MINUTES OF THE meeting
of the
ASSEMBLY Committee on Health and Human Services
Seventy-First Session
February 19, 2001
The Committee on Health and Human Serviceswas called to order at 1:30 p.m., on Monday, February 19, 2001. Chairman Ellen Koivisto 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. Ellen Koivisto, Chairman
Ms. Kathy McClain, Vice Chairman
Ms. Sharron Angle
Ms. Merle Berman
Ms. Dawn Gibbons
Ms. Sheila Leslie
Mr. Mark Manendo
Ms. Bonnie Parnell
Ms. Debbie Smith
Ms. Sandra Tiffany
Mr. Wendell Williams
COMMITTEE MEMBERS ABSENT:
Mrs. Vivian Freeman
GUEST LEGISLATORS PRESENT:
None
STAFF MEMBERS PRESENT:
Marla McDade Williams, Committee Policy Analyst
Darlene Rubin, Committee Secretary
OTHERS PRESENT:
Jon Sasser, Esquire, Washoe Legal Services
Roger Volker, Director, Great Basin Primary Care Association
Bobbie Gang, Lobbyist, Nevada Women’s Lobby
Louise Bayard-de-Volo, Lobbyist, Nevada Women’s Lobby
Elizabeth Pederson, Lobbyist, Nevada League of Women Voters
Jan Gilbert, Lobbyist, Progressive Leadership Alliance of Nevada
R. Alexis Miller, Public Affairs Coordinator, Planned Parenthood
Susan Pacult, Program Administrator, Clark County Social Service
Janice Pine, Director, Governmental Relations, Saint Mary’s Health Network
Charles Duarte, Administrator, Department of Human Resources, Division of Health Care Financing and Policy
Chairman Koivisto opened the meeting with committee introductions.
· BDR 38-534 – Allows the Silver-Haired Legislative Forum to operate independently of the Division of Aging Services (A.B. 195).
VICE CHAIRMAN MCCLAIN MOVED FOR COMMITTEE INTRODUCTION OF BDR 38-534.
ASSEMBLYWOMAN BERMAN SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
· BDR 38-224 – Prohibits the Department of Human Resources from considering the assets of certain persons to determine their eligibility for Medicaid (A.B. 196).
ASSEMBLYWOMAN LESLIE MOVED FOR COMMITTEE
INTRODUCTION OF BDR 38-224.
ASSEMBLYWOMAN GIBBONS SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
Chairman Koivisto next introduced a request from Assemblyman Carpenter for a resolution to Congress indicating support to amend the Social Security Act to provide that the reductions in Social Security benefits which were required in the case of spouses and surviving spouses who were also receiving certain government pensions be equal to the amount by which the total amount of the combined monthly benefits before reduction and monthly pension exceeded $1,200 (BDR R-1484 later introduced as A.J.R. 10).
ASSEMBLYWOMAN GIBBONS MOVED FOR COMMITTEE
INTRODUCTION OF A RESOLUTION TO CONGRESS TO AMEND
THE SOCIAL SECURITY ACT.
ASSEMBLYWOMAN LESLIE SECONDED THE MOTION.
THE MOTION CARRIED UNANIMOUSLY.
Chairman Koivisto then turned the meeting over to Vice Chairman McClain so that Mrs. Koivisto could introduce Assembly Bill 31.
Assembly Bill 31: Requires department of human resources to include presumptive eligibility for certain persons in state plan for Medicaid and children’s health insurance program. (BDR 38-221)
Assemblywoman Koivisto introduced A.B. 31 on behalf of the Legislative Committee on Health Care that she chaired during the 1999-2000 interim. Committee members at the June 6, 2000, meeting had adopted the measure. The two key components to the bill:
Mrs. Koivisto stated that based on estimates provided by the staff of the DHR, the bill included an appropriation of over $31 million to implement presumptive eligibility in both Medicaid and Nevada Check-Up programs. She explained that presumptive eligibility was a method of granting Medicaid eligibility on an immediate short-term basis. Federal law allowed states to grant traditional Medicaid providers the ability to make presumptive eligibility determinations. During a presumptive eligibility period health care providers were reimbursed for services provided to patients regardless of whether the patient was ultimately determined to be eligible for Medicaid. Federal regulations required that presumptive eligibility be made available on a statewide basis and the process could not be restricted to subgroups of the Medicaid population.
Mrs. Koivisto added that besides paying providers for services rendered at the time of a patient visit, other reasons advocated for adopting presumptive eligibility were:
Mrs. Koivisto added that if implemented in the Nevada Check-Up program, presumptive eligibility might increase enrollment in the program and prevent the state from a situation where not all of the federal money set aside for Nevada Check-Up was used. She said that Nevada had not accessed millions of dollars in Check-Up funds. Some key issues that should be considered concerning presumptive eligibility were:
Mrs. Koivisto advised that testimony at the Interim Committee on Health Care had further indicated six states had extended the use of presumptive eligibility for Medicaid children and three states had adopted presumptive eligibility but had not implemented it, while 29 states used presumptive eligibility only for Medicaid pregnant women and six states used presumptive eligibility in their children’s health insurance programs. However, no states that had a state-only CHIP used presumptive eligibility. Those states that used presumptive eligibility in their CHIP’s did so under what was known as a “Medicaid-expanded CHIP.”
Mrs. Koivisto concluded by stating that Nevada would pay one way or the other and it seemed most sensible to access the federal dollars available. It was important to do that and A.B. 31 provided the way.
Next to testify was John Sasser, Esquire, representing Washoe Legal Services and the Nevada Statewide Covering Kids Coalition, of which he was co-chair. Mr. Sasser provided Exhibit C and referenced the group’s legislative agenda included as an attachment to that exhibit. He indicated that A.B. 31 and A.B. 35 were consistent with that agenda and the coalition supported both bills.
He explained the “Covering Kids Coalition” was an oversight group for the $850,000 grant from the Robert Wood Johnson Foundation to the Great Basin Primary Care Association, the lead agency. Their job was to partner with the state in outreach efforts to enroll uninsured Nevada children in appropriate health insurance programs and to advocate the adoption of policies, such as presumptive eligibility, which simplified the enrollment process.
Mr. Sasser added the legislative agenda had been developed by the coalition’s legislative committee comprised of Bill Welch, Nevada Hospital Association; Larry Matheis, Nevada State Medical Association; Ann Corey, Northern Nevada United Way; Roger Volker, Director, Great Basin Primary Care Association; Bobbie Gang, Nevada Women’s Lobby; Cloyd Phillips, Community Services Agency; and Caroline Ford, Director, Center for Education and Health Services Outreach at the University of Nevada, Reno, School of Medicine.
The coalition supported presumptive eligibility because it accomplished two important purposes:
1. It provided as early an access as possible to prenatal care for pregnant women who were going onto the Medicaid program.
2. It helped to enroll children in both Nevada Check-Up and in the Medicaid for children, because it captured them at a time when the most attention was being paid to their need for medical care, when they were sick and at a doctor’s office.
Mr. Sasser explained that presumptive eligibility was a process whereby when a sick child was taken to a doctor’s office or emergency room, someone on the provider’s staff would take a cursory scan of the parent’s financial information. If it appeared the child was eligible for Medicaid or Check-Up, the provider could presume eligibility and provide services knowing they would be paid for those services whether or not the child was ultimately found eligible. Further, there was a presumptive eligibility period of from one month to two months in which services would continue to be rendered and the provider paid while the state went through the process of determining eligibility.
He stated that Congress had offered presumptive eligibility for pregnant women since 1988; however Nevada had chosen not to exercise that option. As a result it had impacted the state’s ability to provide early prenatal care to pregnant women. During testimony before the Interim Committee on Health Care, Dr. Mary Guinan, Nevada State Health Officer, testified that Nevada’s low weight infant births had increased 7 percent over a 10-year period from 1985 to 1995, that over half of low-weight births resulted in some long-term physical or mental disability, and much of that was caused by smoking in the first trimester.
Mr. Sasser emphasized that under the state’s current Medicaid system it was impossible to obtain prenatal care in the first trimester. Presumptive eligibility would enable the woman to immediately go to a provider as soon as she learned she was pregnant. Medicaid paid for almost 9,000 births a year. The average cost of a birth was about $5,700, while the average cost of a low-weight birth was $26,000. If potential low-weight birth hazards were detected early and prevented money would be saved immediately and, because there would be fewer children born with mental or physical disabilities, the savings would extend far into the future.
Mr. Sasser advised that the Governor, in his budget, recognized the importance of early access to prenatal care and proposed an alternative that he called “expedited eligibility.” Under that proposal a 12-person group of 6 eligibility teams would fast track all pregnant women’s applications and attempt to take an action within 7 days.
Mr. Sasser noted two additional groups affected by presumptive eligibility:
The Governor had not proposed presumptive eligibility for Check-Up Kids, rather, he had asked for money for a one-shot appropriation to develop an interactive Web-based application, the ultimate goal of which was the same as presumptive eligibility. In that proposal, the patient would go to the doctor’s office and a staff person would go online and, provided the patient had the proper documentation, the patient could be signed up and enrolled in minutes. Mr. Sasser explained that method might prove to be the best solution, although not quite as good from the provider’s perspective, because the patient might not have the proper documentation with him at the time to prove eligibility.
The Governor, in his budget, also proposed the elimination of the assets test for Medicaid Kids, the same bill for which the committee had earlier adopted an introduction (BDR–38-224). That would enable many children to get on the program much more easily.
Mr. Sasser applauded the Governor’s efforts and believed the proposals set forth above were a marked improvement over the current situation; however, they did not go quite far enough. Only presumptive eligibility guaranteed payment to providers in all cases for services rendered at an initial visit.
Mr. Sasser urged passage of A.B. 31 and A.B. 35 because the Committee on Health and Human Services was a policy committee and early prenatal care and signing up children for appropriate medical care was good policy. That message needed to be sent to the Committee on Ways and Means where the bills would next be heard, because that committee would then be able to see the details of the Governor’s proposal, which no one had yet seen, and determine if the bills were appropriate and what the reasonable costs might be.
Assemblywoman Gibbons asked if “expedited eligibility” was only for pregnant women and what criteria the hospital used to determine eligibility. Mr. Sasser responded that the Governor’s proposal for “expedited eligibility” was only for pregnant women. In determining presumptive eligibility, the state had a great deal of control in how it designed the criteria. The state would be responsible for giving the information to the providers that it wished the providers to check, and it had control over which providers would be allowed to determine presumptive eligibility. Further, the state also had control over the number of times a person could go through the process.
Assemblywoman Parnell complimented Mr. Sasser on his presentation. She then asked if the Governor’s expedited approach utilized the available federal dollars. Mr. Sasser responded that all the proposals would utilize federal dollars. In Medicaid there was a 50 percent federal match and in Check-Up there was a 65 percent federal match. He added it was his understanding if a Check-Up Kid was determined presumptively eligible but did not follow through or was not ultimately approved, the state would still receive 65 cents on the dollar from the federal government to cover those costs.
Assemblywoman Angle asked who would pay the charges if the patient were found ineligible. Mr. Sasser answered the payment to the provider would come either from the Medicaid program via the Welfare Division, or from the Check-Up program through Health Care Financing and Policy. He reiterated the federal government would put up to 65 cents for Check-Up and 50 cents for Medicaid.
Assemblywoman Angle asked if individuals were not found eligible would those programs still apply. Mr. Sasser explained that was the meaning of presumptive eligibility; there was a presumptive period of eligibility for 4 to 8 weeks in which providers would know they would be paid for services based on that presumptive determination even if ultimately they were not qualified.
Assemblywoman Leslie asked how many years that same bill had come before the committee. Mr. Sasser responded that presumptive eligibility for pregnant women had been available as a state option since 1988 and he worked on it in the 1989 session where it had not passed, nor had it succeeded in any subsequent sessions. Presumptive eligibility had been available for children since 1997 making it the second time the bill had been introduced. Mrs. Leslie commented it was always the fiscal note that worked against its passage. She asked if anyone had ever done a realistic analysis, and also why the savings was never backed out. Mr. Sasser agreed the savings had never been calculated; part of the reason was that there had been a lack of available data because the state did not have the necessary system to keep up with a lot of the outcome and cost data in the Medicaid program. Another reason why a complete analysis had not been done was because the Governor had come up with another proposal. Mrs. Leslie asked Mr. Sasser to guess at what a real figure might be. Mr. Sasser believed it would be quite low, especially for pregnant women on Medicaid because receiving earlier prenatal treatment, while that treatment would be an added cost initially, would result in a healthier birth so the long-range cost would be offset. Even if 4 to 6 weeks later the woman was found ineligible, all the state would have paid for were a couple of prenatal care visits that were relatively nominal compared to other procedures.
For Check-Up Kids, the costs were equally reasonable. There were the costs of training staff, but staff would be trained to handle the applications anyway. Mr. Sasser remarked that by training the providers well, there would be few mistakes. In any event, Mr. Sasser concurred with Mrs. Leslie that the fiscal note should be significantly lower.
Vice Chairman McClain commented the committee would count on Mrs. Leslie and Mrs. Tiffany to carry that message into the Committee on Ways and Means.
Assemblywoman Gibbons reminded the committee of Chairman Koivisto’s earlier acknowledgement that the state would pay anyway, and it only made good sense to access the federal money available. Mrs. Gibbons added that if expedited eligibility was only for pregnant women, the state would still need A.B. 31 to allow for the care of children and to receive federal funds. Mr. Sasser clarified that technically the division could make a state plan change without a bill; a statutory change was not required to make that happen. It could be done with an amendment. But he believed it was important for the committee to pass the bill because it sent a message to the Committee on Ways and Means that the measure was important. He added he believed the ultimate outcome would be the adoption of the Governor’s proposals, because they were major steps in the right direction, but the bills needed to be there as insurance.
Assemblywoman Tiffany asked the duration of the federal grant. Mr. Sasser responded the 65/35 formula was in effect as long as the federal legislation existed. The law that created the Check-up program was in effect until 2002 when it was up for re-authorization. Mrs. Tiffany asked who would train the eligibility worker staff. Mr. Sasser replied the cost for the 12 workers was in the Governor’s proposal for “expedited eligibility.” However, there had not yet been a hearing on the Welfare Division’s budget so a detailed explanation was not available.
Vice Chairman McClain called the next witness, Roger Volker.
Roger Volker, Executive Director of the Great Basin Primary Care Association, said the group’s studies indicated there were over 350,000 uninsured people in Nevada. About 100,000 were children, and around 70,000 to 80,000 of those children lived in families whose income was below the 200 percent federal poverty level that would allow them to qualify for either Nevada Check-Up or Medicaid. Given Nevada’s population, that was a substantial number of children.
Mr. Volker then addressed the issue of savings. His association represented all of Nevada’s community health centers, most of the tribal clinics, and other non-profit providers that were part of the safety net where people could access health care regardless of their ability to pay. He explained people in Nevada accessed primary care safety net providers about two and one-half times a year. Often the first visit was not paid for. In community health centers in Las Vegas over 75 percent of people accessing health care were uninsured. They were not turned away because they had no insurance or lacked the ability to pay; however the federal funds, which were available to compensate for that health care, were limited and at the current rate would soon be exhausted.
Mr. Volker stressed that presumptive eligibility, or any method the legislature devised to speed up eligibility to make more children able to access health coverage, would substantially benefit the safety net providers in Nevada. Based on the number of visits per year, if the first visit was paid for 75 percent of the time it would return to Nevada over $6 million of federal money not currently being accessed. Those dollars, he added, could go into infrastructure for the safety net and be used for, among other things, buying more dental chairs, hiring more dentists, nurse practitioners, physician’s assistants, physicians and equipment. Clinics could be opened in places where dire need existed. Nevada, he emphasized, was in a health care crisis, caused in part because emergency rooms throughout the state were inundated with persons who should be receiving health care at appropriate clinics, but instead had to go to emergency rooms because those clinics did not exist. That was true in urban as well as rural areas. Currently, those needed dollars were lost to the state’s health care system, and when the health care system was impacted in such a way it was not only low-income families who suffered. When emergency rooms went on “divert” status it meant critical care could not be accessed when and where it was most needed.
Mr. Volker looked forward to a dialogue throughout the legislative process with the committee and with the Governor’s staff to find the most appropriate outcome that speeded the eligibility and enrollment process. He urged the committee to pass both bills because they sent a strong message about a very important issue.
Next, Bobbie Gang, lobbyist for the Nevada Women’s Lobby, introduced Louise Bayard-de-Volo, who was on the steering committee of the Nevada Women’s Lobby.
Louise Bayard-de-Volo presented the committee with Exhibit D, her written testimony. She had been before the committee in 1989 when the issue of presumptive eligibility for pregnant women was first brought forward and she was pleased now to see the issue receive attention and be included in the Governor’s budget. She said that early care was critical, when children were ill or injured and when women were pregnant. She also pointed out that when families did not have money for health care they often delayed or went without it, or used the emergency rooms for basic care and delivery of their babies. That was an unhealthy situation for Nevadans and it was costly for the state. Those costs were often difficult to measure in the long term, not only in reimbursement of uncovered care but also the ongoing costs associated with untreated health conditions and low birth-weight babies. Presumptive eligibility offered a solution to those problems. It was the best outreach tool available; it allowed people to receive needed care immediately and with dignity.
Ms. Bayard-de-Volo referenced the Nevada Women’s Agenda (Exhibit E), made available previously to committee members, that outlined the issues and was a collaborative project of several groups and individuals. She emphasized particularly the issue of presumptive eligibility for pregnant women and, in addition to what had been testified to earlier, pointed out that in 1998, 23 percent of Nevada women had not received prenatal care in their first trimester. Moreover, four percent had no prenatal care. In conclusion, Ms. Bayard-de-Volo urged passage of both A.B. 31 and A.B. 35.
Assemblywoman Gibbons asked what happened when a person, first cared for under presumptive eligibility but later found ineligible, could not afford to continue treatment. Ms. Bayard-de-Volo answered that was what currently happened; the women would forego further care until it was time for delivery. She said, however, there might be other programs available.
The next witness was Elizabeth Pederson, who appeared on behalf of the Nevada State League of Women Voters. Ms. Pederson provided her written testimony as Exhibit F. She reiterated the reasons given by those who testified earlier in support of A.B. 31 and A.B. 35. She added how important prenatal care was for impoverished women as it linked them with important social services. Further, women who received prenatal care were more likely to seek preventative care for their infants once they were born. Presumptive eligibility would be especially beneficial to adolescents. Ms. Pederson noted that in 1996, one-third of uninsured adolescents aged 13-18 were eligible for Medicaid but were not enrolled. Teen mothers were less likely to receive prenatal care and more likely to smoke, hence had a greater risk of having a low birth weight baby.
Ms. Pederson pointed out that Governor Guinn’s proposal for “expedited eligibility,” required one-shot appropriations to be implemented; therefore, the passage of A.B. 31 and A.B. 35 would make it a continuing program. She concurred with other witnesses that the fiscal note was probably grossly overestimated.
Vice Chairman McClain temporarily suspended testimony on A.B. 31 and stated it would be resumed after Assemblywoman Berman presented her bill, A.B. 35. She then introduced Assemblywoman Berman.
Assembly Bill 35: Requires department of human resources to include presumptive eligibility for children who are less than 19 years of age in children’s health insurance program and to establish program of training to assist and encourage persons to enroll children in children’s health insurance program. (BDR 38-214)
Assemblywoman Merle Berman, representing District 2, introduced A.B. 35 which would allow for presumptive eligibility determinations in the Nevada Check-Up program, Nevada’s children’s health insurance program. The Division of Health Care Financing and Policy (HCFP) received approval to establish the Nevada Check-Up program in 1998 which was designed to provide health insurance for children 18 years of age and younger from low-income families that were uninsured by ineligible for Medicaid.
She explained the program had been established to insure that all of Nevada’s children had access to adequate health care. Uninsured children were more likely to have continuing health problems and their family often had difficulty obtaining the needed health care. That often forced parents to rely on costly emergency room care for their children that placed significant financial burden on the parents and on all taxpayers. Inadequate health care could be reflected in a child’s inability to perform well in school, and many undetected medical problems caused them to be labeled as learning impaired or as having behavioral problems. Additionally, she said the state was hurting the long-term success of its children because there was no system in place for their health needs. When an uninsured child was brought into a clinic or doctor’s office for treatment, the facility was forced to absorb the cost of treating that child. That caused the facility to find alternative methods for recouping those costs. Ultimately the burden of providing medical care to the uninsured fell on the taxpayer. For those reasons the state needed to be proactive in improving access to health insurance and one way to do that was passage of A.B. 35.
Mrs. Berman then presented Exhibit G, entitled Subpart L—Option for Coverage of Special Groups, Sec. 435.1100 - 435.1102 of the State Children’s Health Insurance Program Final Rule (HCFA-2006-FC), which covered the definitions related to presumptive eligibility for children who were less than 19 years of age. She read the definition of presumptive eligibility as follows:
Presumptive eligibility was the period that began with the date on which a qualified provider determined on the basis of preliminary information that the family income did not exceed the applicable income level of eligibility under the state plan, and ended with the day on which the determination was made with respect to the eligibility for medical assistance under the state plan, or where a person had not filed an application by the last day of the month following the month during which the provider made the determination.
Mrs. Berman added it would allow certain health care providers to encourage the uninsured individual to complete the application for the program at the time they received medical treatment. In turn that would allow physicians and others to receive reimbursement for the specified period of time after the initial visit and for subsequent visits regardless of ultimate eligibility for Medicaid or Check-Up.
Mrs. Berman continued stating that implementing presumptive eligibility would not grant a physician or another safety net provider the authority to determine the eligibility of a client; only the state could make that determination. The purpose of presumptive eligibility was to get money to the safety net providers so that the cost of providing medical care to the uninsured individual did not transfer back to the taxpayer. She added another reason for adopting presumptive eligibility was that a typical family of four qualified for Nevada Check-Up if it had an income of no more $33,400, based on the 1999 federal poverty level figures. By allowing physicians or other safety net providers to encourage uninsured families to apply for the Nevada Check-Up program, it improved the state’s ability to determine the number of families in the state who did not have health insurance. The number could be obtained by tracking the number of successful as well as unsuccessful applications to the program.
Finally, the state needed to be more proactive in selling the importance of health insurance to families. Buying health insurance could be expensive, but not buying health insurance was a risk with the potential to have long-term negative impact on the child and his family. Mrs. Berman urged the committee to support A.B. 35.
Assemblywoman Leslie asked if section 3 in A.B. 35 was the same as sections 1 and 2 in A.B. 31. Mrs. Berman confirmed that it was. Mrs. Leslie noted the difference in Mrs. Berman’s bill was in the mandatory training. Mrs. Berman said in southern Nevada there were some Vista workers who had been trained to sign children up for the program, but more workers were needed. One worker would be the bare minimum and presented a fiscal note of approximately $60,000 including salary and benefits. The total fiscal note was almost $1 million a year, most of that for medical payments, and the rest allocated to one full-time position with travel and other items. Mrs. Berman noted that the main housing for the program was in northern Nevada, but 70 percent of the population was signed up in southern Nevada. The paper work had to be sent to northern Nevada then be returned to southern Nevada. There was a lot of responsibility and paperwork in determining eligibility. With a worker in southern Nevada the process could be speeded up.
Assemblywoman Gibbons wondered, assuming the committee agreed, if the bills should be passed separately or should the duplicate provisions be included in A.B. 31 so one of the bills would not get derailed in the Committee on Ways and Means. Mrs. Berman said any way the bills could be passed would be helpful.
Assemblywoman McClain asked about the huge variance in fiscal notes, from $1 million for A.B. 31 to $30 million for A.B. 35. An immediate answer was not forthcoming and it was hoped other witnesses might provide that information.
Chairman Koivisto introduced additional witnesses for A.B. 31 and noted most of them had signed up to speak about both bills.
Jan Gilbert, representing the Progressive Leadership Alliance of Nevada (PLAN) announced support for both A.B. 31 and A.B. 35. She stated the difference between the bills was that one was for Check-Up and the other was for pregnant women and Check-Up. She said that although the pregnant women made the cost somewhat more expensive, no one in her group believed the fiscal note was accurate. She added that since 29 states had implemented the program they had to realize there would be a benefit to their state. If the cost had been as excessive as the fiscal note presumed those states would not have implemented the program. Regarding Check-Up, which was included in both bills, the first year of the program quite a few people had signed up. When the second year arrived, many families chose not to sign up again because they had not accessed the program. The money those families paid for insurance was significant given their income levels and if they had not used the coverage then it was easy for them to discontinue the coverage. Mrs. Gilbert said presumptive eligibility made those families realize the need for the insurance program. It showed them immediately what they received for their money; when they went to a provider with a sick child and were presumed eligible, they received treatment; consequently they saw the program worked for them.
Mrs. Gilbert added A.B. 35 had the training factor specified and training was needed as staffing for Check-Up had been minimal. However there was merit to both bills and she urged passage of both.
Assemblywoman Parnell remarked that since presumptive eligibility had been implemented in 29 states the committee should be able to obtain data on fiscal impact, actual cost versus savings.
Marla McDade Williams, Committee Policy Analyst, responded that the Legislative Committee on Health Care had a presentation from a representative of the National Conference of State Legislators (NCSL). At that time she was asked to provide that information and she said the states did not track that data. It was not something the states could easily attribute to presumptive eligibility, it was a question members continually asked but the information was simply not available. Those states made a determination to go with presumptive eligibility and deal with the costs as they arrived.
Chairman Koivisto felt data should be available on the number of people served and the cost of the program. Ms. Williams agreed to look into that and report back.
Next to speak was Alexis Miller, representing Planned Parenthood Mar Monte and Planned Parenthood of Southern Nevada. She expressed support for A.B. 31 and A.B. 35 for all the reasons previously stated by other witnesses. She added her group greatly appreciated the Governor’s proposal for “expedited eligibility” and looked forward to the continued expansion of health care options for all Nevadans.
Bobbie Gang, Nevada Women’s Lobby, came forward again in support of A.B. 35, and urged the bills be kept separate. After testimony before the Interim Committee on Health Care she had hoped to see three bills on presumptive eligibility; one for pregnant women, one for children in Medicaid, and one for children in Nevada Check-Up. She urged passage of A.B. 35 with the training component, because it was extremely important to have trained workers who were able to help people eligible for the Nevada Check-Up program to understand what an insurance program could mean to them and to their children.
Susan Pacult, Program Administrator, Clark County Social Service (CCSS), spoke in support of A.B. 31 and A.B. 35, and presented her written testimony (Exhibit H). She stated both bills would assist the State of Nevada in its efforts to enroll eligible clients into low-income health insurance programs, Medicaid and Check-Up. Ms. Pacult added that in response to the Governor’s Steering Committee to conduct a fundamental review of state government, Clark County Social Service and University Medical Center (UMC) began a pilot program to provide eligibility determination services for Nevada Check-Up clients in January 2001. Those services reduced the time processing required, because staff no longer had to perform eligibility determination and only had to mail out enrollment materials to eligible families. Clark County and UMC assumed financial responsibility for any claims submitted for payment on behalf of enrollees, even if ultimately determined to be ineligible by the Department of Human Recourses (DHR).
Ms. Pacult continued adding UMC was a prime location where uninsured families sought medical services, as well as Clark County Social Service was often an entry point for families subsequently referred to Temporary Assistance for Needy Families (TANF). Consequently, CCSS would be willing to partner with the DHR in the development of pilot programs employing presumptive eligibility criteria to facilitate health coverage for the state’s most needy citizens.
Chairman Koivisto asked for an educated guess on the cost of such a program. Ms. Pacult said she had spoken with Jon Sasser and they were in agreement the $29 million fiscal note for children was high and, they agreed, was based on an assumption that every Medicaid-eligible child would be enrolled immediately. They felt it should be significantly lower. Ms. Pacult did not have data available from the above-referenced pilot program as it had only begun in January 2001. However, many applications had been made at UMC and forwarded to the Welfare Division and the Check-Up staff.
Next to speak was Janice Pine, Director, Governmental Relations, Saint Mary’s Health Network, in support of A.B. 31 and A.B. 35. However, she voiced concern over one aspect of the latter bill. Specifically, the education or training requirement seemed to be very limited. Accordingly, she requested the education be available for all hospitals and clinics that served the low-income patients. Ms. Pine would like that issue to be addressed when the subcommittee met.
Assemblywoman Leslie asked if Saint Mary’s wanted to participate in that training. Ms. Pine said, “yes,” that Saint Mary’s would be considered an essential community provider even though it was not federally funded. She added that the training for getting children signed up would be an important part of any hospital. Some hospitals did not fall under the Nevada Revised Statutes (NRS)-stated definition and there were very few federally qualified health centers in the state compared to the numbers of clinics that did see the low-income patients.
Mrs. Leslie commented that accordingly, the fiscal note would be increased because of the need to add more people. Ms. Pine was unsure how much it would need to be increased; if it covered every hospital, one person could be in one place and provide training for eligibility workers on a large scale. Mrs. Leslie liked that idea.
Assemblywoman Berman also complimented Ms. Pine on her idea. She added how difficult it had been to sign people up; she had found someone to sit in UMC and do sign up, and also a Vista worker to accompany Dr. Bernie Feldman in the Clinic on Wheels bus out of Sunrise Hospital.
Next, Charles Duarte, Administrator, Department of Human Resources (DHR), Division of Health Care Financing and Policy (HCFP), appeared in opposition to A.B. 31 and A.B. 35. He provided written testimony (Exhibit I). He summarized his testimony as followed:
Mr. Duarte noted the Governor’s proposal of almost $10 million to support the elimination of the asset test for the CHAP group included pregnant women and children in Medicaid. The Governor also requested funding for “expedited eligibility” processing for pregnant women. However, the “expedited eligibility” processing could not be done without the elimination of the CHAP asset test. Mr. Duarte believed those two things together would have a significant impact on improving access to care for pregnant women in their first trimester and access to care for children. It would also expedite claims payment opportunities for providers, hopefully making them more interested in continuing with the Medicaid program.
Mr. Duarte believed the single most important thing HCFP could do to improve access to care for the targeted populations would be to eliminate the asset test.
For Nevada Check-Up, Mr. Duarte informed, the Governor had included $42 million to expand caseloads. Some changes in operations in DHR had already been made to improve eligibility processing and more could be done to improve timeliness. For example, outstationing eligibility workers had been put into operation and further internal operations could be improved to determine eligibility more quickly.
Mr. Duarte stated that for both programs, Medicaid and Check-Up, the Governor had also included a $500,000 one-shot appropriation that would allow the DHR to develop a Web-based application process for three important programs: Medicaid, TANF, and Nevada Check-Up. He believed the agency could develop a system that would be available to the community to assist in signing up applicants or to families to sign up their members for those important programs. That information would then become available to eligibility certification specialists in the Welfare Division for Medicaid and Nevada Check-Up staff to make the final determination of eligibility.
Mr. Duarte stated he could not support either bill because the Governor’s budget did not include funding to implement presumptive eligibility for Medicaid or for Nevada Check-Up.
Assemblywoman Leslie asked if in Hawaii, from where Mr. Duarte had come, presumptive eligibility had been chosen for those population groups. He responded Hawaii had dropped presumptive eligibility in 1994 when it began its 1115 waiver program called “Quest.” The waiver program, explained Mr. Duarte, allowed the Medicaid program to expand eligibility beyond the traditional Medicaid population to include low-income families. In other words, the services were provided but eligibility was not presumptive. Mrs. Leslie explained she was trying to make a connection between if the services were provided would there be a better outcome for women and children. She asked if Mr. Duarte agreed with that hypothesis. He said he agreed that presumptive eligibility for pregnant women had the effect of expediting payment to providers for those services. He also believed that the asset test elimination would do the same thing. If the state implemented presumptive eligibility and did not eliminate the asset test, there would be a problem in that the woman would ultimately have to file an application. She may then disappear only to reappear sometime later and file another application, and disappear again. Thus there would only be periodic episodic care that would not ultimately result in the outcome of improved access to service.
Mr. Duarte noted presumptive eligibility was actually a two-step process, not a one-step process. He explained the clinic on behalf of the mother filled out a presumptive application. That was then submitted within certain time frames to the eligibility determination agency, Medicaid or Welfare. Thereafter, the welfare agency contacted the mother to fill out a formal application for Medicaid. The presumptive application and the real application had to be put together and worked on just like any eligibility determination. Assemblywoman McClain said she looked at that as a concurrent process, and the woman was actually getting the help she needed.
Assemblywoman Gibbons was concerned about the two-step process because it could take longer than the 30 to 45 days. However, without presumptive eligibility where was the assurance the pregnant woman or child would be treated by a provider. Mr. Duarte said the question was whether providers would take that as a positive step, and he believed they would because it would expedite payment. Under all other programs, providers knew they had to wait for payment and sometimes that could be lengthy when the eligibility was a difficult case. If the process was speeded up, payment would be made more promptly and the provider would be more amenable to seeing the patient on the first day.
Mr. Duarte said it should be kept in mind that in Medicaid costs of care could be covered three months retroactively from the date of application. That meant providers could establish a date before which they would receive three months of payments, then by expediting the eligibility process all those claims would be paid more promptly.
Assemblywoman Parnell asked Mr. Duarte how many children were currently enrolled in Nevada Check-Up. Mr. Duarte said there were 16,015 enrolled over the one and one-half years since its inception. Mrs. Parnell said Mr. Duarte had provided a lot of information, however, the bottom line of his position was the one-sentence statement (Exhibit I), that because the Governor’s budget did not include funding to implement presumptive eligibility, Mr. Duarte could not support the bills. Mrs. Parnell felt that statement was based not on the bill’s merits but simply because it had not been part of the Governor’s budget. She had hoped to see a more philosophical reason. Mr. Duarte said if she ended his testimony at that sentence it would appear as purely fiscal reasoning. However by reading on she would see the Governor’s budget supported alternatives to presumptive eligibility, which he believed was more effective in achieving the same goal.
Assemblywoman McClain asked who paid the bill for someone who went into a hospital without insurance, without making an application for presumptive eligibility. Mr. Duarte believed the hospital would pay that cost, through indigent funds and bringing in federal dollars and matched funds. Mrs. McClain said presumptive eligibility appeared to be the best way to handle uninsured persons.
Assemblywoman Smith asked if Mr. Duarte supported the Governor’s concept through his budget that would also include elimination of the asset test, where would that take place; how would the asset test be eliminated to make it all work. Mr. Duarte responded that the asset test was an eligibility requirement that the state could adopt on its own choice so it would simply be a matter of submitting a state plan amendment to the HCFP to amend the eligibility rules in the state plan. HCFP would, of course, need the funding to implement it. Ms. Smith asked for details on the funding. Mr. Duarte replied the predominant cost was caseload driven as well as for some administrative costs that would be incurred. He believed a number of people not otherwise eligible for that Medicaid program would become eligible, as well as those who had not applied because of the asset test. Ms. Smith asked about the fiscal note. Mr. Duarte said it was approximately $9 million. He added that the cost of covering children in Medicaid through the elimination of the asset test would be funded at 65 percent federal dollars, not 50 percent as previously testified.
Chairman Koivisto pointed out legislation would be forthcoming to eliminate the asset test. She added the committee was pleased that the Governor had included that as part of his budget. However, one of the major problems was that without presumptive eligibility it was difficult to get providers willing to provide care and as a policy committee it was their job to see that those people who needed care were provided for. The state and ultimately the taxpayers were the ones who had to pay the bill; therefore, if federal dollars could be accessed to do that, that was what must be done.
Assemblywoman McClain asked the names of at least 5 of the 29 states that had presumptive eligibility because she believed some data must be available. She then asked the per child cost of a Medicaid case. Mr. Duarte responded the average cost for a healthy child was around $125 per month, which covered preventative care and all Medicaid benefits.
Chairman Koivisto advised A.B. 31 and A.B. 35 would go into a work session on February 28, 2001, when the committee’s decision would be made.
With no further business before the committee, Chairman Koivisto adjourned the meeting at 3:22 p.m.
RESPECTFULLY SUBMITTED:
Darlene Rubin
Committee Secretary
APPROVED BY:
Assemblywoman Ellen Koivisto, Chairman
DATE: