been conflicting issues, and he felt the amendment would straighten it out. Some of the facilities came voluntarily and received oversight on that basis.

Assemblywoman Buckley asked for clarification of the amendment. Mr. Panelli said just one facility in the state was currently licensed under that provision. For the past 6 years there had been no complaints concerning any care provided by the facility and in fact for 20 years there had been no complaints about the facility. Ms. Buckley asked if he was not concerned because there were no individuals at the facility who were frail, disabled, or elderly. Mr. Panelli said that was true. He explained it had been in the statute since the state had homes for unwed mothers. Mr. Panelli's written testimony was provided as EXHIBIT I.

ASSEMBLYWOMAN BUCKLEY MOVED TO AMEND AND DO PASS A.B. 167.

ASSEMBLYWOMAN MCCLAIN SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

The chairman opened the work session on A.B. 249.

Marla Williams explained the bill had been held over from the last work session. The amendment was contained at tab C, EXHIBIT J. Kathryn Bliss Holt from the Attorney General's Office provided information and some committee members had asked to review that information. The amendment:

• Gave the agency the ability to collect from the undivided estate of a Medicaid recipient the amount of incorrectly paid benefits. It made it consistent with the current definition of estate as it related to the ability to recover incorrectly paid benefits from Medicaid recipients.

• 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 the time of death. It included property held in joint tenancy or other arrangements where title normally passed upon the death of the recipient.

• In section 3, it included "undivided estate" instead of "estate."

Assemblywoman Buckley said she had spoken to the Attorney General's Office and to Jon Sasser, and had reviewed the court decisions. The parties reviewed it and refined it a bit more and she was satisfied with what had been developed. The parties clarified the law with respect to the two types of overpayments and Ms. Buckley was satisfied it was fair and reasonable.

Jon Sasser, Washoe Legal Services, provided EXHIBIT K, an amendment he was able to develop with the Attorney General's Office. It would be an addition to section 3 regarding the Welfare Division's ability to compromise claims and waive overpayments and to accomplish that by regulation.

Charles Hilsabeck, deputy attorney general, Welfare Division, Attorney General's Office, clarified that the amendment affected paragraph 3, section 1 of the bill.

Assemblywoman McClain asked Assemblywoman Buckley if the bill would be in conflict with bills being heard in the Committee on Judiciary. Ms. Buckley said "No." She added she liked the additional clarification afforded by the amendment because it gave discretion where, for example, if someone received a month of food stamps by mistake, it would give the state some flexibility with the problem.

ASSEMBLYMAN WILLIAMS MOVED TO AMEND AND DO PASS A.B. 249.

ASSEMBLYWOMAN BUCKLEY SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

Chairman Freeman opened the work session on A.B. 251.

Marla Williams explained when the testimony was originally heard on A.B. 251

members posed questions to representatives of University Medical Center (UMC). Mr. Don Haight submitted the information at tab D, EXHIBIT J, in response to those questions:

1. How much money could UMC save by membership in a Group Purchasing Organization (GPO). At a savings of 2 to 5 percent, annual savings would amount to between $360,000 and $900,000 on nonpharmaceutical supplies. Additional savings would be noticed on pharmaceuticals.
2. How much would it cost to belong to a GPO. An annual membership fee was $10,000.
3. Had managed care organizations (MCOs) affected the type of pharmaceuticals dispensed by UMC. The increase in MCOs had little effect on UMC in that area.

ASSEMBLYWOMAN BERMAN MOVED TO DO PASS A.B. 251.

ASSEMBLYMAN THOMAS SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

Chairman Freeman opened the work session on A.B. 337.

Ms. Williams said A.B. 337 had been sponsored by Assemblywoman Buckley.

Assemblywoman Buckley said the amendment changed the eligibility level from 150 percent to 185 percent of the federal poverty level to make it consistent with the computer programming, and changed the amount of assistance available from $200 to $700.

ASSEMBLYWOMAN GIBBONS MOVED TO AMEND AND DO PASS A.B. 337.

ASSEMBLYMAN THOMAS SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

The Chairman opened the work session on A.B. 280.

Ms. Williams said A.B. 280 had been brought forward by Assemblywoman Buckley. It was discussed at tab E, EXHIBIT J.

Ms. Buckley said the amendment was lengthy and complicated but no different than the original concept of the bill. The bill tried to make outdated aversive techniques illegal and discourage their use. It covered mental health, mental retardation, schools, and anyone who dealt with individuals, especially children, with disabilities. The amendment attempted to incorporate when in severe situations institutional care interventions might be permitted that were aversive in nature but stated positive behavioral supports had to be used first. It also incorporated federal protection, such as a doctor's order and other items.

The parties had been working very hard; Cynthia Pyzel with the Attorney General's Office, and Sara Winters and others from the Association for Persons with Severe Handicaps (TASH) Group. They wanted more refinements but with the legislative deadline it was difficult for something so complicated to be completed. Ms. Buckley said if the committee supported the bill in its current form, when the amendment reached the Legal Division, she would have the opportunity to refine additional items with Ms. Pyzel and Ms. Berkeley. The intent and the layout would not change.

VICE CHAIRMAN KOIVISTO MOVED TO AMEND AND DO PASS A.B. 280.

ASSEMBLYMAN THOMAS SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

Ms. Williams said the first part of the amendment to the measure was found at tab F, EXHIBIT J.

• It deleted subsection 1 of section 2, lines 3 through 5 on page 1 and replaced it with: "The State Board of Health shall adopt regulations requiring the fluoridation of each public water system that serves a population of 100,000 or more."

• It deleted section 3, lines 12 through 13 on page 3, and replaced it with: "The provisions of NRS 445A.025 to 445A.050, inclusive, apply only to those public water systems that serve a population of less than 100,000."

The third part of the amendment was provided in a separate memo by Assemblywoman Giunchigliani and marked EXHIBIT L.

• It inserted a new subsection 8 of section 2 of the bill which stated: "Those public water systems whose groundwater production is less than fifteen percent of their average annual production during nondrought years, and whose groundwater production wells are part of a common distribution system, served by a fluoridated supply is interrupted during emergencies and routine maintenance as determined by the utility."

Assemblywoman Angle said she had concerns about the fluoridation issue and would rather err on the side of caution. The possibilities of harm that could be done to children, the issue of freedom of choice that would be denied to people who could not afford the alternative water, and the potential of opening the state to liability were the reasons she would vote "No."

Assemblyman Thomas said although some testimony caused concern he had nevertheless received overwhelming support for the bill from his constituents and he would therefore support the bill.

Assemblywoman Gibbons said she would be voting "No," as her constituents wished.

Mrs. Freeman asked for a motion.

VICE CHAIRMAN KOIVISTO MOVED TO AMEND AND DO PASS A.B. 284.

ASSEMBLYWOMAN BUCKLEY SECONDED THE MOTION.

MOTION CARRIED WITH ASSEMBLYWOMEN ANGLE, GIBBONS, BERMAN AND VON TOBEL OPPOSED.

Chairman Freeman said the committee would meet its deadline and did not anticipate any evening or weekend meetings.

With no further business before the committee, Mrs. Freeman adjourned the meeting at 3:30 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

DATE: