Seventieth Session

March 23, 1999

The hearing of the Assembly Committee on Ways and Means was called to order at 3:40 p.m. on Thursday March 23, 1999 by Chairman Morse Arberry Jr. 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.

Barbara Buckley, Assemblywoman for District Eight in Clark County, said A.B. 310 created an ombudsman for managed care patients. Ms. Buckley sponsored A.B. 356 in the 1997 legislature, which was dubbed "the patient bill of rights." She also had the opportunity to sponsor and work on the Nevada Health Care Reform Project, where she learned a lot about managed care and the transformation taking place in the state's health care system. Ms. Buckley said in the past nine years the state went from having a debate on universal health care, to the state's fee for service system, and then back to managed care. At the time the switch was made, it was done without a vote, in an effort to control spiraling health care costs.

There were promises made that if the state focused on prevention, it would lower costs for all. Ms. Buckley stated if the state covered prevention, it would help to contain health care costs. She argued the problem with managed care was although it was a laudable goal it was intertwined with a system whereby someone else was making a health care decision for the patient, other than the patient or the treating physician. There was concern the insurance companies had a financial motive to deny care. The less the company approved, the less money it had to expend and the more it could earn. Some Health Maintenance Organizations (HMO) and Managed Care Organizations (MCO) were doing a good job, but the

expend and the more it could earn. Some Health Maintenance Organizations (HMO) and Managed Care Organizations (MCO) were doing a good job, but the state needed to make sure the system was balanced, and A.B. 156 (1997) was one step toward making sure the patient had some rights.

Ms. Buckley saw A.B. 310 as furthering that work. Since the enactment of A.B. 156 (1997), whenever people had concerns, more often than not they sought out Ms. Buckley or a colleague. In the year and a half since the last session, Ms. Buckley joked her new hobby was to help people get approvals from their HMOs. Either federal agencies or local news stations gave out her phone number so she was constantly on the phone working out these problems for people. Ms. Buckley said she worked on getting approval for mastectomies, surgery, prescriptions, wheelchairs and crutches. She stated what was missing from the system was an office that was devoted full time to working for the patients when they needed something and were getting denied. Also, if the service was not covered, the patient needed someone to explain it to them who did not have a conflict of interest. That was why Ms. Buckley supported A.B. 310. She referred to an amended version of the bill (Exhibit C). The bill created the office of the ombudsman in section seven within the Bureau of Consumer Protection in the Office of the Attorney General. Based upon Ms. Buckley’s research, she believed that was the best place for the office to be. Some had argued that the best place for the office to be was in the Division of Insurance. Ms. Buckley disagreed. The division was a regulatory body, whose job was to be impartial, and to revoke someone's license for not complying with the law. It was not their job to stick up for the patient, although certainly they did that on occasion when they found the patient was right.

Additionally, the Bureau of Consumer Protection more closely mirrored the goal of what an advocate should be. The Insurance Division was understaffed and overwhelmed, in Ms. Buckley's opinion. She did not think that division was the best one to take on a new job and additional responsibility.

The duties of the office were listed in section eight. The duties included assisting consumers with understanding health care plans, assisting consumers in understanding their rights and responsibilities, and identifying, investigating and mediating complaints on behalf of clients who needed help. The office would also ensure clients had timely access to an ombudsman. The ombudsman could review the medical and health insurance records to get to the bottom of the complaint.

The funding mechanism was found in section 19, and proposed the office be funded by charging $1 per patient enrolled in a managed care organization. Ms. Buckley did not believe there were sufficient funds in the General Fund at that point so she had identified a specific funding source to be used.

Ms. Buckley reiterated in the past year-and-a-half she had handled hundreds of calls. The Insurance Division had also tracked calls and had received 13,000 calls in that time period. Not all of the calls were problems, but the calls needed to be addressed. She said as Chairman of the Commerce Committee, she had already seen 25 managed care bills. Those bills addressed issues such as rural hospitals saying they were on the list of a managed care organization where people in those communities were told they could not go to them. Another issue was emergency treatment denials which allegedly occurred after the person was stabilized. Mr. Buckley said she thought what was missing was someone to enforce the laws already in place. Enforcement was needed, and someone needed to stand up for patients' rights. That was what the office of the ombudsman did.

One of the criticisms of the bill Ms. Buckley had heard was that the state did not need the office, since the managed care offices had people who worked there to address problems. Also, people argued there were not that many calls to Ms. Buckley asking for help. She said for 500 people to find her home phone number when she did not even represent them, there had to be a problem. Some argued that they already paid taxes, so why did they have to pay $1 per patient? She said if the managed care organizations were not causing the problem, she would not be there trying to address those problems. She thought $1 per patient was very reasonable. The state charged mobile home parks $12 a space to create a trust fund, so $1 per patient was not a lot of money.

Ms. Buckley said she was aware many of the MCOs were very concerned the office of the ombudsman would be placed under the Attorney General. They thought it sounded too legal or forceful. Ms. Buckley said placing it in the Consumer Affairs Bureau made the most sense.

Ruth Mills, Coordinator of the Nevada Health Care Reform Project, gave the following testimony.

Mr. Goldwater noted the bill required a managed care organization to submit to the commissioner the number of patients it treated. That was the number from which the dollar assessment would be made.

Ms. Mills said the bill was changed to per enrollee instead of tracking individual patients. Chairman Arberry asked what fiscal impacts those amendments would have. Ms. Buckley replied all of the amendments had been discussed in the Commerce Committee, and would require an "amend and do pass." The changes would refine the duties and change the tracking measures. The fiscal note that had been prepared by the Attorney General's office assumed it was per enrollee and not per patient, so there would be no fiscal changes as a result of those amendments.

Mr. Beers said he was surprised to learn of the scattered governance of health care in the state. He asked if this ombudsman would help the situation, or whether he or she would have to say "sorry, your issue is with the federal government and we can't help you." Ms. Buckley replied a portion of the insured were covered by Nevada law, and a portion were self employed and covered by federal law. Currently there was a bill before Congress to allow states to regulate all insurance matters. She added until the federal government gave the state more control, it could only regulate and legislate what it had control over. She pointed out that most of the people who were exempt under the federal law had third party administrators. The third party administrators were mostly the same insurers who were already a part of the process. If the company was a federally regulated company, Ms. Buckley would still try to help them find the proper resources to address their claims.

Cynthia Bunch, Nevada Nurses Association, stated she supported A.B. 310.

Fred Schmidt, Consumer Advocate for the State of Nevada in the Attorney General's Office, said the fiscal note was sent to the legislature the afternoon before. He then handed out copies of the note (Exhibit E). Mr. Schmidt indicated the Office of the Attorney General supported the legislation, and added the office was not the advocate of the bill, but did review it. After reviewing it, the office contacted other states to find out if their offices performed such functions. Mr. Schmidt said it was not unique, and there were other states that had similar legislation passed. The office also looked at the fiscal aspects of the bill and determined what sort of resources the office would need to perform the functions outlined in the bill. It was critical to the bill, in order to have any success, that there were adequate resources to perform the tasks laid out in the bill. From discussions with the states of New York and Illinois, the office determined the type of personnel that would be needed. That included an ombudsman who would be a lawyer and have legal expertise in health care law. The other four positions would be non-lawyer positions, filled by people who had health care knowledge who could assist those in need. Those positions included two health insurance specialists, a program officer, and a clerical person.

Mr. Schmidt identified two important aspects of the bill; consumer education and litigation, in terms of the need for expert witnesses. There was also $15,000 appropriated for public education and $60,000 appropriated under the expert witness category. That type of resource would enable the bureau, through that division, to access trained medical personnel for the purpose of giving medical advice on situations to justify when the ombudsman felt a treatment that was denied was medically necessary. To the extent there would be limited instances when litigation would be needed, it would also provide a source of funding to provide expert witness testimony. From talking to other states, almost 90 percent of calls presented to the ombudsman would be presented to the health care specialist and would not involve lawyers or litigation of any type. The threat of litigation though, was an important component of the office's capability. Mr. Schmidt estimated the number of people clearly covered under the law would cost in the range of around 400,000. Assuming that was the case the bill would be very effective in that it would begin the office a year from now. That would allow the insurance commissioner to collect the funds and remit them to the Attorney General's budget so that they were in place when operation started July 1, 2000. Mr. Schmidt said the estimate for the amount of money outlined in the fiscal note was more than adequate, and -was based on numbers that primarily came out of 1996 statistics. He stated the fiscal note was reasonable and responsible and related directly to the funding mechanism in Section 19 of the bill, then amended. Mr. Schmidt said it would be his honor to take on the responsibility of that task.

Mr. Arberry asked about the revenue side of the fiscal note, and how much it would actually generate. Mr. Schmidt said the revenue side was a simple equation. One dollar multiplied by the number of HMO and PPO enrollees in the state as of the current date. Ms. Buckley said her records showed it would be $400,000 per year. When the Fiscal Division confirmed all of that, Ms. Buckley said the committee would see that the budget fit the amount currently brought to it.

Mr. Goldwater asked who would be performing the audit function to determine if the HMO's paid correctly. Mr. Schmidt said the bill placed that responsibility on the insurance commissioner. The insurance commissioner already regulated those entities, and Mr. Schmidt assumed he collected fees related to those organizations. Also, the bill required the commissioner to remit the amount for deposit. Mr. Schmidt said the report indicated under traditional health care coverage, which included HMOs, PPOs, and fee for service coverage, the number of people covered totaled 487,000. When the fiscal note was prepared, the office tried to be conservative to try and ensure the dollar would pay for enough programs, and generate enough funds to pay for the unit. If there were any extra funds, it might be appropriate at a later time to adjust the fee so it did not generate too much money. It was important to make sure the amount of money was adequate to cover the fiscal note, and Mr. Schmidt felt it did.

Mr. Hettrick noted Mr. Schmidt mentioned hiring a health care professional for the office, and that Mr. Schmidt did not think this would be an issue with the Attorney General. The threat though would be beneficial because the office would be in the Attorney General's domain. Mr. Hettrick said those companies were honest companies and if the intent was to threaten, he thought it was inappropriate. Mr. Schmidt said as far as he was concerned there was a significant difference from a consumer's perspective when they were trying to deal with a company that was denying a claim. If the consumer tried to remedy the situation themselves, there was a different perception on the part of the entity who was making the decision, than if there was a person who had legal authority. This was a difference in perception, and was important since the majority of claims that were handled within the insurance commission were related to delays in settling claims. Mr. Schmidt thought people would experience fewer delays if they had an advocate who could make a statement on their behalf.

Mr. Hettrick said his understanding of the way the MCOs worked was they had a doctor who ultimately decided on the denial of care or the modification of care. Would there be a doctor in the office who could discuss the merits of treatment? Mr. Schmidt said to put a full time doctor in the office would be virtually cost prohibitive. Also, it was not necessary on a daily basis. Mr. Schmidt thought it was necessary to have people there who understood medical technology, knew how to talk with doctors and understood health care laws. On the other hand, there was a provision for a source of funds for expert witnesses and litigation, which could be used to have a doctor acting as a consultant to provide counsel when there was a significant difference in opinion. That would give a check on behalf of the patient, but might also verify the opinion of the provider.

Mr. Hettrick asked if an expert witness had to be hired to confirm a doctor's opinion, would the office do this as a consultation, or an expert witness. Mr. Schmidt said the amount allocated would not pay for many expert witnesses, and he expected that money to be used effectively for consultation. That type of money was used in the utility advocacy unit to obtain advice and assistance related to utility matters. Mr. Hettrick argued even as a consultant it would take more time rather than less time. Most of the time when the MCOs received complaints they were handled very quickly. He was concerned those changes would not speed up the project. Mr. Hettrick was also concerned with the issue of collecting and auditing the money. Ms. Buckley answered the MCOs did handle and resolve a large number of concerns, and would continue to do so. The ombudsman was there only for people who did not have their claims resolved in a timely manner and who did not get the help they needed. Also, it made sense to have people with health care experience to be the specialist, with an attorney who had health law experience supervising them. Ms. Buckley said it was more cost efficient that way than it would be to hire a doctor. Many of the complaints Ms. Buckley had resolved in the last year did not require a doctor to solve them. The woman who had a mastectomy, for example, had a case that Ms. Buckley worked to resolve since she was advocating for the client and explaining the medical indicators to the provider. Ms. Buckley said someone was needed to push a little bit, and did not need to be a doctor. There was a list of doctors already ready to consult on the issue. There would not be a traditional expert witness fee either. On the insurance commissioner, many of the companies were Nevada bound and honorable. Ms. Buckley said if the commissioner had reason to doubt those numbers, she could put a fiscal note on them. Mr. Schmidt said he thought the numbers expected to generate the funds would be consistent with the numbers shown by the insurance commissioner addressing the number of enrollees. That capability was there if the legislature felt it was necessary to perform an audit at any time. Mr. Schmidt said this would not involve any full time employee position. If the insurance commissioner felt there would be a fiscal impact, she would have to come and explain that to the legislature since Mr. Schmidt did not want to speak for that office.

Alice Molasky-Arman, Department of Insurance, said the department did receive a request for a fiscal note from the Legislative Counsel Bureau several months ago on the bill. As she recalled it was approximately $60-65,000 per year for the insurance commissioner's office to carry out its responsibilities, including the assessment. There were several assessments the departments collected from insurers and licensees. There was an element of enforcement to that assessment obligation. The department did have licensees and holders of certificates of authority who failed to pay assessments on a timely basis. There was a certain amount of record taking that was entailed in such collections. Additionally another part of the fiscal note was entered because of the responsibility of the commissioner to provide records to the office of the ombudsman. Any or all parts of the department's records of health insurance contract filings, rate filings, and advertising material were included.

Paul Gowins, speaking on behalf of the Disability Forum, said his organization was part of the Health Care Reform Project. Mr. Gowins referred to Exhibit F (on file at the Legislative Research Library), a document prepared by the Nevada Health and Law Program, and said the document contained relevant information. There was one document in particular, on page 5 of the exhibit, which addressed what would happen with an ombudsman program. The document outlined some of the key elements of such a program, and discussed adequacies of the program and how independent it would be. Mr. Gowins said on page 10 of Exhibit F there were some examples of ombudsman programs in other states, and some staffing differentials. Mr. Gowins said the document provided a consumer oriented outlook and outlined some of the issues the committee would be looking at when making decisions. He added there were bills on this issue that would also need to be addressed. The Disability Forum supported the concepts found in the study.

Mr. Goldwater asked if any of the 400,000 enrollees discussed previously were involved in state managed care. Ms. Buckley said the plan was to exclude that so there would be no General Fund impact.

Mr. Hettrick said he had concerns about putting the office of the ombudsman in the Attorney General's office. Mr. Gowins said he had discussed it with consumer groups and they did not want that office in state government, but wanted it in a legal advocacy aspect, outside, of state government. The disability groups made a compromise and said they would support the office being in the Attorney General's office. When the commissioner's office was mentioned the groups felt it was like watching a chicken in a henhouse because the commissioner dealt with those people on a daily basis. The commissioner went to lunch with those people, and knew them as friends. Mr. Gowins said it was very hard to advocate when a person was doing business with those people on a daily basis. He added the disability community felt the advocacy component was important. With no teeth, it meant nothing.

Ed Fend, American Association of Retired Persons (AARP), said he supported A.B. 310. He spoke in opposition to a bill brought up in the Senate that was going to

place the office in the insurance commissioner's office. The AARP strongly supported A.B. 310.

Bobby Gang, Nevada Women's Lobby and National Association of Social Workers, stated she supported A.B. 310 along with the Progressive Leadership Alliance of Nevada.

Laurie England, Division of Health Care, Finance and Policy, asked if the intent was that Medicaid managed care would be exempt from the ombudsman bill. Ms. England stated an exemption would create the potential for a tremendous amount of confusion within the Medicaid managed care population. Ms. England said the recipients were under mandatory managed care, federal and state regulations, and were in accordance with the balanced budget act. It was Ms. England's recommendation that it be totally exempted. If that was not the case there needed to be a significant amount of collaboration made possible by the office of the ombudsman to avoid confusion. The division did monitor the quantification and qualification of those parameters.

Mr. Goldwater asked if Ms. England was from a state or federal Health Care Financing Administration. Ms. England answered she worked for the Division of Health Care Finance and Policy. Mr. Goldwater asked if Ms. England communicated her concerns to the sponsor of the bill. She answered she had not. Mr. Goldwater added as a matter of protocol, he hated it when the agencies came up and testified against his bills without telling him. He noted that Ms. England seemed to be in fact advocating for the bill. Mr. Goldwater did not see how an ombudsman could possibly complicate the process. Ms. England said it was that it would confuse the process more than complicate it. Mr. Goldwater said an ombudsman could point out remedies that were not being used at that point.

Bob Ostrovsky, Nevadans for Affordable Health Care, said his organization was interested in keeping the cost of health care under control and in finding ways to provide insurance to the uninsured. He pointed out the bill imposed a tax on small employers, not on Medicaid or Taft-Hartley trust funds. The bill applied a tax only to those companies that bought their insurance in the open market as a fully insured product, or to individuals who bought insurance policies in the state. For the most part it was small to medium sized employers who bought those plans. Those employers were being asked to pay for a service to be provided to every beneficiary in the state, including ARISA plans and Taft-Hartley trust funds. Mr. Ostrovsky said his organization believed the ombudsman was an appropriate mechanism that should be in place and the organization supported the office being in the insurance commissioner's office. The organization also supported the bill coming from general tax revenues. Mr. Ostrovsky suggested taking the funds out of the insurance premium taxes being paid by some people. He added that didn't work either because the funds couldn't be taken only from the self-insured. Affordable Health Care thought the obligation was a General Fund obligation, and that the $400,000 budget was going to be small. The organization also had concerns about placing the office in the Consumer Advocate's office.

Mr. Ostrovsky said in the previous year the Consumer Advocate's office had a five-year backlog. He thought the office would now have to gear up- to do a new job. At least in the insurance commissioner's office there was access to the plans and documents, and people understood the issues. If the office was weak in some areas, such as in medical advice, someone ought to be hired for that. In the 1997 legislature an 800 number was installed to give the public access to information. That had only been in use for less than 18 months and already the legislature was talking about redefining it and moving it somewhere else. Mr. Ostrovsky said this was wasteful government and was wasting a lot of effort that had already been put into the insurance commissioner's office. For many reasons, Affordable Health Care did not support an effort to create a tax on small employers for all Nevadans. Mr. Ostrovsky urged the committee to look for General Fund money to process such legislation on ombudsman. He strongly encouraged the committee to put the office in the insurance commissioner's office.

Mrs. Chowning asked if Mr. Ostrovsky thought the office for hospital patients should be a General Funded department. It was totally funded with assessments to the hospitals, which was a budget of approximately $200,000 that served around 200 patients. That was in effect an ombudsman, with the assessment coming directly from the industry in which the disputes originated. Mr. Ostrovsky suggested everyone in the state was using the hospital, and had the right to use that office in the event of a dispute. The hospital was getting its income from all sources; self-insured, and Taft-Hartley plans.

Pam Miller, Registered Nurse and American Association of Managed Care Nurses (AAMCN) Board Member, said her organization was formed to help correct inaccuracies portrayed about MCOs in the community. The AAMCN was concerned that the ombudsman was being placed in the Attorney General's office, which, in essence, criminalized the MCOs. The AAMCN felt if the bill was drafted in fairness, it would apply to all medical insurance populations, and not just the private sector. They also felt that was a duplication of a process that was already in existence, and the cost of the program did add up. Those 400,000 members accessed care through the MCOs, and the cost would end up on the individual enrollee. The insurance companies were doing proactive programs for members, including programs on disease management, quality improvement, and catastrophic case management. The cost of the program would go to the private sector, and the money would start to dwindle as all of the extra costs were added. As specialized professionals in the field, the AAMCN did not advocate sacrificing quality care. Who was the advocate for the member? Ms. Miller said as case manager she was an advocate for that member within the MCO. The case manager was the person who helped explain things, and who understood the benefits and how to maximize them. The caseworker also understood the appeals process and helped the member through it. If there was a problem, that case was sent to the case manager. A member would receive a letter when a claim was denied, but what often happened was the member would receive a call from the case manager who would explain the denial and the process. More often than not the problem was a simple miscommunication and once the information was brought forth the appeal was turned around. There were nurses out there who advocated quality care within their MCOs who did it well. Adding the bill just added another layer of bureaucracy, which did not really help the consumer out there who would then have to pay for the bill. As a consumer who bought her own heath premiums, Ms. Miller said she was not interested in having those premiums go up.

Ms. Giunchigliani commented she did not think the bill would really raise anyone's premiums. In fact, the bill may help save costs by making sure the consumer knew what was available to them. In the long run a commensurate reduction would be seen. That was the goal, and it should be noted the committee would not even be discussing the need for an ombudsman if there were not complaints registered. If the insurance industry really cared, they would cover prevention -in the first place, and make sure the consumers were protected.

Fred Hillerby, Home Town Health Plan and the Nevada Association of Health Plans, said he took thousands of calls a year from consumers. He believed there were consumers that needed assistance, and if that was so, this discussion should address where that help belonged. The insurance division's role was to regulate insurance, and it was not really there for the consumer. Mr. Hillerby said Nevada Revised Statutes (NRS) NRS.679A.140 was passed in 1971 and stated the purposes of the insurance division's office: to protect policy holders; to implement the public interest in the business of insurance; insure that policy holders, claimants and insurers are treated fairly and equitably; and prevent misleading, unfair and monopolistic practices in the insurance industry. Mr. Hillerby said the consumer division's job was to deal with consumers. The industry was already under a bifurcated regulatory scheme and had responsibilities to the division of health and the insurance division. A third layer was not warranted at that time. Mr. Hillerby added the funding mechanism had already been discussed so he would not get into it. He reminded the committee they were asking less then 1/3 of the population to fund a function that would be available to the entire population. There was no equity in that. Mr. Hillerby said if that was an important issue the committee could find room in the General Fund for it, instead of figuring out someone else to pass the responsibility on to.

Ms. Giunchigliani asked if Mr. Hillerby's objection was to the location of the ombudsman, and if he otherwise supported the bill. Mr. Hillerby said the office ought to go in the insurance division. Mr. Hillerby said the division was there practically begging for their share to effectively regulate an industry that needed good regulation. The industry needed good regulation because the consumer was protected that way, as well as the good business operators.

Marie Saldo, Health Plan of Nevada and the Nevada Association of Health Plans, pointed out the bill did not require exhausting the internal remedies of the health plans that exist, nor did it require them to live within the policies. She added it was not fair to dismiss the investment in technology and resources made over the last several years. Industry-wide, the health plans had more than 700,000 phone calls from their members over the course of the last year. In her office, there were 461,000 calls. Three-thousand of those calls went to appeal, and over 50 percent were overturned. To imply that the health plans were not trying to make their systems easy to navigate was grossly unfair. Ms. Saldo did not deny that people did fall through the cracks and things could always be done better, but the investment and the technology were there. The health plans put in a lot of effort in 1997 so that they could add members to the review committees. The health plans had always been there, and came to the table. This time, a tax was being imposed on everyone.

Ms. Giunchigliani said the issue was the need to find a way to compliment what the MCOs were already doing internally by utilizing the state ombudsman.

The heating on A.B. 310 was closed.

The discussion of the budget was moved to Thursday March 25, 1999.

Vonne Chowning, Assemblywoman, said A.B. 356 was an appropriation of $200,000 for a continuation of a very successful program in Clark County. The

program was a family literacy program that helped students who were non-English proficient or limited-English proficient. The money had been used for kindergarten students as well as family members. Not only could the children be taught English, but their parents were also helped. Three out of four students brought a relative with them to the program when they participated. Mrs. Chowning said she wanted the families to be involved with the program since family involvement was an important component to learning. One positive outcome of the program was the parents were much more comfortable at the school sites. Without exception, every single one of the family members was non-English speaking, or limited-English speaking. Seventy-five percent of high school students in the state had not passed the math portion of the proficiency exam. Much of the program gave the students instruction so that their oral skills were advanced overall in school. Part of Mrs. Chowning's task was to create an evaluation because she was on the Ways and Means Committee and was very fiscally conservative at home as well, and she wanted accountability and evaluation. There were pre- and post-tests done on the students and 47 percent of them showed proficiency in English.

Mrs. Chowning said she wished there was that kind of accountability in pre- and post-testing in all learning programs. In the literacy program the dollars were accounted for as well. The program was operating in 18 schools, where over 350 kindergartners had been reached, and 500 books distributed.

Martha Tittle, Clark County School District, said the district was very grateful for the committee's willingness to provide resources to the area's non-English and limited-English speaking children.

Clara Miranda, Administrative Specialist at the English Learner Programs Department of Clark County School District, supported A.B. 356. Her testimony went as follows:

Mrs. Cegavske asked if there was not enough funding in the program to get each child his or her own individual book. Ms. Miranda answered the copied books were not textbooks but were culturally appropriate reading books. There were 20 copies of the books, and the children could take them home. Ms. Miranda added most of the titles the program had were in English, and they needed to acquire more books in Spanish. Mrs. Cegavske asked what the extra duty reference was, and what type of training was involved. Also, she wanted to know if the instructional materials included books or a booklet. Ms. Miranda replied the materials were actual books, and the program had purchased a series of books and materials that had been developed for the English as a Second Language component of the program. The program was expanding to provide actual books. The extra duty pay for teachers was $20 per hour for an after-school type of activity as well as weekend activities. Mrs. Cegavske asked if the program utilized what the school had and used the instructional materials as a supplement. Ms. Miranda answered the materials were specifically designed to promote literacy and were literature based reading materials. Mrs. Cegavske asked how much one copy of a book would cost. Ray Medina answered approximately $2.95.

Mr. Medina said the reason the program needed the books and materials was they trained the parents how to work with literature in the home with the children. If the program trained the parents how to do that, there needed to be something that could be sent home with the child to practice on. The goal was to get those kids into English, although everyone called the program a bilingual program. Instead, it was the goal of the program to make those kids bilingual, since the program was not interested in monolingual children. In reality, if those children were going to be successful in the Clark County region, and in the United States in general, they had to be able to speak English.

Ms. Giunchigliani asked if there was side-by-side learning being done in the program, and if the program was tracking the children who had been in the program. She added that made good sense, and she was curious to see what the successes of the program children would be.

Bobbie Gang, Nevada Women's Lobby and the National Association of Social Workers, said both organizations strongly supported A.B. 356. Nevada had a more diverse and growing student population than ever before. Also, there were new legislative requirements that students meet higher standards. Setting higher standards, without eliminating the inequities facing children with English language problems, would make those problems even worse. Mrs. Gang added she hoped the legislature would continue to support and expand the program.

The hearing on A.B. 356 was closed.

Marta Williams, Senior Research Analyst Legislative Counsel Bureau, spoke on behalf of Senator Raymond Rawson, Chairman of the Interim Legislative Committee on Health Care. A.B. 146 resulted from a subcommittee for the aged and disabled on Medicaid. Essentially, that measure gave the Health Care Committee some oversight over a study to assess how they could determine the quality of care that people who were not on Medicaid managed care programs were getting.

Don Hataway, Budget Division, said the committee might want to consider making the bill effective on, or before, June 30, 1999 instead of in the next fiscal year. For example, the Maximus money might be in excess of what the state already reserved for reversion. It might be more appropriate to take the money out of surplus from that biennium and not compete with funding from next biennium.

The hearing on A.B. 146 was closed.

RESPECTFULLY SUBMITTED:

Cynthia M. Cendagorta

Committee Secretary

APPROVED BY:

Assemblyman Morse Arberry Jr., Chairman

DATE: