MINUTES OF THE
JOINT Subcommittee on Human Resources/K-12
of the
Assembly Committee on Ways and Means
AND THE
Senate Committee on Finance
Seventy-second Session
April 3, 2003
The Joint Subcommittee on Human Resources/K-12 of the Assembly Committee on Ways and Means and the Senate Committee on Finance was called to order by Chairman Sheila Leslie at 8:00 a.m. on Thursday, April 3, 2003. 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.
Assembly COMMITTEE MEMBERS PRESENT:
Ms. Sheila Leslie, Chairman
Mrs. Dawn Gibbons
Ms. Chris Giunchigliani, Vice Chairman
Mr. David Goldwater
Mr. Lynn Hettrick
Senate COMMITTEE MEMBERS PRESENT:
Senator Raymond D. Rawson, Chairman
Senator William J. Raggio
Senator Barbara Cegavske
Senator Bernice Mathews
STAFF MEMBERS PRESENT:
Mark W. Stevens, Assembly Fiscal Analyst
Gary L. Ghiggeri, Senate Fiscal Analyst
Steven J. Abba, Principal Deputy Fiscal Analyst
Larry L. Peri, Senior Program Analyst
Bob Atkinson, Program Analyst
Julie Brand, Program Analyst
Michael J. Chapman, Program Analyst
James D. Earl, Committee Secretary
OTHERS PRESENT:
Michael J. Willden, Director, Department of Human Resources
Blaine Rose, Administrative Services Officer, Community Connections, Department of Human Resources
Michael J. Torvinen, Administrative Services Officer, Administration, Department of Human Resources
Edward E. Cotton, Administrator, Division of Child and Family Services, Department of Human Resources
James B. Baumann, Administrative Services Officer, Division of Child and Family Services, Department of Human Resources
Diane R. Comeaux, Deputy Administrator, Division of Child and Family Services, Department of Human Resources
Madilyn L. Maire, Information Systems Manager, Division of Child and Family Services, Department of Human Resources
Charles C. Duarte, Administrator, Division of Health Care Financing and Policy, Department of Human Resources
Debbra J. King, Administrative Officer, Division of Health Care Financing and Policy, Department of Human Resources
Mary Wherry, Deputy Administrator, Division of Health Care Financing and Policy, Department of Human Resources
Carlos Brandenburg, Ph.D., Administrator, Division of Mental Health and Development Services, Department of Human Resources
Alexander Haartz, Deputy Administrator, Health Division, Department of Human Resources
Philip Weyrick, Administrative Services Officer, Health Division, Department of Human Resources
Maria Canfield, Chief, Bureau of Alcohol and Drug Abuse, Health Division, Department of Human Resources
Carol Sala, Administrator, Aging Services Division, Department of Human Resources
Carla L. Watson, Administrative Services Officer, Aging Services Division, Department of Human Resources
Nancy K. Ford, Administrator, Welfare Division, Department of Human Resources
Jerry Allen, Chief, Child Care Program, Welfare Division, Department of Human Resources
HUMAN RESOURCES/K-12 – OVERVIEW
Assemblywoman Leslie:
We do not want to hear repetitive testimony. We start closing budgets shortly. We are interested in placing new information on the record in response to committee member questions. We may need clarification of certain issues so that we can be prepared to make decisions. I ask that answers be brief and concise.
Senator Rawson:
We are not scheduled to close issues today. However, any direction we can provide staff will assist in later preparation for closure.
Assemblywoman Leslie:
I agree. If we reach consensus, that would help staff. We will now address budget account (B/A) 101-3150.
DHR Administration – Budget page HR ADMIN-1 (Volume 2) Budget Account 101‑3150
Assemblywoman Leslie:
The budget includes $2.9 million in MAXIMUS revenue. Your department believes less revenue will actually be available. Is there more recent information regarding collections?
Michael J. Willden, Director, Department of Human Resources:
We provided two responses to Legislative Counsel Bureau (LCB) staff dealing with MAXIMUS, one on March 11 and one on March 20. My update is from the later response. The Executive Budget was built with approximately $2.9 million of MAXIMUS revenue authority for fiscal year (FY) 2004 and FY 2005. We have met with MAXIMUS recently to obtain its best estimates on collections. We also tried to answer questions relating to the reversion in FY 2003. MAXIMUS’s best estimate is $1.675 million in FY 2004, and $1.725 million in FY 2005.
A note of caution, that is the best estimate for projects in the pipeline, based on the success and failure rate we have seen during the last year. There are a couple of big projects in the initial stages of planning. One deals with the university dental and physician practice plans. We have no idea whether this will be a dry hole or whether we will be able to bring in federal dollars. That project is not included in the estimate. We have not even received the management letter describing how to move forward; it is only conceptual currently.
Senator Rawson:
This seems the appropriate time to mention that the budget does not include a continuation of the $500,000 annual transfer to the Bureau of Alcohol and Drug Abuse (BADA) for child and adolescent issues. It does not seem we should be cutting this. While we may be able to save money in the overall budget, this is a potential addition.
Mr. Willden:
We provided a list of items for possible MAXIMUS funding. I want to provide an update of the list. The first year of suggested spending items totals some $1.9 million; the second year totals a little under $1.5 million. There are two items that should be removed from the list. The first is the Senate Bill (S.B.) 137 study of institutionalized persons. That bill has been amended in such a way that we may not even need a fiscal note; almost $500,000 could come off the list as a result. This would reduce FY 2004 spending to about $1.4 million allowing us to cover the remainder of the list. The second issue is a possible Community Services Block Grant (CSBG) shortfall. The latest information I have is that there will be no shortfall in FY 2003. No one knows what the federal government will do in future years so the $450,000 we have listed is a very soft number.
SENATE BILL 137: Establishes Legislative Committee on Persons With Disabilities. (BDR 17-700)
Assemblywoman Leslie:
Would you revise that list indicating your priorities? Senator Rawson indicated his interest in substance abuse money.
Mr. Willden:
That is on the list as able to be funded.
Assemblywoman Leslie:
Are Senator O’Connell’s suicide prevention items on your list?
Mr. Willden:
Yes, it is ranked number 2.
Assemblywoman Leslie:
Did you build into the budget $364,000 from MAXIMUS for the new Grants Management Unit?
Mr. Willden:
There is $195,000 in the first year. That is MAXIMUS money that goes into the Title XX shortfall. It flows into the Grants Management Unit. There is $200,000 in the second year.
Assemblywoman Leslie:
Does that have to be funded before we fund anything else on the list?
Mr. Willden:
Yes, or there will be a shortfall.
Assemblywoman Leslie:
We are concerned about positions being transferred into this account. Will grantees of the Grants Management Unit, particularly those benefited by the Healthy Nevada Fund, receive less money as a result of increased personnel costs? Our numbers show a shortfall of $194,000 for the Healthy Nevada Fund alone.
Mr. Willden:
I am reasonably confident we did a spreadsheet showing the net would not be reduced. I just have to find it.
Assemblywoman Leslie:
We can come back to that.
Let us go on to the Health Insurance Portability and Accountability Act of 1997 (HIPAA) issues. Maybe we can cover it generally here and not deal with it in each account. We understand you have withdrawn the request for three of the eight new positions. Have you prioritized among the five positions?
Mr. Willden:
We have not done any more work other than the documents we submitted with previous testimony. Our top priority is the three large divisions most heavily impacted: the Division of Health Care Financing and Policy; the Division of Mental Health and Developmental Services; and the Division of Child and Family Services. The Health Division would come next. The lowest priority would be the Aging Services Division.
Assemblywoman Leslie:
That falls in line with my thinking. Let us turn to the Healthy Nevada Fund. The budget contemplates addressing the waiting list for the Senior Rx program by increasing enrollment from 7500 participants to 12,160. Is that still the plan in light of Phillip Morris’s current problems relating to its continuing ability to pay tobacco settlement money?
Healthy Nevada Fund – Budget page HR ADMIN-22 (Volume 2) Budget Account 262‑3261
Mr. Willden:
There are two significant issues I would like to work on before budget closure. The first is the Phillip Morris issue. I have not had a chance to address the impact of recent news. The second large issue is the cost per member per month. We have testified previously we have an opportunity to amend our current contract. If we get a better deal, we can obviously serve more recipients with tobacco money than with the General Fund. We continue to work on the pharmacy plus waiver through the Medicaid division. We will not know whether we will receive that waiver for some months. We want a budget that can take enrollment in the Senior Rx program to 12,000 enrollees, but there are three outstanding issues; the pharmacy plus waiver, the tobacco settlement, and the cost per member per month.
Assemblywoman Leslie:
Please keep fiscal staff updated so we can make a good decision. There is a request for a new auditor position in the director’s office. If that is not approved, it does not make sense to transfer the auditor position from Healthy Nevada since there would be nothing to consolidate?
Mr. Willden:
That is correct.
Assemblywoman Leslie:
Are we going to exceed the three percent cap on administrative expenses?
Mr. Willden:
Pursuant to staff request, we submitted a memo dated March 26 providing revised administrative cost calculations. I have not had any follow-up conversations. There was an erroneous calculation when the Executive Budget was built. Our revision shows an administrative shortfall in FY 2004 of about $2300 and a shortfall in FY 2005 of $22,441. We believe the shortfall can be offset by adjusting our request for costs to print and revise applications. We have about $25,000 annually for application printing and revision of the application. Both numbers could be offset by bringing that side of the expense equation to zero.
Assemblywoman Leslie:
That makes sense, I think. Have we received notice of the federal award under Title XX of the Social Security Act?
HR, Purchase of Social Services – Budget page HR ADMIN-31 (Volume 2) Budget Account 101-3237
Blaine Rose, Administrative Services Officer, Community Connections, Department of Human Resources:
We received our final State allocations for FY 2003 about 2 weeks ago. We do not yet have the grant award letter. We do not have money in the bank, but the allocation increased above the budgeted amount and above the estimate of the Federal Funds Information for States (FFIS). We will have a work program in FY 2003 increasing our authority. We expect at least that amount will be coming in the next biennium. The FFIS estimates about a 2 percent increase for FY 2004.
Assemblywoman Leslie:
If we do receive more money, are our only options to increase grants or to reduce General Fund money?
Ms. Rose:
We could do one or the other or a combination of both.
Mr. Willden:
We could also reduce the Temporary Assistance to Needy Families (TANF) transfer to Title XX.
Senator Rawson:
We will not know what the State will be receiving until after we close the budget. Should we choose a middle-of-the-road estimate now to base things on?
Ms. Rose:
I provided Mr. Peri alternative scenarios. The most conservative assumed the known FY 2003 amount would apply to FY 2004 and FY 2005. The middle‑ground scenario would take the FY 2003 amount and apply it to FY 2004 but apply the FFIS estimate to FY 2005. I also provided several additional scenarios. You have a choice between what we have in hand or the projection of the FFIS. Nevada seems to show an increase in these grants over recent years since the grants are population modified. As a result, even when total federal funding is flat, Nevada’s share increases.
Senator Rawson:
I suggest staff prepare a middle-of-the-road estimate. I do not think we need to take the lowest, and I am not comfortable taking the highest.
Assemblywoman Leslie:
That makes sense. Let us return to the Grants Management Unit. I will ask Mr. Peri to address our concerns.
HR, Grants Management Unit – Budget page HR ADMIN-54 (Volume 3) Budget Account 101‑3195
Larry L. Peri, Senior Program Analyst, Fiscal Analysis Division, Legislative Counsel Bureau:
This involves our memo dated March 4. Your response was provided on March 11. Attachment L asked for a comparison of the funds entering the unit and the funds leaving. There are a number of pluses and minuses displayed on the chart. Some grants show reductions while others show increases. Overall, we want to make the committee aware that grants from the Healthy Nevada Fund do decrease by a net of approximately $192,000 over the biennium. There are other grants where funds increase. The department’s position was that there would be an increase in net flow-through funds to some recipients by about $300,000 over the biennium.
Mr. Willden:
That is correct.
Assemblywoman Leslie:
I am a supporter of the Grants Management Unit. However, I do not like to see grants to communities reduced. I do not know if there is anything we can do about the hit taken by the Healthy Nevada Fund.
Michael J. Torvinen, Administrative Services Officer, Administration, Department of Human Resources:
The Grants Management Unit uses a very simplified cost allocation method based on total revenues. We will allocate money to grants as they are used based on an appropriate methodology. I have recently received allocation training and we will be more specific and defensible in grant allocation.
Assemblywoman Leslie:
That is fair. I ask only that you take another look and do what you can to reduce the shortfalls imposed on communities. You are asking for one new position; there are nine inbound transfers. I think that is commendable. I think this will improve grants in the department. There is a salary shortfall of $15,000. We need to settle on an option to deal with this. As you know, we would prefer we not use General Funds. If you have a preference, you need to let us know.
Mr. Torvinen:
We will come up with something and convey it to staff.
Assemblywoman Leslie:
Let us move on to the Division of Child and Family Services (DCFS). We first want to address E-475 recommending the addition of two new Social Welfare Managers, as hearing officers and an ombudsman, and an Administrative Assistant I. I understand this will provide a means for youth to complain about possible mistreatment. Would you review the situation for us?
HR, Children and Family Administration – Budget page DCFS-1 (Volume 2) Budget Account 101‑3145
Edward E. Cotton, Administrator, Division of Child and Family Services, Department of Human Resources:
That unit involves four functions. We have been trying to address issues raised by the Civil Rights of Institutionalized Persons Act (CRIPA), specifically those identified by the U.S. Department of Justice (DOJ) at the Nevada Youth Training Center. One issue is the grievance procedure. As initially established, complainants were required to go through staff who were either part of the grievance or supervised the personnel who were the subject of the grievance. All grievances now involve readily available forms. Youth are advised on confidentiality procedures, and the grievance forms are now deposited in a lock box available only to the superintendent.
There are still DOJ concerns that this revision is not sufficient. Accordingly, this unit would provide an arbitrator to resolve grievances that were not handled by the superintendent of the facility. It is important that this arbitrator not be related to the institutions.
Assemblywoman Leslie:
Is one of these positions specifically designed to perform that function?
Mr. Cotton:
None of the four functions is sufficient to support a full-time position. We envision two staff trained to perform all four functions. One of the two professional staff would respond to a grievance. We have not worked through the details; we might have one person handle complaints from Caliente and another person handle complaints from the Nevada Youth Training Center.
The second major function is that of administrative hearing officer. I am concerned that our system remains divided despite steps taken in the past. There are three separate units dealing with child abuse and neglect investigations, and three separate, different processes for holding hearings. As we reported in previous hearings, we are being sued in federal court over the workings of the appeals process. Someone against whom a complaint for abuse or neglect has his name put into a central registry system. There are issues relating to the removal of a name, the appeal process, and whether removal is done consistently by trained personnel. We have had extensive discussions with officials in Clark and Washoe Counties; they are interested in this unit being within the State system so that anyone appealing from an abuse and neglect decision would do so through a single point.
One of the recommended positions would be a trained hearing officer. Clark County estimates a caseload of 36 annually; we estimate about 15 annually from rural regions; Washoe estimates 20 cases annually. These numbers do not include cases from institutions, but we estimate those to be less than 10 a year. Lastly, I am aware of two cases recently heard by hearing officers who do not have that as their primary function. I have become involved in these cases; they were thrown out because of significant deficiencies during the hearing. This puts the kids involved at risk. I think it is important to have this function centered on people trained as hearing officers.
The other two functions include an ombudsman office sought by the statewide foster parents group. It provides a place for foster parents to contact if they feel they are not being provided with what they need either from DCFS or the involved county. For example, foster parents could call this office if they disagreed with a decision to move a child. This office would be outside the normal line of authority and, therefore, provide an independent investigative voice. The fourth function is designed to look at our procedures in order to implement best practices. We want this to be other than a sideline to another job. We do not have a lot of central office people at DCFS, and this would help.
Assemblywoman Leslie:
Those sound like good ideas, but I do not know whether the State can afford four positions.
Senator Cegavske:
It is interesting to hear your concerns about hearing officers. We are listening to another bill brought forward by Clark County where parents and the school district are concerned about hearing officers for special education. Lack of training is a concern there as well. Do you have hearing officers who are paid by the State working in your area on a continuous basis?
Mr. Cotton:
No, we do not. I do want to clarify we are requesting three positions, not four. The hearings are conducted differently in each of the three entities. The State person who does rural hearings is actually a mental health specialist whose primary job is out-of-state placements for children with high-level needs.
Assemblywoman Leslie:
Do you believe we do not have hearing officers qualified to address these matters of concern?
Mr. Cotton:
I do not believe there is sufficient guidance regarding the setup of a hearing and its focus. For example, I recently reviewed a hearing tape. The focus was on whether the family was adequate as a future foster home; the real issue should have been whether the family was or was not involved in the abuse brought before the hearing. Many other issues come into hearings now. The basis of the lawsuit is whether abuse occurred. There is training that is necessary.
Senator Cegavske:
I am not hearing that you have the ability to provide necessary training. Do you have this ability?
Mr. Cotton:
Yes, I did this training in Illinois. We had an entire unit handling appeals. It worked very well, and we were in a much better position to respond to complaints or lawsuits.
Senator Cegavske:
I am confused. You want one person to act as an ombudsman. Do you want this person to act as a hearing officer as well? Do you not have qualified hearing officers now? If the answer is “yes,” do you have the ability to train them? You answered that question in the affirmative, so I am having difficulty understanding the concern.
Mr. Cotton:
My concern is that these functions are currently performed by people as a sideline to their current jobs. These people are not up-to-date on current practice. Even if trained, they would not be able to make these functions their principle focus.
Senator Cegavske:
Thank you. We are considering hiring two people in special education who would be hearing officers. They would be attorneys and would have an understanding of the applicable law. Is that something we need to look at in this area? Do you currently use a pool of State hearing officers?
Mr. Cotton:
Our “pool” for rural appeals consists of one person who performs that task as an additional duty. I believe it is done differently in Clark and Washoe Counties. This enhancement unit is designed to create that pool.
Senator Cegavske:
I think this is an area where we definitely need some help. Moving on, what is Clark County doing along the lines envisioned in E-477? Can that program be expanded?
Mr. Cotton:
We have not had that discussion. Clark County has a centralized Child Protective Services intake process that takes all calls locally. Washoe County has a single number. We have not discussed whether Clark County would be willing to take calls from rural counties and pass them on.
Senator Cegavske:
If we have created a system in two places, perhaps we do not need a third.
Assemblywoman Leslie:
We should listen to what Clark County says. It might be awkward for it to handle rural calls. Coming back to this unit, is the third professional here in E‑477, and the two other professionals we have been discussing in E-475?
Mr. Cotton:
Yes, that is correct.
Assemblywoman Leslie:
My only other question involves HIPAA. Can the M-501 position be funded federally or through the cost allocation process?
James B. Baumann, Administrative Services Officer, Division of Child and Family Services, Department of Human Resources:
Some Medicaid money you have seen in other budgets is provided through a quality assurance unit in the Division of Mental Health and Developmental Services (MHDS). We do not have a comparable unit.
Assemblywoman Leslie:
Is there no way?
Mr. Baumann:
Costs we expend today will become part of the cost finding mechanism when costs are raised. It takes about 2 years for that process to catch up. It is unlikely we will receive federal money in this biennium; however, when our costs go up in the future …
Assemblywoman Leslie:
We would like you to keep in mind that it would be easier if this were funded with a minimum amount of General Fund dollars. We would like to move on to child welfare integration. We have taken a lot of testimony on this issue, and I thank you for the hard work it has taken to produce these numbers.
Child Welfare Integration – Budget page DCFS-11 (Volume 2) Budget Account 101‑3142
Senator Rawson:
We know what this decision unit will cost. We can instruct LCB staff to prepare it whether we have sufficient revenue or not. I do not see any reason to go over this further.
Assemblywoman Leslie:
We do need to talk about caseload updates. The counties were complaining they were unsure that data was accurate. I believe we were going to receive updated information by April 1, but that has not been received.
Diane R. Comeaux, Deputy Administrator, Division of Child and Family Services, Department of Human Resources:
We do have updated caseload data from Washoe County, and we are working with Clark County. The caseload in Washoe County is growing at the rate we estimated so no adjustment is necessary. The situation in Clark County is more difficult, but we should have an answer for you by tomorrow.
Assemblywoman Leslie:
Let us turn to E-475 and the Unified Nevada Information Technology for Youth (UNITY) system, Nevada’s federally mandated Statewide Automated Child Welfare Information System (SACWIS). I understand we are considering two new positions.
HR, UNITY/SACWIS – Budget page DCFS-20 (Volume 2) Budget Account 101‑3143
Madilyn L. Maire, Information Systems Manager, Division of Child and Family Services, Department of Human Resources:
The E-475 decision unit is for a Management Analyst and a Program Officer to begin work on enhancements required to the UNITY system. The UNITY system is now staffed as a maintenance and operations project. The enhancements are needed to comply with State and local requirements. For instance, we need to develop an automated eligibility determination module. We have a recoding module, but need the new module. We also need modifications involving reporting of various types. We do not have sufficient staff at present.
Assemblywoman Leslie:
Let us move on to the Youth Community Services budget. It seems most of the increase in funding is for caseload increases. Are these caseloads anticipated to change?
HR, Youth Community Services – Budget page DCFS-29 (Volume 2) Budget Account 101‑3229
Ms. Comeaux:
We do not have any changes in the anticipated caseloads.
Assemblywoman Leslie:
We will address the Juvenile Correctional Facility budget. The schedule you recommended for staff phase in has not been met. Where are we from your perspective? Are you planning to provide a new implementation schedule?
HR, C&FS – Juvenile Correctional Facility – Budget page DCFS-53 Budget Account 101-3148
Mr. Cotton:
We can provide a new implementation schedule. There has been much discussion about where the Legislature wants to go, and we are really waiting for guidance.
Assemblywoman Leslie:
Obviously the key decision is whether to adopt a private sector alternative to State operation. The subcommittee is going to have to make this soon.
Mr. Willden:
Clearly we cannot proceed on the schedule associated with the Executive Budget. It will take 4 to 6 months from time of decision to opening of a facility. The question is whether to proceed with State employees: do we start hiring key staff, and does that staff begin training line staff? If we are not going to open a facility with State staff, we need to go through the request for proposal (RFP) process again. Publishing an RFP will probably add 3 months to the 4‑ to 6‑month timeframe. This is because of the time involved in writing the RFP, putting it out for bid, allowing for vendor selection, and accounting for vendor hiring of necessary personnel.
Assemblywoman Leslie:
These times are actually very helpful.
Senator Rawson:
There is a serious problem with children backing up in the system. I am horrified that it will take 6 months to provide relief. We should have the necessary conversation sooner rather than later. We need to move off the dime; it almost no longer matters to me what decision we make. Which will be cheaper, the State or privatized model?
Mr. Willden:
We know the State’s cost will be about $141 per day per bed. We know from the previous RFP that the bids ranged from $149 a day to $162 or $163 a day. Those bid numbers were prior to negotiation, and we anticipate we could negotiate those numbers lower. Regardless what company wins the bid, it is unlikely to be significantly cheaper than the State costs. I have talked to the last two bidders and one prospective bidder. I do not know what they will bid, although we have sent some clear messages because we have been so public about what it would cost the State to run the facility. Anyone would be dumb to bid more than that. Bidders now know the numbers, and I do not think we will get a better deal.
Senator Rawson:
What is the fastest implementation?
Mr. Willden:
A State-run facility is the fastest way to open the facility.
Senator Rawson:
I would plead with the committee to make a decision so we can get moving.
Senator Cegavske:
What does it cost us to send someone out of State? How many people do we now have outside Nevada, and how many more will we have in the next 6 months?
Mr. Willden:
I did not bring those numbers today; I can get them to you by the end of the day. The costs range from as low as $113 a day to go out of State to the Tennessee center. The Rite of Passage in-State program costs in the mid‑$120s.
Assemblywoman Leslie:
We want to gear up for a decision soon. Would you assemble all the numbers so we can be ready? I would like to ask staff to put this item on our next work session schedule so that we can make a decision.
Assemblyman Hettrick:
If Rite of Passage will take a juvenile into its own facility for, say, $125 a day, where it has to bear costs of facility ownership, why would it not run our facility for that amount? If it does own the building, should not Rite of Passage be able to operate our facility for less?
Mr. Willden:
I met with Rite of Passage representatives yesterday. They made it clear to me that they could not run Summit View in the mid-$120s. That facility is different from the type of community facility Rite of Passage operates. It is a secure facility with required staffing ratios. We have talked about this in the past. There is a need to maintain a 1:8 ratio on the day shift and a 1:16 ratio on night shifts. These may be richer ratios than are in the community facilities. There is no doubt Rite of Passage could run Summit View. Let me be clear; this is not a hill for me to die for. I want to get a facility opened. If we want to issue an RFP and get another set of bid numbers, and if they are better than what the State can do, then we should award the contract.
Assemblyman Hettrick:
I brought this up because when Senator Cegavske asked about out-of-state costs, it raised the question in my mind whether we should even open a facility.
Mr. Willden:
Not all youth can be sent to Rite of Passage. That program has criteria established as to what type of youth can be accepted. We would send youth to Summit View who would not be taken by Rite of Passage. There are some problems that program cannot manage.
Assemblyman Hettrick:
Does the out of state, $113 per day group represent those youth Rite of Passage cannot take?
Mr. Willden:
Yes, the Tennessee facility is a secure facility.
Mr. Cotton:
I would like to point out that both those contracts are presently being renegotiated. The rates we quoted will probably be different from July 1 forward. We do not yet know the new rates. We also need a no-decline policy, something we do not have now at other facilities.
Senator Cegavske:
How long would it take for an RFP? Why was action curtailed on the previous RFP?
Mr. Willden:
We stopped the prior RFP process, and we had actually selected a vendor to run the Summit youth facility, because revenue issues in the post-September 11th period, combined with the 3 percent cut, raised significant funding questions. We simply stopped the process until the funding picture became clear. I am sitting here hoping that a tax revenue decision will make funding more clear. It will take a minimum of 3 months for us to put an RFP on the street. We can update the old one and apply the lessons we learned. Negotiation would take additional time. It would probably take from 3 to 5 months to get a firm under contract.
Senator Cegavske:
Does the State want to do this?
Mr. Willden:
The State wants to open Summit View.
Senator Cegavske:
Do you want to run it?
Mr. Willden:
The State wants to run it.
Senator Cegavske:
Can you do it?
Mr. Willden:
Yes, we can.
Assemblywoman Leslie:
Senator Raggio?
Senator Raggio:
Those were my exact questions.
Assemblywoman Leslie:
We know what we need to decide and will try to do so as soon as possible. Let us move on to the Caliente and NYTC budgets. We appreciate the facility tour. We asked for a budget amendment on mental health issues, will that be forthcoming?
HR, Caliente Youth Center – Budget page DCFS-58 (Volume 2) Budget Account 101-3179
HR, Nevada Youth Training Center – Budget page DCFS-63 (Volume 2) Budget Account 101-3259
Mr. Baumann:
We are working on the amendment; it will take a bit of time to do the numbers.
Assemblywoman Leslie:
I want to note that E-400 contains a new Assistant Superintendent position at Caliente. Are you still anxious to have this position?
Mr. Cotton:
Yes. Many of the changes we have instituted require an Assistant Superintendent.
Assemblywoman Leslie:
Let us move on to Youth Parole. There is $113,000 in the budget for psychiatric consultations and medications. I am glad to see this, but want to make sure we are also addressing this issue in our institutions as well as post release.
HR, Youth Parole Services – Budget page DCFS-68 (Volume 2) Budget Account 101‑3263
Assemblywoman Leslie:
I see that the HIPAA position is gone from the child and adolescent services budget in the north. Are you looking for more money for UNITY in this budget as well? How do these UNITY requests relate?
HR, Northern Nevada Child & Adolescent Services – Budget page DCFS-72 (Volume 2) Budget Account 101-3281
Mr. Baumann:
The position in B/A 101-3281 is for an information systems specialist tied to the Avatar system replacing AIMS, currently run from Las Vegas. The staff currently assigned to support the system are MHDS employees. We are asking for this position and one in the budget in the south to run the Avatar system.
Assemblywoman Leslie:
Do both budgets have both a contractor and a new position? Why do you need both? Would $173,000 annually be for a contract programmer?
Mr. Baumann:
Staff will enter information into the Avatar system interfaced to the UNITY system. Our theory is that information, relating to individuals in the mental health system who may transfer into the child welfare system, will be available to caseworkers, enabling them to recognize the presence of mental health issues.
Assemblywoman Leslie:
Do you need it because the State is still maintaining the back end of the treatment for child welfare?
Mr. Baumann:
The back end really has nothing to do with it. We want caseworkers to know there had been prior mental health contact involving a particular child. If so, case managers could coordinate treatment.
Assemblywoman Leslie:
It would be helpful if you provided an explanatory memo to staff.
Mr. Baumann:
We will do that.
Assemblywoman Leslie:
It looks like we are planning to close the eight-bed Children’s Acute Care Unit at Desert Willow Treatment Center. What is the plan for the next biennium? Will we keep it closed?
HR, Southern Nevada Child & Adolescent Services – Budget page DCFS-79 (Volume 2) Budget Account 101-3646
Mr. Baumann:
We still contemplate closing that facility because of budget constraints. The last discussion I had was to put it on hold. We have not found savings elsewhere.
Senator Rawson:
It seems to me this is a budget decision. A number of us have visited the facility. The information we have is that it is not prudent to close it. We are willing to listen to good policy reasons for closure, but my assumption is that we should keep it open. I have just as much concern about the Specialized Adolescent Treatment Program. The kids in that program are sexual offenders. We have tried for 15 years to build a facility to handle them. Now, we appear to be closing it. It seems to me that both should be kept open.
Mr. Cotton:
As we testified earlier, there are two reasons for moving on the children’s unit. First, the average usage over the years has been 4.8 beds used out of 8, and there are beds at other places, specifically Monte Vista, to handle that overload. Secondly, we want to implement a policy of stepping kids down. I believe the program is a good one, but so is the program at Monte Vista. When we looked at cuts, we considered underused programs, such as the acute care unit, and what direction we wanted to move toward in the future. We want to move to step‑down, wraparound services that put kids in community-based foster homes, and then buy services around those. There will always be a need for acute short-term care for kids in that age group, but our decision unit was built around the belief that those kids could be picked up by Monte Vista.
Senator Rawson:
I do not want to speak against Monte Vista, but it is not the facility that this is. This facility is nicer and newer. Patients are not housed with adults. It seems to me that this unit offers better control than anywhere else.
We also have a number of subcommittee members asking if now is not the time to take both the northern and southern child and adolescent services and put them into mental health. We probably could do that and it would be cost neutral. Is there a reason why we should, or should not, do that?
Mr. Cotton:
I certainly have issues with that. Discussions about Summit View as well as Desert Willow have to do with the establishment of a continuum of care for children and having them grouped in one location. I think having all the mental health and children and family services in one department would be helpful, but I came from a system where children’s services were part of adult services. It did not work well. We had to build a General Fund child mental health system within family services in order to get services to children. There is a different focus when dealing with adult services. We are trying to ensure the big three, child welfare, children’s mental health, and juvenile justice, get tied into a continuum of care. We want to move to a seamless system. We are close to that in mental health, but not as close in juvenile justice. One of my goals in the last 6 months is to get things tied together. Issues overlap; often the same kids are involved at various times in their lives. I think the system works better the way it is.
Assemblywoman Leslie:
I was involved in children’s issues when it was in mental health; I have been involved since the Legislature moved it. It has not worked well in either place. Some kids do not get mental health care regardless. I dare say it is worse today than 10 years ago. I do not know the answer, but we need to take a close look.
Senator Cegavske:
I agree with many of Senator Rawson’s comments. In considering an administrative move, we need to recognize that many children need mental health care as adolescents and also through adulthood. I do concur with Senator Rawson on E-200 and E-203 in the Southern Nevada Child and Adolescent Services budget.
Assemblywoman Leslie:
I think there is still concern on closure of the Therapeutic Family Care Program in E-201, mainly whether there will be sufficient support for foster homes in these instances. Are you comfortable with the budget request?
Mr. Cotton:
Yes, I am. This program was established because of the lack of capacity in private agencies. Our staff in the south feels the private agencies can now handle the capacity.
Assemblywoman Leslie:
I want to return briefly to the Desert Willow situation. If we did proceed with closure, the children would have to be served somewhere. Did we ever determine whether those costs had been identified in other budgets?
Mr. Cotton:
The kids do have to be served somewhere. We do not have an exact outline of where the money would come from. We have many children, almost 40 percent, in higher levels of care. We intend to reduce that greatly, freeing up both federal and State money to be used to purchase wrap-around services for the children.
Assemblywoman Leslie:
Are you counting on savings from moving other children out of higher-level care to pay for the children affected by closing these facilities?
Mr. Cotton:
Yes, and also to pay for the kids previously in higher-level care. A residential program may cost $400 a day or $12,000 per month. Moving to a foster home, even a specialized one, costing $900 a month would make $10,000 or $11,000 available. That amount will not be needed for the affected child.
Assemblywoman Leslie:
I think we need to see some analysis to learn where those numbers come from.
I also want to talk about merging the First Step Early Childhood Services Program in with early childhood services at the Special Children’s Clinic. Some parents are concerned that moving the program administratively will result in longer waiting lists and a drop in service quality.
Mr. Willden:
Similar concerns have been expressed to me. I understand, but politely disagree. The Special Children’s Clinic model of serving children from birth to age 3 is different from the first step model. What we want to do in the integration is to take the best from both models. I believe the Special Children’s Clinics have a lot to learn from the First Step and Happy programs. I cannot see the State running three separate models in the future.
Assemblywoman Leslie:
I agree. I think the programs should be consolidated. Could your staff identify parents in the south who have expressed concerns and meet with them?
Mr. Willden:
I will be happy to do that. We should not lose track of the fact that we are not getting children’s assessments done in a timely manner. We have over 500 children on the waiting list. I have two cases on my desk now where we are inches away from major lawsuits in this area.
Assemblywoman Leslie:
Let us move on to health care financing and policy. I am certain you are aware we are taking a hard look at the TANF projections. That will obviously affect this budget. I want to put you on notice. This will be one of the last budgets to close.
Health Care Financing and Policy – Budget page HCF&P-1 (Volume 2) Budget Account 101-3158
Assemblywoman Leslie:
Thank you for prioritizing the six new positions in M-200. We need an update on M-501. We want to ensure the Medicaid Management Information System (MMIS) remains on track. We would also like to hear about the reduction in claims inventory and the switch over. I understand that will cause more claims to be paid earlier.
HR, HCF&P, Nevada Medicaid, Title XIX – Budget page HCF&P-11 (Volume 2) Budget Account 101-3243
Charles C. Duarte, Administrator, Division of Health Care Financing and Policy, Department of Human Resources:
The MMIS continues to be on track. We had a quality assurance meeting yesterday with our vendor; these take place weekly. We have areas of concern and high‑priority items, but no one is panicked. We have plans to address the staff loading needed to complete major portions of the project on time.
We have been more than successful in trying to reduce our claims inventory. This is a plus for the provider community, but it is also a problem for the fiscal operations of the division. Our estimated claims inventory was approximately 100,000 claims. We are well below that with around 72,000 claims. This presents an issue for us.
Debbra J. King, Administrative Officer, Division of Health Care Financing and Policy, Department of Human Resources:
Decision unit M-501 included funding to pay down the claims inventory backlog from 100,000 claims to about 10,000 claims, which is the anticipated inventory once MMIS goes on-line in October. The good news is that we are down to 65,000 claims. I do not have the final March figures. The claims reduction piece of M-501 is in place. The bad news is that those claims have now been paid in FY 2003. As a result, our supplemental appropriation need will go up.
Assemblywoman Leslie:
We understand. Please ensure our staff has the correct numbers so that we can move forward correctly.
I think we have covered rate increases sufficiently in previous hearings. However, as regards E-351, we are still a little confused in understanding how moving to fee for service addresses access to dental care. Is this really the correct approach?
Mr. Duarte:
Questions about improvement in access with managed care have been answered. We have seen that including primary dental care in our health maintenance organization (HMO) program results in an improvement in access for children. The current statistics from the two HMOs, through the University of Nevada School of Dentistry, indicate access may be reaching capacity in the south. It certainly is far better than what we had before moving this into the HMO system through the school of dentistry. I do not disagree that having a point of accountability with the managed-care program would improve access, particularly in northern Nevada in the Washoe County area. I still think we will have difficulties with that because of the availability of providers willing to take Medicaid dental fees in northern and rural Nevada. We have a proposal to increase some dental fees in those areas. We have seen access improvements in the past as a result of increased fees. Both models work. Fees address the issue. Managed care with appropriate capitation rates addresses the issue. I remain skeptical whether we can implement a managed-care program in the northern and rural areas. I need to see greater provider participation, but, perhaps this is something we can move toward.
Assemblywoman Leslie:
Okay, I think I understand what you said, and I think you understand our concern.
Ms. King:
I would like to point out that the requested rate increase for orthodontia is outside HMO payment. It is paid as a pass-through.
Senator Cegavske:
I would like to return briefly to M-501. I request periodic reports to the Interim Finance Committee (IFC), specifically, I would like to learn in the July meeting and thereafter what progress is being made.
Assemblywoman Leslie:
If you could do that, it would be helpful.
Mr. Duarte:
We would be glad to do that.
Assemblywoman Leslie:
We had discussion in previous hearings about eligibility criteria associated with E-425, the Medicaid buy-in and the Health Insurance for Work Advancement (HIWA). We asked for costs, projected caseload, and different eligibility criteria. Is that available?
Mr. Duarte:
Staff have put together a response based on eligibility models in other states. We should have that by close of business today.
Assemblywoman Leslie:
I think we have covered the county match program and the Child Health Assurance Program (CHAP). Have we changed the plan associated with M-592, the Medicaid waiver associated with the transition of personal care attendant services?
Ms. King:
We are behind the eight ball on decision unit M-592. The plan was changed in January 2001. However, we did not change our service delivery methodology under the Community Home-Based Initiatives Program (CHIP) waiver to comply with plan requirements.
Assemblywoman Leslie:
When will that be done?
Ms. King:
It will be done in July if we obtain the necessary funding. If we do not get funding, we will remain out of compliance with the State plan.
Assemblywoman Leslie:
The entire Medicaid State plan issue is still confusing, particularly how it is changed. Obviously, we want to be in compliance.
The physically disabled wavier program would add 160 new slots in E-455 and E-456. The current waiting list is 99 individuals. My understanding is that some positions have been frozen and that is the reason we have not moved forward. Is that correct?
Mr. Duarte:
Yes, that is correct.
Assemblywoman Leslie:
When will the positions be unfrozen? It does no good to appropriate money if the positions are frozen and we cannot get people served. We do not want to appropriate money only to have it sit there.
Mr. Duarte:
We have submitted justifications to fill those positions. I understand the difficulty of filling them because of the fiscal situation.
Assemblywoman Leslie:
Do you have any idea whether that will be granted? We want the program to work. However, we cannot help anyone if we appropriate money and the positions remain frozen. That makes no sense. Let me simply say that this is a real concern.
Mr. Duarte:
We understand that. We have tried to adjust caseloads in order to move individuals on the waiting list into slots, but we have slowed work on that program.
Assemblywoman Leslie:
We have talked about several models dealing with assisted living in E-457. Is there a specific service delivery model?
Mary Wherry, Deputy Administrator, Division of Health Care Financing and Policy, Department of Human Resources:
Assemblywoman Buckley has a bill; I am assuming it will move out of committee and go forward. That bill has been amended in such a way that I do not believe there would be a large discrepancy between the definition of assisted living and what we consider group care today. As a result, I do not think our projections will be affected.
Assemblywoman Leslie:
I agree. I heard that bill in committee yesterday. We will just move forward with what we have in the budget.
Turning to the budget reductions in E-600, we understand that the Governor has decided not to reduce the reimbursement rates for the obstetrics/gynecologists (OB/GYNs). Where are we going to make up the savings of about $1.8 or $1.9 million each fiscal year?
Mr. Duarte:
We need to save about $1.7 million each fiscal year. We have determined that savings from some of our step therapy pharmaceutical protocols, particularly for some of the gastric acid and arthritis drugs, are higher than estimated. They will cover the cost of keeping the OB/GYN rates whole.
Assemblywoman Leslie:
How much is the savings?
Mr. Duarte:
It is almost exactly what we need to cover the OB/GYN costs. We will be providing that data to Legislative staff this afternoon.
Assemblywoman Leslie:
We understand the personal care aide (PCA) services, life skills training, and physician training in the cost containment initiatives in E-601. The preferred drug list (PDL) has been a significant issue. I understand you will be contracting out for a PDL manager. Where is the money going to come from? Will we need a budget amendment to cover the new direction?
Mr. Duarte:
We need additional estimates from other states in order to determine our PDL costs. We have preliminary estimates, but would prefer waiting until our April 16 response to Legislative staff. We have negotiated some items Legislators wanted to see included in the program. There will also be a delay in implementation that will necessitate a budget change. We will put together a package for you.
Assemblywoman Leslie:
Would that also include the maximum allowable cost (MAC) pricing? That would be affected as well. We look forward to receiving that because some large numbers are involved.
Let us move on to Nevada check-up. The caseload increase has slowed to 5 percent over the last 8 months where before it was 11 percent over the last year. Where do you think the caseload is going?
HR, HCF&P, Nevada Check-Up Program – Budget page HCF&P-31 (Volume 2) Budget Account 101-3178
Mr. Duarte:
I believe the Nevada check-up caseload growth trend line will continue along those we estimated and the Governor recommended. We will have further numbers when we rerun our caseload projections; we estimate those will be available to Legislative staff the week of April 14. We have seen a slowdown. Programs have a rapid caseload rise in the beginning. Although we still have a large number of uninsured children, there is some consistency to the increases we are seeing on a monthly basis.
Assemblywoman Leslie:
Do you think it is reasonable to move forward with the numbers built into the budget?
Mr. Duarte:
We are going to be rerunning those numbers.
Assemblywoman Leslie:
We will need those as soon as we can. We previously discussed the possibility of raising the monthly premiums a modest amount since they have never been raised. I have a concern about collection. Can we make it easier for families to pay, thereby collecting a greater amount? We will want to consider options in our final work session.
Mr. Duarte:
I agree. We have not done an adequate job in collecting those premiums and purging individuals who have not paid. We identified about 1900 children or cases that are delinquent in payment in March. Another adjustment we will be making in caseload involves redeterminations and premium collection efforts.
Assemblywoman Leslie:
Are you proceeding with the concept of allowing once-a-year payment rather than smaller quarterly payments?
Mr. Duarte:
Yes. Staff have already revised the application to indicate that option.
Senator Cegavske:
Are you still running a campaign to solicit enrollment? How much do you spend in that area?
Mr. Duarte:
We are a grantee of the Robert Wood Johnson Foundation. We spend about $2 million in outreach over a 4-year period when grant and federal funds are combined. The period of our grant was 4 years. The dollars from the foundation are matchable with federal funds from both the Medicaid program and the Nevada Check-Up Program. The vast majority of that money funds community‑based agencies conducting outreach activities throughout Nevada.
Senator Cegavske:
How are you providing outreach?
Mr. Duarte:
The community-based programs reach into schools and community centers. There is a vast array of efforts underway.
Senator Cegavske:
This is something you can provide to me later. The entire committee may not want to see it.
Mr. Duarte:
I will be glad to do that.
Assemblywoman Leslie:
We want to cover the intergovernmental transfer program. The upper‑payment level is going to net approximately $3.7 million a year for the State. Can you confirm this? Also, can you confirm that amount is not yet reflected in the Executive Budget?
Ms. King:
I believe a budget modification has been submitted.
Assemblywoman Leslie:
It was not in the budget, but we now have an amendment. Can you tell me what the amendment suggests we will spend that money on?
Ms. King:
The amendment would put that saving into reserve.
Assemblywoman Leslie:
We will want to look at that in our final work session. Let us now move on to the mental health budget. Let us start with rate increases. We understand there may be a technical adjustment and an inflation increase. We see no major issues with pharmacist reclassification. Turning to the administration budget, there is concern about eliminating the psychiatric resident program with the University of Nevada, Reno (UNR). I have the sense from the committee we do not want to eliminate this. Have you reconsidered this issue since our first hearing?
HR, MHDS Administration – Budget page MHDS-1 (Volume 2) Budget Account 101-3168
Carlos Brandenburg, Ph.D., Administrator, Division of Mental Health and Development Services, Department of Human Resources:
There are two separate decision units involved. One involves four residents at the Northern Nevada Adult Mental Health Services (NNAMHS); the decision unit involving the Lakes Crossing facility is funded within the fiscal year 2003 cap. We simply could not fit the residency program within the budget cuts.
Assemblywoman Leslie:
This only involves $143,000 annually.
Dr. Brandenburg:
There is no possible way I can fund it within existing resources.
Assemblywoman Leslie:
It seems like a good buy.
Dr. Brandenburg:
It is a great buy. My present understanding is that the dean of the medical school was approaching the chancellor to see if the school could contribute part of the funding.
Assemblywoman Leslie:
Would you check on that; it is a real concern.
Senator Rawson:
It seems to me this program is one we cannot cut. This is like nursing. We are now suggesting that costs be taken out of the formula. We understand that everyone’s budget is tight. I see this as an area we need to add back in.
Assemblywoman Leslie:
I agree. Let us move on. I want to point out that module E-600 eliminates an eight-bed residential treatment program. I want to ensure that money is being put into community placements.
Dr. Brandenburg:
Absolutely. There are two intensive supportive living arrangements, five regular plus supportive living arrangements (SLAs), and eight regular SLAs in that B/A. We wanted to develop a more effective residential program than what we had; and, we have had better outcomes with the SLAs than with the existing residential treatment program.
Senator Rawson:
Does Assembly Bill (A.B.) 29 have some General Fund impact?
ASSEMBLY BILL 29: Provides for additional administrative assessment to be collected in certain cases involving misdemeanors to pay for certain programs established by district courts. (BDR 14-130)
Assemblywoman Leslie:
That involves court assessment fee for special courts.
Senator Rawson:
Do we have any idea where that bill is in the process?
Assemblywoman Leslie:
I do not know. I have stayed out of it since that is where I work.
Senator Rawson:
That legislation would replace some General Fund dollars.
Assemblywoman Leslie:
Yes, it would. We will get an update before our next work session.
Let us move on to Lakes Crossing. I think we understand the psychologist position. We eliminated five positions at the Clark County Detention Center. We have more money in training, and then there is the psychiatry residency program. I have no questions.
HR, Facility for the Mental Offender – Budget page MHDS-18 (Volume 2) Budget Account 101-3645
Assemblywoman Leslie:
Let us move on to the supplemental appropriation for rural clinics. Our understanding is that you have amended the request. Instead of $614,000, you will need $740,000. Is that correct?
2003-2005 Executive Budget Supplemental Appropriations to FY 2003 – Budget page INTRO-18 (Volume 1)
Dr. Brandenburg:
That is correct.
Assemblywoman Leslie:
Is that because we cannot fill those positions, and, therefore, they cannot generate revenue?
Dr. Brandenburg:
That is the major issue we are looking at. We had an average of about 13 vacant positions last fiscal year. Numerous variables were involved. We were trying to recruit licensed clinical social workers. This is difficult to do for service in rural areas. We were able to change the “licensed clinical social workers” to “mental health counselors.” This expanded the applicant pool. We hope to be able to recruit. However, you are correct. Our inability to bring in revenue is due to the fact that each of these positions has to bring in about $40,000. This is the reason for the supplement.
Assemblywoman Leslie:
I understand, but there are a number of enhancements here for caseload. I hesitate even to use the word “enhancement” because we are finally starting to serve people who have been on waiting lists for a long time. Is it realistic to expect we can hire people to serve where we need them?
Dr. Brandenburg:
That is a good question, and one we constantly ask. We believe we will be able to attract staff with the options we have, thereby bringing staff into rural areas. We are fortunate that Oregon’s inability to pass its tax package has resulted in a great many layoffs and a great many severely mentally ill being on the streets. As a result we have a great number of applicants, social workers and mental health counselors, who want to work for us because they are losing jobs in Oregon.
Senator Rawson:
Did we have a bill dealing with social worker interns?
Assemblywoman Leslie:
Are you thinking of a situation where they have been able to bill Medicaid?
Dr. Brandenburg:
I believe that was one of our recommendations. One of the barriers we faced is that we could not bill Medicaid.
Senator Rawson:
Do you know if we have processed that bill?
Dr. Brandenburg:
I am unaware of it.
Senator Rawson:
If someone can send us a bill number, we will consider it.
Assemblywoman Leslie:
I agree.
Senator Cegavske:
My question is a general one. There has been controversy over the definition of a “waiting list.” Do you have a definition? Is someone who phones in an inquiry counted? What are the criteria, and I realize this may vary across services? I would like to have this defined in the areas of our concern.
Dr. Brandenburg:
We will be more than happy to provide that. This is one of the strengths of our division. We have very operationally-defined criteria based on community standards.
Assemblywoman Leslie:
Assemblywoman Giunchigliani has reminded me of a bill in the Assembly Committee on Ways and Means regarding the lack of mental health facilities in Laughlin. Are you aware of this problem? Why can we not get mental health facilities out there?
Dr. Brandenburg:
That was on our items for special consideration, and it did not make the cut. We understand the tremendous need, but we were trying to enhance the infrastructure first, before looking at additional programs. That is why the Laughlin clinic is not in our budget.
Assemblywoman Leslie:
Would you agree it is toward the top of the list?
Dr. Brandenburg:
It is. It is our first priority for rural clinics.
Assemblywoman Leslie:
I agree we need to hire people in the clinics we already have. If we cannot solve that issue, we cannot solve the Laughlin problem.
Let us move on to Southern Nevada Adult Mental Health Services. I know the budget recommends adding another Program for Assertive Community Treatment (PACT) team. We have 23 people on the waiting list, and anticipate that with the new team, we would be able to serve an additional 72 clients. How quickly would the PACT team be up and running and able to take on that caseload? Would it be able to do so from the beginning of the biennium or is there a phase-in plan?
HR, Southern Nevada Adult Mental Health Services – Budget page MHDS-34 (Volume 2) Budget Account 101-3161
Dr. Brandenburg:
The decision unit is predicated on a phase in. We anticipate bringing in 23 immediately and phase in the remaining throughout the biennium.
Assemblywoman Leslie:
I want to commend you. I think the plan to address the mental health needs in southern Nevada is an excellent one. I think it is realistic. I am jealous because they are getting some things I have wanted for a long time, but I cannot deny the need is there. I think it will work.
Senator Rawson:
We have met to deal with the issue of diversion and relieving the hospitals. Do you have an idea of what can be done?
Dr. Brandenburg:
We will be presenting three options internally this morning. I am sure Mr. Willden will be consulting with the Governor’s office after that. We will return to you.
Assemblywoman Leslie:
Let us move on to developmental services, starting with the Sierra Regional Center. You are reducing beds in E-600, but you are also putting more money into community residential placements. What relationship does this have to the Olmstead decision?
HR, Sierra Regional Center – Budget page MHDS-51 (Volume 2) Budget Account 101-3280
HR, Desert Regional Center – Budget page MHDS-59 (Volume 2) Budget Account 101-3279
HR, Rural Regional Center – Budget page MHDS-70 (Volume 2) Budget Account 101-3167
Dr. Brandenburg:
This represents Nevada’s implementation of the Olmstead decision. We have been able to reduce the number of our Intermediate Care Facility/Mental Retardation beds. Those patients have been moved into the community. We have experience across three biennium periods and are now building on our successes. This decision unit puts us in an excellent position to defend any Olmstead-like litigation. This is part of a statewide plan, involving the Desert Regional Center and the Rural Regional Center as well as the Sierra Regional Center.
Assemblywoman Leslie:
Is it realistic to add all staff in E-431 effective on October 1? Is there a phase-in plan that might save money as well as be more realistic?
Dr. Brandenburg:
We feel we can bring them on board on October 1 based on our past experience. We have done similar additions each of the last two bienniums.
Assemblywoman Leslie:
Decision unit E-450 also raises Olmstead issues. We are bringing people back from out-of-state institutions. Is this revenue neutral?
Dr. Brandenburg:
There will be some cost savings, but not for this upcoming biennium. Currently, it is pretty much cost neutral. There will be some Medicaid savings. Cost savings will occur after 2 years. We will be moving from a static setting to community placement. Four years ago, we repatriated about 23 individuals in institutional facilities in Utah. All but three were eventually placed in the community.
Assemblywoman Leslie:
Of course, this is better for the families as well.
Dr. Brandenburg:
Benefits include quality of care, and our ability to move people into a less restrictive environment. It is difficult for us to determine whether out-of-state patients can be moved to a less restrictive environment.
Assemblywoman Leslie:
We understand the Carson City office relocation. We also think it very important that all our programs be accredited. The Governor’s recommendation for the family preservation program involves some $509,000. Would this allow an increase of payments to families back to the $310 the Legislature approved last session? Would this also serve an additional 90 families as projected?
HR, Family Preservation Program – Budget page MHDS-67 (Volume 2) Budget Account 101-3166
Dr. Brandenburg:
This is our most cost-effective program. If families did not take care of their profoundly retarded youngsters, the children would be in institutional settings. It would cost the State almost ten times the amount we pay families if these children were institutionalized. We are trying to assist families in their efforts to provide quality care.
Assemblywoman Leslie:
In many ways this is the best of all possible worlds. The children stay with their families and the State is saved huge amounts of money.
We will hear next from the Health Division. I want to begin by asking whether the HIPAA position can be funded at an 85 percent level through indirect cost assessment rather than using general funds.
HR, Office of Health Administration – Budget page HEALTH-1 (Volume 2) Budget Account 101-3223
Alexander Haartz, Deputy Administrator, Health Division, Department of Human Resources:
The answer, provisionally, is “yes.” We would need to apply the same cost allocation principles we do for other positions to ensure we can justifiably charge that much based on the funding within the programs. Some General Fund programs are HIPAA intensive. As a result, the funding may be 75 percent overall rather than 85 percent. We can explore a better allocation.
Assemblywoman Leslie:
Please try and do that if you can. Did you submit your list of new positions in priority order in B/A 101-3223? Did we ask you to do that?
Mr. Haartz:
You did not ask, but we will be glad to provide that in priority order.
Senator Rawson:
We also want an assurance that there is enough indirect cost to fund those positions.
Mr. Haartz:
The answer to that question is that we do as well. We will not create or fill a position unless we have the ability to generate the administrative charge.
HR, Vital Statistics – Budget Page HEALTH-7 (Volume 2)
Budget Account 101-3190
HR, Health Aid to Counties – Budget Page HEALTH-16 (Volume 2)
Budget Account 101-3209
HR, Consumer Health Protection – Budget page HEALTH-18 (Volume 2) Budget Account 101-3194
HR, Community Health Services – Budget page HEALTH-40 (Volume 2) Budget Account 101-3224
Assemblywoman Leslie:
We understand vital statistics. We understand that the counties are unhappy, but we do not have money. In considering consumer health protection, we are considering new fees to be presented to the State Board of Health at its August/September meeting. Will that allow you sufficient time to implement the fees supporting your FY 2004 budget request?
Mr. Haartz:
We believe that is sufficient time. The fees are for annual licensure. As a result, the fees are not prorated. Our goal is to make the August State Board of Health meeting. Depending on community input and possible revisions, we might have to bring this before the September meeting. It will be done in that fall period.
HR, Sexually Transmitted Disease Control – Budget page HEALTH-54 (Volume 2) Budget Account 101-3215
Assemblywoman Leslie:
I think we have satisfied the question associated with the AIDS Drug Assistance Program (ADAP) regarding a waiting list in southern Nevada. Is it your understanding that there is no waiting list and that everyone who qualifies is being served?
Mr. Haartz:
That is correct.
HR, Immunization Program – Budget Page HEALTH-59 (Volume 2)
Budget Account 101-321
HR, Special Children’s Clinic – Budget page HEALTH-70 (Volume 2) Budget Account 101-3208
Assemblywoman Leslie:
We do not have questions on immunization. We talked about special children earlier. I ask that you listen to the concerns of the parents in southern Nevada and address those concerns so they do not fester.
Mr. Haartz:
We will be happy to do that.
Assemblywoman Leslie:
I understand that the waiting time in southern Nevada is much longer than in northern Nevada. Will most of the money in E-501 be directed to the southern Nevada clinic?
Mr. Haartz:
Yes. It will be divided proportionately based on waiting list size. The longest is in southern Nevada.
HR, Health Alcohol & Drug Rehabilitation – Budget page HEALTH-86 (Volume 2) Budget Account 101-3170
Assemblywoman Leslie:
Turning to alcohol and drug rehabilitation, we talked about MAXIMUS earlier, and you heard the committee’s strong support for funding at $500,000 annually. Funding through a block grant increase seems to be an option. Can you comment on the increase in the block grant? If we did take that route, and I like it because it shows our intent that we want the adolescent treatment funding there, does it take money away from adult treatment?
Mr. Haartz:
If the funding received were level, we would be faced with that situation. Mr. Weyrick can best answer what we might do with a funding increase.
Philip Weyrick, Administrative Services Officer, Health Division, Department of Human Resources:
We do not yet have a grant award, although there are promises it will be here soon. Based on discussions, we believe we will receive an increase of about $500,000. This would enable us to support that effort without cutting other services.
Assemblywoman Leslie:
Do you have an alternative plan for that $500,000? Where was it supposed to go?
Mr. Weyrick:
As far as I know, we were waiting for the funding grant before any allocation. I do not believe there would be any cut in what has already been proposed.
Senator Rawson:
Perhaps we can prioritize so that the first $500,000 is used here, and the next money goes to grants management or whatever. Is that reasonable?
Mr. Haartz:
There would be no argument from the Health Division with regard to using increased funding for adolescent treatment services, especially if MAXIMUS funding were not available.
Maria Canfield, Chief, Bureau of Alcohol and Drug Abuse, Health Division, Department of Human Resources:
We anticipate a block grant increase of about $500,000. For our current year, 70 percent of that is earmarked for treatment. We currently anticipate all those funds going to adolescents.
Assemblywoman Leslie:
That is for FY 2003. Will there be an additional increase for FY 2004 and FY 2005?
Ms. Canfield:
We have no idea. We are making funding decisions now for the next 3 years.
Assemblywoman Leslie:
I want to ensure I understand. Have you already targeted 70 percent of the $500,000 for treatment? Is the remaining 30 percent unavailable because it has to be used for prevention?
Ms. Canfield:
It has to go to prevention, administration, and evaluation.
Assemblywoman Leslie:
We will turn to aging next. We want to make sure we cover those issues because this will be one of the first budgets we will be closing. We continue to be concerned about the use of tobacco settlement money to fund positions, especially those not providing direct services to clients. Last session we asked that other revenue sources be found. Do you have any comments?
HR, Aging Services Grants – Budget page AGING-1 (Volume 2) Budget Account 262-3140
Carol Sala, Administrator, Aging Services Division, Department of Human Resources:
We have looked for additional revenue sources, but we do not have any. The positions funded by tobacco settlements involve direct oversight of services.
Assemblywoman Leslie:
Are they management staff?
Ms. Sala:
They are social workers who coordinate services. They coordinate the providers, set up services for clients, and manage those services.
Assemblywoman Leslie:
Are you saying they direct services?
Ms. Sala:
Yes. They monitor. They visit client homes monthly to see what clients need and to check the quality of care.
Assemblywoman Leslie:
This makes us uncomfortable. You probably heard this morning about the Philip Morris situation. The tobacco money is great while we have it, but what happens when we no longer have it? That remains our concern.
How much would it cost the General Fund if we had to use it to fund all the things now funded through the tobacco settlement?
Carla L. Watson, Administrative Services Officer, Aging Services Division, Department of Human Resources:
Are you asking about what is new in the budget, what is new, or both?
Assemblywoman Leslie:
I am asking about both, and a breakdown would be helpful.
Ms. Watson:
I have a schedule I can provide staff today.
Assemblywoman Leslie:
You heard the discussion on HIPAA. If we have to cut back, we might consider a position combination. In E-458, the Medicaid Title XIX account, five new positions are envisioned. Is this the ombudsman program for elderly protection?
Ms. Watson:
That is correct.
Assemblywoman Leslie:
I understand you plan on reducing the average caseload from 60 cases per month to approximately 50 cases per month and on increasing courtesy visits to nursing homes from 50 percent to 100 percent. Would you explain how you will leverage existing State salary appropriations?
Ms. Watson:
Our existing ombudsman positions are primarily funded from the General Fund. We are not using these General Funds to match any federal funds. We are proposing to use them for matching to bring in Title XIX funds.
Assemblywoman Leslie:
That makes sense. In senior services, the CHIP waiver in E-451 involves 80 additional slots. Do you have those slated to begin in October 2004? Why are we waiting until October 2004?
HR, Senior Services Program – Budget page AGING-14 (Volume 2) Budget Account 101-3146
Ms. Sala:
We have the slots in E-451 coming on board at a gradual pace starting in October 2004. Twenty will come on board then; the rest of the increase will occur over the biennium.
Assemblywoman Leslie:
What is the reason we are waiting more than a year to begin?
Ms. Sala:
Originally we had four social worker positions in that unit. After building the budget, we had to cut two of those positions in cost savings.
Assemblywoman Leslie:
Is this just to save money?
Ms. Sala:
Yes.
Assemblywoman Leslie:
Are you adding two administrative positions in FY 2004?
Ms. Sala:
Yes. One is an Administrative Assistant III to provide support to social workers. The other position is an Accounting Clerk I. We had an identical position in our last biennium budget. Initially, the position was frozen, and then it was lost to cost savings. In other words, in the last 2 years, the additional slots and additional billings have been absorbed by current staff. We really need that position because we have only one clerk now.
Assemblywoman Leslie:
It sounds as though you have thought this through. Does M-200 involve 108 new slots in addition?
Ms. Sala:
Correct, that is 108 slots over the biennium.
Assemblywoman Leslie:
Can you defer this into the next biennium? Is there really a need for these 80 slots over the 108 slots?
Ms. Sala:
Yes. The 80 slots built into E-451 address the waiting list. Fortunately the waiting list has declined, but that is due to partnering with UNR by using its geriatric resource team to assess some waiting list people.
Assemblywoman Leslie:
I ask because E-452 involves another 100 slots associated with the adult group care waiver.
Ms. Sala:
The group care waiver is different from the CHIP care waiver. Part of this is based on the needs identified in the strategic plan; the other is based on Barbara Buckley’s bill and the assisted‑living project. We anticipate that will generate a greater need.
Assemblywoman Leslie:
I understand the explanation.
Mr. Willden:
Before we finish discussing the aging budget, I want to talk about one of the waiting list issues, involving S.B. No. 174 of the 71st Session and E-459. The department is sending a letter to you on this subject that you should have within the week. The interim study considered services needed by the severely functionally disabled. Those client needs were addressed in the Medicaid budget and in the aging budget, but they were not addressed in the office of community based services budget. We would like to have you consider how the dollars are allocated among the three populations; we are not asking for more money. Without reallocation, we will have one population completely unserved.
Assemblywoman Leslie:
This is very confusing, and I look forward to your letter. Let us move on to the elder protective service and homemaker programs. Five more positions are requested. The most important item here seems to be the increase in face‑to‑face investigations, from 50 percent, which I find appalling, to 90 percent, a lot closer to where I think we should be.
HR, EPS/Homemaker Programs – Budget page AGING-25 (Volume 2) Budget Account 101-3252
Ms. Sala:
We fund both the elder protective service (EPS) program and the homemaker program out of Title XX monies. We do not anticipate increasing staff or services in the homemaker program because the need is in the EPS program. While there is a need in the homemaker program, we do not anticipate additional Title XX funds. Two requested positions are intake workers, one in the north and one in the south. They will take phone calls, relieving current EPS workers of that duty. That will effectively increase social work staff.
Assemblywoman Leslie:
We want to ensure vulnerable elderly people are seen.
Ms. Sala:
We see that as a real need.
Assemblywoman Leslie:
Is the caseload number of 30 per social worker realistic?
Ms. Sala:
Our goal is 25 ongoing cases per social worker; that is the national average. Considering the backlog and the new positions, we hope to be able to reduce the caseload to 25.
Assemblywoman Leslie:
We do want to close this budget relatively early, and so, again, look forward to your letter.
Let us turn to welfare, our last major budget. We do not have to spend much time on caseload. You should be aware, however, that our staff will be presenting several alternatives regarding caseload projections. There is room for discussion, and we would appreciate your assistance. I know we have been told, “It is what it is.” We have to move on this issue, and you will not be getting what you submitted. We will be looking at future alternative scenarios, and the subcommittee will have to select one. We would appreciate anything you can do to ensure that the options we consider are realistic.
Let us talk about the childcare shortfall. The subcommittee has not heard this before. We are greatly concerned to learn of the mistake in the carryforward funds that will have a dramatic impact on the availability of money for childcare. What happened? Why did it happen? How do we ensure it is not repeated? What is the plan now?
HR, Child Assistance and Development – Budget page WELFARE-37 (Volume 2) Budget Account 101-3267
Nancy K. Ford, Administrator, Welfare Division, Department of Human Resources:
The childcare budget through 2002 contained a carryforward of approximately $9 million of federal funds. Due to caseload increases and the interest in reducing waiting lists, that money was spent in waiting list prevention. The budget, however, was built assuming the $9 million carryforward continued to exist. We now have to revise the budget downward significantly.
We propose to cut in various areas. We indicated in our budget hearing that we would cut our requested position. We are also deleting replacement equipment from our budget request. We are reducing expenditures in the at-risk category of childcare and in the discretionary category in childcare. We are increasing expenditures in the mandatory categories. As you know, the TANF caseload exploded. That has a domino effect on childcare because of the TANF mandate. The New Employees of Nevada (NEON) Program cases and the Assistance with Childcare for the Employed (ACE) Program cases are still being served; however, there are waiting lists in both the at-risk and discretionary categories.
We have frozen acceptance of new discretionary cases and new at-risk cases. We are not taking new cases in these categories.
We are looking at alternatives for managing this budget in the future to avoid this problem. We are considering requiring non-needy caretakers in kinship care to meet the income test for childcare. Currently, there is no income test applied to the caretaker; only the child’s income is considered, and most children have no income. Imposing the income test on caretakers would require them meeting the same criteria as other people in the discretionary and at-risk categories.
Assemblywoman Leslie:
My concern with what you have said so far is that by freezing the waiting lists in those categories, people may have to stop working in order to care for their children. Will our TANF caseloads increase by implementing your plan?
Ms. Ford:
That is always a possibility, particularly in the at-risk category. The at-risk category is already below 185 percent of need, the entry-level income test for TANF cash. In that case, a person would become a mandatory recipient.
Assemblywoman Leslie:
What happens if we do not have enough money for the mandatory recipients?
Ms. Ford:
We would then have to cut back on the ACE program. This is a transitional category. We would try to serve the mandatories as long as possible.
We are also considering instituting co-payments to every category. A minimal co-payment would be added for those at 100 percent of poverty; these are currently paid completely with childcare dollars. This would save money to serve more people.
Assemblywoman Leslie:
Are we going to be able to collect tiny co-payments? We have not been doing a good job of that in checkup.
Ms. Ford:
I do not know. We used to have a co-payment; we eliminated it several years ago.
Senator Rawson:
I think we should at least consider the effect of some co-payment. We need to get it plotted out so we can consider it.
Jerry Allen, Chief, Child Care Program, Welfare Division, Department of Human Resources:
We in childcare do not collect the co-payment; it is paid directly to the childcare provider by the parent.
Assemblywoman Leslie:
Thank you for that clarification. The State is not really good at collecting money, but childcare centers are because they see the parents every day. I think we need something in writing that addresses the issues we have identified today. I do not want to leave at session end without knowing how the shortfall will impact childcare, whether the TANF caseload will increase, and, if the income test is imposed, whether more TANF funds will be freed up. This all really concerns me.
Ms. Ford:
I would like to point out that 52.9 percent of our childcare recipients do not make a co-payment. Hopefully, that will help in some way. We want to make the co-payment “very minimal.” We want people to move toward self‑sufficiency. Part of self-sufficiency is an ability to pay bills. Having a minimal co‑payment will help that process.
Assemblywoman Leslie:
Another area of continuing concern is the TANF budget reductions. Clark and Washoe Counties took a huge hit. I am also concerned about the nonprofit contracts in domestic violence and substance abuse. I hate to see us give up on these programs, including the kinship care program. Could you provide that chart again for our budget closing? I would like to have those numbers handy in case there is any way to replace those funds in the event the outlook looks better in May.
We will move on to the child support enforcement budget. I understand Senate Bill (S.B.) 186 is in the judiciary committee. I know nothing about its likelihood of passage. If it is not approved, and your budget is based on its approval, what is your contingency plan?
SENATE BILL 186: Imposes fee upon obligor each time employer withholds income for payment of support for child. (BDR 3-446)
Ms Ford:
We would have to cut staff. We would also need to figure out additional ways to come up with savings. The change in the funding map impacted the State’s share of collections. Hopefully, this $2 fee will pass to help make up that difference.
Assemblywoman Leslie:
Will you be submitting a budget amendment in this area?
Ms. Ford:
We will submit it tomorrow.
Assemblywoman Leslie:
The last area is energy assistance. There was concern earlier about having sufficient money for administration, specifically to ensure the Las Vegas office remained open and was adequately staffed. Have you provided a funding map showing how this will work?
Ms. Ford:
We have not provided a funding map, but we can do so. The housing division has allowed us to carry forward the grant money it gave us for last biennium. That will help.
Assemblyman Goldwater:
I do not know how this affects the issue, but the IFC just approved $200,000 for the housing division from the federal government.
Assemblywoman Leslie:
The outstanding issue is the TANF caseload projections and the associated staffing. These are big budget items.
Ms. Ford:
I would like to reiterate. Staffing is not just tied to the TANF caseload, but is mainly driven by food stamps and Medicaid caseloads that continue to increase.
Assemblywoman Leslie:
That means it is even more complicated and difficult to get a handle on.
Ms. Ford:
That is correct. Historically, our projections in the food stamp and Medicaid areas have been very accurate. The difficult area has been TANF because of what has happened in the last year. It has been very volatile.
Assemblywoman Leslie:
We have to settle on a number. We do not want to under project or over project.
Ms. Ford:
We have the same goal.
Assemblywoman Leslie:
I would like to thank you all. We will be making decisions in our next work session. We stand adjourned at 10:30 a.m.
RESPECTFULLY SUBMITTED:
James D. Earl,
Committee Secretary
APPROVED BY:
Assemblyman Sheila Leslie, Chairman
DATE:
Senator Raymond D. Rawson, Chairman
DATE: