The Joint Subcommittee on Human Resources/K-12 of the Senate Committee on Finance and the Assembly Committee on Ways and Means was called to order by Chairman William J. Raggio, at 8:00 a.m., on Thursday, March 11, 1999, in Room 3137 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Attendance Roster. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.

SENATE COMMITTEE MEMBERS PRESENT:

Senator Raymond D. Rawson, Chairman

Senator William J. Raggio

Senator Bob Coffin

Senator Bernice Mathews

ASSEMBLY COMMITTEE MEMBERS PRESENT:

Ms. Jan Evans, Chairman

Mr. Joseph (Joe) E. Dini, Jr.

Mr. David E. Goldwater

Mr. Lynn C. Hettrick

Mr. David R. Parks

STAFF MEMBERS PRESENT:

Patricia Hampton, Committee Secretary

OTHERS PRESENT:

Janice A. Wright, Acting Administrator, Health Care Financing and Policy Division, Department of Human Resources, stated that as of March 4, 1999, 10,385 children have applied for the Nevada Check-Up program. She noted 5,640 children have been approved and of those, 4,508 are enrolled and receiving health care services. The remaining 1,132 will be enrolled once premium payments and the enrollment form have been received.

Ms. Wright stated the U.S. Census Bureau estimates there are approximately 43,000 in Nevada who may be eligible for the program because they are below the 200 percent of the federal poverty level. She pointed out Urban Institute studies indicate of those 43,000, 27,000 are actually below the 200 percent of poverty level, 17,000 would be eligible for Nevada Check-Up and the remaining 10,000 would be eligible for Medicaid.

Ms. Wright explained the program provides Health Maintenance Organization (HMO) type coverage for physician and in- and outpatient hospital services, pharmacy, X-ray, laboratory, dental, vision, nursing home care, emergency and nonemergency transportation, and therapies. She pointed out that three HMOs, Amil International of Nevada, NevadaCare, Inc., and Health Plan of Nevada, are signed up to provide these services.

Ms. Wright said Nevada Check-Up has five full-time employees, one of which is dedicated to marketing and outreach. Beginning in January 1998, Nevada Check-Up staff began developing the marketing and outreach strategies which were included in the state plan submitted to the Health Care Financing Administration (HCFA). Ms. Wright stated staff began meeting in early 1998 with various public and private organizations, including school districts, regarding the program.

Ms. Wright said that in March 1998, with the support of the 17 school district superintendents more than 400,000 applications were distributed throughout the districts, as well as to each Welfare Division district office and to other community organizations. The Nevada Check-Up staff has also attended community events to market the program and assist families in completing applications. Ms. Wright said that to date, more than 500,000 applications have been distributed throughout Nevada.

Ms. Wright stated the staff has been working with Native American entities, including the Head Start program and the Indian Health Services’ (IHS) tribal clinics and hospitals, to inform and educate the groups about the program She said the key is to have the tribal councils inform families about the benefits of being on the Nevada Check-Up program. She noted that in addition to receiving health care services from the current IHS provider, health care can also be received from non-IHS providers. She said staff has given presentations to the executive tribal councils and at meetings and conferences, and the program applications have also been provided through the school districts to all children K-12 (Kindergarten through Grade 12).

Ms. Wright stated that as of March 1999, 278 Native American children have applied for the Nevada Check-Up program and 86 are actually enrolled. She said this equates to 1.9 percent of the total children enrolled in the program. She said the state demographer has indicated the Native American population in Nevada is 33,000, or 1.8 percent of the state’s total population. Therefore, the program has a proportionate number of individual Native Americans enrolled as represented in the state demographics, she said.

Ms. Wright stated staff is working with the tribal councils on how Native American families can be assisted in paying the quarterly premium. Enrolled tribal members can receive free medical services through IHS clinics and may choose not to enroll in Nevada Check-Up. Ms. Wright said program staff have also implemented a number of creative marketing techniques such as mass distribution statewide in Sunday newspapers, public service announcements and interviews on local television and radio stations (including the Hispanic stations), advertising on Model Dairy milk cartons, fliers in Domino Pizza boxes, and fliers enclosed with unemployment checks. She noted families have been assisted with applications at health fairs, federally qualified health centers in Las Vegas, the school districts, Saint Mary’s Hospital, and Washoe Health Systems.

Ms. Wright pointed out the program has been working with the National Governors’ Association to access the association’s campaign, which is entitled "Insure Kids Now." She said that on February 23, 1999, President and Mrs. Clinton announced a venture, which includes a toll-free hotline,1-877-KIDS NOW, that will accept calls from families and direct the calls to each individual’s state Check-Up program or Community Home-Based Initiatives Program (CHIP). She pointed out that Nevada’s bilingual 24-hour toll-free number is Nevada’s hotline. She said that on the first day President and Mrs. Clinton announced the federal program, Nevada’s toll-free hotline received more than 85 calls.

Ms. Wright stated fliers were distributed to children enrolled in the reduced or free lunch program in the schools. Additionally the department has been working with the statewide Covering Kids Coalition of the Great Basin Primary Care Association with their effort to apply for a Robert Wood Johnson Grant Foundation grant..

Ms. Wright said the coalition was originally requesting more than a $1 million grant award over a 3-year period; however, the grant application was revised to approximately $850,000. Should the association’s application be approved, the monies will be used for statewide marketing and outreach at the grassroots level to enroll uninsured children in the Medicaid or Nevada Check-Up program. Ms. Wright stated approximately 20 states have been awarded the "Covering Kids" grant.

Ms. Wright reviewed activities for the second phase of the marketing and outreach efforts which began March 1, 1999. She said the national program "Insure Kids Now" will phase in radio campaigns in Nevada over the next 4 months. Outreach eligibility staff will be provided throughout the state, at prearranged times and locations, to assist with application completion for target populations. Ms. Wright pointed out that outreach will be during nonbusiness hours so that working individuals will have an opportunity to fill out applications during nonworking hours. She said there will be coordination with other agencies to insert information about Nevada Check-Up in other agency handouts and applications such as Women Infants & Children USDA Special Supplemental Food (WIC) and Title V programs.

Ms. Wright stated more eligibility training will be provided to community-based organizations, including schools, federally qualified health centers, Head Start programs, IHS, and sister agencies. She said coordination with the 17 school districts will be continued and information about Nevada Check-Up will be provided through school registration, school nurses, and the reduced or free lunch programs. She pointed out there is coordination with the schools sports programs by inserting information about the Nevada Check-up program in the schools’ mandatory physical examination forms.

Ms. Wright explained that coordination with child-care centers, faith-based organizations, Boys and Girls Clubs, and temporary personnel organizations will also be continued. She said there is a division plan for an "on the road" rural tour which will be contacting schools, hospitals, and sister agencies to schedule meetings and distribute posters and brochures to the groups, as well as to physicians, pharmacies, community health centers and hospitals.

Ms. Wright stated the agency is seeking a celebrity to act as a spokesperson for Nevada Check-Up. She said a major reason for having the children’s health program separate from the Welfare Division is to remove the concept of "being on welfare." She emphasized Nevada Check-Up is not an expanded Medicaid program and is therefore not an entitlement program. She said this allows for control of the program cost. She stated the program can cover children of families with incomes up to 200 percent of federal poverty level and allows eligibility coverage for up to 1 year. The program also charges and collects quarterly premiums.

Ms. Wright pointed out that as of March 1, 1999, the Nevada Check-Up program has collected more than $64,000 in premium payments and this money is used to offset the cost of administering the program.

Ms. Wright stated that the second reason to separate the program from the Welfare Division is to allow for a simplified application and eligibility process. The Nevada Check-Up application process is simple in that the application packet is bilingual and includes information on both Nevada Check-Up and Medicaid. Ms. Wright pointed out the application is a 1-page, 2-sided application and bilingual staff is available during office hours and on the toll-free hotline after hours to respond to callers’ needs. She said a face-to-face interview is not required for the program. The only documentation a family has to provide with the application for Nevada Check-Up is a copy of the two most recent pay stubs for each financially responsible working adult in the household and the two most recent federal income tax returns for a self-employed household. Ms. Wright noted a resource or assets test is not required and the eligibility is based on the gross annual income.

Ms. Wright said that even though the number of pages in the Medicaid application has been reduced, the application process is more cumbersome than for the Nevada Check-Up program. She explained that Medicaid and Nevada Check-Up have devised a Medicaid screening process to determine whether or not a child who is applying for Nevada Check-Up may be eligible for Nevada Medicaid. Individuals appearing to be eligible for Medicaid are notified so application can be made to the Medicaid program.

Ms. Wright called attention to a number of success stories of children enrolled in the Nevada Check-Up program. She mentioned an infant, under the age of one, who was found to have lead poisoning. She said the child might have had neurological disorders had the poisoning not been detected. She called attention to a 4-year-old who had undergone two ear surgeries and needed a third, which he has received. She said the child is now learning how to talk. Ms. Wright said a 9-year-old, who for over 6 months had been having headaches of unknown origin, is now receiving additional tests covered under the program. The final case was a 17-year-old awaiting a heart transplant. Ms. Wright said the procedure will be covered under the Check-Up program.

Ms. Wright stated Nevada Check-Up’s proposed marketing and outreach slogan will be "Check-out, Check-Up." She maintained the success stories are examples of what the children’s health insurance program is all about.

Ms. Wright called attention to the fact Nevada Check-Up is not included in the base budget because it was not approved by the previous legislative session but was approved through the Interim Finance Committee (IFC) during the interim. She explained all of the base expenditures have been moved into enhancement module E-275. This module recommends continuation of the funding for the program. Ms. Wright called attention to the deletion of two positions previously approved by IFC. She said the projected rates for the program are $1,300 in Fiscal Year (FY) 2000 and $1,350 in FY 2001. Ms. Wright stated 10,000 children are anticipated to be served over the upcoming biennium.

Ms. Wright stated module E-904 recommends transferring a Personnel Analyst II position from the check-up budget to the Division of Health Care Financing and Policy’s administrative budget.

Ms. Evans asked what the agency originally requested for the check-up budget versus what the Governor has recommended. She asked what the figures the agency requested represent. Ms. Wright answered the agency had requested funding for additional caseload and positions. She said the difference in the first year of the biennium included funding for seven new positions, and $8.9 million to cover an anticipated 16,875 children in FY 2000 and $16 million in FY 2001 to cover 21,875 children. She stated the only other differences between the agency’s request and the Governor’s recommendation had to do with several Child Health Assurance Program (CHAP) enhancements which would have increased Medicaid expenditures and reduced expenditures by a corresponding amount in the Nevada Check-Up program. The purpose of the proposal was to make a more "seamless" process.

Ms. Evans asked "about the operation of the three HMOs in the counties other than Clark County." Ms. Wright explained that in counties without HMOs a fee-for-service is used. She said that based on the 5,640 children who have applied and been enrolled, 3,021 are in Clark County and the remainder are served on a"fee-for-service" basis outside of Clark County. She stated the agency anticipates working with the HMOs to develop provider networks in other areas. She said there is an opportunity for an additional contract, which was to go to the State Board of Examiners (BOE) the previous day, that would add United HealthCare as an additional HMO to Clark County. Ms. Wright stated she is anticipating approval of the contract. Additional HMOs are being sought to provide service in Washoe County, she testified. Ms. Wright pointed out only one HMO is under contract in Washoe County at this time.

Ms. Evans asked whether the reimbursement rate is a factor. Ms. Wright responded the reimbursement rate has not been cited as a problem. She said one concern of the HMOs is that Nevada Check-Up is a new program and the companies want to review the program and determine whether or not it fits into the company plans. She pointed out there have been successes with the existing HMOs that have contracted services in Clark County and she is hopeful their success will send a message to other companies that the program is viable, the rate structure does work, and the compensation will be fair.

Ms. Evans said she would like to hear from the companies on this issue. She pointed out the numbers are so far rather small and said there needs to be a critical mass to attract an HMO. She asked what the differential is between fee-for-service and a contracted or negotiated rate. Ms. Wright answered there is no way to gauge this because whatever the service is, the fee is reimbursed at the Medicaid rate.

Ms. Evans asked how the application for the check-up program and Medicaid compares to those in other states. Ms. Wright addressed what has been done in Arizona and California in comparison to Nevada. She said the children’s health program application in Nevada is separate from Medicaid whereas in Arizona and California the applications are joint. She stated the similarities are that there are no asset tests and there is a waiting period. There is a 6-month waiting period for the health insurance in Arizona and Nevada and a 3-month waiting period in California.

Ms. Wright stated according to the census bureau projections, the check-up program has enrolled 10 percent of the estimated number of uninsured children in Nevada. She said Arizona has enrolled 6 percent and California has enrolled 5 percent. Both of the other states have benefited from large grant awards for marketing and outreach. Ms. Wright emphasized this has not been the case in Nevada and considering the number of children enrolled, the Nevada program seems to be successful.

Ms. Wright added the application is in English and Spanish and has not been a barrier to the program. She reiterated the hot-line runs 24 hours a day to provide assistance to anyone interested in the program.

Ms. Evans asked whether there is a need to provide for individuals speaking other languages. Ms. Wright answered that of the total 10,385 children who have applied, Hispanics were the largest non-English-speaking group. She said that due to limited resources, efforts have not been made to expand to other languages, but that is something which needs to be studied further. She indicated if it is found there are enough individuals of a particular ethnic group enrolling in or showing interest in the program, every effort will be made to contract with someone who can provide assistance in the group’s language.

Ms. Evans asked how service is currently provided to those in other ethnic groups. Ms. Wright responded the agency has been very successful in securing assistance from community organizations within the particular ethnic groups and there has not been a barrier to service for these individuals.

Ms. Evans asked what the possibility of receiving the grant for marketing would do to enrollment in addition to what has been outlined in the outreach effort. Ms. Wright answered that at the time the program was started the projection was there would be more than 10,000 enrollees. She said some families are very willing to seek out this type of insurance, but other families are reluctant and have difficulties that cause them not to enroll in the program.

Ms. Wright pointed out the anticipated numbers of children to be enrolled have been scaled back for the upcoming biennium. If additional marketing and outreach efforts were increased this would increase eligibility and enrollment; the program would reach 10,000 enrollment, and this would create a waiting list for services. Ms. Wright noted if that were to occur, alternative resources should be considered. She said one thing that can be done is to look at the current premium information and make a determination as to whether or not premiums should be raised. Second, she said, the eligibility criteria can be adjusted with respect to income levels.

Ms. Wright stated that waiting lists are always created in waiver programs, and should some individuals currently enrolled become ineligible, these openings could be filled from the waiting list. She said close monitoring will be required.

Senator Rawson expressed concern over the number of children needing these services. He asked Ms. Wright to prepare information showing what could be done with an additional $1 million, $3 million, and $5 million from the General Fund. He emphasized he does not hold out the hope this is possible but said there is a need to know what additional funding would mean to the program in terms of number of children served. Ms. Wright said this information will be provided to staff.

Ms. Wright referred to the Governor’s statement that "no child would be turned away from this program." She said the agency will be working very closely with the Governor’s Office in making accommodations to this program that will allow all eligible children to receive these services. Senator Rawson said a cap has been set at 10,000 because of the budget. He asked, "How will the 12,000^th child be worked into the program?" Ms. Wright said the agency will provide information to fiscal staff on possible options.

Mr. Goldwater inquired whether the program could be attached to Medicaid should Senator Rawson’s concerns be realized. He asked Ms. Wright to revisit the unfunded decision units. Ms. Wright restated her response to Ms. Evans’ questions provided information on the unfunded decision units. She reiterated there was a difference in the unfunded decision units of $7.1 million and of that, seven positions were eliminated and the projected caseload was reduced. Ms. Wright also clarified that the reductions were also due to some CHAP expansions built into the Medicaid program that were ultimately not funded. Ms. Wright stated that makes up the difference between what the agency requested and the Governor recommended.

Mr. Goldwater asked who proposed the CHAP expansions to Medicaid. Ms. Wright replied the agency requested expansions to the Medicaid program. She said the purpose was to make the two programs more "seamless" so there would not be families with one child in the Medicaid program and another in the Nevada Check-Up program. She stated the difficulty is that the Medicaid program is bigger and more expensive and as eligibility is increased on the Medicaid side to allow children into Medicaid, money will be saved in the Nevada Check-Up program. She said the problem is, fewer dollars are saved in the Check-Up program because it is smaller and it takes a lot more money to fund the Medicaid children.

Ms. Wright stated these were the decision modules that made up part of the unfunded decision units. She explained there were four modules. These modules would increase the CHAP age limit to age 18, remove the CHAP assets test, increase the income for Medicaid to 133 percent for all children, and provide continuous eligibility.

Ms. Wright testified there are currently five full-time-equivalent (FTE) Nevada Check-Up staff running the program. She said placing those staff members in Medicaid would have one adverse effect. She explained that once the Medicaid program is expanded, it becomes an entitlement program and the dollars that are expended can no longer be limited. Mr. Goldwater interjected Nevada Check-Up is an entitlement, the Governor has declared it so, and if the number of children are to be limited he wants to know when the children will be "cut off," when the benefits are reduced, and so forth. He stated Nevada Check-Up may not be called an entitlement program, but if it is not and the state intends to reduce benefits the Legislature needs to know well in advance and plan for this possibility in great detail. Ms. Wright pointed out it is never too late to make the decision to place the program in Medicaid. She said that at this point savings would not be generated by "folding" the programs together. In fact, she maintained, it would cost more to bring the programs together.

Ms. Wright said she would do her best to address Mr. Goldwater’s concerns when she submitted program options to the fiscal staff. Senator Rawson said the idea of developing a seamless program, through the waiver process, that changes Medicaid "should not be given up." He stated a medically needed program could be defined that would be more beneficial to the state by using Medicaid.

Senator Rawson said of the 43,000 children identified below 200 percent of poverty, 17,000 are expected to go into the Check-Up program and the remainder are probably Medicaid-eligible. He asked whether there is sufficient funding to identify the Medicaid-eligible children. Ms. Wright pointed out the Urban Institute had estimated 10,000 of the 27,000 below the 200 percent of federal poverty level would be eligible for Medicaid. She said if there are 10,000 moving into the Medicaid program, initially it will be difficult, with the existing resources, to supply services. Ms. Wright noted the agency is having difficulty serving the existing population.

Ms. Wright said that previously she provided testimony regarding some of the difficulties the agency would encounter in trying to serve the Medicaid-eligible children, not only in the existing fiscal year, but in the upcoming biennium.

Senator Rawson asked whether the agency could go to the IFC if the Medicaid-eligible were identified halfway through the biennium and the maximum number of participants was being approached. Ms. Wright responded the Medicaid program cannot request additional money from the IFC. She said the agency would like to have the ability to carry forward program money from FY 2000 to FY 2001. She said she will report to the fiscal staff on a regular basis. She said this can be a subject for the IFC to consider. Senator Rawson stressed the Legislature does not want to face a special legislative session in the interim to deal with this type of issue and he wants to make sure there is a contingency plan.

Ms. Evans asked whether the match required for Nevada Check-Up would continue at the 65-to-35 level. Ms. Wright answered it is anticipated the match will continue at that level throughout the program. Ms. Evans pointed out the attractive match is another incentive to bring all eligible children into the program.

HR, Homemaking Services – Budget Page HCF&P-28 (Volume 2)

Budget Account 101-3250

Ms. Wright testified 100 percent of the revenue in this budget is federal revenue. She said discussion was held during the 1997 Legislative Session on transferring the Elder Protective Services (EPS) and Homemaker programs to the Aging Services Division. She stated there were some difficulties at the end of session so the two programs were placed in the Division of Health Care Financing and Policy. She said the division was directed to come before the IFC and submit a report in December 1997 with a recommendation as to whether these programs should be transferred. It was the recommendation of the Department of Human Resources to transfer the programs out of the Division of Health Care Financing and Policy into the Aging Services Division, but action could not be taken at that time because there were fiscal difficulties for the Aging Services Division that would not be accommodated during the interim. Ms. Wright said it continues to be the division’s recommendation to transfer the Homemaker program to the Aging Services Division, but the Aging Services Division budget presentation will address some additional needs.

Senator Rawson stated Ms. Wright’s input might be needed on the Homemaking Services budget. He said that what is essentially seen is an increase in the administrative costs and a decrease in services. He agreed it might make sense to make the change, but the end result is fewer people will receive services. He said the joint subcommittee is concerned about this.

Jan Gilbert, Lobbyist, Progressive Leadership Alliance of Nevada, said the individuals leaving welfare after the 2-year limit in 2000 will be going on TANF Medical Services Only and yet the projected numbers for FY 2000 are quite low at a 3.55 percent increase. She acknowledged the individuals are currently on Medicaid along with welfare, but this is a category set aside for TANF Med Only. She pointed out that growth in FY 1999 was 12.16 percent and it would appear something is wrong with the projected growth figures.

Ms. Gilbert said it is alarming to see such a small projected increase when in reality there will be a large number of people leaving welfare. She stressed she does not want to see the state "in a bind" in the year 2000 when the needs cannot be addressed and other services have to be cut in order to provide services. Senator Rawson stated these projections will be reviewed at the end of March.

Ms. Gilbert stated there is concern the numbers will rise in the Nevada Check-Up program and the idea of a waiting list is discouraging. She stressed this program is not an entitlement, rather an insurance program for low income families. She said she would not like to see the alternatives mentioned being implemented because it would be a discouragement to people who are very enthusiastic about the program. Senator Rawson pointed out the alarming aspect is the increasing number of uninsured.

Jon L. Sasser, Lobbyist, Washoe Legal Services, said a great deal of the interim health committee’s time was spent overseeing the early stages of the Check-Up program and making recommendations which included making the program "seamless" with Medicaid. He said he is more concerned than ever about the program. He acknowledged the "incredible" job done by the existing staff in marketing the program but said these individuals do not have the time to go into the neighborhoods and meet with community groups.

Mr. Sasser maintained the purpose of the Robert Wood Johnson Grant is not to supplant what the state is supposed to do, but to work in cooperation with the state to reach families in the neighborhoods. He emphasized the grant will not supply the staff to take the place of what the state should do.

Mr. Sasser noted the Governor is saying the program is not capped and a child will not be turned away, but Ms. Wright is discussing what will be done when the cap is reached. He pointed out that last year 86,000 children were at some level of having no insurance. He said there is an ironclad 6-month waiting list, "in terms of when an individual had insurance." Mr. Sasser said the projected caseload increase for Medicaid is too small.

Mr. Sasser stated the lengthy application described for Medicaid covers several programs and it is his understanding that before plans were dropped for a "seamless" program, staff had developed a 2-page joint CHAP and Check-Up application that could have been used and would have been very user-friendly. Mr. Sasser said that as an advocate for children, he is concerned the number of participants is being artificially limited.

HR, Aging Older Americans Act – Budget Page AGING-1 (Volume 2)

Budget Account 101-3151

Carla Sloan, Administrator, Aging Services Division, Department of Human Resources, stated previous concerns in this budget revolved around the Older Volunteer programs and the Senior Ride program. She said the Senior Ride issues have been addressed.

Ms. Sloan provided an information handout on the Older Volunteer programs (Exhibit C). She stated the information represents a breakdown of the source of funding for individual programs. She said the 7 programs began receiving funding from the state during the last biennium. Prior to that time only 3 programs had received state funding. She pointed out the handout shows the continuation of the funding for the 3 volunteer programs because those revenues are part of the base budget. The other programs would require approval of an enhancement that is not included in the Governor’s budget, she stated.

Mr. Dini asked where the Home Companion program fits in. Ms. Sloan replied the Home Companion program is part of a senior volunteer program. She said Rural Nevada RSVP offers the Home Companion program. Mr. Dini asked whether funding has been eliminated for the program in Carson City. Ms. Sloan answered there is no funding for the Carson City and Clark County Home Companion programs, or for the Senior Companion programs in Las Vegas and northern Nevada.

Senator Rawson noted the Sanford Center is the only program funded. Ms. Sloan said that at one time the Foster Grandparent programs and the RSVP program at the university required a match for federal grants. She said her understanding is the match is no longer required, but that is how it began.

Mr. Dini stated it appears a lot is done with $40,000 a year and all of the volunteers, to keep people out of nursing homes. He said it would seem the budget could be expanded to reinstate these types of programs to make life better for senior citizens. Ms. Sloan stated the programs do provide a very valuable service and have met program goals, and performance indicators are "right on-line."

Senator Rawson asked whether there is any possibility of increased grants or donations to cover some of the cost. Ms. Sloan replied all programs have been encouraged to research fundraising and the division will work with the programs to provide technical assistance to increase fundraising skills. She said the programs are eligible to compete for Title III-B funding received under the Older Americans Act. She pointed out that currently the two Senior Companion programs do receive Title III-B funding. She said the division is receiving grant applications for the federal funds and the awards will be made on a 2-year cycle. Ms. Sloan explained it is important to understand no increase has been received in federal Older Americans Act funding, so if she is required to provide for a program that has not previously received state funds there will be a reduction to the funding level of a program that is currently receiving the federal funding.

Senator Raggio stated there are approximately 600 people involved in the program and if one of the individuals ends up in a nursing home the $40,000 savings will be lost. He stated if there are no General Fund dollars available for the programs, there is a need to be smart and creative to see whether there are other sources of funding.

Mr. Goldwater pointed out that last year the Democratic-Republican basketball game raised approximately $10,000 for the Boys and Girls Club and this year funds will be raised for the Foster Grandparent program. He said the game might be one source of a donation to the Home Companion programs in Carson City and Clark County and the Senior Companion programs in Las Vegas and northern Nevada.

Senator Raggio asked whether the net change in each program shown in Exhibit C is the change for one year. Ms. Sloan responded yes. Senator Raggio pointed out that in order to restore the programs the net changes would have to be added together and that figure doubled. He asked whether the $17,249 for the RSVP programs represents the Home Companion programs that are deleted. Ms. Sloan explained the RSVP program is one of the programs which will receive funding through the base budget. Senator Raggio said it was his understanding there is a differential between what the funding was for this year and what is proposed for next year. He noted the Home Companion programs are not listed. Ms. Sloan said that is correct. Senator Raggio asked the total cost of the Home Companion programs that are being deleted. Ms. Sloan answered the total enhancement funded in the last biennium was approximately $248,000 a year for all volunteer programs.

Ms. Sloan emphasized it would take a total of $360,000 to restore the programs to current funding levels. Senator Raggio said this is his concern. He said everyone would like to restore the programs; however, it is important to take the whole picture into consideration rather than pick one or two programs. He requested statistics on all the programs eliminated. Ms. Sloan stated the Home Companion program is provided by the Rural RSVP program. She said the $40,000 that has been cut from the program is reflected in Exhibit C. She explained the $40,000 does not fully fund the program.

Senator Rawson pointed out the funding was an enhancement last biennium and asked whether the programs can continue in some form if cut back to the levels that existed before the enhancement. Ms. Sloan answered that if the programs were cut to the levels that existed before the enhancement and funds were earmarked as they are now in the base budget, the only programs that could be funded are the 2 Foster Grandparent programs and the Reno RSVP program.

Ms. Sloan explained that because the programs no longer need the funding for match, there is the option of not earmarking the funds for the 3 programs and allowing the 7 programs to compete for the grant funding

Ms. Evans said she does not understand what the figures in Exhibit C represent, especially in terms of percentages. She stated the Older Americans Act on page 3 of The Executive Budget shows the RSVP work program decreasing from $112,000 to $18,000, which she remarked is a significant difference. She pointed out the Foster Grandparents work program was $184,000 and the recommendation for funding is $92,000. She said what is indicated in The Executive Budget does not equate to what is shown in Exhibit C.

Ms. Sloan stressed Exhibit C is not intended to show only state funds, it shows the total funding sources program by program. She said the Rural RSVP program received a total of $410,761 for all services and the percentages shown are the percentages of the total program budget. She noted the state funding of $40,000 is 10 percent of the total budget. Ms. Sloan pointed out that Exhibit C is not intended to give a reflection of the division budget request. She said the reductions between the work program and the agency request are the difference between the full enhancement of $360,000 and the $111,000 now in the base budget.

Senator Rawson inquired about the Nevada Elders on the Net (NEON) project. Ms. Sloan said Project NEON is a component of the Insurance Counseling and Assistance (ICA) program that was transferred from the Division of Insurance to the Aging Services Division effective October 1, 1998. She stated the project will establish a website that will allow consumers, family members and seniors to access information on Medicare benefits and a number of other services available for older persons in the state and nationally.

Ms. Sloan explained that because this is a website project, before the division could go to IFC with the work program to accept the federal grant for the project it would need the Department of Information Technology (DoIT) to approve the computer component. She said hardware and software will be provided to 20 locations throughout the state for use by volunteers and seniors to access the site.

Ms. Sloan said DoIT has reviewed the computer portion but wanted to review the entire program. She stated the division has provided the information and DoIT has a clear understanding of both the project and the technology. She said a "signed off" plan will be submitted to DoIT today and she expects that agency to sign off also. She testified the work plan has been revised and as soon as DoIT approves the plan the division will go to the IFC.

Ms. Evans noted the Senior Ride program budget is based on 16,000 coupon books a year. She asked whether this is the number of books used in the past. Ms. Sloan answered yes. Ms. Evans stated it appears everything will work out with the Taxicab Authority funding, but she asked the joint subcommittee to consider a letter of intent to the Taxicab Authority stating that if revenue can support increased numbers, perhaps the Authority could come to the IFC for authorization to increase the numbers. Senator Rawson stated he would like to see 24,000 of the books be made available if possible. He said a letter of intent will be directed to the Taxicab Authority.

Ms. Sloan noted discussions have been completed with the Nevada Department of Transportation (NDOT) and the department has agreed to provide the funding to produce and print the transportation pamphlets.

HR, Senior Services Program – Budget Page AGING-10 (Volume 2)

Budget Account 101-3146

Ms. Sloan testified the home- and community-based waiver programs are funded through this budget. She said that since the last meeting, information has been provided on the waiting lists and the per-person cost of service. Senator Rawson stated the waiting lists are longer than one would like. He asked whether there is priority by income. Ms. Sloan answered a preference is given to those at greatest risk coming out of a hospital or a group care facility. Senator Rawson said he understands most of the high priority lists are being met. Ms. Sloan agreed.

Senator Rawson stated the figure to be aware of is the $628 a month per person to add an individual to the Community Home-Based Initiatives Program (CHIP) in FY 2000. To change the waiting list would cost approximately $7,500 per placement. Ms. Evans asked when the last CHIP increase occurred. Ms. Sloan answered Title XX funding was received during the last legislative session. She said that under Title XX funding the eligibility criteria for most of the families applying for CHAP include family income, whereas CHIP counts only individual income. She stated this prohibits the program from being expanded as would have been desired, but the funding might have made a difference for the state program.

Senator Rawson pointed out there is not a waiting list on Title XX funds. Ms. Sloan agreed it is those above the income ceiling who are on the waiting lists. Ms. Evans noted the last significant funding increase for the state program was in FY 1996 when funding increased from $67,000 to $315, 000.

HR, Homemaker – Budget Page AGING-16 (Volume 2)

Budget Account 101-3252

Senator Rawson stated administrative expenses are increasing and services are decreasing by at least $75,000 a year. He said there seems to be a decrease in what is the real purpose of the program (the services). He asked whether some individuals can be transferred with this program. He stressed there needs to be an explanation of the staffing.

Ms. Sloan said this is a program funded primarily with Title XX money and cuts are being worked out in the program that would impact the delivery of services regardless of which budget the program is funded through. She explained that everything which is not direct homemaker service is defined as administrative services, such as social workers, supervisory staff, and additional resources that are not the field workers who are providing the direct service in the home. She said that because the two programs are blended into one budget account, it is difficult in some ways to separate the EPS program from the Homemaker program when looking at costs. She stated both programs provide critical services to individuals who are at great risk for institutionalization or exploitation and abuse.

Ms. Sloan said the Aging Services Division currently has a staff of approximately 72. She pointed out the change will transfer 15 professional staff who are social workers. They are included in the administrative budget. There is also a transfer of one supervisor. In neither of the transfers was there an accommodation for any accounting staff or payroll assistance. Ms. Sloan pointed out that when the 80 homemaker employees are included, many of whom are part-time state employees—which requires additional accounting—the division’s small accounting staff cannot take on added responsibility.

Ms. Sloan said the larger staff in Medicaid has been able to absorb some of the duties by "piece-mealing" and performing other duties as assigned, but the Aging Services Division cannot do that. Senator Rawson acknowledged there is limited staff and only so much can be done without added resources.

Ms. Wright, Administrator, Division of Health Care Financing and Policy (DHCFP) stated this is the compounding of an issue created a number of years ago when the program was originally in the Welfare Division and it became more and more difficult for the division to properly staff the programs. She said that in 1997, when the Welfare Division transferred 18 staff from the administrative budget into the Medicaid budget they included three of the positions that had never worked in EPS or Homemaker programs, they were Medicaid positions.

Ms. Wright stated the Division of Health Care Financing and Policy took the positions and found that 15 of these were EPS positions and all of the EPS positions are being transferred to the Aging Services Division. She pointed out this program has not been adequately staffed for a long time. She said no one could handle the programs without additional staff. Ms. Wright stated that currently individuals are working a few hours on the program and then going to other tasks. She stressed it will be very difficult to continue without putting additional support into the program, no matter where it resides.

Senator Rawson noted the transfer seems logical, but asked what the benefits of the transfer are. Ms. Sloan testified the Aging Services Division currently investigates elder abuse through the long-term care ombudsman program. She explained the EPS program is unique in that there is no income eligibility. She said the state has an agreement with Clark County Protective Services whereby that agency serves everyone who is not Medicaid-eligible. The state provides the service throughout the remainder of the state. Ms. Sloan said there has been an agreement with EPS for some time where the ombudsman would investigate complaints of those in long-term care while community complaints would be handled by the Welfare Division or the Medicaid agency.

Ms. Sloan said the agency is experienced in the issue of elder rights and elder abuse. She noted that in the last biennium some funding was received through the Peace Officers Standards and Training (P.O.S.T.) budget and a trilogy was produced to be used for elder abuse training for law enforcement officials. She said that prior to this, a video was produced to train medical professionals. She called attention to the close working association with the attorney general’s office in the area of elder abuse and elder protective services.

Ms. Sloan maintained the agency is very experienced in the area of home- and community-based care and homemaker service delivery, which is at the heart of the CHIP program. She stated there is an understanding of the difficulty in managing a program such as CHIP and establishing care plans and providing services such as those under the Homemaker program. The agency has the expertise and resources to operate the program, she said.

Ms. Sloan said bringing these programs to the Aging Services Division will provide a greater efficiency. She stated that those working in the EPS and Homemaker programs are partners in the "aging network" and will have the other social workers immediately available as resources, as well as having community networking resources available. She maintained the program will be strengthened significantly. She said she wished she could say growth would occur in the program by having it in the Aging Services Division, but she does not know that will be the case. Growth of approximately 21 percent is expected in elder protective referrals, based on the history of the program. Ms. Sloan said no growth is expected in the Homemaker program because it relies on funding.

Senator Rawson said that with the increase in benefits of the 80 employees, there will be a significant increase in salary costs. He inquired whether on a natural attrition basis it is possible to reach a lower salary cost to make up for some of the increase. Ms. Sloan answered there has been discussion in this regard and the department would like to move toward that without putting anyone out of work. She said service can be provided at a reduced cost by using contract services. She pointed out that may not be possible in rural areas because there are not many individual contractors under the CHIP program in rural areas. She said it is unknown whether state employees would be willing to go to an individual contract. She stated that as employees move out of the program the department will definitely try to replace them with contract services.

Ms. Sloan maintained there is a broad feeling within the Department of Human Resources this is the right thing to do and there is commitment to a successful transition. She stated the requested resources will provide for the transition and a successful stabilization of the program.

Senator Rawson adjourned the meeting at 9:45 a.m.

RESPECTFULLY SUBMITTED:

Patricia Hampton,

Committee Secretary

APPROVED BY:

Raymond D. Rawson, Chairman

DATE:

Ms. Jan Evans, Chairman

DATE: