The Committee on Health and Human Services was called to order at 1:45 p.m. on Monday, April 5, 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

Ms. Kathy Von Tobel

Mr. Wendell Williams

COMMITTEE MEMBERS ABSENT:

Mr. Kelly Thomas

GUEST LEGISLATORS PRESENT:

Assemblywoman Chris Giunchigliani, District 9

Assemblyman Greg Brower, District 37

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Following roll call, Chairman Freeman announced A.B. 365, scheduled for hearing, would be rescheduled and the meeting would be a work session for a number of bills. She asked Marla Williams to introduce the bills under discussion.

Marla Williams, Committee Policy Analyst, provided a work session document (EXHIBIT C). The first bill to be discussed was A.B. 265.

The committee first heard the measure on March 3, 1999. It had been amended and passed out. The amendment had not been returned, however, Assemblywoman Leslie had additional information and a new amendment to offer, described at tab A of EXHIBIT C. The new amendment would add a facility for medically monitored detoxification to the definitions of facilities that were regulated by the Bureau of Licensure and Certification. It would be a modified medical facility and would therefore add a definition to "medical facilities" in Nevada Revised Statutes (NRS) 449.0151.

Assemblywoman Leslie had been working on the bill since it was heard in committee and believed the new amendment offered a simpler solution. Initially the bill asked to move all the licensing responsibilities for substance abuse programs from health licensing to the Bureau of Alcohol and Drug Abuse (BADA) which was in a different department of state government. In working with the Health Division licensing and the substance abuse programs a two-facet approach was agreed upon. One had to be done in the statute, as described by Ms. Williams, and the second required a letter of intent. BADA had been working with health licensing on regulations specific to substance abuse programs. They had agreed to dust off those regulations and work with the programs through the public hearing process to get those regulations finished. A letter of intent was needed that stated BADA was pursuing that course of action.

Discussion ensued about whether the committee had to rescind the prior "amend and do pass" and make a new motion to "amend and do pass," with the new amendment and request a letter of intent.

Chairman Freeman asked for a new motion.

Mrs. Freeman asked Ms. Williams to have the letter of intent ready by the end of the week.

Ms. Williams referred to tab B of EXHIBIT C which discussed the amendment for A.B. 141. Action had been taken initially on February 10, 1999; however, in reviewing the minutes she had not found an official motion for adopting the amendment. The legal division finished its draft of the amendment and Cynthia Pyzel of the Attorney General's Office indicated it met her intent with the addition, on page 3, of the wording "medical director or his designee." The addition would ensure someone had the authority to act in the medical director's absence.

A copy of the proposed amendment was also provided to the Nevada Disability Advocacy and Law Center where Jack Mays and Jill Smith indicated the amendment met what they felt was the intent of the bill.

Mrs. Freeman remarked the measure had been discussed at length in the interim committee and had taken a long time to come about, and she was pleased with the result.

Assemblywoman Leslie said the amendment had been the one she wanted to have time to discuss with Dr. Carlos Brandenburg, and he had said it was fine.

Chairman Freeman opened the work session on A.B. 69.

Marla Williams reported that on March 24, 1999, a motion was made to amend and rerefer to the committee. The bill was sponsored by Assemblyman David Goldwater on behalf of Clark County and University Medical Center that revised provisions governing payment of hospitals for treating disproportionate share (DSH) of Medicaid patients, indigent patients, or other low income patients. The amendment had been received and faxed to Bill Hale, CEO, University Medical Center, for review. Mr. Hale had advised the amendment was consistent with what he wanted to do with the bill.

Ms. Williams referred to tab C of EXHIBIT C which contained a mock up of the changes that would be made in the bill. The amendment language included an additional section of the Nevada Revised Statute (NRS) 422.382.

Assemblywoman Gibbons asked if anyone had spoken to Sunrise Hospital for their comments on the amendment. Ms. Williams said "No." She sent it only to the bill sponsor.

Assemblywoman Leslie reported she had some complaints from counties that wanted a chance to look at the amendment and make sure it would not hurt rural hospitals. She wanted to explore that further and postpone action until the next meeting.

Assemblywoman Von Tobel said she understood A.B. 69 would go to the Committee on Ways and Means as it would affect the budget. In the interest of timeliness, she suggested a vote on policy and amend and rerefer to the Committee on Ways and Means.

Robert Barengo, representing Sunrise Hospital, Las Vegas, said the amendment did not conform to the request of Sunrise Hospital nor did it conform to what Assemblyman Goldwater recited at the previous meeting. What Mr. Goldwater had said at that time was there was certain money the state had that was going to be spread among the hospitals. He wanted that portion of the new money to be able to be accessed by any hospital that served DSH payment.

Mr. Barengo said the amendment presented only took the money and put it back in to the old formula. It did not indicate there should be new recipients of the money held by the state.

Chairman Freeman said the bill would be rescheduled to allow Mr. Goldwater to be present to tell the committee exactly what he wanted A.B. 69 to do.

Mrs. Freeman closed the work session on A.B. 69 and opened the work session on A.B. 429.

Ms. Williams discussed the amendments for A.B. 429 located at tab D, EXHIBIT C. One of the amendments addressed the amendments brought forward by Janice Wright, Deputy Administrator, Division of Health Care Financing and Policy. It would extend or eliminate the "sunset" provision on the division and allow them to continue as an official division.

Tab E, EXHIBIT C, contained the fiscal note prepared by the division in response to a proposed amendment to add a due process provision as requested by Assemblywoman Buckley. The third item included the language to allow the due process provision on page 5 of handout entitled "Proposed Amendments to A.B. 429" (EXHIBIT D), which added a new section to NRS Chapter 422 as followed:

1. "Applicants for the Children's Health Insurance Program who disagree with the denial of their application may request a case review and hearing before an impartial hearing officer by filing a written request within 30 days of the Notice of Decision at the address specified in the notice.
2. The Division of Health Care Financing and Policy shall adopt regulations regarding the review and hearing before an impartial hearing officer which must include a requirement for a written decision.
3. The applicant may at any time within 30 days after the date on which the written decision is mailed petition the district court of the judicial district to review the decision. The district court shall review the decision on the record. The decision and record must be certified as correct and filed with the clerk of the court by the administrator of the Division of Health Care Financing and Policy.
4. The review by the court must be conducted in accordance with NRS 422.299."

Nancy Angres, Chief Deputy Attorney General, representing the Division of Health Care Financing and Policy, reported she had discussions with Jon Sasser regarding the due process issue. It was a decision the committee had to make as to whether denials of that type of insurance would actually go before a hearing officer. If the committee believed it should go before a hearing officer then the amendment on page 5 of EXHIBIT D would address that issue and the agency would adopt regulations governing that hearing. In order to defray the fiscal note, she had worked with Mr. Sasser and they felt hearing officers within the department who had not participated in the decision could be used. The agency would be willing to absorb any other costs, which would not be that significant, in the interest of getting the bill passed.

Chairman Freeman felt that Assemblywoman Buckley's concerns had been addressed by the actions described and asked for a motion.

ASSEMBLYWOMAN LESLIE MOVED TO AMEND TO DO PASS

A.B. 429 WITH THE PROPOSED AMENDMENTS AS OUTLINED IN EXHIBIT D AND THE ADDITIONAL LANGUAGE PROPOSED BY THE DIVISION OF HEALTH CARE FINANCING AND POLICY.

ASSEMBLYMAN WILLIAMS SECONDED THE MOTION.

THE MOTION CARRIED WITH ASSEMBLYWOMAN ANGLE OPPOSED.

Chairman Freeman opened the work session on A.B. 373.

Marla Williams reported A.B. 373 was Assemblywoman Chris Giunchigliani's bill that would make changes concerning health care facilities. The measure was heard on March 29, 1999, and no action was taken at that time. It was heard again on March 31, 1999, with additional testimony from individuals opposed to the bill who indicated concern about the proposed amendment which would prohibit referral fees currently paid by residential homecare operators. The proposed amendment did not incorporate any of the suggestions made by those individuals.

Ms. Williams explained the proposed amendment, provided at tab F, EXHIBIT C, as followed:

• Add a new subsection to section 3 that required regulations prohibit referral fees from being paid by a facility to which a person was referred. However, the regulations would not prohibit a consumer from paying a referral fee. That was to eliminate homes from paying a "bounty" for referrals and also prevent an individual being moved to generate more fees.

• Add a new subsection to section 3 that stated: "This section does not apply to a medical facility that is currently licensed by the Bureau of Licensure and Certification."

• Delete section 4 and sections 10 through 19. Those were the sections Senator Dina Titus's amendments would have replaced however the committee decided against doing that.

• Add a new subsection to section 5 allowing "homes for individual residential care" in counties with a population less than 100,000. In counties with populations greater than 100,000 the homes must be licensed.

• Add a provision to the bill that stated: "A license to operate is not transferable to any other person or physical location, and the license is valid only for the administrator named on the license." That required a license for each home operated by an individual administrator.

• On page 4, line 12, delete "plans" and insert "regulations."

• Add a new subsection to section 8 that stated: "If the administrator operates more than one home and the group home has been closed due to substantiated complaints of abuse, exploitation, isolation, and neglect of residents then all homes operated by that individual must be closed, relocation expenses paid for by the operator/owner, and his license suspended or revoked as determined by the Bureau of Licensure and Certification."

• A new subsection to section 8 that stated: "A facility may not operate until a license has been issued by the department."

• A new subsection to section 8 that stated: "Upon notice that a facility may be operating as an unlicensed facility, the department shall make an onsite investigation within 72 hours."

• A new subsection to section 8 that stated: "Funds collected from penalties should be retained by the Bureau of Licensure and Certification."

Assemblywoman Von Tobel said in testimony heard earlier that addressed the referral fee issue, seniors who were least able to pay a fee would now be the ones who had to pay the fee. She could not support the bill if that was the language. It was not fair to ask seniors who needed help finding the home to pay for the referral. She was also concerned about the closure of all homes operated by a licensee because of a complaint in one of the homes. She wondered where the seniors in those homes would go, and who would pay for them to be relocated.

Ms. Williams clarified the provision regarding closure stating that it would happen only as a result of a substantiated complaint. Ms. Von Tobel still did not like that provision, citing the other homes might be perfectly operated with no complaints. Mrs. Freeman said particularly in Clark County there had been many cases of abuse in residential care homes and perhaps it was important to let the operators know that every home had to be properly operated or closure of all homes would result.

Assemblywoman Berman said there was confusion over that point and she was not happy with it as now written.

Assemblywoman Chris Giunchigliani was asked about the multiple home closure issue. She said that had been suggested by Ed Fend, American Association of Retired Persons (AARP) and because she felt his original suggestion too broad, she and Marla Williams worked to tighten the provision by adding the words "substantiated complaint."

Ms. Berman continued to be concerned about multiple home closures, wondering why not remove the person causing the complaint instead of closing the home. Also some homes were operated by management companies and the owner or licensee would not be aware of abusive or other situations. She felt the other side of the coin should also be considered. Ms. Giunchigliani said the license was issued to the operator of the home, there was a due process for hearings and so on. If a management company was operating the home, it was the owner's responsibility to make sure that company would operate it according to accepted practices and rules.

Ms. Williams clarified under current statute if an operator's license was revoked, then he could not operate any home or homes, and homes had to be found for all residents of the facilities.

Chairman Freeman asked if the committee was comfortable with the amendment and hearing no objections she then asked for a motion.

Ms. Von Tobel said she was still uncomfortable with the senior paying the fee. She reiterated her earlier reasons and therefore could not support the bill. Ms. Giunchigliani said she appreciated Ms. Von Tobel's concern. However, contrary to the testimony of the individual who operated the referral service who stated she charged a fee of 40 percent of the first month's rent, the same individual told her earlier she generally charged a flat fee of $500. So the amount apparently changed depending upon when one spoke to that individual. Ms. Giunchigliani went on to say she had received countless e mails from the Long-Term Care Board that licensed the group home administrators as well as from nurses around the United States who believed the facility should not be the one to pay because of the headhunter status. Many persons did not need to pay; social services and hospitals had the ability to make placements. Furthermore, so as not to prohibit referral fees entirely, a senior or a family member, who needed assistance in finding a home for a senior would be able to hire an agency and could then pay that agency for the service. It was the more responsible way, rather than putting the group home administrator or owner in the awkward position "of having to wheel and deal for a body." She said she had talked to many group home administrators who said they were uncomfortable with the fee process.

Mrs. Freeman remarked the whole concept of finder's fees was bothersome.

Ms. Berman asked if an owner of multiple homes had ever been closed down and what were the ramifications. Ms. Giunchigliani said she knew of none. What the Long-Term Care Board had tried to do was work with the owners; however, the Bureau of Licensure and Certification would be watching more carefully for areas of abuse. The owner had the right of due process and homes were not arbitrarily closed. She felt caution would be exercised. The need was great for those type homes and many of the operators did a good job. She said she would try to obtain more information prior to the vote being taken on the floor.

Ms. Buckley said she had grave concerns about referral fees and whether people were being referred just because the home paid the fee. In fact when she had asked the referral agency owner how many referrals were made to homes who had not paid her a fee, she had said "about 5 percent." Further, Clark County and Washoe County Social Services had done a good job in placements and moreover, it was against the law to release a person from the hospital without having a placement for them, so just how great a community service were those referral agencies providing. Finally, she agreed with Ms. Von Tobel's concern about charging the senior the fee. It might be best to eliminate referral fees altogether.

Chairman Freeman agreed and felt referral fees were exploitative. A discussion ensued with general agreement that no fees should be allowed. Ms. Giunchigliani said that had been her initial thought but did not want to put anyone out of business.

ASSEMBLYWOMAN LESLIE MOVED TO AMEND AND DO PASS A.B. 373, WITH THE ADDITIONAL AMENDMENT TO PROHIBIT REFERRAL FEES.

VICE CHAIRMAN KOIVISTO SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

Mrs. Freeman asked Ms. Williams to return the amendment to the committee when it had been cleaned up so members could make sure it conveyed their intent.

Mrs. Freeman opened the work session on A.B. 533.

Marla Williams advised the measure had been heard earlier and no action was taken. Assemblyman Brower, the bill's sponsor, had proposed an amendment.

Assemblyman Greg Brower, representing District 37, provided an "(a)" version and a "(b)" version of a proposed amendment to A.B. 533, marked EXHIBIT E. Those proposals were based on the committee's earlier questions, conversations with Chairman Freeman and Assemblywoman Buckley, and counsel, and version "(b)" was the preferred amendment. The operative clause was at section 2 (d) which would require a vote of the people to create a hospital district. If that course of action was taken then subsection (c) would not be necessary.

Chairman Freeman asked Ms. Buckley if the proposed amendment "(b)" answered her concerns. Ms. Buckley said it did. She then asked about the provisions of Nevada Revised Statutes (NRS) 450.620(3) that the proposed amendment stated "do not apply" was to ensure that the county had fully funded its indigent care and why was that in there.

Madelyn Shipman, Washoe County District Attorney's Office, responded "the underlying purpose of a hospital district was to create a county hospital. The presumption was not to form a taxing district to create a hospital if the appropriate reimbursements and other funding mechanisms required by law were not in place for the existing hospital. Washoe County had no county hospital. If a district were created the board of trustees would contract with Washoe County Social Services Department to make those determinations for people who would be going into that hospital."

Ms. Buckley posed a hypothetical situation that "Washoe County had not created a hospital district but still had obligations to fund indigent care through other facilities. Would anything in this section affect that. For example, that it could fulfill its obligations in Incline before it could fulfill its obligation to poor people in Reno."

Ms. Shipman said "No. I ran the amendment through Washoe County Social Services director who is in charge of the dispensation and determination of how those funds are dealt with and she had no problem with this and felt it would be fine." Ms. Shipman added the county imposed the maximum 10 cents for indigent care and those funds were spread as far they could be on a proportionate basis. In the last 4 years the county had paid an additional amount to the various hospitals eligible for the money.

Assemblywoman Von Tobel said among the 250 e mails she had received in the last 2 days, one had come from a person who likened the bill to one in the 1997 session that attempted to set up a separate school district for Incline Village. That person was concerned and she was too. Mr. Brower said it would only provide that the community, upon a vote of the majority, could contract to ensure that it had emergency and other services in the area. He added there was no parallel or analogy between the two issues.

Ms. Shipman pointed out the current law was not being changed. Nothing prohibited the creation of a district for a portion of a county. The only thing being changed was the purpose for which the district was being formed.

Ms. Buckley asked if the vote of the people was for supporting the establishment of the district for that purpose as well as the taxing mechanism. Ms. Shipman responded it was for both, the need and the tax. Mr. Brower reminded the committee that under current statute a vote of the people was not required to establish a hospital district and he deferred to the committee as to whether they wanted to make it a requirement in that limited context. He felt the people in Incline Village would vote for the district because they recognized the need, but it would be a departure from current law.

Mrs. Freeman remarked they had discussed the possibility of a preamble explaining Mr. Brower's intent and she wondered if he felt it was needed.

Mr. Brower did not. He felt the various determinations that the commission must make, as set forth in the amendment, established the intent.

Ms. Shipman referred to the earlier conversation about not needing 2(c) if 2(d) was employed. In which case the motion should include removing the proposed (c) and move (d) up to the (c) position.

Ms. Gibbons said she would like to remove that language so it would be clear when the people voted for the proposed district that it was a new taxing district. Ms. Shipman suggested the wording "there is a vote of the people in the proposed district supporting the establishment of a taxing district" and that would get the idea across.

Chairman Freeman asked for a motion to amend and do pass A.B. 533.

Mrs. Freeman announced the committee had heard all the bills but one, which would be heard the following night at 6:00 p.m. The committee was still posted for a meeting on April 7, 1999, but it would not last long.

With no further business before the committee, Chairman Freeman adjourned the meeting at 2:40 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

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