The Committee on Health and Human Services was called to order at 2:20 p.m., on Wednesday, April 21, 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. Dawn Gibbons

Ms. Sheila Leslie

Mr. Mark Manendo

Ms. Kathy McClain

Mr. Kelly Thomas

Ms. Kathy Von Tobel

COMMITTEE MEMBERS ABSENT:

Ms. Barbara Buckley

Mr. Wendell Williams

GUEST LEGISLATORS PRESENT:

Senator Dina Titus, District 7

STAFF MEMBERS PRESENT:

OTHERS PRESENT:

Following roll call, Chairman Freeman opened the hearing on S.B. 35.

First to speak in support of S.B. 35 was Maynard Yasmer, administrator, Department of Employment, Training, and Rehabilitation. He explained the bill presented a methodology of reasonable accommodation for people unable to stand in line for long periods of time at such places as the Department of Motor Vehicles (DMV). It had some fiscal impact on DMV, who would address that issue separately.

Mr. Yasmer said also there were some typographical errors on the bill and provided an amendment for that purpose. Exhibit C sought to amend section 1, lines 11, 12, and 13 to read: "Entitles the person to an immediate, appropriate accommodation to avoid arduous standing or sitting in a waiting line pursuant to the provisions of section 8 of this act."

Chairman Freeman cited the fiscal note which was $231,000 the first year increasing to $246,000 the second year. Mr. Yasmer agreed it sounded excessive.

Dana Mathiesen, Program Officer, Department of Motor Vehicles and Public Safety, stated a new fiscal note had been submitted that was much lower than the figure quoted above. She provided the fiscal note (Exhibit D).

On reading the fiscal note, Chairman Freeman recited the amount of $49,340 for year 2000, based on the current number of handicap placards and license plates issued. Revenues were projected at the $4 level per ID card.

Senator Dina Titus, District 7, bill sponsor, provided background on S.B 35. Her friend and constituent Vallan Beckford in Las Vegas, requested her to consider legislation to assist handicapped people who were required to wait in long lines at such places as the Department of Motor Vehicles. Mr. Beckford pointed out to her although handicapped people were provided with parking spaces that allowed easier access to stores and so on, once inside an establishment the purpose was defeated if they had to wait in a long line for service.

In the interest of reducing the fiscal impact, Senator Titus had limited the scope of her bill to cover only those people with permanent disabilities. The cost would be greatly reduced because the handicapped person would simply get a special card at the time of obtaining the handicapped license plate. S.B. 35 had not been referred to the Committee on Finance after being heard in the Senate Committee on Human Resources and Facilities.

Senator Titus said another concern had been brought to her attention that she wanted to clarify. S.B. 35 would not provide expedited service or preferential treatment for eligibility to handicapped individuals, the bill simply accommodated persons who were unable to stand in line due to their handicap. For that reason, an amendment had been requested as stated earlier by Mr. Yasmer.

Assemblywoman Leslie said there appeared to be a conflict in the bill language. Page 1, line 10, referred to a person with a permanent disability as certified by a physician, and later on page 2, line 21, it read the permit was valid for the period the physician had certified the person had a disability. Senator Titus explained even people with a continuing permanent disability had to renew their license plates periodically. Ms. Leslie then asked how the elderly fit into the special accommodation. Senator Titus responded it would be nice to be able to include the elderly; however, it was a difficult area to define, whether to do it by age or infirmity.

Mr. Yasmer said it was his understanding some elderly were eligible and did get special parking permits, therefore, if the expedited service permit was tied to the special permit parking they would also be eligible.

Assemblyman Manendo questioned page 2, line 18, that asked for "any other information the department may require" and wanted to know what that might be. Dana Mathiesen replied she was not sure to what that referred but would report back to the committee with the information.

Chairman Freeman asked the gentleman in the Las Vegas videoconference site to testify.

Vallan C. Beckford identified himself and referred to the bill's language on page 2, section 6, which stated: "a disability which limits or impairs the ability to walk" should be changed to "a disability which limits or impairs the ability to walk or stand for a prolonged period." A similar addition should also be made in section 7 at line 23. That amendment would enable someone who suffered from a disability like emphysema and arthritis, as he did, to be accommodated. Mr. Beckford also pointed out not everyone who was handicapped showed clearly visible signs of disability.

Senator Titus thanked Mr. Beckford for suggesting the proposed legislation and believed even if it did not cover all aspects of the problem the first time it could be expanded upon in the future.

Chairman Freeman and Senator Titus discussed the fiscal ramifications of S.B. 35 and the fact the bill had not gone to the Committee on Finance. It was believed there would not be a significant additional cost to put a card in with the handicapped plates or permit. Mrs. Freeman said she would like to check with the Committee on Ways and Means.

Dana Mathiesen said the Department of Motor Vehicles had requested the effective date of the bill be delayed until July 2000, so it could be incorporated into their new technology. It was expected in August 1999; however, any additions now would be considered enhancements, which could not occur until July 2000.

Mrs. Freeman said the committee would vote on it with the amendment at the next meeting, and if the Committee on Ways and Means wanted to see if it would be referred to them.

Senator Titus, co-sponsor of the bill with Senator Raggio, remarked she believed hospice care was one of the best ways to provide compassionate service and health care and was also economical. In the 1997 session they passed the hospice bill which provided for hospice coverage under Medicaid. The present bill, S.B. 382, was not an expansion of service or a mandated benefit but changed some definitions to make it apply more equitably.

Chairman Freeman asked why the language "free standing" was removed; were hospices located in established medical centers.

Peter Barcus, president of the Hospice Association of Nevada, stated the bill would allow that opportunity. Currently it was not allowed in the State of Nevada which was the only state in the country that had a free standing modifier to describe a hospice facility. It would simply eliminate the wording and permit hospice facilities in nursing homes, hospitals, or anyplace that met life safety health codes. Mr. Barcus provided his written testimony, Exhibit E.

Senator Titus commented the present statute had been drafted when the only hospice was Nathan Adelson Hospice that operated as a free standing facility. Since that time, the state had hospice care out of hospitals and other facilities and the reason for broadening the definition was to enable those facilities to be covered as well.

Mr. Barcus said there were 3 licensed hospice facilities in Las Vegas for a total of 68 hospice beds.

Assemblywoman Leslie asked for an explanation of section 8, subsection 2, and the changes regarding construction. Mr. Barcus said those changes were only grammatical.

Assemblyman Manendo asked why "free standing" had been added to the statutes in 1989. Mr. Barcus responded 1989 had been when the initial hospice licensing rules were established and at that time there was only one hospice facility in the state and was a free standing hospice facility. Since then the hospice industry changed to recognize the increasing needs for inpatient stays as well as for homecare visiting nurse programs.

Ms. Leslie asked about page 2, paragraph 3. Had there been any controversy about the nurse being able to pronounce a patient dead, and had it changed so that more than nurse could do that. Mr. Barcus said the bill did not change the existing rules which did permit a registered nurse to pronounce a patient dead. What was currently in place was the hospice had to predict which nurse would be the one and the physician had to sign that as a physician's order, and it was almost impossible to predict. The Board of Nursing had no problem with it in terms of the requirement that it must be a registered nurse that made the pronouncement.

Vice Chairman Koivisto asked if the registered nurse who pronounced the death was also responsible for releasing the body to the funeral director. Mr. Barcus responded the pronouncement of death was the nurse's responsibility and once that occurred the funeral home was notified. In actual practice, the nurse generally would stay until the funeral home came.

Chairman Freeman remarked it was unusual for registered nurses to be able to do that, however, acknowledged a hospice was different.

Mr. Manendo asked if the physician had to authorize the death pronouncement within a specific time period. Mr. Barcus stated the Board of Health recently held hearings and would be adopting a new administrative code pertaining to the pronouncement of death. Current administrative code said if a patient had not seen a doctor within 10 days of their death, it was an unattended death and as a result the county health officer would be called in to do an investigation. In a hospice case that was not appropriate or needed. The Board of Health had agreed with the Hospice Association's recommendation to change the administrative code to conform with the law to remove that burden.

There was no further discussion and Chairman Freeman asked for a motion.

ASSEMBLYMAN MANENDO MOVED TO DO PASS S.B. 382.

ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.

THE MOTION CARRIED UNANIMOUSLY.

Chairman Freeman opened the hearing on S.C.R. 6 and S.C.R. 8 jointly.

Jon Sasser, representing Washoe Legal Services and three other civil legal services programs, appeared in support of S.C.R. 6 and S.C.R. 8. Those resolutions arose from the interim committee on health. A variety of important issues were addressed over the interim and the committee prioritized those which required a bill in the 1999 session, and those that needed further investigation and action in 2 years. S.C.R. 6 and S.C.R. 8 were among those deferred.

There had been considerable discussion over community based waiver programs which were aimed at keeping people out of long-term care institutions. The programs allowed people to be cared for in their own home as opposed to going into institutions. To be eligible for the program one had to prove he could be cared for as cheaply or for less at home as in an institution.

S.C.R. 6 asked the question: Were the people of Nevada doing all they could in that area in terms of styling the most innovative community based waivers. It also asked the Division of Health to take a national survey on what was going on in other states regarding community based waiver and report those findings to the interim committee on health.

S.C.R. 8 dealt with the existing programs in the State of Nevada. There were four waivers: one for the elderly, called the Community Home-Based Initiatives Program (CHIP), one for the disabled, one for persons with mental retardation and related conditions, and one approved by the legislature for the more severely disabled, and there was an issue pending whether it would go forward. The three or four existing programs had waiting lists and there had been considerable testimony in the interim committee on the hardship that caused. Presently there were 130 on the waiting list for the disabled program. Waiting periods of a year or 2 were the norm, because until someone died there was not an opening. There were approximately 500 on the waiting list for the elderly program, with waits of 3 to 6 months primarily in Clark County. S.C.R. 8 asked the Division of Health to take a look at that program and determine what actions might be necessary to eliminate those waiting lists.

In closing Mr. Sasser urged support of both resolutions. He also voiced support on behalf of Paula Berkely, representing Educare and the Truckee Meadows Human Services Association.

Chairman Freeman asked how the measures had done in the Committee on Finance. Mr. Sasser said the study of what was happening in other states had no fiscal impact for the current session.

Janice Wright, administrator, Division of Health Care Financing and Policy (HCFP), stated the measures were discussed with a variety of other study bills from the interim health care committee. In discussions with Senator Rawson he asked about combining some of the measures instead of funding each individual study, since many dealt with similar issues. Some of the studies had appropriations attached and the potential existed for combining them. Regarding the waivers, Ms. Wright said there were currently four, and the one omitted had been the Division for Aging Services' adult group care facility waiver.

Mrs. Freeman asked Ms. Wright to come back to the committee with recommendations and the fiscal notes. Ms. Wright said each individual study would require a half to a full time staff person, depending on the scope of the study. Each one could also be done with no impact to staff if they were contracted out. Recommendations from $50,000 to $100,000 had been received. She also said she would provide information on the cost of one combined ongoing study over the next 2 years.

Assemblywoman Leslie said she was tired of studies and more interested in what could be done to address that serious problem. She also requested clarification on the fourth waiver program.

Mr. Sasser responded that S.B. 433, passed in the 1997 session, would provide a waiver for the more severely disabled persons who needed services beyond those authorized in the current waiver. There was to have been a waiver package developed and submitted to the Federal Government during the last 2 years. It was initially submitted to the Federal Government and they suggested some changes. The Division of Health was in the process of working on those changes when the budget crisis occurred. The decision was made by the budget office to revert the half million dollars set aside for the last biennium and there had been no money put in for the upcoming biennium for that waiver to go online. Both the joint subcommittees reviewing the community based waiver program and Medicaid had heard significant testimony about putting money back into the budget for the upcoming biennium. Mr. Sasser's coalition had included that in its pared down priorities submitted to the Committee on Finance. That would not affect the two resolutions addressed.

Ms. Leslie asked what the consequences would be if the waiver were not completed. Ms. Wright responded that she had been present at the meetings held on the Department of Employment, Training and Rehabilitation (DETR) waiver. The original proposal prepared by DETR was to serve 48 clients including 10 who were Medicaid-eligible and institutionalized. It would allow them to seek alternative housing which would then be able to centralize their care in terms of personal care assistants (PCAs) and homemaker services and some of the related therapies they would require. The difficulty with the waiver was that because nothing had been built into the executive budget it would have to come out of existing savings. The budget office then looked to HCFP to say Medicaid ought to be able to demonstrate some savings to be able to fund the waiver. However, since only 10 people were currently institutionalized it would be difficult for Medicaid budget to fund the slots for all 48 people and the additional services required. It had come down to a money issue. Another difficulty was trying to determine if there was a cost benefit.

One of the things for which Health Care Financing Administration would look was if they were going to fund at 50/50, they would want to see that HCFP would keep the cost of the waiver less than the cost of institutionalization. The cost savings did not occur at the moment the waiver was approved, it was further down the road. The cost savings really occurred when people could be prevented from going into an institution as opposed to those people already there.

Ms. Leslie said she would support the resolutions, but if she sat on the Committee on Ways and Means, she would have to weigh carefully spending the money to study a problem knowing no money would be put into solving the problem.

Mrs. Freeman remarked a lot of that was done in the legislature. She asked about the 48 people mentioned earlier. Ms. Wright answered they were the targeted population for the new proposed waiver for DETR. Mr. Sasser clarified that a waiver, unlike Medicaid, was not an entitlement service. The state actually negotiated with the Federal Government for an exact number of people who would be served and when even one person over that amount applied they were put on a waiting list. Unless the state agreed to fund a higher number it would continue to have those waiting lists. Ms. Wright added currently 135 Medicaid clients were being served by the physically disabled waiver.

Chairman Freeman asked to be kept posted on what happened with the resolutions in the Committees on Finance and Taxation and with the recommendations of the Economic Forum. She asked to have the information before the first of May so the committee could discuss what action would be taken on the resolutions.

With no further business before the committee, Chairman Freeman adjourned the meeting at 3:00 p.m.

RESPECTFULLY SUBMITTED:

Darlene Rubin,

Committee Secretary

APPROVED BY:

Assemblywoman Vivian Freeman, Chairman

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