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The Idaho Department of Health and Welfare (IDHW) Director Karl Kurtz introduced his management staff, Deputy Director Joseph Brunson, Deputy Director Joyce McRobert, Deputy Director Gary Broker, Division of Health Administrator Richard Schultz, Division of Welfare Administrator Scott Cunningham, Division of Family and Community Services (FACS) Administrator Kenneth Deibert, and Division of Medicaid Deputy Administrator Kathleen Allyn. Other management staff introduced included Region I Director Michelle Britton from Coeur d'Alene, Region IV Director Randy Woods from Boise, Region VII Director Joan Gridney from Idaho Falls, and Acting Administrator Division of Medicaid Randy May.

Director Kurtz distributed a chart outlining the overall IDHW statistics, and the 2003 appropriations. The Department serves a total of 338,926 Idaho residents.

1. General Funds - $359.6 million
2. Total IDHW funds $1.2 billion
3. Year 2003 authorized full-time staff positions of 2,999
4. Appropriation by Divisions: Medicaid 70.5 percent, Welfare 10.1 percent, Councils 0.3 percent, Indirect Support 2.6 percent, Health 4.3 percent, and Family and Community Services 12.2 percent.

1. Medicaid's spending by program - Basic Medicaid is 97.5 percent, CHIP (Children's Health Insurance Program) 2.2 percent, Facility Standards 0.3 percent and has 196 positions. The Medicaid expenditure categories are benefits at 95.7 percent, operating 2.9 percent, and personnel 1.4 percent. Medicaid has 196 full-time staff positions.



2. FACS (Family and Community Services) spending by program - Child Welfare 28.6 percent, state hospitals 28.4 percent, Children's Mental Health 8.8 percent, Adult Mental Health 12.6 percent, Substance Abuse 9.2 percent, Developmental Disabilities 12.4, FACS expenditure categories are personnel 56.1 percent, benefits 26.9 percent, and operating 17.0 percent. FACS has 1,683 full-time staff positions.



3. Welfare's spending by program - eligibility 28.7 percent, community action 12.9 percent, child care 29.7 percent, cash payment 12.3 percent, and child support 16.4 percent. Welfare expenditure categories include benefits of 58.3 percent, personnel 23.6 percent, and operating 18.1 percent. This division has 657full-time staff positions.



4. Public Health's spending by program - women, infants and children 34.1 percent, environmental health 2.3 percent, emergency medical services (EMS) 6.8 percent, immunization 8.9 percent, health promotion 9.7 percent, labs 10.0 percent, vital stats 11.3 percent, and physical health 16.9 percent. This division has 178 full-time staff positions.

Senator Stegner asked Mr. Schultz to explain what children are served by the programs, who is eligible for services, who is targeted for services, and what is the focus of programs. Mr. Schultz explained that each program has different eligibility criteria. He briefly outlined the following programs.

Children's Special Health Program - Any child in the state can access the program. The program contracts for clinics around the state that are staffed by physician specialists, who diagnose and provide consultation for children with special health needs, such as cardiac, neurologic, orthopedic, craniofacial, cleft lip and palate, and cystic fibrosis. The program assists in paying, on a sliding fee scale, for treatment of uninsured children with these diagnoses. If a child is insured, the insurance company is billed. This program is not a benefit's program. This is a public health program and serves about 2,400 children each year.

Immunization - This program provides about 500,000 doses of childhood vaccine for all children in the state. No eligibility is required for immunizations. Vaccines are provided free to physicians throughout the state. More than 700 physicians in Idaho administer the vaccine. The program tracks adverse reactions (about 0.1 percent), the immunization rate at two years of age (75 percent), and schools' entry (95 percent), monitors physicians' use of the vaccine to assure quality and efficiency, and promotes vaccination of children.

Newborn Screening/Genetics Clinics - Every child in Idaho is required to have newborn screening on birth. This program provides physicians with access to laboratory analysis of blood samples collected on all newborns (about 21,000/year) for metabolic abnormalities. If diagnosed early and with proper intervention, the impact the abnormalities have on decreased mental capacity or potential death can be averted.

There are no geneticists in the state, the program contracts with geneticists from the medical schools in surrounding states to staff clinics in Idaho, where they provide consultative services to patients referred from physicians throughout the state. Approximately 210 families, to individuals are seen annually. The cost for newborn screening previously had been paid by the State, but is now paid by the parents.

Reproductive Health - This is a program that provides services to mostly low-income women. Payments are based on a sliding fee scale. The majority of services provided through the Bureau of Clinical Preventive Services are contracted through the District Health Departments, so the site for the delivery of services is at the local Health District clinic. The District Health Departments provide family planning services to women throughout Idaho. The program serves approximately 30,000 women per year, the majority of whom are low incomes.

STD/AIDS - No eligibility requirement for services. The program contracts with District Health Departments to hold clinics for the diagnosis and treatment of people with sexually transmitted diseases (STD's) and their partners. Additionally, the clinics provide diagnostic services for human immunodeficiency viruses (HIV) and acquired immunodeficiency syndrome (AIDS), approximately 30 new HIV/year and 25 new AIDS/year. If a HIV-positive patient is less than 300 percent of the poverty level, they may qualify for the federal-funded AIDS Drug Assistance Program, (approximately 90 patients). The drugs are meant to reduce the patient's viral load, making them less infectious and maintaining their health status longer.

Women, Infants and Children (WIC) - This is the largest program within the division, both monetarily and in the number of people served. The program contracts with District Health Departments and some tribes to provide clinical assessment of the nutritional status of pregnant or breast-feeding women and children under the age of five (5) years, who are below 185 percent of the poverty level. If the patient is found to be nutritionally compromised, prescription food checks (worth approximately $38/monthly) are provided for specific food items to meet the nutritional risk. Approximately 33,000 patients are served annually.

Bureau of Health Promotion - This is a non clinical bureau and the majority of programs in the bureau are population-based health promotion programs. The Bureau provides preventive health programs and services to local Health Departments, schools, businesses, hospitals and other community-based organizations to improve the health of Idahoans. The Bureau has programs in adolescent pregnancy prevention, arthritis, asthma, breast and cervical cancer early detection, injury prevention, oral health and tobacco prevention and control, diabetes control, and rape prevention and education.

Bureau of Environmental Health and Safety - Provides environmental health education, food protection, indoor environment and worker health and safety services. The Bureau works closely with the Department of Environmental Quality, and with the seven District Health Departments in Idaho.

The focus is on providing the public with information on how to reduce their risk of harm from exposure to various environmental contaminants. The work is done primarily at sites that are or being considered as potential Superfund sites (lead at Bunker Hill and the Coeur d'Alene Basin, selenium around Soda Springs, arsenic at Blackbird Mine, (approximately 10 sites around the state are actively being worked). Health consultations are also provided to communities that request assistance in evaluating health concerns surrounding an environmental contaminant, such as cancer concerns at Oldtown. Fish advisories are issued when contaminants in fish reach levels of concern, most recently mercury at Brownlee, C.J. Strike, and Salmon Falls Creek reservoirs, and selenium in East Mill Creek.

Bureau of Health Policy and Vital Statistics - This group converts health data into information. It is responsible for producing the annual vital statistics report for Idaho, which contains all the information on births, deaths, and divorces in Idaho. It also performs surveys of the population to determine health risks, such as the Behavior Risk Factor Survey (BRFS), and the Pregnancy Risk Assessment Tracking Survey. The surveys provide the most time-sensitive information on which to develop or revise health program efforts. The survey data reflect changing attitudes and, more important, behaviors, which are good predictors of mortality. This group identifies our health problems and how too most effectively address them.

Emergency Medical Services (EMS) - This program is responsible for identifying emergency medical system weaknesses and developing proposals to improve its performance. Two of the most recent initiatives have focused on improving training and guidelines for treating children and development of a Trauma Registry that, when implemented, will link pre-hospital with hospital emergency room data to assess the quality of patient care in both settings. The program is also responsible for staffing the State Child Mortality Review Committee, which is responsible for reviewing all child deaths occurring in the state to determine if there are system changes that should be made to reduce childhood deaths.

The EMS program is also responsible for the licensure of all EMS units in Idaho (approximately 200) and certification of EMS personnel, approximately 4,500 staffs, 68 percent of whom are volunteers.

The EMS is responsible for the Communications Center which operates 24 hours a day, 365 days a year. It dispatches rural EMS units without 911 systems and air ambulances, offers flight-following monitor flight progress; provides communication links between any EMS unit and the hospital to which they're transporting a patient.

The EMS program administers grants to primarily rural EMS units, EMS consultants, and provide local units with information and assistance in maintaining viable EMS services.

Public Health Laboratory - Laboratory sites are located in Coeur d'Alene, Pocatello, and Boise. This group performs analysis of environmental samples (about 12,000 yearly), primarily for the Department of Environmental Quality. They are responsible for licensing all clinical laboratories in Idaho (approximately 800) and inspecting all clinical X-ray equipment in the state, approximately 1,250 sites.

The Microbiology Laboratory receives about 16,000 samples annually from Idaho clinical laboratories to confirm test results, and from District Health Department clinics and disease investigations. It also performs other tests such as tuberculosis and environmental specimens for biological agents.

The Virology/Serology Laboratory deals with some of the nastiest critters - viruses. It is the only lab in Idaho that tests for rabies, about 20 exposures yearly. This group would more than likely be the lab to identify smallpox, if it is introduced in Idaho.

The Microbiology and the Virology/Serology labs receive samples from hospital and physician laboratories for confirmation. Both laboratories are key labs in investigating disease outbreaks.

Office of Epidemiology - This office is the focal point for medical consultation regarding communicable diseases. It is also the coordination point with District Health Departments for investigation of and development of strategies to interrupt disease transmission throughout Idaho.

Office of Rural Health and Primary Care - This office provides consultation to rural communities on ways to improve or maintain access to health care locally. The office administers the $250,000 Rural Access Grant program as well as other federal grant programs to improve rural hospital viability, such as the Critical Access Hospital Program.

Mr. Schultz briefly discussed two proposed pieces of legislation. One pertains to the authority to quarantine and isolation of individuals with infectious disease. The second relates to housekeeping issues created when the Division of Environmental Quality (DEQ) was separated from IDHW. The enforcement authorities were transferred to DEQ; therefore, the food enforcement statutes were also transferred, and those statutes need to be under the public health laws.

The Division administers various self-reliant programs such as child support collections, Food Stamps, child care and cash assistance, while requiring people to strive to become employed and self-reliant. Other programs include food commodities, energy assistance, telephone assistance, weatherization assistance and other services funded through the federal Community Services Block Grant Program. The Division reviews the needs of individuals and families, designing and integrating health care, child support services, temporary cash support and employment training.

The total number of applications for services during fiscal year 2002 was more than 154,000. The Division has 657 authorized full-time positions of which 525 are self-reliant employees. The balance of positions are located in the Central office or other statewide sites. We have found about a 60 percent increase in the application for services, which is about 58,000 more applications for services over the last five (5) years.

Mr. Cunningham explained TAFI (Temporary Assistance for Families in Idaho). TAFI provides cash assistance to needy families with children. The Department partners with families, community programs, employers, and other agencies such as the Department of Labor, Vocation Rehabilitation, area learning centers for adults, to help participants obtain jobs and achieve self-reliance. There is a 24-month lifetime limit for adults to receive cash assistance. To receive TAFI, most adult participants must seek education, training or employment opportunities. People leaving TAFI often continue receiving benefits in other programs such as Food Stamps, Medicaid and child care. The average number of participants who received TAFI in year 2002 was approximately 2,300, and about $5.3 million was paid in benefits.

Aid to the Aged, Blind and Disabled (AABD) - AABD provides cash assistance to certain low-income participants who are blind, disabled or age 65 or older. In SFY 2002, a monthly average of about 11,000 people received cash payments under this program. This program connects with Medicaid for a more comprehensive service.

Another direct benefit program is the Food Stamp Program. This program helps low-income families maintain good health and nutrition. This is a federally funded, mandated program managed by the State. Idaho determines the eligibility for families to receive the benefits. The average number of families in Idaho in SFY 2002 who received food stamps is about 67,000 with a cost of about $58 million.

Idaho Child Care Program (ICCP) - This is another benefit program. ICCP subsidizes child care costs for low-income families while parents work or attend educational or training programs. ICCP helps families become self-reliant and gainfully employed. In SFY 2002, we served more than 10,000 children per month with a total cost of about $27.7 million.

Benefit Delivery - Benefit delivery in the self-reliance program has undergone significant change in recent years. Beginning in 1998, the Electronic Benefit Transfer (EBT) System was implemented statewide to increase efficiency and reduce the cost of benefit payments for the self-reliance program. The Department implemented the Quest card to be used for payments of Child Support, Food Stamps, TAFI, and AABD. Payments are made electronically.

Self-Reliance - Employment-related Services - The Department provides employment-related services to qualified individuals. Adult participants in the TAFI Program and certain adults in the Food Stamp program are required to take part in these employment services to receive benefits. The Department contracts with agencies and vendors to help families search for, gain and keep employment.

The Food Stamp Program includes the Job Search and Assistance Program (JSAP) which was expanded throughout the state in 1998, part of the Welfare Reform Act. The goal is to provide Food Stamp recipients with employment tools, which they can use to become self-reliant. JSAP can help in a job search and referrals, unpaid work-experience opportunities, job skills training and education. Last year, approximately 5,900 food stamp participants received assistance from JSAP.

Child Support Services - The Idaho Child Support Program (ICSP) promotes physical and economic health of families by ensuring parents are financially responsible for their children. The program helps locate non-custodial (absent) parents and enforces their obligations to provide financial and medical support for their children.

In SFY 2002, Child Support Services administered a monthly average of 76,425 non-county child support cases, collecting and distributing more than $102.4 million. Services include establishing paternity, locating non-custodial parents, establishing court orders for child support, and collecting and distributing child support payments through the Electronic Payment System (EPS).

In 1999, the federal government determined all child support cases should be administered by a single agency in each state. Health and Welfare was chosen by the State Legislature to assume this responsibility. The Department had handled most child support cases in the state and now has assumed collection and distribution of more than 16,000 additional child support cases that were previously administered by county courts. In SFY 2002, the Department administered more than 92,000 child support cases, and collected $140.3 million. ICSP uses a variety of methods to enforce child support orders. The primary tool for enforcing payments is wage withholding. Other tools include new hire reporting through electronic data matching, license suspension, and direct collection methods. In SFY 2002, there were 1,120 licenses suspended, but very few professional licenses have been suspended. Most license suspensions are driver license.

Self-Reliance: Community Services - The Division of Welfare administers federal grant programs to improve living conditions for low-income households and encourage self-reliance. These programs are available to qualifying communities and residents.

Community Services Block Grant - The federal anti poverty block grant is distributed throughout all 44 counties of Idaho by Community Action Agencies and the Idaho Migrant Council. The goals are to revitalize low-income communities, reduce poverty and empower families and individuals to become self-reliant. The grants can be used to provide emergency and supportive services, employment readiness, food, housing, and transportation assistance. A total of $3.1 million was distributed during SFY 2002, serving more than 19,200 people quarterly.

Emergency Food Assistance Program (TEFAP) - The TEFAP distributes USDA purchased commodities through Community Action Agencies to help supplement the diets of Idaho's low-income population. Commodities valued at $1.7 million were distributed in SFY 2002 to an average of 31,000 households per quarter. Cost of administering the program was $222,241. The administrative portion of this program is 98 percent federally funded.

Community Food and Nutrition Program - This program provides education about food distribution and nutrition through Community Action Agencies and the Idaho Migrant Council to low-income people. The program helps coordinate private and public food assistance programs to better serve low-income populations. Funding comes through the Community Service Block Grant and totaled $17,402 in SFY 2002.

Low-Income Home Energy Assistance Program - This program helps Idaho's low-income population pay a portion of their home heating cost and provides energy conservation education through Community Action Agencies. Payment is made to heating suppliers and vendors. A federal grant from the U.S. Department of Health and Human Services funds this program, spending $12.3 million and serving more than 29,000 Idaho households in SFY 2002.

Telephone Service Assistance Program - This is a small program costing $342,163 in benefits in SFY 2002 while helping more than 32,000 households. The program provides assistance with telephone installation, and/or monthly service to low-income residents. Benefits are provided by the telephone companies through charges included on their customers' phone bills.

Weatherization Assistance Program - Reimburses community action and nonprofit agencies that install energy conservation measures for low-income people, particularly the elderly, disabled and families with small children. This federally funded program served more than 1,400 households, spending $1.8 million in SFY 2002.

Mr. Cunningham discussed the faith-based initiatives generated by President Bush. The goal is to help more faith and community-based organizations to learn how to partner in community-based services. The Department sees this as a wonderful opportunity to establish partnerships within communities, and to work and establish a richer network of services. Religious organizations must serve all individuals, and federal funds cannot be used for religious activities.

Healthy Families in Nampa Collation - This is a partnership in cooperation with Region X (Seattle) Administration of Family and Children Services. It is a group of people who have gotten together who want to do something to help support healthy marriages and responsible fatherhood. They have applied for a grant and, if approved, they will provide services such as marriage counseling, skill development, parenting skills training, to help parents in Nampa. The application has been submitted.

Senator Darrington asked about the error-rate for Idaho, and how is the Department currently doing with its error rate. Mr. Cunningham stated the Department continues to receive incentive awards from the federal government in the TAFI program for performance. Idaho's participation rate is very good. During the last two years, Idaho has dropped a percentage point in the Food Stamp error rate. Idaho is at or below national norms on error rates. This is considered an indicator of how well the Department's staffs are doing their jobs.

Within the Department, FACS is designated as the lead agency for the operation of the system of care for adult and children's mental health, adult and children's developmental disabilities services, infant and toddler program, substance abuse, child welfare, which includes child protection, adoption and foster care. The Division is also responsible for the operations of the State's three hospitals. Idaho State School and Hospital in Nampa provides intensive residential services for persons with severe developmental disabilities. State Hospital South in Blackfoot provides inpatient and skilled nursing services to adults and adolescents with serious and persistent mental illness. State Hospital North in Orofino provides intensive inpatient treatment to adults also affected by serious and persistent mental illness.

In SFY 2002, more than 100,000 citizens had some contact with the various services and programs offered by the division. That is approximately a 9 percent increase in the number of individuals who accessed our services and programs compared to SFY 2001. Our current budget for SFY 2003 is about $148 million which is $11 million less than the appropriation we received in SFY 2002. The Division has eliminated 69 positions during the past 18 months. Staffing reductions occurred primarily through the elimination of administrative staff and positions that supported Regional Mental Health Authority and disability services. Staff reductions occurred in all programs except Child Protective Services.

We have been faced with many difficult decisions related to how best to manage the reductions in funding, decisions we have had to make. Balancing resources with needs is a constant challenge. As we considered how best to manage our current resources, we based our decisions on the following priorities:

1. We worked to avoid major impacts in the programs that the Department has statutory responsibility to provide.
2. We made every effort to avoid staffing and service reductions that would impact community, staff and consumer safety.
3. We were mindful of the need to provide federally required maintenance of effort funding for our mental health, substance abuse, and infant and toddler programs. Had we not maintained a federally prescribed level of state participation in these programs, we would have risked losing significant amounts of federal funding.

As we approached the decision-making process over the past 18 months to address the required holdbacks in State General Funds, careful consideration of the entire continuum of services that the Division is responsible for was made prior to reaching the final budget reductions. No one likes to see reductions in services for the people we serve. The staffs of this Division are committed to working with you and the people whom we serve to find the best solutions to the challenging task of balancing resources and needs.

Since this presentation is intended to provide an orientation of the work of the Division, I will give you a brief description of each of the programs we manage.

Idaho CareLine - This is a bilingual, toll-free telephone information and referral service (1-800-926-2588). This past year, CareLine has joined forces with private nonprofit groups to expand information and referral services across the state, and to include health and human service programs' information in addition to the IDHW information. In SFY 2002, more than 38,000 calls for information about health and human service providers in the State were received.

Children and Family Services - This is one of the most significant programs managed by the Division. This program is responsible for child protection service, foster care, adoption, children's mental health, Indian child welfare, and licensing of children's residential treatment facilities.

Staff who work in the child protective services are responsible for screening and assess each report or referral of child abuse or neglect that is brought to our attention. Our Child Protection Services focuses on safety, permanence, and the well-being of children. We work cooperatively with the police, prosecutors and the courts to address the safety needs of children who are abused or neglected. In 2002, we had 783 substantiated cases of abuse and neglected in Idaho.

One common misconception about the Department's role in Child Protective Services, our staff do not remove children who are abused or neglected from their parents. A child can only be removed from their parents by the action of law enforcement or a judge once the child is determined to be in imminent danger, and cannot be safely cared for within the current family structure. When this determination is made, our staff are then responsible for providing a safe and nurturing environment for the child to live, until they can safely be reunited with their family, or in some cases adopted by other caring families.

Foster Care Program - The cornerstone of our child's welfare system is the Foster Care Program. Foster families provide for a supportive temporary home for children placed in state custody, Last year we placed 2,260 children in foster care in Idaho. In most cases we are successful in reuniting the children with their natural families. For those children where this is not possible, we seek to find adoptive families. In FY 2002, 92 children found new families to care for them through our adoption programs.

Children's Mental Health Program - Children who experience serious emotional disturbances can receive services through this program. Services are provided through a system of public and private partnerships that offer outpatient, inpatient and residential care. The state has been working to develop a broad system of care to meet the needs of children and their families with serious emotional disorders based upon a monitored agreement with the federal courts. The state entered into this agreement as a result of a suit filed against Idaho known as the Jeff D. case. The Idaho Council on Children's Mental Health, which is a partnership of the Governor's office, Legislature, Department of Health and Welfare, Department of Education, Department of Juvenile Corrections, concerned citizens, providers, and advocates, is leading the effort to assure the state's compliance with the court settlement.

This past fiscal year, we were able to provide assessments for 3,766 children, which is almost 1,200 more than the previous fiscal year, and to provide outpatient treatment to more than 9,000 children, either through the resources of departmental staff or through contracts with private providers. Staffs provide crisis services, assessments, service authorization, provider enrollment, training, and quality assurance. Approximately 85 percent of the children who qualify for children's mental health services are eligible for Medicaid reimbursed services.

Another vital service provided by the Division is our programs for adults who are mentally ill. Our services are focused primarily on providing care to people with serious and persistent mental illness such as schizophrenia or major depression. Services include crisis response, evaluation, case management, treatment, including psychiatric evaluations, medication management and counseling. We also provide court-related support services and placement coordination with the hospital or residential care as required. Staff of the seven regional mental health programs, act as the regional mental health authorities to evaluate, determine eligibility and authorize care for individuals eligible for Medicaid-funded psychosocial rehabilitation services.

The majority of treatment services for Medicaid eligible clients is provided through a network of private providers. Individuals, who meet the program eligibility requirements but lack the financial resources to purchase services or to receive them through the Medicaid program, receive their care directly from our staff. In SFY 2002, more than 6,000 individuals received services from our mental health programs. This is about an 8 percent increase from SFY 2001. Since July 2001, our staffing in the regional mental health programs has decreased by 23 staffs. We have accomplished cost savings by reducing administrative staff and shifting the assessment functions of the regional mental health authority to the private sector. These changes have not been accomplished without creating additional challenges for a program that has been ranked 47^th lowest in per capita funding in the United States. We have less staff to respond to crisis calls, work with courts, support resource development and to manage and evaluate program effectiveness.

Substance Abuse - This is a unique program within the Division given all of the treatment services for this clients' population is contracted out to private providers. The 6.5 divisional staffs who work in this program area are responsible for the overall management of prevention services, program planning, staff development, contract management and DUI evaluator licensing and program evaluation. We work closely with providers, concerned citizens, law enforcement, courts and advocates to set priorities for treatment and prevention activities in each of the seven regions.

We contract with all of the State universities and colleges to provide certified alcohol and drug counselor training. We also partner with the Supreme Court to fund many of the drug court programs currently operating throughout Idaho. Through our collaborative efforts with the courts, schools, Department of Correction, Juvenile Corrections and our communities, we feel that a system of care based on best practice models is being established in Idaho. In SFY 2002, we served 6,153 clients by this program. This is an 8 percent increase in utilization over the previous fiscal year.

Substance abuse staffs in partnership with the Idaho State Police also have the lead agency responsibility for the Tobacco Project. This program is designed to reduce the sale of tobacco to minors by education of merchants, retail permitting and inspections. The State's rate of tobacco sales to minors is 12 percent lower than when the program began in 1999.

Developmental Disabilities (DD) - This program provides services to people who are developmentally disabled. These programs are designed to provide care and support of individuals and their families with developmental disabilities. The programs are designed to provide services for infants to the elderly. The major components of the developmental disabilities services are family support, which is designed to help families maintain children and adults in their homes rather than in institutions.

Idaho Infant Toddler Program - This program serves children from birth to age three (3), coordinates early intervention and treatment services for children and their families. The Division partners with families to plan and provide comprehensive services including speech, occupational, developmental, medical and social work services to enhance each child's developmental potential. We served 2,424 children, and a 4 percent increase from last year.

Because of the increase in the number of children and families served and the reductions in funds, we have needed to reduce the level of services provided to many of the families involved in this program.

As the lead agency for the developmental disabilities services, the Division provides intake, eligibility determination, service authorization, provider enrollment, training and quality assurance functions for both the children and adult developmental disabilities program. Regional offices contract with private providers for therapy, housing, employment and personal assistance services as well as case management activities. Of the adults receiving services through the DD program, 93 percent of them qualify for the Medicaid program. We determined 79 percent of the children and 63 percent of the individuals served in the Infant and Toddler Program are eligible to receive Medicaid-funded services through Medicaid reimbursement. We have 11,857 people or 8.8 percent more individuals with developmental disabilities received services funded by the Medicaid program this past fiscal year than in FY 2001.

Even with the growth in people served, state staff available to screen, assess, determine eligibility, treat and manage care has decreased by 17 staffs or 9 percent less staff than in FY 2001. Along with the three institutions that were mentioned earlier, these are the programs and services that the Division of Family and Community Services functions as the lead agency.

As the lead agency for these programs, we are responsible for assuring a system of care is available to individuals and their families who meet service and financial eligibility criteria. A system of care provides both for clinical services and program management.

Mr. Deibert had previously distributed a chart listing the 19 core services provided or contracted out, listing key functions that must be in place to assure the efficient operation of the various programs and services that the Division manages. The list identifies the types of direct service functions that need to be provided to deliver treatment for individuals or families. The Division is not only responsible for assuring that the care is available when and how it is needed, they are also charged with the responsibility to provide oversight of the various management and support functions the staff must perform to assure compliance with numerous state and federal statues and regulations. They also enroll and license providers, provide training and technical assistance and quality assurance reviews for hundreds of private providers in each of the program areas.

He explained the Division interacts with 80-plus Councils, Advisory Boards, Interagency Committees, Consumer and Advocacy Groups to gain input on current service systems performance and the development of services to meet additional needs. The responsibilities are numerous. The work that we perform is complex and challenging. The individuals that we serve have multiple and complex needs that we strive to find effective interventions that will assist them in developing life skills so they may function as independently as possible.

As we look to the future, the work of the Division must be focused on providing leadership for the development and implementation of a sustainable and integrated service delivery system. We must support models of care that reflect best practice and rules that foster responsibility and effective use of resources. Most important, we must assure through our system of care, the safety of our most vulnerable citizens, the children, the mentally ill and the developmentally disabled. We will need to continue to foster more partnerships with public and private organizations. As our population grows in Idaho, we can anticipate continued growth in the demand for services. We have many challenges, but we can also point to many positive outcomes.

As time allows, the committee would like for administrators to return later during the legislative session and discuss health issues such as Smallpox, community action agencies, and programs. An updated version of the IDHW's acronyms was requested and will be sent to committee members.

Mr. Deibert reported he is very confident that assessments done when a child 's case is assigned, it is correct. The Division each month randomly selects at least ten (10) percent of child protective cases managed by FACS, and conducts a complete risk assessment to ensure the assessment completed is the correct assessment and appropriate for the needs of the child. The Quality Protective Services conducts a followup and quality assurance assessment ensures the New Jersey situation does not happen in Idaho. In June 2003, FACS will involved in a Family and Children review which is a federal review conducted in every state in the United States. The federal government will review six criteria of performance. At this time, Idaho is in compliance with three (3) of the criteria and is close to being in compliance with the others. No state in the U.S. has passed the federal review. Of the 32 states reviewed so far, none have passed the review. Idaho has improvements to make in the system, and plans to have a will not pass, but we intend to have a comprehensive plan that will address those issues.

Senator Ingram asked about the number of cases investigated for abuse or neglect, and the number of cases investigated by a fraud investigator. [The information about the number of cases investigated by a fraud investigator will be sent to him by the IDHW.]

Senator Burkett asked about the FACS criteria for placing children with extended family members as opposed to non family members and how that is determined, and if the criteria or protocol is different in drug related child protective cases as opposed to child sexual abuse cases. Does it take a period of time to qualify an extended family member for the child to be placed with them?

Mr. Deibert explained the application process to become a foster home. A review of the family home and criminal history background checks must be conducted prior to placing a child in a home. The same certification process is used to certify family or non-family foster homes. The priority preference for placing children who come into the custody of IDHW, is to place the child in an extended family member's home, if at all possible. If an extended family related home is unavailable, the child will be place in a certified foster home. A risk assessment must be conducted. There is a specific process that must be followed.

Senator Darrington asked who makes the immediate decision about the placing of a child. Is it a decision of law enforcement or the Department of Health and Welfare? If it is a department decision, why can't a child be placed with a family member who knows and has a relationship with the child, as this would cause less stress and trauma in the life of the child. He prefers a child be placed with a family member, particularly with a grandparent, rather than foster care. Mr. Deibert explained, when a child is declared in imminent danger by law enforcement, and they contact child protection, our normal response, in the vast majority of cases, is to place the child outside the family environment until a risk assessment is completed, review the circumstances of the abuse or neglected complaint, and evaluate the support system that the child might have available. (NOTE: Refer to minutes, Thursday, January 16, 2003, page 4, motion)

Senator Ingram expressed his concerns about the placement of children. If the Department must go through the evaluation process prior to a placement, why is the court system requiring an outside evaluation? Why can't FACS use the same evaluation report done by the courts? Mr. Deibert reported the Department very seldom is involved in custody issues such as in a divorce or family separation. Courts often order an assessment of a parent or family environment to make a determination for the placement of a child as a result of the divorce. That is not a role for the Department's child protection unit.

Department of Health and Welfare Director Karl Kurtz outlined the presentation for today.

The Division is comprised of two organizational units, Information Services, and Technology Services. These two units provide program support, administration, customer services issues; and internet and intranet application development, mainframe support, wide and local area network support, operations, resource security and database and warehousing support.

He explained e-government is becoming an increasingly important component in the Department's efforts to improve customer services and save money through more efficient and creative use of computer technology. ITSD provides the technical support for the coordination and leverage of resources, skills, knowledge and methodologies for these key electronic government projects.

the Division of Medicaid administers the state's Medicaid program. This includes developing and implementing program policy consistent with federal requirements, managing the quality and utilization of services, and overseeing the payment process for services. As the prior presentations indicated, a few of these functions are shared with other Divisions. The Division of Welfare works with the Division of Medicaid in developing eligibility policy but Division of Welfare staff in the field make most of the Medicaid financial eligibility determinations. The Division of Family and Community Services (or FACS) works with Medicaid to develop policy for services for people with mental retardation or developmental disabilities and, to a limited extent, is a direct care provider of some Medicaid services, for example, at Idaho State School and Hospital.

Within the Division of Medicaid, we also carry out the statutory state licensing of health care facilities through the Bureau of Facility Standards. This entails initial and periodic inspections of any state-licensed facility, whether or not it cares for Medicaid clients, as well as investigations of complaints about the facilities. Such facilities include hospitals, nursing homes, intermediate care facilities for persons with mental retardation, residential or assisted living facilities, and ambulatory surgical centers.

In addition, the federal government contracts with the Department for the Bureau of Facility Standards to certify health care facilities as Medicare providers. Because the Medicare certification process requires inspections similar to those needed for state licensure, the Department is able to combine these activities to prevent duplication of effort and obtain federal matching funds for these activities.

Because of the complexity of the Medicaid program and its significance to the state budget, I plan to spend the remainder of my time discussing the Medicaid program and how it works.

Historical overview and purpose of medicaid

The enactment of Social Security in 1934 with its focus on health care services for mothers and children started a national debate about the need for some form of health insurance to provide protection against unpredictable and potentially catastrophic medical costs. That debate ultimately led Congress in 1965 to enact the Medicare and Medicaid programs as Title XVIII and Title XIX, respectively, of the Social Security Act.

Medicare or Title XVIII was established to cover the specific medical care needs of the elderly and is available to most people over age 65 regardless of income. Coverage was added in 1973 for certain disabled persons and certain persons with kidney disease. Medicare is administered by the federal government.

Medicaid or Title XIX is the nation's health insurance program for many low-income Americans. Medicaid is a jointly-funded federal/state entitlement program, administered by the states, that pays for medical assistance for certain individuals and families with low incomes and resources.

In Medicaid, each state, within federal guidelines, (1) establishes eligibility standards; (2) determines the type, amount, duration, and scope of services; (3) sets the rate of payment for services; and (4) administers the state's program. Medicaid policies for eligibility, services, and payment are complex and vary considerably, even among states of similar size or geographic proximity.

In Idaho, we have a fairly basic program. There currently is, on average, about 150,000 people on Medicaid, which includes about 105,000 children. The state has chosen not to cover all of the groups or services that would be matched by federal dollars. Even so, Idaho is projected to spend about $849 million on Medicaid in fiscal year 2003 -- about $234 million of that in state general funds.

In some ways, Medicaid fills a role that private insurance can't. Most people who use Medicaid can't afford private insurance or need services that are not available from private insurers such as services for persons with developmental disabilities or traumatic brain injury. Even, coverage of mental illness by the private sector is only minimal.

The Department of Health and Welfare provides few direct healthcare services; there is already a private healthcare system in place to do that. Through Medicaid, we support the existing health care structure ­ the physicians, nurses, hospitals, and nursing homes -- critical to maintaining a healthy population. In fact, Idaho Medicaid pays more in benefits in Idaho than Blue Cross and Blue Shield combined. The $849 million that Medicaid spends goes directly or indirectly into the private sector, creating a viable health care industry that serves all the citizens of Idaho.

Because of the escalating costs of the program, Medicaid has intensified its focus on the development of quality improvement processes and care management tools that can create a healthier public and result in a more efficient use of tax dollars.

Who gets medicaid? In order to participate in the Medicaid program, states are required to provide Medicaid coverage for certain groups of individuals who receive federally assisted income-maintenance payments, as well as for related groups not receiving cash payments. These mandatory Medicaid "categorically needy" eligibility groups basically fall into three low-income groups: parents and children, the elderly, persons with disabilities.

Parents and children - Historically, most women and children were eligible for Medicaid because they were eligible for cash assistance through the Aid to Families with Dependent Children (AFDC) program. The repeal of the AFDC program by the 1996 welfare reform law broke the automatic link between cash assistance and Medicaid. Even so, similar poverty guidelines are used to identify low income families with children who must be covered by Medicaid. Also, pregnant women and children in families with incomes below 134 percent of the federal poverty limit (2002: $24,000 for family of 4) must be covered.

Elderly - Now you might think that Medicare (the federal program for the elderly) would take care of most health care costs of the poor elderly. However, Medicare primarily covers hospital and physician care. It does not cover most nursing home or other long term care costs or most outpatient prescription drugs. But Medicaid pays for these and other services not covered by Medicare when someone is covered by both Medicare and Medicaid.

Whether or not they have Medicare, many elderly people must be covered by Medicaid because they receive cash assistance through the Supplemental Security Income (SSI) program ­ basically they are poor. Others have too much income to qualify for SSI but "spend down" to mandatory Medicaid eligibility by incurring high medical or long-term care expenses ­ in other words, they become poor.

Disabled - Many people with disabilities also must be covered by Medicaid because they receive cash assistance through the SSI program or because they incur large medical expenses and meet their "spend down" obligation.

Optional categories that Idaho has chosen to cover consist primarily of low income children, persons with disabilities, or the elderly.

Note that it is not enough just to be poor to qualify for Medicaid; an individual must also fit into a covered eligibility category (e.g., pregnant woman, child, etc.). Many people with low incomes, including childless couples and single, childless adults who are not aged or disabled cannot receive Medicaid even though they are poor.

Additionally, in 1997, Congress enacted Title XXI of the Social Security Act which allowed states to provide health insurance for children in families with incomes over the Medicaid eligibility level. This is the State Children's Health Insurance Program or S-CHIP. Rather than developing a separate insurance program for CHIP kids, Idaho insures them through the Medicaid program. Children from families with household incomes from 134 percent to 150 percent of the federal poverty limit (2002: $24,000 to $27,000, family of 4) qualify for S-CHIP. At the end of state fiscal year 2002, there were over 12,000 children enrolled in S-CHIP.

WHAT DOES MEDICAID COVER? - By choosing to participate in Medicaid, Idaho must cover a minimum set of benefits. These federally mandated benefits include:

hospital care (inpatient and outpatient)

nursing home care

physician services

laboratory and x-ray services

Idaho has also chosen the option of covering additional services and receiving federal matching funds for those services. These optional services include:

prescription drugs

home- and community-based services

Services for people with developmental disabilities

Mental health services

States have discretion to vary the amount, duration, or scope of the services that they cover, including the mandatory services, but in all cases the service must be "sufficient in amount, duration, and scope to reasonably achieve its purpose."

PAYMENT FOR MEDICAID - Medicaid pays medical care providers directly for services provided to Medicaid clients. The payment rates must be sufficient to allow Medicaid recipients to receive services comparable to services available to the general population in that area. Providers participating in Medicaid must accept Medicaid payment rates as payment in full.

The Federal Government pays a share of the medical assistance expenditures under each State's Medicaid program. That share, known as the Federal Medical Assistance Percentage (FMAP), is determined annually by a formula that compares the State's average per capita income with the national income average. States with higher per capita income are reimbursed a smaller share of their costs. Idaho receives about a 70 percent federal/ 30 percent state match. For S-CHIP the federal match rate is higher, with 80 percent of the program paid for with federal dollars and 20 percent with state general funds.

The Federal Government also shares in each State's expenditures for the administration of the Medicaid program. Most administrative costs are matched at 50 percent, although higher percentages are paid for certain activities and functions, such as development of mechanized claims processing systems.

MEDICAID TRENDS - Over the years Medicaid eligibility has been expanded beyond its original ties with eligibility for cash programs.

Federal legislation in the late 1980s mandated Medicaid coverage to an expanded number of low-income pregnant women, poor children, and to some Medicare beneficiaries who are not eligible for any cash assistance program. Other federal legislative requirements have increased the scope of the program to the point that about 45 percent of the Idaho Medicaid budget goes toward meeting federal mandates.

In addition to federal mandates, Idaho has enacted certain mandates into law. These state mandated Medicaid services include prescription drugs, developmental disability services, breast and cervical cancer treatment, and adult vision and hearing. Approximately 43 percent of the Idaho Medicaid budget is governed by state law. In all, 88 percent of the Idaho Medicaid budget is driven by either federal or state law.

In most years since their inception, state Medicaid programs have had very rapid growth in expenditures. In Idaho, this rapid growth in Medicaid expenditures as been due primarily to the following factors:

The increase in size of the Medicaid-covered populations as a result of federal and state mandates, population growth, and economic recession.

The expanded coverage and utilization of services.

The increase in the number of people requiring acute and/or long-term health care services.

The results of technological advances to keep a greater number of critically ill or severely injured persons alive.

The increase in payment rates to providers of health care services, when compared to general inflation.

As with all health insurance programs, most Medicaid recipients require relatively small average expenditures per person each year, and a relatively small proportion incurs very large costs. In Idaho, the aged and people, including children, with disabilities make up 23 percent of the Medicaid population but account for approximately 70 percent of the costs. By comparison, children without disabilities, including S-CHIP kids, make up 67 percent of the insured population but 22 percent of the costs.

MANAGING THE COST OF MEDICAID - Even in good economic times, budgeting for Medicaid is difficult. Because Medicaid is an entitlement program, the state is required to pay for all medically necessary covered services that are provided to persons enrolled in the program.

There are three basic ways to affect the amount spent in Medicaid:

By the number of people on the program;

By the number and duration of covered services; and

By the amount paid for services.

A fourth tool -- managing health care services to eliminate unnecessary or ineffective care ­ can achieve some dramatic cost avoidances in the short term by providing cost and utilization controls that have been missing. Once these management tools are place, however, further cost control from care management is achieved in the long term through better care and the management of chronic illnesses.

As you are aware, the Governor implemented several holdbacks to help keep the state budget in line. The Department has seen four budget cuts since 2001. In Medicaid alone, this has meant $115 million in cost avoidance.

These reductions were met by tightening administrative spending, taking advantage of federal matching dollars where possible, and using care management tools. In the end, that was still not enough and Idaho Medicaid had to reduce services for some clients and reimbursement to some providers to be able to reach the $115 million target we needed to hit by the end of state fiscal year 2003.

The Medicaid program is now undertaking more intensive review of programs and services primarily focused on the high cost areas of the program. The top six spending areas in the program are hospitals, nursing facilities, prescription drugs, developmental disability services, physician services, and mental health services.

Medicaid is working to increase enrollment in Healthy Connections ­ a program that links Medicaid clients with primary care providers who manage their care. Through this program, Medicaid avoids spending about $31 per month for each Healthy Connections enrollee. The target is to enroll 68 percent of Medicaid clients in Healthy Connections by the end of state fiscal year 2003 and, so far, the Department is ahead of schedule to reach that target. Through Healthy Connections, Medicaid also can implement disease management programs for clients with chronic diseases like diabetes and asthma. Such programs will improve the health of these clients and slow the growth of Medicaid expenses.

Management steps are being developed for the prescription drug program that could reduce the Medicaid pharmacy budget by $42 million. There steps include denying early refill of prescriptions, requiring prior approval of certain therapeutic drug classes, reviewing high prescription volume clients, and implementation of a preferred drug list

In addition, the Medicaid program has developed lower cost alternatives to institutional care such as nursing home care or intermediate care facilities for persons with mental retardation. Known as home and community based services waivers (or HCBS waivers), these four programs allow eligible elderly and disabled individuals to receive the services they need without having to be placed in an institution. The costs for supplying the waiver services must be no greater than the cost of the institution and, in fact, average significantly less than the cost of institutional care.

The current economy brings the sustainability of Medicaid's present scope into question and has prompted considerable debate about the future design of the program. The economic predictions for fiscal year 2004 show the need to maintain the current reductions and find more ways of managing costs. However, unless current projected revenues increase, the state may also need to make significant reductions in the people or services that are covered or the amount that is paid for services.

SUMMARY - As the Governor and Department work with the Legislature to define the future of Idaho Medicaid, it is important to keep the following in mind:

As the National Conference of State Legislatures puts it: "There are no easy answers to the problem of health care financing for the poor. Every proposed solution raises difficult issues of fairness, equity, access, and quality of care. No answer to the question of Medicaid cost containment is free of controversy and political risk."

Other considerations --

For every state dollar taken out of Idaho Medicaid, the state loses an additional $2.3 dollars in federal funds.

The Idaho Medicaid program channels a significant amount of money into the overall health care infrastructure. Significant reductions in the Medicaid program can adversely affect the entire state health care delivery system.

Preventive medicine, including care and disease state management, is a proven way of controlling health care costs. Studies confirm that early intervention and prevention programs are more effective in avoiding health care costs than waiting for people to become more ill and consequently, more costly to treat.

We look forward to working with you in determining the future direction of this most important program.

He discussed the budget recommends submitted to the Governor for the 2004 budget. He will have three (3) supplement requests, but none for Medicaid. The requested supplements will total approximately $3 million.

The Governor has not approved the budget for SFY 2004.

The Department has reduced spending about $140 million during the past holdbacks. Cumulatively, about 168 positions were eliminated. The majority of the Department's money, about 80 percent, goes to benefits for programs such as child care, Medicaid, but some reductions in programs has been necessary due to budget holdbacks.

Director Kurtz expressed concerns to be consider, such as future long-term care budget impacts, baby-boomers' impact on the Medicaid program and the funds needed to support Medicaid. As nursing home expenditures increase, (currently we provide about 70 - 75 percent of all funding for nursing homes in Idaho, how can we manage this need? As the population ages, and the successes in extending the life expectancy, (historically those expenses fall to Medicaid) how are we going to sustain the Medicaid Program? Medical and insurance costs are increasing about 8 to 12 percent, how can this be sustained with the State's revenue system?

Quality

1. The Air Quality Permitting Program completed the issuing of Title V operating permits; eliminated permits to construct application backlog, and Office of Performance Evaluation review.
2. TMDLs completed on schedule and settled the lawsuit.
3. Improved water quality in Cascade Reservoir and Middle Snake River.
4. Moving forward on Pit 9 at INEEL - retrieval of buried plutonium-contaminated waste.
5. Coeur d'Alene Basin Environmental Improvement Project Commission - local control over superfund implementation.
6. Air Quality Consent Order with Monsanto - good for environment, industry, and economy.
7. Development of environmental priorities for the Amalgamated Sugar facilities - good for environment, the company and the economy.
8. Grants and Loans - aid economy while meeting infrastructure needs.

Mr. Allred described some of the challenges for the Department in fiscal year 2004. Such as:

1. Relations with EPA - maintaining state decision making.
2. Air quality in the Treasure Valley - ozone and PM.
3. Smoke management.
4. NPDES program for customers.
5. Groundwater - nitrate priority areas
6. Increasing public challenges to permit issuance.
7. Drinking water - aiding small water systems meet new federal standards.

1. Maintain matching funds for federal grants - Water Pollution Control Account.

Grants and Loans - There have been 63 grants for water and wastewater improvements made primarily to Idaho rural communities and totaling approximately $1 million. These grants are used to plan and design facilities to improve drinking water and wastewater systems that serve the citizens of Idaho. Grants allow communities to utilize scarce resources on other community needs and prevent the need for raising additional revenue to cover costs.

Loans totaling $49,600,000 have been made in Idaho to 14 communities to construct needed improvements in water and wastewater systems. This also brings needed resources into the community and aid in their financial stability. Funds have increased economic activities in communities as well as provided the infrastructure for continued economic growth.

Water Pollution Control Fund Statute - The ratio for every $1 Idaho spends brings in $5 in federal funds. The Drinking Water Loan Account is $51,830,000, Wastewater Loan Account is $131,854,000, totaling $183,684,000 for loans.

Remediation Reductions - As a result of past budget cuts, DEQ suspended remediation work on the former MK-Rail site in Boise, and the PCE contaminated site in Garden City. We eliminated work on all above ground storage tank sites except for emergencies which resulted in a 25 percent reduction in the amount of time spent on AST sites. DEQ postponed a planned $50,000 contract to evaluate the use of logyard residual materials in mine remediation in the Coeur d'Alene Basin for two years. Additional remediation projects were also delayed.

DEQ has eliminated the AST budget. In cases where we had to respond to AST emergencies (such as ASTs which caused the flash fire in Malad), we sought outside assistance, e.g., EPA did initial site characterization under emergency response), but we still needed to pay for time DEQ staff put into responding to emergencies which in many cases is significant. That time is charged to regions' general remediation budget, and decreases the time and money available to work on other state remediation projects.

Lawsuits - Mr. Alfred discussed contested cases initiated before the Board of Environmental Quality, and not administrative enforcement or other administrative actions. A total of 34 lawsuits was handled during the past year. These included active cases, some of which are still ongoing. DEQ had 19 contested cases in the last year, and some are still ongoing.

19.0101.0201

The two anesthesia permits available are the General Anesthesia/Deep Sedation permit and the Conscious Sedation permit. The administration of general anesthesia/deep sedation entails putting a patient in an induced state of unconsciousness or depressed consciousness in order to provide treatment. The administration of conscious sedation entails putting a patient in a minimally depressed state of consciousness in order to provide treatment.

There are currently 63 anesthesia permit holders in Idaho. Of that number, 36 are conscious sedation permits and 27 are general anesthesia/deep sedation permits. On average, there are approximately five (5) new applications for an anesthesia permit each calendar year.

23.0101.0201

23.0101.0202

The Board of Medicine wishes to express to the Legislature its concern with an expanding scope of practice for health care providers.

The issues addressed by the committee members regarding gaps in health care providers availability are at the heart of the concerns of the Board, that scopes of practice are sometimes expanded in an attempt to fill gaps beyond the usual scope of practice of the profession.

The Board of Medicine wishes to make the Legislature aware of its concerns of expanding scope of practice and offers no opposition to the rules presented by the Board of Nursing.

27.0101.0201

27.0101.0202

27.0101.0203

27.0101.0204

27.0101.0205

24.0301.0201

24.0501.0201

24.0901.0201

SENATE HEALTH AND WELFARE

Wednesday, January 15, 2003 - Minutes - Page 2 home administrators. This rule deletes the reference under nursing home administrator-in-training requirement to the facility administrator not being the preceptor.

24.1101.0201

24.1201.0201

Roger Hales, attorney for the Bureau of Occupational Licenses, testified about the fee requirement of IDAPA 24.1201.0201.

24.1201.0202

24.1401.0201

Gregory Dickerson, a licensed Master Social Worker in Idaho President

SENATE HEALTH AND WELFARE

Wednesday, January 15, 2003 - Minutes - Page 3

of the Mental Health Provider Association, testified in opposition to IDAPA 24.1401.0201.

Bill Benkula, a licensed social worker, presented testimony in opposition to IDAPA 24.1401.0201.

Roger Hales, attorney for the Bureau of Occupational Licenses, requested the Senate Health and Welfare Committee to hold IDAPA 24.1401.0201to allow additional time in order to resolve issues pertaining to the rule changes.

After a lengthy discussion and review of IDAPA 24.1401.0201, and at the request of the Bureau of Occupational License, Vice Chairman Compton determined to hold IDAPA 24.1401.0201, relating to social workers, until a meeting can be held to try and resolve the issues presented in opposition to the rule changes.

24.1501.0201

24.1601.0201

24.1701.0201

the qualification for licensure to be that they have received certification

SENATE HEALTH AND WELFARE

Wednesday, January 15, 2003 - Minutes - Page 4

from NCAAOM (National Certification for Acupuncture and Oriental Medicine); changes renewal of license to be in accordance with Section 67-2614, Idaho Code; establishes continuing education requirements; and establishes waiver of continuing education requirements for an inactive license.

24.1901.0201 and IDAPA

24.1901.0202

facility administrators. The rule further defines courses approved for continuing education; changes the requirement for renewal of a license to be in accordance with Section 67-2614, Idaho Code; increases the license application fee with Section 67-2614, Idaho Code; increases the license application fee to $50 and deletes reference to recertification in annual renewal fee.

IDAPA 24.1901.0202, a pending rule, relating to residential care facility administrators. This rule establishes that an applicant for examination shall be required to register with and pay the examination fee to NAB; deletes contents of examination; establishes passing score to be determined by NAB; deletes requirement for retakes; adds approved courses of study for licensure.

The NAB (National Association of Board of Examiners of Long Term Care Administrators) provides all testing services to this Board. This rule establishes the testing provisions.

15.0101.0201

Seconded by Senator Bailey. Motion carried by voice vote.

15.0102.0201

Motion carried by voice vote.

Discussions about IDAPA 15.0102.0201included areas pertaining to adult protection cases, closure of cases and followup of those closures, reviewing cases, adult abuse or neglect and body bruising on clients, investigating cases not referred to Law Enforcement, mandates and requirements, household incomes and sliding fee scale, person(s) unable to provide care for themself, guardianship of adult, lack of support staff, and case management. The ICOA does not determine cases by gross income.

15.0121.0201

22.0101.0101

The rule provides an opportunity for physicians who have graduated from an unapproved medical school, but have demonstrated competency through board certification, education evaluation, and postgraduate training in the U.S. or Canada the opportunity to work in Idaho and fill urgent physician vacancies in rural areas of the state. Applicants, legislators on the behalf of applicants, hospitals and health care agencies have supplicated the Board in the past to make the rules for foreign graduates more flexible and allow them to employ these otherwise qualified individuals.

22.0101.0201

22.0103.0201

22.0105.0201

22.0109.0201

The changes in the text of the pending rule that differ from the proposed rule are: to remove the Code of Ethics as incorporated by reference and add it as Appendix A; to add text to accurately identify the Accreditation Council for Occupational Therapy Education as the American Occupational Therapy Association's Accreditation Council for Occupational Therapy Education pursuant to a comment made by the American Occupational Therapy Association; to add the specific date for qualification for licensur by endorsement as noted by a comment by an Occupational Therapy Licensure Board member; and to add text to require in rule that an applicant must report any licenses issued as well as any denied.

22.0113.0201

EXCUSED:

After a lengthy discussion and review of IDAPA 58.0101.0201, it was determined to hold IDAPA 58.0101.0201, for further review and can be rescheduled at a later date.

The air quality rules establish requirements for three (3) types of air quality permits: permits to construct for new or modified sources, Tier II operating permits, and Tier I operating permits for major sources regulated by Title V of the Clean Air Act. The rule proposes revision to several specific provisions, i.e., the update of the citations to the federal regulations incorporated by reference; adjustment of the permit to construct application requirements for toxic air pollutants to ensure consideration of the cumulative effect of multiple air pollution sources and incremental increases in emissions; removal of the grain-loading standard; correction to a cross-reference section number regarding the pre-permit to construct process; revision of time frames for filing appeals to make them consistent with provisions of the Rules of Administrative Procedure before the Board of Environmental Quality; clarification of Tier I permit application submission by owners or operators of deferred Tier I sources; clarification of current policies used in interpreting and applying the rules for Tier I operating permit insignificant activities; clarification of the process for handling the expiration and renewal of Tier operating permits; correction of errors in spelling and capitalization in the toxic air pollutant increment tables and updating of compound values; and, addition of new abbreviations.

The proposed fee structure continues to use a combination of service- and emissions-based calculations to allow for an equitable allocation of fee payments among the facilities and to comply with a requirement of state statute that the fee has an incentive for emissions reductions. To better interface with the availability of information and state fiscal year cycles, it is proposed that the dates for submission of registration information and fee payments be changed. Removal of provisions imposing radionuclide emissions registration and fee and fee payments be changed. Removal of provisions imposing radionuclide emissions registration and fee requirements on the U.S. Department of Energy facilities is also proposed. The rule contains language stating when and if deferred sources are required to submit a Tier I permit application, the DEQ will reconsider the registration and fee requirements to determine whether an alternative basis to regulate those types of sources should be developed.

58. 0103.0201

The Department of Environmental Quality (DEQ) is evaluating the various conditions and circumstances that are used for making determinations of when public or central wastewater treatment facilities are reasonably accessible to undeveloped property. DEQ conducts reviews of proposed subdivisions at the request of city and county governmental agencies.

The purpose of this rule making is to provide greater detail to DEQ and the Health Districts in making decisions as to when central wastewater treatment facilities are reasonably accessible for new development and for issuing subsurface sewage disposal permits. The rule is needed to protect public health from ground water degradation due to nitrate contributions from septic systems in areas where subdivisions may be better served by central wastewater facilities. The rule establishes the conditions in which septic systems are an acceptable alternative to central wastewater treatment facilities.

The rule revises the list of systems installed by complex septic system installers; deletes the exemption from licensure requirement for public works' contractors and specified that homeowners and residents may install their own systems; revises the separation distance to surface waters by adding additional categories for watertight pipe (irrigation) and tiled ditches; and adopts additional siting criteria.

The rule allows local jurisdictions to adopt rules, standards, or ordinances that are more stringent than these rules. The rule title is changed from Individual/Subsurface Sewage Disposal rules to Individual/Subsurface Sewage Treatment and Distribution rules. The rule also sets down the procedures to revoke permits and to issue failing permits.

DEQ received public comments concerning the proposed rule and has revised the initial proposal as allowed under Section 67-5227, Idaho Code.

If the rule is adopted, the DEQ will have specific factors to evaluate when determining if a property has reasonable access to a central wastewater treatment facility. The factors to use in determining when a permit should or should not be issued are clearly identified. The rule provides consistency, certainty and specificity as to when property is considered to have reasonable access to a central wastewater treatment facility, thus minimizing the director's discretionary authority.

John Eaton, a representative for the Building Contractors Association of Idaho, testified in opposition IDAPA 58.0103.0201.

He reported the Idaho Building Contractors Association (IBCA) opposes passage of the DEQ proposed rule increasing regulations on septic tank installation in Idaho. If passed, the rule would significantly limit construction practices throughout the state, and would have an adverse effect on the cost of affordable housing. Although IBCA was not originally included as one of the organizations invited to participate in the negotiated rule making process with DEQ, we did attempt to work with DEQ throughout the fall of 2002 to develop language to address the Department's stated concerns. Unfortunately, we were not able to negotiate any change in language on several key provisions, and some new provisions were added that increased the stringency of the proposed rule. A major concern is the rule does not include a grandfather clause.

Dave Mabe, administrator, State Water Quality Division, DEQ, explained how the DEQ pursued IDAPA 58.0103.0201. In summary, he believes that generally this is a good set of guidelines for the director to consider as he looks at whether or not something should be hooked up to a septic system. If the Senate Health and Welfare Committee decides to not put this rule in place at this time, Mr. Mabe requested the committee help DEQ discern, in that process, what is the legislative intent, and how does the committee want the DEQ to act differently in the next proposal they bring to the committee next year?

After a lengthy review and discussion of IDAPA 58.0103.0201, the following action was taken.

58.0106.0201 and 58.0106.0202

Mr. Ehler explained the rule was reviewed by the Environmental Common Sense Committee, and the State Board of Environmental Quality. Negotiated rule making was held.

IDAPA 58.0106.0202 repeals the previous solid waste management rules (chapter repeal), and rewritten as IDAPA 58.0106.0201.

Richard Rush, Vice President of the Idaho Commerce and Industry Association (IACA), testified and recommended approval of IDAPA 58.0106.0202.

At the discretion of Vice Chairman Compton, IDAPA 58.0106.0201 and 58.0106.0202 will be held in Committee and will be rescheduled later, this postponement is to allow committee members additional time to review this rule making docket.

58.0108.0102

Additionally, a number of housekeeping changes are included in this rule. The engineering standards apply to newly designed public water systems and to significant modifications proposed for existing public water systems. As such, they affect consulting engineers, developers of new systems, and owners of new and existing systems. The housekeeping changes are for the benefit of all users of the rules and also serve to meet standards established by the Legislature and the Department of Administration.

The engineering standards for design, construction, and operation of public water systems regulate activities that are not regulated by the federal government. These standards were promulgated to fulfill the requirements, Idaho Code 39-118,and predate the Safe Drinking Water Act.

Negotiated rule making was held and groups involved included the Idaho Rural Water Association, Idaho Ground Water Users Association, JUB Engineering, Carollo Engineering, American Water Works Association, Idaho Professional Geologists, Idaho Department of Water Resources, DEQ Water Quality Engineers, Cities of American Falls, Blackfoot, and Lewiston.

If adopted, the regulated community will benefit from rules that reflect current industry standards and are generally easier to use. Certain practices that have proven to be ineffective will be eliminated.

Filter Backwash Recycling Rule - requires public water systems that use surface water or ground water under the direct influence of surface water to notify the State if they recycle and waste fluids from their treatment process. Systems must provide the State with descriptions of their recycling practices and identify the point at which these recycled streams enter the treatment train.

Long Term 1 Enhanced Surface Water Treatment Rule - requires public water systems that use surface water or ground water under the direct influence of surface water and serve less than 10,000 persons to meet tighter standards for turbidity, to monitor individual filter bed turbidity continuously, and to undertake corrective actions if turbidity excursions occur. Systems must prepare a disinfection profile of their treatment plant unless they can demonstrate to the State that they have disinfection by-product levels that are less than 80 percent of the maximum contaminant levels set forth in the Stage 1 Disinfection By-products Rule.

DEQ received no public comments. If adopted, this rule will maintain Idaho's primacy agreement for administration of the Safe Drinking Water Act.

16.0505.0201 and

58.0114.0201

This rule making allows local government and the health districts to adopt equivalent or more stringent fees to cover the services provided. Some units of local government have adopted environmental fee ordinances and some health districts have revised fee rules that were adopted under their boards' rule making authority. The environmental fee structure needs to be flexible, across the state, to reflect the costs of providing environmental services rather than using a flat fee. Some health district environmental service costs are greater than other districts and the fees need to be reflective of the costs so that services can continue to be provided to the public. The districts with higher costs need the flexibility to revise fee structures to cover costs of providing services. DEQ received no public comments.

16.0205.0201

Mr. Duke discussed the eligibility requirements to obtain services, the 200 percent poverty level, substance abuse, and the Ryan White Care Act.

16.0210-0201

Isolation - The separation of infected persons, persons who may have been exposed to a highly contagious infectious agent, or of persons suspected to be infected, from other persons to such places, under such conditions, and for such time as will prevent transmission of the infectious agent. The place of isolation shall be designated by the Department or the District Board of Health.

16.0212.0201 and

16.0212.0202

This rule rewrites the entire chapter of rules governing procedures and testing to be performed on newborn infants. The testing of newborn infants for phenylketonuria and other preventable diseases and the instillation of an opthalmic preparation in the eyes of the newborn to prevent Opthalmia Neonatorum. The rules specify the time and manner of testing as directed in Section 39-909, Idaho Code.

Negotiated rule making was held and groups involved included the Idaho Hospital Association, Idaho Perinatal Project, Division of Medicaid, Idaho Medical Association, and Idaho Chapter of the March of Dimes. The Department of Health and Welfare is directed by Idaho Statute to prescribe what tests shall be made for preventable diseases and the time and manner of such testing.

There were 20,000 registered births in Idaho last year. A test kit, covering the newborn testing costs the parent(s) $18.00.

Senator Burkett requested a copy of the old rule to be repealed. No copy was available; therefore, at the discretion of Chairman Brandt the rules will be held until Wednesday, January 23, 2003, so a review of the chapter proposed to be repealed is available.

16.0000.0201

During 2002, the Legislature passed HB 406 and signed into law amending Title 54, Chapter 32, of the Social Work Licensing Act to change the titles and designations of social workers. To make rules consistent with the new professional titles adopted in law. The rule changes the titles of Certified Social Worker, Certified Social Worker-Private Practice to Licensed Master's Social Worker, Licensed Clinical Social Worker, and Licensed Clinical Professional Counselor respectively. The impact of the rules is that providers and consumers will see a non substantive name change in three professional titles.

16.0307.0101

These rules were developed to bring time lines for completion of plans of care into congruence with federal requirements and to refine the definition of a home health agency. The change in time lines reflects a change in federal requirements from 62 to 60 days. Another change was initiated in partnership with the Idaho Association of Home Health Agencies. The definition clarifies who must be licensed as a home health agency. To be a licensed home health agency, the agency must be primarily engaged in providing skilled nursing and at least one other health care service (home health aide, physical therapy, occupational therapy, speech therapy, nutritional services, respiratory therapy) in a patient's home.

16.0212.0201 and

16.0212.0202

16.0309.0201

This pending rule affects the way some payments are processed for care received in residential care facilities and certified family homes. Cash payments were previously paid to residents through the Division of Welfare. Because of legislation in 2001, SCR 110, Medicaid now pays providers directly. Generally, this change in payment methodology created an opportunity to leverage Medicaid funds and improve the reimbursement for personal care services. The net savings to the state general fund in 2002 was approximately $1 million. For the most part, the change was invisible to the recipient.

The Division of Medicaid successfully negotiated reimbursement rates with industry representatives in 2001. These rules were presented as temporary rules during last legislative session and were approved by both Houses. The resulting change has been in effect since January 2002. The only barrier in implementation was the unwillingness of several facilities to enroll as Medicaid providers. The Department decided to allow recipients in these non-Medicaid facilities to remain in these homes and continue to receive cash payments rather than force residents from these homes. The Department continues to work with these providers to encourage Medicaid provider enrollment. For the majority of the stakeholders, this rule change was welcome and positive reflecting the right price for the right care.

16.0309.0202

Provider rates for commercial, non commercial, and individual transportation providers will be reimbursed on a per mile basis, at a rate established by the Department after a study of costs has been conducted. These studies will be conducted no less than every three (3) years.

Meal reimbursement for Medicaid clients will also be reimbursed at a rate established by the Department. The Department has implemented rate changes for transportation providers effective January 1, 2002, in response to the budget holdback. For FY2002, the savings reached was $910,000, and the estimated savings for FY2003 is $3.7 million.

There were three (3) positive comments received.

16.0309.0204

This rule change would allow the Division of Medicaid to pursue medical support costs from absent parents who have been court ordered to pay medical support for his/her child. The text of the pending rule has been amended in accordance with Section 67-5227, Idaho Code.

16.0309.0206

This rule involves changes to the way the Medicaid program pays for Medicare Part B crossover claims. This rule was developed to reduce Medicaid expenditures to meet the funds available following the budget shortfall, and to provide services at the right price. No hearings were held, and three (3) comments were received during the comment period. Two (2) comments were positive and one (1) negative.

Before this rule change, Medicaid automatically paid the total amount of the Medicare Part B coinsurance and deductible amount on all Medicare and Medicaid, which "crossed over" to Medicaid. Following this change, Medicaid will cover the difference between the Medicare payment amount and either the Medicare allowable amount, or the medicaid-allowed amount for the service, whichever is less. As Medicaid generally pays less than Medicare, the amount paid is generally reduced, resulting in savings to the Medicaid program. These rules specifically address physicians, hospital outpatient, and ambulance providers. However, other Part B service providers such as durable medical equipment, physical therapy, psychology and other medical service providers are also impacted. This change in payment methodology is projected to save $2.3 million during the current fiscal year.

16.0309.0207

No public hearings were held, and two (2) comments were received, both were positive. Before this rule change, individuals were paid for residential habilitation services in the home of the participant under both of the Department's Developmental Disability waivers. Because this arrangement was allowed, the Department was found to be responsible for the withholding of FICA, FUTA, and SUTA payments. As pointed out by the Legislative Auditors, this practice was time consuming and costly to the Department. In addition, the Department was considered to be the Common Law employer of such individuals, creating a potential liability risk.

All other independent providers such as Personal Care Service and Aged and Disabled Waiver providers have been required to be employees of an agency for some time. This rule change treats all providers of similar services consistently by the Department. These rules also clarify that RESHAB providers who provide services in their own homes as Certified Family Homes must be affiliated with an RESHAB Agency for training and oversight.

16.0309.0208

This change is required by a change in federal law. These are negotiated rules, no public hearings were held, and during the comment period two (2) comments were received, both positive.

Section 702 of the Benefits Improvement and Protection Act (BIPA) of year 2000 required that states pay encounter rates to FQHCs and RHCs using a prospective payment system with a federally specified base year, and then inflating their payments using a national index.

Previously, providers were paid on a retrospective, cost settlement basis. These rules were negotiated with the affected industries. They clarify the types of encounters which can be reimbursed by Medicaid, including the addition of a dental encounter for FQHCs. The description of what service constitutes an encounter is updated to conform the federal requirements and actual industry practice.

16.0309.0210

This rule primarily deals with clarifying the language and consistently using the term "participant" throughout the affected sections of rule. In these sections, Medicaid currently refers to the same person as a client, patient, and eligible individual. No public hearings were held. Three (3) positive comments were received during the comment period.

In Section 146, which covers Personal Care Services, the requirements for a supervising RN (registered nurse) visit at least every 90 days was eliminated, and it is left up to the participant and the Department's Nurse Reviewer to determine the frequency of the RN visits, or if any such visits are necessary for the particular individual.

Change in Section 149 which covers "client contribution for waiver services" essentially condenses a page of verbiage on how to calculate the participant's personal needs allowance into a single chart. This is designed to make this section of rule much more understandable for both the Department and the public. Except for the addition of how an over or underpayment is handled in Subsection .11, no actual change in current practice is made based on this clarification.

16.0309.0212

The rule changes are basically technical in nature and clarify provider qualifications, and updates terminology to make these rules more consistent with the terminology found in the Department's other Home and Community-based waivers. The term "participant" is used throughout to identify a person using services to standardize the language. Diagnosis codes for "concussion" and "intercranial injury of other and unspecified nature" are added to the list of qualifying diagnoses. The term "Individual support plan" is replaced by the term "Plan of Care."

No hearings were held about this rule, and two (2) positive comments were received.

16.0309.0211

The purpose of these rules is to establish clear standards for professionals rendering Medicaid services. These rules refer to Developmental Disability Agency rules found in IDAPA 16.0411.0201 that specifies the details of these requirements.

This pending rule points to the requirements in the Developmental Disability Agency rules that clarify the professional requirements for individuals providing intensive behavioral intervention to children in children, ages 0-21 years old that has self-injurious, aggressive or severely maladaptive behavior and severe deficits in areas of verbal and nonverbal communication. These services require prior authorization, periodic and annual review. Provider qualifications include specific degree requirements and experience. The existing rules allowed for various interpretation and these pending rules help clarify professional experience, educational, and training requirements.

Negotiated rule making was not formally conducted. However, notification was sent to affected stakeholders with a draft copy of these rules asking for input. Three (3) hearings were held to provide an opportunity for individuals to testify. Twenty-seven comments were received, most opposed the original proposed language. However, individuals expressed the need to ensure that quality services are provided by competent professionals. Although amendments were made to the original rules, the department maintains that these rules sufficiently define the qualifications necessary to assure its recipients are receiving the appropriate care. Legislative Services reviewed these rules and had no substantive or procedural concerns.

16.0309.0215

These temporary rules relax some of the provider requirements for targeted service coordinators and targeted case managers because of reduced reimbursement and benefit limitations. The Governor asked the Division of Medicaid, like other state agencies, to reduce its expenditures by 3.5 percent. Medicaid reviewed various benefit reduction options. There are three (3) primary ways to reduce expenditures beyond improving management techniques. These include:

1. Changing Medicaid eligibility to make it more difficult to qualify for benefits;
2. Reducing or eliminating optional benefits, and
3. Reducing provider reimbursement.

Additionally, Medicaid is limited in its ability to reduce or cut certain services that are federally mandated. Ms. Clement distributed a chart pertaining to the service category and explained which service is required by federal or state mandates or by rule, and if a rate-set is a federal mandate, state mandate, or a rule. (Attachment #1)

Medicaid attempted to minimize the impact on recipients by reducing reimbursement and limiting benefits, rather than eliminating services.

The services identified in this rule docket are case management services for developmentally disabled and mentally ill Medicaid recipients. The services are brokerage services in which case managers help direct individuals to resources. These are not diagnostic or treatment services. These changes do not affect any other developmental disability or mental health services that Medicaid recipients are currently receiving or may need in the future.

For disabled individuals, crisis case management services continue to be available through Medicaid. For mentally ill individuals, crisis hours are contained in the new four-hour per month limitation. Individuals who need additional crisis case management may access these services through psychosocial rehabilitation and mental health clinics. Additionally, the department's regional mental health program is also available any time of day to provide help during crisis.

As of December 2002, there were 64 providers actively providing mental health case management services to 1,800 Medicaid recipients. In fiscal year 2002, Medicaid spent approximately $6.0 million for this service.

Fifty-six (56) providers actively providing targeted service coordination for approximately 1,900 developmentally delayed adults. Medicaid spent approximately $3.5 million for targeted service coordination for these recipients.

There were 66 active providers rendering target service coordination to 2,200 Medicaid children. Medicaid's 2002 cost for this service totaled $3.9 million.

The budget hold back, based on the limit on available case management hours and the projected reduction in targeted service coordination, is projected to save $2.2 million in 2003.

While Medicaid has attempted to minimize the effects of these reductions on recipients and providers, it acknowledges that there will be some individuals whose needs are not met, and providers who will be unable to provide the same level of care. Medicaid staff has been meeting with providers to work through these issues.

The Department of Health and Welfare (DHW) received 289 requests for hearings. Nine written comments were received, seven of these were negative - with most expressing concerns that the reductions will result in higher costs resulting from emergency and hospital care that could have been avoided through case management. The DHW will hold two hearings early this year to give individuals the opportunity to testify.

Maureen McDonald testified in opposition of IDAPA 16.0309.0215.

Diane Strunk testified in opposition of IDAPA 16.0309.0215.

Steve Hansen testified and provided written comments in opposition of IDAPA 16.0309.0215. In summary, he recommended that these temporary rules, (IDAPA 16.0309.0215) be adopted only with strong language from this committee, and the Legislature as a whole, that requires the Department of Health and Welfare continue to aggressively negotiate and implement rules which:

1. Will relieve the providers of case management and service coordination from professional liabilities which may be directly associated with these rules, as they relate to the areas of client abandonment.

1. Prohibits the Department from using inconsistent and arbitrary interpretations which might be hidden in provider agreements or regional guidelines which are not specifically defined in rule in the future.

1. Ensures that the Department's expectations of service coordinators are reflected in both rule and practice in order to ensure that such expectations match the recent cut in reimbursement for the service.

1. Ensures that a single person be identified at the state level by the Department who can determine equity in the regional interpretation and implementation of any rules relating to service coordination for adults with developmental disabilities or EPSDT service coordination, and have the authority to give direction as needed.

1. Ensures that when the idea of offering cost of living adjustments to Health and Welfare employees in the future, such as consideration is accompanied by the Department's good faith review of similar adjustments for those providers who are in the trenches, doing the work that the taxpayer intends their tax dollars to support.

1. Ensures that the additional rule recommendations which are being developed in the current case management work group be adopted in the form of new temporary proposed rules no later than April 1, 2003, with necessary revisions being made throughout this year, and complete the promulgation process before the next legislative session. The department should agree to assist in travel costs associated with current members of that workgroup being able to participate in that process.

Laura Scuri testified in opposition to IDAPA 16.0309.0215.

Debbie Johnson provided written comments and is strongly opposed to these rules. In summary she wrote, "as families we are the gatekeepers of these services. We know the ones that work and the ones that don't. We can also help you identify areas in which to examine and the ones that need praise. The current rules, with the exception of the payment portion works well. For many Idaho families TSC/CM services are their lifelines."

Karen Canfield of Boise, opposed IDAPA 16.0309.0215. In summary, she wrote "Medicaid is a complex challenge, but it seems that the cuts could be made in a more equitable fashion say...2.5 percent across the board, rather than taking it all away from disabled adults and children, that have lost so much already in the way of benefits the last several years."

Penney Friedlander of Coeur d'Alene, wrote opposing any budget cuts. The Trinity Group Homes, Inc., in Coeur d'Alene, is a nonprofit agency providing a supportive group home environment to adults who have been diagnosed with major mental illnesses. " We have experienced a direct loss of service providers in Coeur d'Alene due to an inability for the providers to cover costs. The situation is dire. We implore you to analyze the effects of budgetary changes in determining whether costs will be reduced. Consider the larger picture."

Bob Madderra submitted written comments in opposition to the rules. He wrote "the already limited amount of four hours costs the state of Idaho more money due to the alternative when crisis situations occur. Persons with mental illnesses need differing amounts of targeted case management. Limiting it to four hours is unreasonable, and there needs to be more flexibility for cases that need additional attention."

After reviewing the rule, and with specific attention to areas on pages 49, 55 and 61 of IDAPA 16.0309.0215, and listening to testimonies, Senator Kennedy explained that it appears to him in our discussion of who is taking comparative hits as a result in the reductions of service, he has to think that the group taking the biggest hit are the recipients in the mental health situation who are not even being represented before the committee today.

At the discretion of Vice Chairman Compton, an additional review of IDAPA 16.0309.0215 will be scheduled at a later date in order to allow committee members additional time to consider the rule prior to making a decision.

16.0310.0202

This rule removes Idaho legislative intent language that capped intermediate care facility rates from July 1, 2000 through June 30, 2002. The changes also allow the existing rate methodology which relies on the prospective payment system to be restored beginning July 1, 2002.

Intermediate care facilities provide services to mentally retarded individuals. These individuals typically have higher level of care needs and are unable to function effectively in the community. Sixty-four (64) intermediate care facilities in Idaho serve approximately 470 individuals. The cost of providing care in fiscal year 2002 totaled $34.5 million. By lifting these caps, the total annual cost to Medicaid is estimated at $35.5 million in fiscal year 2003, and $36.2 million in fiscal year 2004. This reflects an average annual increase of approximately 2.3 percent.

Medicaid has been routinely meeting with industry representatives to ensure requirements are reasonable, costs are managed and care is safely and effectively rendered. Intermediate care facility providers perform a valued service to Medicaid recipients whose needs are uniquely served by this industry.

16.0310.0203

Hospital services represent the largest Medicaid expenditure category, followed by nursing home and pharmacy services. Medicaid payments for hospitals during state fiscal year 2002 were made in four general categories:

1. inpatient hospital services totaled approximately $104 million
2. outpatient hospital services totaled $35 million
3. hospitals also received $10.3 million in a disproportionate share (DSH), and
4. another $10.4 million in federal upper payment limit (FUPL).

The DSH and FUPL payments are based on Medicaid inpatient utilization rates.

The first two payment categories are based on hospital claims submitted to Medicaid. Hospitals receive interim payments based on a percent of charges, and are later subject to a cost settlement process managed by Medicaid's contractor auditor, Myers & Stauffer.

All hospitals received prior notice of the 3.5 percent reduction in their interim payments, and the related change that will occur during the cost settlement process.

Steve Millard, president of the Idaho Hospital Association(IHA) testified and the Association does not oppose the rules. He recommended the committee approve the rules.

EXCUSED:

16.0309.0215

The purpose of this docket is to meet budget holdback directives while continuing to meet the Department of Health and Welfare's commitment to providing access to the right care for the right price.

These rules relax some of the provider requirements for targeted service coordinators and targeted case managers because of reduced reimbursement and benefit limitations.

Several persons sent letters or provided a precise indication or testimony in opposition to IDAPA 16.0309.0215.

The Committee held a lengthy discussion about the ongoing debate about the reduction of case management hours (20 hrs to 4hrs) per month, what is federal or state mandated services, safety value, emergency hours, general and federal funds and mandates, and asked those in opposition to IDAPA 16.0309.0215 what suggestions could be offered to the Department of Health and Welfare to provide budget cuts to programs, and increase in taxes to avoid and afford programs.

A Medicaid status report for January 2003, a budget snapshot, was reviewed. The Department of Health and Welfare has seen four budget cuts since 2001. In Medicaid, this has meant $115 million in cost avoidance. Medicaid is projected to spend about $849 million in fiscal year 2003 - about $234 of that in state general funds. There are three basic ways to affect the amount spent in Medicaid. They are:

1. By the number of people on the program;

2. By the number and duration of covered services; and

3. By the amount paid for services.

A fourth tool-managing health care services to eliminate unnecessary or

ineffective care - can achieve some dramatic cost avoidances in the short term by providing cost and utilization controls that have been missing.

Cost containment initiatives during the past fiscal year included:

1. Changing the discount for pharmacy reimbursement from A WP -11

percent to 12 percent,

2. Requiring prior authorization on brand name prescriptions,

3. Restricting early prescription refills,

4. Including the Children's Health Insurance Plan in the drug rebate

program,

5. Changing the initial hospital length of a stay from 4 days to 3 days,

6. Creating a standardized reimbursement method for transportation

services,

7. Requiring prior authorization for durable medical equipment,

8. Changing the reimbursement methodology for Medicare crossover

claims,

9. Limiting adult dental benefits to emergency services,

10. Applying the Medicare rates to selected Medicaid services,

11. Increases Healthy Connections enrollment,

12. Reducing reimbursement rates for case management services for

DD,

13. Limiting case management hours for MI,

14. Reducing hospital reimbursement,

15. Requiring prior authorization for select classifications of medications.

1. Medicaid absorbed about 2.6 percent of a holdback beginning in November 2002. This was originally 3.5 percent, but the Governor asked the Division to hold off its planned implementation of waiver cutbacks.
2. State General Fund still needs to find approximately $160 million to address revenue shortfalls.
3. For every state dollar taken out of Idaho Medicaid, the state loses an additional $2.3 dollars in federal funds.

Committee members discussed the problems that the Department of Health and Welfare must face during this tight budget situation. A way of controlling expenditures, maintaining personnel to perform services, and when rules are mandated by federal or state determination. Senator Darrington pointed out that Line 18 of the following chart would explain this program. Senator Darrington encouraged committee members to use the chart to help determine if a program is mandated and service is required.

At the discretion of Vice Chairman Compton, no decision will be made at this time regarding IDAPA 16.0309.0215.

16.0311.0301

This bed cap was first set in 2000 in intent language attached to the appropriation for medical assistance. This temporary rule was promulgated at that time to implement the legislative intent language. The bed cap language was repeated in the appropriation for 2001 and the Department requested a year's extension of this rule. Although the bed cap language was not repeated in the 2002 appropriation bill, the Department requested and received an extension of the bed cap for another year.

The Department consulted with the Idaho Association of Community Options and Resources, the ICF/MR association, and there is no objection to this request from the association. The Department is aware of no concerns from any other group.

Committee members requested Medicaid to provide data about persons place out-of-state and if, at the time of that placement, Idaho had empty beds.

16.0314.0201

This rule change was initiated in partnership with the Idaho Hospital Association. This change updates the rules to the current standard of practice and reflects federal guidelines and standards. The Joint Commission on Accreditation for Healthcare Organizations holds hospitals to state rules and requirements. The current rule requires a history and physical examination to be performed within 72 hours of admission. This rule change allows physicians to complete a history and physical exam up to sever (7) days prior to a planned admission and shortens the completion time to 48 hours for all other patients except emergency admissions.

16.0319.0101

Ms. Ransom reported that during the 2000 legislative session, the Board and Care Act and the Residential Care Act for the Elderly was amended to allow a provider to make application to care for up to four (4) residents in a certified family home. These rules were developed with input from providers, advocates, and consumers through public meetings and members of the Board and Care Council and the Residential Care for the Elderly.

These rules will assist in ensuring residents receive the right care, in the right setting with the right outcomes in the most cost efficient manner.

16.0319.0102

This rule was developed in response to a recommendation by the Board and Care Council for the Elderly and the Residential Care Council. This rule requires a CHF to arrange for emergency transportation of residents with medical and/or behavioral emergencies. Providers are not equipped or trained to provide this type of service. This rule change will help ensure residents who have emergent needs are met.

16.0322.0101

This rule was developed in response to a recommendation by the Board and Care Council for the Elderly and the Residential Care Council. This rule requires a Residential or Assisted Living Facilities to arrange for emergency transportation of residents with medical and/or behavioral emergencies. Providers are not equipped or trained to provide this type of service. This rule change will help ensure residents who have emergent needs are met.

16.0322.0201

These rule changes were made to align the rules with statutory changes made by Senate Bill 1365 to the Board and Care Act and the Resident Care Act for the Elderly during the 55^th session of the 2000 Legislature.

These rules correct the name of Residential OR Assisted Living Facilities, add a new definition, an authorized provider to recognize nurse practitioners and clinical nurse specialists licensed by the Board of Nursing and physician assistants. Changes reflect current standards and name changes of the National Boards or Councils.

Ensures all residents, not just the elderly, are to be informed of their right to develop advanced directives; modifies and ensures rules referring to administrators qualifications are consistent with the Department of Health and Welfare's rules governing criminal history clearance.

EXCUSED:

SEATTLE WA

She explained one of Secretary Thompson's goals is a healthy America. He launched his comprehensive initiative on disease prevention in a National Press Club speech April 30, outlining steps that individuals can take on their own for good health.

1. A new Web site "HealthierUS.gov" has been created.
2. Physical activity - outlined the special benefits of physical activity and moderate exercise for older Americans. Center for Disease Control (CDC) launched a $190 million multicultural media campaign in July aimed at promoting a healthier lifestyle for young people.
3. Healthy diet - A report was released in June showing that overweight and obesity cost America $117 billion annually and accounts for at least 14 percent of deaths in the U.S., or some 300,000 premature deaths each year. Nearly one-third (1/3) of U.S. adults now classify as obese, and obesity among young people is growing rapidly.
4. In October, $100 million was made available to tribal organizations for prevention and treatment of diabetes among American Indians and Alaska Natives. On average, American Indians and Alaska Natives are 2.6 times more likely to have diabetes than non-Hispanic whites of similar age.
5. HIV/AIDS - In addition to efforts to improve health for all Americans through healthy diet and exercise, HHS maintained and expanded its efforts to prevent HIV/AIDS and support treatment, both domestically and internationally. Total HHS spending on HIV/AIDS increased from $11.4 billion in FY2001 to $12.1 billion in FY2002, with a further increase of almost $1 billion proposed in the President's budget for FY2003. HHS' contribution to the global effort against HIV/AIDS increased from $276 million in FY2001 to $486 million in FY2002.



6. Bioterrorism preparedness - America ended the year 2002 much better prepared to confront terrorism. Under HHS Secretary Tommy G. Thompson's leadership, the department led the nation's efforts to be ready in particular for possible incidents of bioterror. HHS' budget for bioterrorism increased tenfold, from $305 million for FY2001 to $2.98 billion in FY2002. Of the budget increase, more than $1 billion was provided to states and major cities to support increased preparedness by hospitals and public health systems. The objective is local preparedness, with national resources ready to be deployed immediately whenever and wherever needed.



7. Smallpox and other vaccines - HHS took steps to provide enough smallpox vaccine to be able to vaccinate every American, in the possible event of a release of this disease. In December, President Bush announced a careful policy of voluntary vaccination for front-line health care and emergency personnel, to ensure effective response if the disease were released. Vaccination of others is not recommended at this time, in the absence of an emergency. In addition, production of the current anthrax vaccine was resumed, and research into improved vaccines for anthrax and other diseases was accelerated.



8. Disease surveillance and communications - In order to detect any possible release of disease agents by terrorists, the nation's disease surveillance system is being expanded, with spending increased from $67 million in FY2001 to $940 million in FY2002. This expansion will also help to quickly identify outbreaks of naturally-occurring diseases. The nation's network of public health laboratories is being expanded.



9. Teen smoking - Results from the "Monitoring the Future" survey for 2002, showed a significant decrease in smoking by teens, accelerating a trend that began after teen smoking reached a high point in 1996. This year's survey also showed that teen alcohol consumption was down, as was teens' use of illicit drugs.

1. In 2002, HHS approved waiver and plan amendments for state SCHIP and Medicaid programs that expanded access to health coverage to more than 600,000 additional Americans. These changes provided additional services to more than one (1) million other beneficiaries. Since the start of the Bush Administration, HHS has approved waivers and plan amendments that expand access to coverage to nearly 1.8 million Americans and improved benefits for more than five (5) million other Americans.

Other areas briefly discussed were a one-page list of acronyms used by HHS, delay and lengthy of time to process Waiver requests (goal is a 90-day turnaround), and promoting seniors' access to prescription drugs.

58.0101.0201

After review, the Committee addressed concerns and questions about several sections in IDAPA 58.0101.0201, including Section 603.01(e) the burning of plastics, i.e., plastic bailing twine; Section 603.01(g) burning petroleum products; Section 603.01(h) burning lumber treated with preservatives; Section 611.02 on-site wastes burning, and Section 611.03 daylight burning only. Also of concern is the enforcement procedure, and keeping the old rule in place while rejecting this new proposal.

Discussion: After discussion to reject part or all of IDAPA 58.0101.0201, it was determined the complete new rule would be rejected. The Department of Environmental Quality can bring a new docket to the committee next year.

Motion to reject IDAPA 58.0101.0201 was approved by voice vote.

58.0106.0201 and

58.0106.0202

16.0309.0217

Other changes in the rule relate to the assessment of late penalties. At the current time, the Department of Health and Welfare is allowed to assess a penalty to providers for submitting a late review to our contracted quality improvement organization. This rule would allow a penalty to be assessed by the Department for internal reviews. This would ensure that all procedures are submitted in a timely manner for review in order to support public health and safety.

16.0309.0218

This docket addresses the right service for the right price and eliminates Medicaid payment for the entry of laboratory results into the Clozapine National Registry for participants who require this medication for the treatment of their mental illness.

In October 2001, the Department of Health and Welfare (DHW) reduced its payment for this service from $29.07 to $5 in order too more accurately reflect the complexity of the service and bring our payment into line with what other states were paying. Further, DHW's research found that Utah, Wyoming, Montana, and Nevada were not paying for this service at all under their Medicaid programs. During SFY 2002, Medicaid paid $39,143 for this service. In light of the state's financial picture, continued payment by Idaho Medicaid could not be justified.

16.0309.0301

Medicaid payment for out-of-state nursing home care is very limited and generally is only allowed if the care the person needs are not available in an Idaho facility. Because of the complexity of the current acuity-based reimbursement for instate nursing homes, the Department of Health and Welfare has elected to pay out-of-state facilities the same rate as they receive from the Medicaid program in their home state. This simplified their billing and claim submission and is the method previously and currently used by the department.

16.0310.0201

This docket is a companion to IDAPA 16.0309.0208 and describes the method to pay federally qualified health centers and rural health clinics based on a federally required prospective payment system. These rules delete the previous reimbursement system and replace it with a reference to the method specified in the Federal Law.

This change was negotiated with the affected industries before the rules were promulgated. No public hearings were held and two (2) positive comments were received.

16.0310.0204

This rule change removes wheelchairs from the content of care for Intermediate Care Facilities for the Mentally Retarded. This rule change was negotiated between the Department of Health and Welfare and the ICF/MR industry.

This change has three positive effects:

1. It eliminates the cash flow problem experiences by small ICF/MR facilities when a participant requires a highly specialized and expensive wheelchair.
2. As the Medicaid program pays for such chairs on a fee schedule rather than billed charges, the cost is less to the Medicaid program.
3. The participant is more readily accepted for admission into the small facilities and keeps the wheelchair, no matter if he moves between facilities and into a community placement.

16.0310.0301

This docket addresses the payment of out-of-state nursing home care, and is the companion of IDAPA 16.0309.0301. No hearings were held, and two (2) positive comments were received during the comment period.

This rule allows the Department of Health and Welfare to reimburse out-of-state nursing homes using the rate being paid by the Medicaid jurisdiction in which the facility is located. Technical changes are also made to update manual section references and other editorial changes. In addition, this docket adds a section on incorporation by reference and incorporates 42 CFR Part 447, and the Medicare Provider Reimbursement Manual into these rules.

EXCUSED:

The following ten (10) IDAPA rules were presented by Phil Gordon from the Division of Welfare.

16.0301.0201

This rule assists families who go off cash assistance due to work, to continue receiving Medicaid for six (6) months with up to an additional six (6) months, if the participant remains employed. These changes will help transition these individuals to work and move families off welfare.

This rule also adds back rules that specify those items that are not counted in determining income available to the participant, as prescribed by federal regulations-income exclusions. Some of those are:

1. Commodities and Food Stamps
2. Housing subsidies, and
3. Income tax refunds.

16.0304.0103

Food Stamp families will receive an increase in their benefits ranging from $5 to $30 depending on the size of the family. For example, a household of one (1) will increase from $130 to $135 per month, and a household of four (4) will increase from $434 to $452.

These changes are superceded by IDAPA 16.0304.0202 - increase for 2002. This rule corrects the language that aligns with federal policy related to aged and disabled individuals who cannot buy and prepare their own meals separately from others in the home.

The Department of Health and Welfare has been applying the correct policy and the automated system is correctly calculating benefits, but now the Department is correcting the rule site.

16.0304.0201

1. Who must register for work.
2. What costs can or cannot be paid for work program funds (in particular, supportive services.
3. When to apply penalties for individuals quitting a job or reducing their work hours.
4. How they can re-establish eligibility.

Next, the rule lengthens FS eligibility for some households, able bodied adults without dependents (ABAWDS) in high unemployment areas beyond the three (3) month limits. A relatively small number of individuals are impacted, i.e., depressed economic areas. For example, northern Idaho, determined by the Department of Labor and listed in rule, Individuals still must comply with the work plan.

The Department of Health and Welfare put into the rule some language that expands work services to a larger FS population. Again, this enables the Department to move more individuals into employment and off public assistance.

16.0304.0202

This puts into rule the annual federally mandated FS "cost of living" increases for 2002. This increases income limits, standard utility allowance, and the FS allotment amount. Per federal regulation, this increased the asset limit for disabled individuals from $2000 to $3000. The Department of Health and Welfare now considers asset limits the same for both elderly and disabled. By federal requirement, the Department added a rule that increased the standard deduction for larger families: households size of four (4) or less is $134, households of size of five (5) is $147, and a household of size six (6) or more is $168.

Now lawful non citizens, who are blind or disabled, can receive Food Stamps. This is a policy and rules change based on federal regulations.

1. 25,000 families on FS - a very small number who would now be able to receive FS under this change.
2. The benefits would be 100 percent federally funded.
3. Increased workloads would be managed.

16.0305.0201

This rule impacts some elderly or disabled individuals living in a homelike setting. They can have their care paid for with federally matched dollars, instead of 100 percent general funds. This nets the State a substantial general fund cost savings.

1. Homelike setting - certified family homes, in someone's home (lives with family).
2. Developmentally disabled adults - residential and assisted living-group home (businesses) that serve disabled and elderly. Lower level of care is required.
3. About 350 individuals - putting individuals on the State Plan PCS (personal care service) Medicaid coverage.
4. Saves $700,000 - instead of costing $1 million a year in state general funds, it now costs $300,000 in general funds.

This rule also allows providers to be paid directly for services.

16.0305.0202

1. Tightens the rule regarding asset transfers - clarifies what transfers are allowable and what transfers are not. Penalties apply to nursing home and Home and community based services (HCBS) clients.
2. Unless a transfer meets the exception requirement, it is presumed (rebuttable presumption) the transfer was made for the purpose of qualifying for Medicaid.
3. This rule will clarify policy and reduce confusion regarding these transfers.

This rule also increases personal needs' allowance for veterans in nursing home. Allows veterans in nursing homes to retain an additional $50 of their income, for personal needs for a total of $90 for incidentals such as shaving needs. This affects approximately 120 veterans in nursing homes. This rule will have a minimal increase to the general fund cost.

The rule clarifies "end of treatment" for breast and cervical cancer patients. This is to ensure that the Division of Medicaid and the Division of Welfare are defining the end of treatment the same.

Discussion:

1. Senator Burkett asked Phil Gordon is presumption rebuttable or not? Mr. Gordon responded "yes" the presumption is rebuttable. It would be the responsibility of the individual who had the assets to prove that they did not make the transfer for the purpose of making themself eligible for Medicaid or in making that transfer, the amount would still be eligible as the value of that asset.



2. Senator Darrington understands that rebuttable presumption is a federal requirement in numerous programs - Medicaid and non-Medicaid. We have to have rebuttable presumption in programs by federal law. Mr. Gordon has the same understanding as Senator Darrington.

1. Senator Burkett stated he thinks it is important that if we change the rules that presumption is rebuttable by individuals or clients, so he moved that the language be changed back on page 121. Karen Gustafson, the rule coordinator for Administrative Rules, explained the Committee could approve or reject the docket, they could reject a subsection without rejecting the complete docket, the underlined text would be returned and the strikeout section would go away.

MOTION was repeated by Senator Burkett - Motion to approve IDAPA 16.0305.0202 with a rejection of the change in .01 on page 121, regards to the language "Rebuttable Presumption."

Point of Clarification: Senator Kennedy asked Senator Burkett if he meant Section 831.01, on page 121 of the rule. He answered "yes."

Motion was seconded by Senator Kennedy.

Roll Call Vote:

Senator Sweet voted No Senator Burkett voted Aye

Senator Ingram voted Aye Senator Bailey voted Aye

Senator Kennedy voted Aye Senator Brandt voted Aye

Senator Compton voted Aye Senator Darrington voted No

Motion received six (6) Ayes and two (2) No (Nays)

16.0305.0203

This rule provides an easier application and benefit renewal process for elderly and disabled individuals by allowing and encouraging telephone interviews, instead of those individuals having to go to the Welfare office. This reduces a hardship for these individuals, and streamlines the eligibility process.

Amended Section 05.05.106.03.c is incorrect and has been removed from the rule. Legal aliens entitled to benefits if blind or disabled, are eligible under a different rule - Section 03.05.106.01.b.

The rule eliminates a Medicaid eligible group who's federal funding ended December 31, 2002. It was a program that helped defray a small portion of their Medicare premium (SLMB 3). The Department ended the program because the federal funding ended.

This rule clarifies and aligns eligibility rules between programs, in an effort to simplify those rules. Qualified Medicare beneficiary (QMB), specified low-income Medicare beneficiary (SLIMBL), and the aid to the aged, blind and disabled (AABD), now consider income and resources (related to exclusion and disregards) the same. This will remove ambiguity that will help the Department operate the program more efficiently. An example or definition of Room and Board is "lives with."

16.0308.0201

It will add back into rule a policy, inadvertently omitted, that requires parents who receive TAFI cash payments to assign legal rights to any Child Support payments to the State (up to the grant amount). This is not a new policy, just correcting a rule site.

16.0414.0301

This rule eliminates the need to update the rules every year, and will save the cost associated with the rulemaking process.

16.0612.0101

The Department of Health and Welfare (DHW) will have a rule (recommended by the Child Care Oversight Committee) that requires a child care agreement between the provider and the Department,

1. This will clarify responsibilities (providers and department),
2. Enhance accountability, and
3. Strengthen the DHW's ability to recoup misspent dollars.

Extends minimum health and safety guidelines to all Idaho Child Care Program (ICCP) providers, including family and relative providers.

Removes the exemption for specific relative providers.

Health and safety guidelines:

1. Must sign self-declaration that no conviction for specific crimes.
2. Agree to health and safety inspection.
3. Maintain a current CPR/First Aid certification.

The third change specifies that Child Care payments will be made directly to the providers.

EXCUSED:

16.0411.0201

The purpose of this docket is to establish clear standards for professionals rendering Medicaid services. This pending rule clarifies the requirements in the Developmental Disability Agency rules regarding the professional requirements for individuals providing intensive behavioral intervention to children in developmental disability agencies and in schools. Intensive behavioral intervention is only available to children, ages 0-21 years old that has self-injurious, aggressive or severely maladaptive behavior and severe deficits in areas of verbal and nonverbal communication. These services require prior authorization, periodic, and annual review. Provider qualifications include specific degree requirements and experience. There has been a lack of clarity in certifying intensive behavior intervention professionals as the current rule allows individuals with "related degrees" to be considered and this lead to confusion and an interest in incorporating all standards in rule rather than leaving them subject to interpretation. The rule includes a provision to grandfather currently certified professionals who continue to provide intensive behavioral intervention services.

Three hearings were held to provide an opportunity for individuals to testify. Twenty-seven (27) comments were received. Most articulated strong opposition to the original proposed language, but there were multiple comments that also indicated a value for high standards and the need for quality through competence. Amendments were made in response to these concerns. At this time, Ms. Jones is unaware of outstanding opposition to the rule language.

Work has begun to improve the training to develop provider competency and demonstrations of competencies. This change to the training system is supported through the University of Idaho Center on Disabilities and Human Development as well as an advisory group made up of providers and family members.

16.0504.0101

Domestic Violence program standards provide guidelines for existing programs and direction for communities that are developing new programs. The Standards Committee has acknowledged that Idaho has reached a level of service provisions that requires development of a formal process to more effectively ensure program accountability and assure victims are treated fairly, professionally, and given the help needed. A minimum quality of services for battered victims and their children should be assured.

Idaho Courts must use only treatment programs that are approved by the Idaho Council on Domestic Violence and Victim Assistance (ICVVA), Idaho Code 18-918. A current list of approved programs is available at www.state.id.us/crimevictim. Where batterers' treatment is ordered by a court, it is now recognized that this treatment should be provided only by those who have an understanding of the complex nature of domestic violence and who meet the standards developed by the ICDVVA and experts in the field of batterers' treatment. In order to be effective, treatment programs for domestic violence perpetrators must meet these standards, and should be closely monitored by representatives of the criminal justice system, members of the community and victim service programs.

The last update of the rules of the council was in 1990. Recent legislative changes to Chapter 52 of the Idaho Code need to be incorporated into the rules as well as updating existing rules. The rule change will incorporate the name change and additional assigned responsibilities of the Council as enacted by the Legislature. Other changes include updating the formatting of the chapter.

16.0506.0201

The Department began requiring criminal history background checks for potential foster parents in the mid-1980's. Most of the background checks performed by the Department are required by the Federal Child Protection Act of 1994, which mandates background checks for those individuals providing services to children and vulnerable adults. At the inception of the background process, the Department was charging just the passthrough amount for the background check and has continued this practice to the present. The current passthrough cost and the current background check fee is $34, $24 for the FBI and $10 for the Bureau of Criminal Identification (BCI). Since the start of this process, the Department has fully absorbed their share of the cost of completing the background check. Due to current financial difficulties, the Department has determined a need to increase the background check fee to begin to cover some of the agency's cost of completing the background check. The Department has in the past several years experienced a substantial increase in the number of background checks performed. The Department has not been in a position to increase staff to handle the increased volume of required background check. The upgraded Criminal History automated system as well as streamlining the complete process, and allow the Department to continue to handle the volume without adding staff.

The text of this pending rule has been amended in accordance with Section 67-5227, Idaho Code.

16.0601.0101

These rules are the result of state and federal changes. In 2001, the Legislature passed two bills that are reflected in these rules. One is the Safe Haven Act, which allows a parent to be exempt from being placed on the child abuse registry if they follow the procedures of abandoning and infant within 30 days of birth.

The other piece of legislation is subsidized guardianship. This process provides support for children and their legal guardian when adoption is not an option for that foster child. The subsidized guardianship parallels the same process that already exists for subsidized adoptions. These guardianships are for foster children whose parental rights have been terminated and adoption has been fully explored, but ruled out for the child.

A recent review of our Federal Title IV-E plan led to several corrections in the rules. Section 403, Section 426, and Section 900 reflect the changes necessary for IV-E compliance. Briefly Title IV-E refers to Section IV-E of the Federal Social Security Act which provides financial assistance to states for foster care and adoption assistance to eligible children in the state's custody.

Other federal changes now require the Department to report on children adopted from foreign countries that are placed in the Department's care. Section 923 sets forth these requirements.

These rules also defined parent and changes were made but not published to consistently reflect the use of the word parent throughout the text. Descriptive summary summarizes the changes.

16.0601.0201

This rule deals with dispositioning child abuse and neglect referrals. Department social workers follow a standardized assessment protocol when there are allegations of child abuse or neglect. The primary concern during the assessment is the safety and well being of the child. Once the assessment has been completed a disposition is documented. An individual who has abused or neglected a child is placed on the department's central registry. A central registry of persons who have abused or neglected children is essential for the continuing protection of our children should that individual become a day care provider, foster parent, or adoptive parent. The central registry is part of the required background check for certain employment or activities involving children or vulnerable adults. The registry is not open to the public.

These rules propose changing from five (5) dispositional codes to two (2). Having two dispositional codes will result in greater inter-rater reliability, reflect more accurately the actual incidents of child abuse and neglect in the state and more importantly helps protect children from individuals that should be on the central registry.

Section 560.01(a) adds the words "family services" to clarify that the incident has to be witnessed by a Department of Health and Welfare worker. Sections 561 and 563 just reorganize the existing language. Persons placed on the central registry have the right to appeal that decision and have their name removed from the registry as stated in Section 561.

16.0601.0301

The Department made some changes to the word parent in a previous docket through an omnibus clerical correction. Upon further review, the department needed to add better language around the word parent. The term Certified Adoption Professional was added in place of the term qualified individual. Sections 889 through 895 incorporates the change in the term as well as reorganizes the existing sections. Section 890.04 provides the standard appeal process for Certified Adoption Professionals should they be decertified by the Department of Health and Welfare.

16.0602.0201

In 2002, the Senate and House unanimously approved the revisions to the Child Care Licensing Act, giving the Department the authority to oversee children's therapeutic outdoor programs in Idaho. The Department believed this was a very strong endorsement of the project and for the protection of children in out-of-home care who receive services in therapeutic outdoor programs.

The change in the statute was the result of a three-year project to update all of the child care licensing standards, and to include therapeutic outdoor programs. During that process, committees consisting of child care providers, consultants, department representatives and consumers, worked extensively in the development of the rules.

Public hearings were held in Coeur d'Alene and Boise. The only comment received was from a neighborhood association in north Idaho who supports the proposed rules. During the presentation in 2002 for the statute change, representatives from the three (3) outdoor programs in Idaho testified before the Legislature in support of the proposed legislation.

In this time of serious budget constraints, the Department must consider the cost of services provided, including those associated with child care licensing. Currently, there are three (3) programs that have submitted applications and are in the process of being licensed. The Department does not anticipate a significant increase in that number. The cost of including outdoor programs to the licensing responsibility of the Department was debated extensively last year, and an estimated cost breakdown was submitted to the House. Because of the limited number of programs in Idaho, and some of them being associated with currently licensed residential programs, the Department believes it can absorb the additional workload with the current staff. Costs associated with the licensure of the outdoor programs consist primarily of per diem and travel. The estimated annual cost is approximately $2,400.

The Department is looking at the possibility of developing a schedule of licensing fees for residential child care facilities, children's agencies and children's outdoor therapeutic programs. This was discussed with all of the workgroups during the rule revision process, and the majority supported a fee schedule, as long as it was fair. There lies part of the challenge. The Department must look at the size of the programs, services offered, for profit vs. not for profit, in determining if fees are appropriate and if so, in what amount.

The Department is currently surveying surrounding states and continuing to communicate with members of the workgroups on this issue.

16.0603.0301

This tevide. We focused reductions in staffing and services to areas where impact on community, staff, and client safety would be avoided.

The FACS reduction plan took into careful consideration the need to achieve required levels for general fund maintenance of effort for mental health, substance abuse, and infant and toddler programs, to avoid reductions in federal dollars. We are seriously close in all of these programs to having state general funding levels that are below the target maintenance of effort levels required by the federal government, for continuation of funding through Block Grant appropriations. Depending upon the program, our match rate ranges from a high of 80 percent to a low of 50 percent. Most of the remaining state general funds appropriated to FACS are heavily leveraged against federal dollars.

The hold back strategy, as it relates to the reductions in sheltered workshops funding, meets the priorities that were established in the budgeting process. The Department fully recognizes the reductions the workshops are being asked to make have impacted the consumers they serve, and have reduced the funds that are available for them to conduct their business operations. But looking at the overall perspective of the impact, and of the alternatives that we faced when developing our plan, there were no-good options, only options that provided varying degrees of disadvantage.

Mr. Deibert discussed the proposal of diverting $443,400 from the Division of Medicaid budget to the FACS budget to fund sheltered workshops. He outlined the process he would use for determining those funds. If he could do as he wanted with those monies ($443,400), he would find ways to leverage those dollars to maximize the overall impact on the service delivery system for social and behavioral services.

If the $443,400 is returned solely to the workshop program, it will not generate any additional federal match funds that could be used to provide services to the citizens of Idaho. It would benefit only those clients, who receive vocational services through the sheltered workshop program, and the community supported employment.

Last week, the Department received notification from the federal government about our allotment for the substance abuse block grant. We anticipated we would receive between $200,000 to $300,000 in additional federal monies, but the notification indicated we would receive $30,000 in additional federal funding for substance abuse services. In that program, we have a 9 percent increase in the rate of utilization. Substance abuse is one of the most significant and perplexing problems we face in Idaho.

He emphasized the Department looked at the overall perspective for services we provide, or asked to provide by constituents. We have greater priorities, at this time, for our social and behavioral services. We have greater opportunities to maximize the availability of funding by a different utilization of savings that have been identified through the Medicaid Program for the $443,000, and requested the committee members to look at the overall perspective of the service delivery system, and the needs that we have in social behavioral services.

He explained these are challenging times for everyone, but funding the sheltered workshops with Medicaid savings is going in the wrong direction.

1. Total projected operating budgets - $22,490,851.
2. Projected revenues from provision of Health and Welfare vocational services (work services and community supported employment) - $3,114,450.
3. Projected revenues from provision of Idaho Division of Vocational Rehabilitation Services (fees for various vocational services) - $997,488.
4. Projected revenues from provision of Health and Welfare Medicaid Services (not vocational services) - $6,872,248.
5. Projected revenues from industrial activities, fund raising and other sources (no fees for vocational services) - $11,506, 665.

He reported, "for every $2.60 made available by the state of Idaho as Health and Welfare and Idaho Division of Vocational Rehabilitation fees for vocational services, the eleven organizations that are members of the Idaho Association of Community Rehabilitation Programs generate $7.40."

M.C. Niland, president of the Western Idaho Training Company in Caldwell and a representative for the Workshop Association, testified in support of restoring $443,400 to the shelter workshop program. She emphasized the effects upon those individuals served by the sheltered workshops. Changes in an individual's work program or living standards can evoke a strong mental or emotional response, or even a violent response, from those affected individuals. She requested the committee seek the necessary $443,400 funding for sheltered workshops.

A motion was made by Senator Compton to ask in the committee's letter to the Joint Finance-Appropriations Committee (JFAC) to fund an additional $443,400 to the Department of Health and Welfare appropriations, and direct the transfer of these additional funds to the sheltered workshop program.

Motion was seconded by Senator Ingram.

DISCUSSION:

1. Original intent language showed a Medicaid savings of $923,700 from which JFAC was going to state that $443,400 of the savings would be diverted to the sheltered workshop program. That cannot possibly happen as the state would lose $1.3 million in matching dollars, then we would not have the $923,700 in Medicaid savings.
2. Ensure JFAC understands the germane committee is asking for an additional funding of $443,400 for the sheltered workshop program, not diverting the funds from Medicaid.
3. The additional funds would be state general revenues of $443,400 and will have noting to do with the Medicaid funds.
4. Frustration of the Department of Health and Welfare and providers, and lack of funds for needy programs.
5. The Department of Health and Welfare should have presented a priority list to the committee, at the beginning of the session, and explained why and how the Department use to determined program cuts. The committee should have been fully informed about the options the Department used to cut programs, and those they did not choose to cut.
6. If no additional funds become available, revisit the workshop program issue.
7. Prioritization of programs.

Senator Bailey called for the question.

The beforehand motion was carried by a voice vote of 5 Ayes and 2 Nays.

Senator Stegner voted No. Senator Brandt voted No.

EXCUSED:

16.0309.0214

Ms. Clement presented a brief overview of the temporary rule docket 16-0309-0214. These rules define Medicaid pharmacy management practices.

The purpose of these temporary rules is to support the Department of Health and Welfare's cost containment efforts by providing access to the right care for the right price.

Idaho paid $114 million for Medicaid prescription drug benefits in fiscal year 2002. Nationally, drug costs have been the fastest growing component of Medicaid expenditures, growing at an annual rate of 20 percent, compared to overall Medicaid expenditure growth of 9 percent.

Prescription drugs are the third most expensive Medicaid benefit following nursing home care and hospital services, and account for 14 percent of the Medicaid budget.

To slow this growth, Idaho ­ like other states are pursuing a variety of cost containment methods including reducing payment rates, requiring generic substitution, and requiring prior authorization of drugs.

Medicaid's existing prescription drug rules do not include the necessary management tools to control spending. The current rules list the specific names of excluded drugs that must be prior authorized by the department.

The number of new brand name drugs and classes of drugs that continuously become available, make it impossible to continue listing each specific drug in rule.

These temporary rules allow Medicaid to review brand name prescription drugs for medical necessity when there may be a less expensive and equally effective drug available.

The concept of "medical necessity" is built into all that Medicaid does in the healthcare field. The state plan, as well as federal rules and state statutes mandates a strict adherence to medical necessity criteria in all areas.

Coupled with medical necessity in the state plan and federal requirements is the principle of "least costly." This rule clearly defines both aspects of this requirement. Medicaid must be able to assure both elements.

These rules describe when a prescription is considered medically necessary, and clarify coverage and limitations.

Additionally, by identifying categories of drugs that must be prior authorized rather than identifying each specific drug, the department does not need to update rules every time a new drug is introduced by the pharmaceutical industry.

Further, under the existing rules, early refills of prescription drugs have been identified as an unnecessary and costly practice that needs to be controlled to reduce unnecessary Medicaid spending.

These temporary rules allow Medicaid to require that 75 percent of the previous prescription has been utilized before Medicaid will pay for a refill. Most private health insurers use 90 percent.

The Department's efforts to address the escalating pharmacy costs intensified in January 2002. Medicaid began implementing a prior authorization process for all drugs exceeding average prescription utilization. On average, 45,000 Medicaid clients receive approximately four prescriptions per month.

After an analysis of the medications it prior authorized, and the resources required to support this initiative, Medicaid determined that a more focused management approach would be more effective than prior authorizing all medications based solely on volume. In addition to reviewing use of prescriptions in amounts exceeding the FDA and currently accepted guidelines, Medicaid identified three therapeutic drug classes for review.

This management review focused on prescription antihistamines, antacids, and antidepressants that were not only prescribed more frequently than other medications, but were also available at varying prices.

Significant costs have been avoided each month since this management review process was implemented in May 2002

Additionally, these rules allow for generic substitution where possible. Medicaid acknowledges that in certain areas ­ especially mental health and other neurological conditions that it is prudent to use brand names as opposed too generic. Medicaid currently functions in this manner.

In addition, therapeutic substitution allows for evaluation within a drug classification to determine clinical efficacy and equivalence, thus allowing price competition to occur based on good science.

The combined effect of these management review approaches, and the 75 percent refill limit, helped to avoid an estimated $4.2 million in pharmacy costs.

These temporary rules became effective in late May. Medicaid's state plan amendment, incorporating the medical necessity definition and clarifying prior authorization requirements was approved by the Centers for Medicare & Medicaid in November 2002.

This rule docket was published in the December Administrative Bulletin. Negotiated rulemaking was not formally conducted because of the mandatory reduction in Medicaid spending, however the Department of Health and Welfare has continuously met with various stakeholders to obtain input.

Two positive comments and thirty-one requests for a hearing were received by the department.

A hearing will be conducted on February 20, 2003 in Boise.

Of those requesting this hearing, 61 percent were received from out-of-state pharmaceutical companies.

Local requests came from advocacy groups and a Boise law firm. Advocacy groups are particularly concerned with maintaining consumer access to newer medications.

These rules will not create a formulary that excludes certain drugs.

These rules will allow Medicaid to make decisions based on good scientific evidence that are already standard practice in commercial health insurance plans.

Medicaid will encourage the utilization of effective medications at the best price, but if a physician provides the evidence that an individual requires a more expensive drug, that drug will be authorized.

The purpose of this rule docket is not about limiting access ­ it is about appropriate access.

Without these rules, the department's ability to manage pharmaceutical costs will be severely restricted.

Medicaid's current budget is based on the expectation that it will be able to continue to manage drug utilization, and slow the rise in our prescription drug costs.

Senator Kennedy discussed a Mountain Home constituent who reported he had surgery and was given a generic pain killer by his doctor. The constituent had a serious reaction to the generic drug. The doctor faxed Medicaid for permission to prescribe the non-generic pain killer, and was denied the right to do that. The question is - in the event someone cannot take the generic substitute recommended by the department, is there a policy that says a patient will go without any medication?

Ms. Clement stated, "No." She will get all the fact pertaining to this case and respond to the question as soon as possible. Senator Brandt explained he had previously contacted the Department of Health and Welfare, and a response should be forthcoming today.

Cynthia Swanson from the National Alliance for the Mentally Ill, testified in opposition to IDAPA 16.0309.0214. She reported the national, state, and local affiliations oppose any restrictions on medications used to treat mentally ill patients.

Jack Lewis, a registered pharmacist in Idaho since 1977, testified in support of the Medicaid rules. Three (3) topics discussed included prior authorization, the 75 percent refill rule, and generic vs brand drugs.

Jim Alexander, a pharmacist in Idaho for 30 years, testified in support of the Medicaid rules. He believes Medicaid is doing the thing right by using generic drugs whenever possible to control the cost of drugs.

Dr. Jim Scheel, a physician in Idaho and a lobbyist for the Idaho Medical Association, testified in opposition to the rules. He has concerns about the 75 percent refill mandate and certain disease classifications such as asthma. He wants physicians to have authority and flexibility to prescribe a drug. The Association realizes the concerns about the increases in pharmaceutical costs, and applauds the Department's efforts in trying to get a handle on the problem. He has concerns about the implementation of the rules.

Thomas Young, MD, for the Division of Medicaid, addressed committee members' questions and concerns pertaining to physicians' flexibility to prescribe drugs; the 72-hour rule to obtain prior authorization and a 24- hour, or less, turnaround time for prior authorization; Medicaid's automated system for prior authorization; some $4.2 million savings in the 2003 Medicaid budget and projected higher savings in the 2004 budget year; quality improvement and studies pertaining to outcomes and recovery times; cross reference of drugs; 156,000 Medicaid patients; children are exempted from the prior authorization rule, and in his opinion, as a practicing physician, Medicaid's effort to control pharmaceutical costs is the right thing to do.

William Roden, representing the Prarmaceutical Research and Manufacturers of America (PhRMA) provided a lengthy testimony in opposition to major portions of IDAPA 16.0309.0214. He testified that on behalf of PhRMA, but more importantly, on behalf of the patients who need the medicines we produce, and the doctors who prescribe them, we believe the temporary rule, as written, is neither in the best interest of constituents who need medicines, nor in the long-term best interest of the health and of the state. There are many issues involved with this rule. He stated his testimony merely touched the surface. Formularies, prior authorization for prescribing practices, preferred drug lists that are dependent for their success in forcing additional rebates by the drug companies, are all issues that should be explored. The one premise they all have common is that "cost" is the determining factor - not the patient or the doctor. He reported this rule has no safeguards for the patient or the doctor. The Department will be the prescriber - the medical practitioner, and it will be based primarily on economic considerations, no the needs of the patient. Mr. Roden requested the temporary rule not go forward, let the Department do its work on the proposed rule, letting it adopt recommendations based on the hearings.

Two persons, who did not testify, but did provided a precise indication in opposition to IDAPA 16.0309.0214, is also noted. (See attached sign-in sheets).

Department of Health and Welfare Deputy Director Joyce McRoberts addressed the questions of Senator Kennedy about a Mountain Home constituent (page 4 of the minutes). She stated the Department had not received a statement from the doctor; therefore, no further action was taken.

Mr. McRoberts distributed a handout explaining changes to the prescription drug rules being made to allow better management of Medicaid spending and to make it easier for clients and providers to understand the Medicaid prescription drug program. The four (4) page handouts are attached. (See attachment # 1)

A discussion and review of numerous sections, subsections, and clarifications of sections, publication and retroactive dates of this rule, was held.

At the discretion of Chairman Brandt, IDAPA 16.0309.0214 will be held in Committee and rescheduled for Tuesday, February 4, 2003, for a final review. This action will allow committee members additional time to review the prescription drug rules.

EXCUSED:

16.0309.0214

Discussion:

1. Several committee members reported they have problems with the rule;
2. One area of concern is, but not limited to, the medical insurance industry;
3. A physician knows best what a patient's medical needs are;
4. Concept of the rule will save state many dollars;
5. Changes will require close monitoring
6. Changes to Sections 805 and 812.03 reviewed;
7. Management care;
8. Will rule return during the 2004 legislative session as a proposed rule;
9. Dramatic fiscal savings during the past six (6) months,
10. The language in the rule.

A roll call vote was requested and granted by the Chairman.

Roll Call Vote:

Senator Ingram voted No Senator Burkett voted Yes

Senator Sweet voted No Senator Stegner voted Yes

Senator Darrington voted Yes Senator Compton voted Yes

Senator Brandt voted Yes Senator Kennedy voted No

Senator Bailey voted No

The motion carried 5 Yes and 4 No.

16.0309.0215

As a result of the reduction in reimbursement for Targeted Service Coordination (TSC), the rule changes removed all caseload limit requirements, and removed the requirement for availability of a care coordinator on a twenty-four (24) hour basis. As a result of the reduction in the ESC (Early Periodic Screening, Diagnosis, and Treatment (EPSDT) Service Coordinator reimbursement, the rule changes remove all caseload limit requirements, and remove the requirement for availability of a care coordinator on a twenty-four (24) basis.

The rule changes will also reduce ongoing Targeted Case Management (TCM) for the mentally ill from unlimited hours to a maximum of four (4) hours per month, remove all caseload limit requirements, remove the requirement for availability of a case manager on a twenty-four (24) hour basis, and specify that crisis assistance will no longer be a required core element of targeted case management. Also, hours available for initial evaluation and service planning were reduced from eight (8) hours to six (6) hours.

Senator Brandt explained he had met with Department of Health and Welfare Director Karl Kurtz, some TSC providers, and others, to try and resolve the issue of the reduction in hours. The Department showed a willingness to work with providers and try to reach a consensus before the Legislature's seine die. He read into the minutes a letter he received from Director Karl Kurtz. (Attachment #1)

Director Kurtz stated in his letter: "As a follow up to our conversation on January 28, 2003, I would like to state that the Department of Health and Welfare shares your committee's concern regarding the 4-hour limit for targeted case management for persons with mental illness. I agree it is important the Department work with providers to develop an agreed upon methodology for crisis case management hours.

Since the Department shares your concern about situations where there is an emergency, we have and will continue to work with the providers in modifying those rules for emergency situations prior to the adjournment of the 2003 legislative session, so the new rules will go into effect in April or at adjournment.

We hope this action addresses the committee's concerns about Docket No.16-0309-0215."

Committee members expressed concerns with IDAPA 16.0309.0215. After a lengthy review of these rules and specific problem areas within the rules on pages 51, 52, 58, and 61, the following action was taken.

Discussion:

1. The rule does not have broad acceptance statewide
2. Face-to-face monthly meetings;
3. The promise of the Department of Health and Welfare;
4. The definition of a case manager's functions and responsibilities,
5. Crisis situations.

The substitute motion was seconded by Senator Ingram.

Roll Call Vote on the substitute motion:

Senator Ingram voted Yes Senator Burkett voted Yes

Senator Sweet voted No Senator Stegner voted No

Senator Darrington voted No Senator Compton voted No

Senator Brandt voted No Senator Kennedy voted Yes

Senator Bailey voted No

The substitute motion failed with 6 No and 3 Yes.

Roll Call Vote on the original motion:

Senator Ingram voted No Senator Burkett voted No

Senator Sweet voted Yes Senator Stegner voted Yes

Senator Darrington voted Yes Senator Compton voted Yes

Senator Brandt voted Yes Senator Kennedy voted No

Senator Bailey voted Yes

The motion carried with 6 Yes and 3 No.

Senator Brandt encouraged everyone to work together to develop rules to help Idahoans in need. He looks forward to working with all the parties involved.

EXCUSED:

24.1401.0201

Ms. Jacobsen reported that opposition to IDAPA 24.1401.0201at the January 15, meeting had been negotiated and issues were resolved.

On January 15, Craig Dickerson had testified opposing this rule making, but testified today he is now in favor of the rule.

16.0309.0213

In 2001, the Legislature amended Idaho law to remove a requirement that the state pay for abortions to save the health of the mother. Implementation was delayed until July 1, 2002, because of a court suit challenging the legality of the amended statute.

The court upheld the amendment. At the time, the court ruled that the state law requirement to have two physicians certify the necessity of an abortion violated federal law and could not be enforced by the state. The court's decision was effective July 1, 2002.

The temporary rule implements both the statutory amendment and court decision by:

1. Removing state payment for abortions to save the health of the mother.
2. Changing the two physician certification requirement to certification by one physician.

An identical proposed rule was published at the same time as this temporary rule. Unfortunately, the comment period expired after the date for submitting rules to be reviewed this session, however, the pending rule will be presented during the 2004 legislative session.

16.0309.0216

The Department of Health and Welfare is requesting that the Committee extend this temporary and proposed rule. These rules are required to comply with legislative intent language in the Department's appropriation bill, and essentially limit adult dental procedures to emergency situations.

Retta Green from the Idaho Community Action Association (ICAN), testified in opposition to IDAPA 16.0309.0216.

J. L. Byington testified in opposition to IDAPA 16.0309.0216, and requested that dental services be restored.

Ronald Matthews from the Idaho Community Action Association, testified in opposition to IDAPA 16.0309.0216.

Jessica Fry testified and explained the difficulties in finding dentist and doctors willing to take Medicaid clients. She did not indicate support or opposition to IDAPA 16.0309.0216.

Committee members reviewed several sections of IDAPA 16.0309.0216, and asked many questions about the rules. The Committee also reviewed numerous pages of the rule such as pages 68, 70, 71, and 72. Other areas discussed included the following:

1. Emergencies and who would deem a case as an emergency. A dentist determines a case as an "emergency";
2. If a dentist deemed a case as an "emergency" would services be provided? Ms. Allyn answer "yes";
3. Dental services for clients more than age 21;
4. Pregnant women and children (PWC);
5. Reimbursement rates;
6. Rule changes will address the Governor's concerns.

A lengthy discussion was also held by the committee members about the Joint Finance Appropriations Committee's (JFAC) directions given to the Department of Health and Welfare to "not cover adult dental" except for an emergency, and the responsibilities of germane committees, and the setting of policies.

At the discretion of Vice Chairman Compton, no decision will be made at this time for IDAPA 16.0309.0216. The rule will be held while the chairman reviews concerns and issues with the House Health and Welfare Committee's chairman.

This legislative change is necessitated by the following:

1. Antiquated Requirements in the Existing Statute - The existing language of Idaho Code 54-918 requires the Board of Dentistry or its agent to conduct written and clinical examinations in dentistry and hygiene in order to ascertain the fitness and qualifications of applicants for licensure in Idaho. That requirement does not change in the proposed legislation. Traditionally, the Board has conducted the written examination through an agent, the American Dental Association. That will not change in the proposed legislation. At one time the Board conducted its own clinical examination and graded the examination in accordance with the mandate of the existing statute (passing grade of 70 percent for each section of an examination with a general average passing grade of 75 percent). Due to increasing numbers of applicants and a lack of appropriate testing facilities as well as trained, independent examiners, in the mid-1980's the Board discontinued conducting the clinical examination and joined with a number of other states to participate in a regional testing organization to conduct the clinical examination. That regional testing organization is referred to as the Western Regional Examining Board (WREB). For purposes of the clinical examination requirement, the Board of Dentistry accepts the results of the WREB examination and, since 2001, also accepts the results of the Central Regional Dental Testing Service (CRDTS). Those testing organizations conduct examinations at dental and dental hygiene schools using trained and calibrated examiners. It will greatly simplify the Board of Dentistry's application of the examination statute if the language is clarified to specifically state that the regional or national testing organizations shall establish the examination's passing grade standard or level of competency.

2. Recent District Court Decision - An applicant for licensure who received a general average passing grade of 74 percent (as opposed to the 75 percent required by the existing statute and the testing entity) on an examination required by the Board of Dentistry brought legal action requesting that the district court direct the Board of Dentistry to issue the applicant a license. The district court found in favor of the applicant and directed the Board to grant the license. The district court determined that the board of Dentistry was required to average the scores of all the examinations conducted, both written and clinical, in order to arrive at a general average passing grade. The Board has traditionally relied upon the literal language of the statute to require that an applicant score at least 70 percent on each section of an individual examination, with the general average grade for each individual examination to be at least 75 percent. Given the disparate nature of the written and clinical examinations, The Board has never favored or adopted the averaging approach identified by the district court in the legal proceeding. Recognizing that the existing language of the examination statute was somewhat imprecise, the Board of Dentistry preferred to revise the language of the statute rather than appeal the adverse district court decision.

The proposed changes to the Board of Dentistry's examination statute does not place any additional costs or examination requirements upon an applicant for licensure. Nor will the proposed legislation cause any additional fiscal impact upon the Board of Dentistry. The examinations currently required of an applicant by the Board of Dentistry will not change. The Board's ability to administer the examination requirements of the Idaho Dental Practice Act will be greatly enhanced by the proposed legislation.

This legislation addresses concerns with the inspection of retail tobacco outlets by an adult enforcement officer with the assistance of a minor at locations often called "age restricted."

Under, Idaho Code Title 39 Chapter 57 Section 04 it is unlawful, ". . . to sell or distribute or offer tobacco products for sale or distribution at retail or to possess tobacco products with the intention of selling at retail without having first obtained a tobacco permit from the department . . . " The permit is provided free of charge. Section 10 paragraph 3 requires "The Department shall conduct at least one (1) random, unannounced inspection per year, with the assistance of a minor, at all locations where tobacco products are sold or distributed at retail to ensure compliance with this chapter." This places the Department in the position of conducting a compliance inspection with the assistance of a minor at all permitted locations including bars and adult entertainment establishments which have "age restrictions" imposed upon them in other statutes. The Department has been assured of the legality of conducting compliance checks with the assistance of a minor in such establishments.

The safety of inspectors, both adult and minor, is a primary concern during all inspection operations. Program policy allows inspectors to not conduct an inspection if either the adult or minor is uncertain or uncomfortable with attempting an inspection at any given location. The level of concern is significantly higher at locations where alcohol is the predominate product served or consumed and at adult entertainment locations.

RS12386 addresses these concerns by first adding a definition for a "minor exempt permit" in Section 02, found in lines 20 through 25 in this legislation. The definition calls out requirements that businesses applying for this permit have at least 55 percent of their total revenues result from the sale of alcoholic beverages for consumption on-site or identified with adult oriented entertainment.

RS 12386 also amends Section 10 to indicate that the Department of Health and Welfare will conduct inspections for minor exempt businesses without the assistance of a minor at locations with a minor exempt permit, and with the assistance of a minor at all other permitted locations.

Businesses receiving a minor exempt permit would be exempt from the random and unannounced inspections with the assistance of a minor routinely conducted by the Department of Health and Welfare. These businesses would be subject to a random and unannounced inspection by an adult inspection officer for all aspects of compliance with Title 39 Chapter 57 except an attempt to purchase tobacco products by a minor.

Businesses with a minor exempt permit, under this amendment, may be subject to an inspection with the assistance of a minor as part of the investigation of a written complaint of such a business selling tobacco products to minors.

The changes proposed in RS 12386 decreases the potential for the compromise of the safety of an inspecting team or minor assisting with compliance inspections, while keeping all permit holders subject to random and unannounced inspections for compliance with Title 39 Chapter 57.

Inspections based upon the investigation of a written complaint and enforcement actions by law enforcement agencies are not effected by this change.

EXCUSED:

There is no fiscal impact to the General Fund. Total funds expended on CHIP are currently governed by a cap of $3.8 million. This legislation allows for outreach from current budgeted funds as long as total expenditures do not exceed the mandated cap.

Idaho Code 32-1214 is substantially impacted by the changes needed to implement the National Medical Support Notice. This section will be rewritten to bring Idaho Code into compliance with the requirements of the NMSN process. This will include an outline of the procedures notifying employers and group health plan administrators of their duties and obligations that are required by the NMSN.

Fiscal Impact - The first year the estimated cost is $60,400 and $45,400 thereafter.

Idaho Code 16-317 allows the Department to designate "other mental health professionals" to be examiners besides those included in statute, but Idaho Code 66-317 restricts the qualifications to designated professional disciplines.

To make the codes consistent, the definition of "Designated Examiner" in Idaho Code 16-243(4) is struck and moved to Idaho Code 66-317. In Idaho Code 66-317 language is added that the designated examiner by "qualified by training and experience in the diagnosis and treatment of mental or mentally related illnesses or conditions." Specific references to degrees are struck from Idaho Code 66-317. Those qualifications will be created in the Department's rules.

The language struck in Idaho Code 66-329(d) again removes specific reference to degrees, but does not take away from the original intent of the law that "at least one (1) designated examiner shall be a psychiatrist, licensed physician or licensed psychologist."

These changes will create consistency between Idaho Code 16-2403, 66-317 and 66-329, and enable the Department of Health and Welfare to create rules to govern the appointment of examiners for adults as well as for children.

After discussion, the Chairman agreed that written comments from constituents discussed or submitted during a public committee meeting can be indicated within the minutes. The Chairman generally responds in writing to constituents' written comments. [After final approval, the Committee's public meeting minutes are posted on the Internet.]

Senator Burkett previously expressed a concern pertaining to IDAPA 16.0309.0215, targeted case management services, presented on January 24, 2003, by Leslie Clement from the Division of Medicaid. Upon clarification with Ms. Clement, her statement shown in the minutes of January 24, 2003, is correct; therefore, the January 24, 2003 minutes will not be amended in that portion of her testimony.

The committee's secretary was directed by the Chairman to change the minutes of January 24, 2003, to reflect written comments submitted by a committee member.

EXCUSED:

Quane Kenyon of Boise, was reappointed by Governor Dirk Kempthorne for a term of four (4) years, commencing January 7, 2003 and expiring January 7, 2007. He is a retired professional journalist. His civic and community activities have included serving on the Idaho State Board of Health and Welfare since July 1999, serving on the State University Centennial Task Force, and co-chair of the State Affairs Committee. He is also a former president of the Idaho Press Club. His political affiliation is Republican.

Reappointment

Richard T. Roeberg M.D., of Caldwell, was reappointed by Governor Dirk Kempthorne for a term of four (4) years, commencing January 7, 2003 and expiring on January 7, 2007. Dr. Roeberg is a retired physician. His civic and community activities have included serving on the Idaho State Board of Health and Welfare since July 1999, serving on the Southwest District Medical Society, Idaho Medical Association, American College of OB-GYN, University of Idaho Alumni Association Board of Directors, University of Idaho Foundation, and as a member of the Rotary International and a member of the Caldwell Rotary Club. His political affiliation is Independent.

Jack T. Riggs, M.D., of Coeur d'Alene, was appointed by Governor Dirk Kempthorne for a term of four (4) years, commencing January 7, 2003 and expiring on January 7, 2007. Dr. Riggs served as Idaho's 38^th Lieutenant Governor, and was elected to the Executive Committee, National Conference of Lt. Governors. He is a former member of the Idaho State Senate.

Dr. Riggs currently serves on as Chair, Idaho Bio-Security Council; Chair, Idaho Council on Children's Mental Health; executive committee member of the National Lieutenant Governor's Association; the council of State Government (CSG), National Executive Committee; CSG National Health Trends Tracking Team, and co-chair, CSG National Health Capacity Task Force.

Floor sponsors are: Senator Compton for Jack T. Riggs, Senator Burkett for Quane Kenyon, and Senator Kennedy for Richard Roeberg.

16.0309.0216

The Department of Health and Welfare requested this temporary and proposed rule be extended. These rules are required to comply with legislative intent language in the Department's appropriation bill, and essentially limits adult dental procedures to emergency situations.

Committee members discussed many concerns and issues pertinent to adult dental care and the Joint Finance Appropriations Committee's (JFAC) legislative intent language. No additional public testimony was heard today on IDAPA 16.0309.0216.

Discussion:

1. Rejection of the rule is putting the Department of Health and Welfare(DHW) into a difficult position;
2. Authorities of Joint Finance Appropriation Committee (JFAC) and germane committees;
3. Addressing the reality of JFAC actions, this being the first opportunity this Committee has had to become involved in this action;
4. Policies of Health and Welfare should be set by the Senate Health and Welfare Committee (germane committee);
5. Financial causes that determined JFAC's action;
6. A possible budget item in the current DHW budget expenditures for about $1.8 million to purchase 79 new automobiles at an average cost of $23,000 per automobile - almost the exact amount of money required for the DHW to fund this $8.4 million project on dental care of adults once it reached the federal match;

1. It was suggested that this Committee send a message, to all affected state agencies, that we deem it more important to take care of the health of Idahoans than it is to, in a tight economic year, purchase 79 new automobiles;
2. Modification of the rule and the expansion of emergency services;
3. Reinstate emergency services;
4. Dentists making the decisions of "emergency situation" and will that cause a significant increase in the number of people obtaining services without increasing the overall cost of the Medicaid program;
5. Legislative intent language;
6. Optional programs and federal program mandates;
7. Priority issues being preventive medical care;
8. Erosion of powers of germane committees through legislative intent language of the budget committee;

Roll Call Vote to reject IDAPA 16.0309.0216:

Senator Ingram voted Yes Senator Burkett voted Yes

Senator Sweet voted Yes Senator Stegner voted Yes

Senator Darrington voted Yes Senator Compton voted Yes

Senator Brandt voted Yes Senator Kennedy voted Yes

Senator Bailey voted Yes

The motion to reject IDAPA 16.0309.0216 was carried unanimously by a voice vote. IDAPA 16.0309.0216 failed.

After the above action, committee members further discussed the following issues:

1. Support of professional and dedicated employees of the Department of Health and Welfare;
2. Authority of JFAC vs. authority of each committee
3. This committee sets policy and JFAC must set budget;
4. How immensely interrelated are committees' setting policy, and when a policy is set it is expected to either raise revenue to meet that policy, or to find revenue by realigning current resources meet that policy.
5. Appreciation to Scott H. Kido, DMD, for his letter and concerns regarding preventive and restorative dental care for adult Medicaid recipients.
6. Committee members' were encouraged to attend the Board of Health and Welfare meetings and expand their knowledge about the department and its rules. [The 2003 Board meetings are January 27, April 25, June 20, and November 6 and 7, 2003]
7. Draft a letter to DHW outlining the wishes and suggestions of the committee.

Mond Warren, bureau chief, Bureau of Fraud and Abuse Investigations, presented an update about the Department's fraud and abuse investigations. The Department's Fraud and Abuse Program consists of the fraud investigation unit and the surveillance and utilization review (SUR) unit. The SUR investigates fraud and abuse within the Medicaid program by monitoring and reviewing provider billing practices, and reviewing provider records of support services billed to the program. The SUR Unit staff works closely with the Medicaid staff to ensure there are proper controls in the Medicaid claims processing system. They work with Medicaid policy staff when policy or guidelines are identified that should be revised or strengthened.

Medicaid investigations are initiated through complaints from providers and clients, referrals from agencies, and through proactive targeting or reviews of claims to identify improper billing. Once investigated, issues may be resolved through provider education or policy revision, recovery of funds from the provider, civil monetary penalties imposed, provider agreement termination or program exclusion, or a referral for prosecution.

The fraud unit investigates department-wide allegations of fraud to include Medicaid providers, Welfare programs and contractors. The Unit also conducts internal investigations.

Fraud investigators are stationed statewide to respond to any investigation, working with other state and federal agencies to investigate and prosecute providers and clients identified as defrauding Medicaid or Welfare programs.

A fraud and abuse chart outlining Medicaid penalties collected, Medicaid cost avoidance, Medicaid dollars collected, identified Medicaid fraud, and identified Welfare fraud cases was reviewed. (Attachment #1)

Mr. Warren informed the Committee the lack of staff impacts the amount of dollars the Bureau of Fraud and Abuse units collected. Additional investigators would increase the ability to respond more quickly and identify and collect more resources. The Bureau currently has 35 pending cases of which 10 are investigations of providers, and 25 are client investigations.

EXCUSED:

This legislation serves to clearly define key terminology, to include: "peer review," "peer review records," and "[atient care records." It also delineates the circumstances upon which records lawfully may be released by the health care organization that owns them; and it clarifies immunity from civil liability. Further, a new section fully delineates the health care organizations' reporting obligations to the state board of medicine and details the sanctions and content of mandatory reports. In addition, the measure clarifies that no physician or surgeon shall be required to report information known, learned or discovered as a result of access to peer review records or participation in peer review. There is no fiscal impact on the state General Fund.

EXCUSED:

EXCUSED:

S1067 addresses concerns with the inspection of retail tobacco outlets by an adult enforcement officer with the assistance of a minor at locations often called "age restricted." Under, Idaho Code Title 39 Chapter 57 Section 04 it is unlawful, "...to sell or distribute or offer tobacco products for sale or distribution at retail or to possess tobacco products with the intention of selling at retail without having first obtained a tobacco permit from the department..." The permit is provided free of charge. Section 10 paragraph 3 requires "The Department shall conduct at least one (1) random, unannounced inspection per year, with the assistance of a minor, at all locations where tobacco products are sold or distributed at retail to ensure compliance with this chapter." This places the Department in the position of conducting a compliance inspection with the assistance of a minor at all permitted locations including bars and adult entertainment establishments which have "age restrictions" imposed upon them in other statutes. The Department has been assured of the legality of conducting compliance checks with the assistance of a minor in such establishments.

The safety of inspectors, both adult and minor, is a primary concern during all inspection operations. Program policy allows inspectors to not conduct an inspection if either the adult or minor is uncertain or uncomfortable with attempting an inspection at any given location. The level of concern is significantly higher at locations where alcohol is the predominated product served or consumed and at adult entertainment locations.

S1067 addresses these concerns by first adding a definition for a "minor exempt permit" in Section 02, found on page one, lines 20 through 25 in the bill. The definition calls out requirements that businesses applying for this permit have at least 55% of their total revenues result from the sale of alcoholic beverages for consumption on site or identified with adult oriented entertainment.

S1067 also amends Section 10 to indicate that the Department will conduct inspections for minor exempt businesses without the assistance of a minor at locations with a minor exempt permit and with the assistance of a minor at all other permitted locations.

Businesses receiving a minor exempt permit would be exempt from the random and unannounced inspections with the assistance of a minor routinely conducted by the Department. These businesses would be subject to a random and unannounced inspection by an adult inspection officer for all aspects of compliance with Title 39 Chapter 57 except an attempt to purchase tobacco products by a minor.

Businesses with a minor exempt permit under this amendment may be subject to an inspection with the assistance of a minor as part of the investigation of a written complaint of such a business selling tobacco products to minors.

The changes proposed in S1067 decreases the potential for the compromise of the safety of an inspecting team or minor assisting with compliance inspections while keeping all permit holders subject to random and unannounced inspections for compliance with Title 39 Chapter 57.

Inspections based upon the investigation of a written complaint and enforcement actions by law enforcement agencies are not effected by this change.

In addition, the proposed revision authorizes and specifies that the Board of Dentistry can require and accept the results of examinations conducted by approved regional and national examining organizations. The proposed legislation also specified that an applicant seeking reinstatement of a lapsed license may be required to successfully complete such examinations in the Board of Dentistry's discretion as will adequately test the applicant's competency.

The proposed legislation is directly in support of the mission of the Department of Health and Welfare, getting children enrolled in private health insurance. Child Support, and the nationwide Child Support program, has a vitally important role because we work on behalf of children who grow up in divorced, never married, or separated families. For these children, the risk of not having health care coverage is great.

Ms. Meyer discussed how these children get covered by private health insurance when parents have it available. The Department has not always done this, but in 1998, welfare reform required every child support order to include provisions for medical support. Since 1998, every child support agency in the nation has been working with thousands of employers and health plan administrators to meet this demand. It is a confusing process, leaving employers and plan administrators overwhelmed, and some children without health insurance coverage.

Immediately after the requirement was implemented, employers and plan administrators began to pressure Congress for uniform policies and strategies to make the system easier and more cost effective.

Congress responded by establishing the Medical Child Support Working Group. This group had 30 members who represented the legitimate competing concerns of employers, small businesses, the health insurance industry, and the government. The group was tasked with "improving the health of our nation's children."

The Congressional work group relied heavily on the experiences of employers and Plan Administrators as they identified the barriers and proposed solutions to enrolling children in their parent's private health insurance, and the proposed legislation represents Idaho's desire to adopt the nationally standardized tools and procedures set forth by the Congressional work group, led by employers and Plan Administrators.

Ms. Meyer talked about requiring the use of standard documents and procedures. It is important to know that these documents and procedures were designed by and for employers and Plan Administrators.

The Department's emphasis is on supporting employers and Plan Administrators because of the vitally important role they play in getting child support dollars, and medical coverage, to families who need these things.

Last year, Idaho's child support program administered more than 76,000 cases, and collected and distributed more than $100 million. Every dollar we collect, and every health insurance policy we establish for a child, rests primarily with employers and Plan Administrators.

Getting and keeping health care coverage for children -- as we are currently doing it -- is complicated and resource intensive for everyone involved. There are no consistent procedures to follow, and this is frustrating, especially for families. The goal of this legislation is very simply "Better health for Idaho's children."

This legislation will help us accomplish that goal by:

1. Eliminating barriers to enrollment and coverage in either parent's private health insurance

2. Ensuring that coverage is obtained in the easiest, most cost effective manner possible for both parents.

On a local level, The Bureau of Child Support has been working with the Department of Insurance and the local chapters of the American Payroll Association, who represent approximately 2000 employers in four states.

We will continue to work closely with them and develop the supports they say they need in order to make this easier:

1. Website -- with a simple orientation, directions, and frequently asked questions (FAQs).

2. 1-800 number

We know our ability to improve in this area means supporting them.

This legislation repeals the current code sections in child support and insurance law, and replaces them with the following:

Section 2 -- Purpose. The State of Idaho has an interest in ensuring children receive health insurance benefits through private means when available.

Section 3 -- Definitions section.

(5) Medical Child Support Order -- This definition has been broadened to include what is now called a Qualified Medical Support Order (QMSO).

--Large self-insured employers like Micron and Albertsons currently require families to go through a second, completely separate court process to establish a qualified medical support order (QMSO).

--This is an expensive, cumbersome process for families.

--This legislation establishes a single process for everyone.

(7) Obligor ­ Parent ordered to carry health insurance ("obligated parent.")

(8) Party -- This term is used when the child is not in the custody of either parent, but IS in the custody of other family members, friends, or is in the custody of the state Foster Care or Department of Juvenile Corrections.

Section 4 -- A large section with nine (9) parts:

Sets forth the standardized requirements and procedures to be used.

Paragraph 1 Establishes one process for establishing a medical support order and does away with the QMSO process.

Paragraph 2 Establishes the National Medical Support Notice (NMSO) as the document that will be used by Child Support agencies, employers and health plan administrators to gather and communicate required information.

1. The state will issue the NMSN for all new child support cases and transmit the document to the obligated parent's employer.

2. Upon receipt of the Notice, the employer is required to review and act on it within 20 business days.

--The Notice will inform the employer of the type of coverage required and the terms of the coverage.

--The Notice includes a response form that will allow employers to notify the child support agency of any reason it cannot provide coverage according to the terms of the order.

--If the employer can provide coverage, they forward the Notice to their insurance plan administrator

3. The plan administrator has 40 days to complete their part of the Notice and return it to the child support agency.

--Their part of the Notice requires information about whether coverage will be provided and when, and a description of the coverage.

4. Procedures for making a plan choice when more than one plan is available:

(1) If the obligated parent has already chosen a plan, the child is enrolled in the same plan.

(2) If the obligated parent has not chosen a plan, the plan administrator will work with the Department or the other parent to choose a plan.

(3) If the other parent is not available to make the choice, the Department will choose the least expensive benefit plan available for the child.

5. The procedures for employers for withholding child support and medical insurance premiums from the obligated parent's income.

--In some cases, the amount of the obligated parent's child support payment, combined with the cost of medical insurance, will exceed 50% of their income. In these cases, the order for medical support will not be enforced.

6. Requires the plan administrator or employer to provide everything necessary to use the insurance benefit to either the Department or the other parent.

7. Requires that insurers not hold state agencies such as Medicaid to different standards for payment of claims.

--Ensuring Medicaid is the payor of last resort.

8. Allows claims to be submitted without the obligated parent's approval.

9. Forbids insurers from considering Medicaid eligibility for children who are eligible for private insurance coverage.

--Ensuring Medicaid is the payor of last resort.

Section 5 -- Lists for employers and plan administrators the exceptions to immediate enrollment:

1. Employer does not offer insurance

2. The obligated parent does not qualify for insurance

3. The obligated parent is no longer employed

4. The obligated parent is a new employee on probation. In these cases, the child will be enrolled when insurance becomes available.

Section 6 -- Makes it clear that a child shall not be denied enrollment in medical insurance because:

1. They were born out of wedlock

2. They are not claimed as a dependent on the obligated parent's federal income tax return

3. They do not live with the obligated parent -- or in the insurer's service area

4. There is no current open enrollment season.

Section 7 -- Requires that all support orders and divorce decrees issued after July 1, 2003 include notice to obligated parents that they must proceed to enroll the child in a health insurance plan, and that failure to do so will result in the Department or the other parent working directly with the employer to enroll the child.

Section 8 ­ Gives the Department the authority to promulgate rules to support the implementation and day-to-day business governed by these new laws. Also provides the obligated parent a way to protest the NMSO (mistake of fact).

Section 9 -- Safety net providing a way to start the process over again.

--This would apply to existing cases where medical support is not being provided as ordered, and to

--Any new cases where insurance has now become available.

--The process starts by notifying the obligated parent, giving them 20 days to apply for health insurance coverage for the child.

--If they fail to follow through, this allows the Department or the other parent to work directly with the employer to establish coverage.

Section 10 -- Prohibits employers from dis-enrolling or eliminating coverage, with these exceptions:

--The obligated parent is no longer required to carry the health insurance

--The child has been enrolled in another plan

--The employer has eliminated family health coverage for all its employees

--The obligated parent is no longer employed

Section 11 -- Requires that the employer notify the Department or the other parent within 20 days when coverage is no longer available.

Section 12 -- Provides a penalty of $300 that may be imposed on employers or health plan administrators if they fail to process the NMSN as required.

Sections 13 through 15 -- Housekeeping, and clean up all cross references.

This legislation simplifies the efforts required of employers and plan administrators -- in ways designed and proposed by them. And because this will improve the health of Idaho's children by making it easier to access private health care coverage.

He explained when sections of the Idaho Code relating to the Department of Health and Welfare were separated from those provisions relating to the Idaho Department of Environmental Quality, the enforcement provisions of the Food Establishment Act were not adjusted accordingly. This bill corrects the references to reflect current enforcement statutes applicable to the Department of Health and Welfare.

EXCUSED:

1. Clarifies the authority of the director of Health and Welfare to impose isolation and quarantine.
2. Clarifies the difference between the two authorities.
3. Establishes a system for a person upon whom isolation or quarantine is imposed, to seek relief through the courts.

This legislation defines isolation as separation of infected persons from others to prevent spread of an infectious agent; quarantine is defined as restriction to or from a place or premises where an infectious agent or hazardous material exists, and provides the authority to impose isolation and quarantine is explicitly stated. Also, the wording allows judicial review of any order of isolation or quarantine.

Diseases which may require isolation include measles, tuberculosis, pneumonic plague, and smallpox. Some other conditions which may require isolation include persons exposed to infectious agents such as anthrax-laden powders, or persons exposed to smallpox.

During the past six (6) years, the health department has not issued an order of quarantine, which would limit the movement of persons into or out of a given locations, such as a building. This authority would be used only if a health risk were determined to occur at a site and it was necessary to do so, such as occurred in Washington DC, last year at the Hart Senate Building during the anthrax attacks.

A number of questions pertaining to "authority" and statute was discussed.

These changes will create consistency between Idaho Code 16-2403, 66-317, and 66-329 and enable the Department of Health and Welfare to create rules to govern the appointment of examiners for adults as well as for children.

This legislation and the definition of a "designated examiner" was difficult to understand as written.

Roll Call Vote on motion to Do Pass:

Senator Ingram voted Yes Senator Burkett voted No

Senator Sweet voted No Senator Stegner voted Yes

Senator Darrington voted Yes Senator Compton voted No

Senator Brandt voted Yes Senator Kennedy voted No

Senator Bailey voted No

The motion totaled 5 No and 4 Yes. Motion failed.

Senator Kennedy read Idaho Code 39-416 - Rules adopted by district board - Procedure.

(1) The district board by the affirmative vote of a majority of its members may adopt, amend or rescind rules and standards as it deems necessary to carry out the purposes and provisions of this act.

(2) Every rule or standard adopted, amended, or rescinded by the district board shall be done in a manner conforming to the provisions of Chapter 52, Title 67, Idaho Code.

(3) At the same time that proposed rules and standards are transmitted to the director of legislative services, they shall be submitted for review and comment to the state board of health and welfare, and to the board of county commissioners of each county within the public health district's jurisdiction. The state board of health and welfare shall, within seventy-five (75) days of receipt of a district board's proposed rules, disapprove of the adoption of the rules if, on the advice of the attorney general, such rules would be in conflict with state laws or rules. The state board of health and welfare shall immediately advise the district board as to the reason for the disapproval.

EXCUSED:

CORRECTIONS

The Idaho Juvenile Justice Commission is an advisory group appointed by the Governor to provide citizen input into the state's juvenile justice policy decisions. The Commission consists of 21 members including a host of multidisciplinary professionals and youth from across the state. The Commission is given the responsibility of distributing up to 250 different grants totaling $2.5 million each fiscal year to local communities throughout Idaho. Outcome-based grant distribution encompasses the entire continuum of care-from prevention to aftercare.

Mr. Reinke presented information pertinent to the Idaho juvenile offender system, such as:

1. Probation, education, detention, etc.;
2. Functional Family Therapy Program (FFT);
3. Performance-based standards;
4. Length of custody (LOC);
5. Custody Review Board;
6. FY2003 original appropriations and FY2002 average cost-per day for education, administration, food services, medical services, maintenance, laundry and clothing, and janitorial services. In FY2002, the total average cost-per day was $169.81;
7. Composition of Custody population, 88 percent male and 12 percent females. And 22 percent of Juveniles have serious emotional disturbance (SED) difficulties
8. A general flow chart of Idaho's juvenile justice process;
9. 6,500 youth are on county probation and for every 10 juveniles committed to IDJC five (5) will commit no further acts of crime and two (2) will be adjudicated of a new misdemeanor or felony (reintegrating into the local juvenile justice system), two (2) will descend to the Idaho Department of Corrections (IDOC), and one (1) will be recommitted to the Idaho Department of Juvenile Corrections.

One of the measures of the Department's success is reducing the juveniles' length of custody in the Department, FY2002 8,000 juveniles in custody, and currently in FY2003 the number is 6,500. The Department recently reported that 55 percent of the juveniles committed to the Department's custody, substance abuse is noted as a primary, secondary or tertiary behavioral problem. Recognizing this as a serious issue, the Department has taken steps to increase the amount of treatment services that are offered to these juveniles in both state and contract facilities.

Another measure of success is the regionalization of services effort. This undertaking is of significant importance to the communities and families of the juveniles in the Department's custody, As more services are regionalized, it increases the opportunity to successfully transition the juvenile back into the community.

Dr. Ryan Hulbert discussed the Idaho Council on Children's Mental Health's (ICCMH) community report card published December 2002. This report card provides an overview of children's mental health services provided through the Department of Health and Welfare, Department of Juvenile Corrections, and the State Department of Education. The services provided are targeted toward children with a serious emotional disturbance and their families. The ultimate goal of the services is to provide the child and family with the services and supports necessary to maximize the family's ability to provide care for their child at home.

The Department of Health and Welfare (DHW) provides services to children with serious emotional disturbance and their families through voluntary agreements with the parents. Children must meet be diagnosed with an emotional disorder and a substantial impairment of functioning in major life activities. In FY 2002 (July 1, 2001 - June 30, 2002) the following children's mental health services were provided to children and families by DHW:

1. 4,273 families contacted Children and Family Services;
2. 1,802 children received comprehensive mental health assessments;
3. 2,282 children and families were provided case management;
4. 42 children were placed in therapeutic foster homes at a cost of $216,510;
5. 1,059 children accessed Department-funded day treatment;
6. 149 families accessed family support services at a total cost of $22,791;
7. 888 Children were placed in hospitals for psychiatric care at a total cost of $6,716,839;
8. 9,085 children accessed outpatient care at a cost of $18,651,865;
9. 120 children accessed residential care through the children's mental health program;
10. 53 children accessed respite care at a cost of $21,825;
11. CAFAS (Child and Adolescent Functional Assessment Scale) - The CAFAS is a standardized nationally recognized instrument that measures a child's functioning in a variety of life domains. The range of scores is 0-240. Children at entry into Department services had an average score on the CAFAS of 107. Children at discharge from Department services had an average score of 62.
12. Family satisfaction surveys - Families receiving children's mental health services from the Department are provided an opportunity every 120 days to anonymously report their impressions of the services provided. Results of the surveys indicate that 93.1 percent rate accesses to services positively, 97.3 percent rate appropriateness of services positively, 97.2 percent rate effectiveness positively, and 93.8 percent rate parental involvement positively.

The Department of Juvenile Corrections (IDJC) serves youth committed to it under the Juvenile Corrections Act, for the care, control and competency development of adjudicated juvenile offenders. The IDJC has a legal mandate to provide reasonable medical care, including mental health care, to all juveniles in its custody who have those needs. The Department is further identifying juveniles in custody who meet the Department of Health and Welfare's definition of having a serious emotional disturbance. Juveniles with serious emotional disturbances constitute only a portion of those in custody who needs mental health care, but they are the most seriously ill and most likely to need community-based services upon their return home.

The IDJC is now tracking the following indicators to better identify the juveniles in the state's custody who are defined as seriously emotionally disturbed (SED).

1. 114 youths identified as SED, August 2002;
2. Average CAFAS score upon initial assessment was 129;
3. 29 youth received a comprehensive assessment by DHW either prior or at the time of commitment to IDJC;
4. 10 youth were staffed by a local council in an effort to provide a comprehensive community-based plan;
5. 20 youth were determined eligible for public mental health services after discharge from IDJC custody;
6. State Department of Education, through local school districts, ensures that eligible students, age 3-21, are provided with appropriate and individualized education under the Individuals with Disabilities Education Act (IDEA). Students must meet the eligibility requirements for emotional disturbance under IDEA;
7. 935 students identified as ED, 3.21 percent of the total special education population, an increase from 2.59 percent in 1999-2000.

The IDJC, in coordination with the Police Officer Standards and Training Academy under guidance from the Juvenile Training Council, has established two (2) academic courses leading to certification, according to a legislative mandate, all county probation officers and detention officers must be certified by October 1, 2004. Currently, detention officer and probation officer courses have successfully graduated a total of approximately 150 students from a diverse cross section of all Idaho counties.

The IDJC has three (3) regions, Region 1 Districts 1 and 2 in Lewiston; Region 2 Districts 3, 4, and 5 in Nampa, and Region 3 Districts 6 and 7 located at St. Anthony, Idaho. Regionalization provides benefits to Idaho citizens by keeping juveniles closer to their home communities and families, increasing the juvenile's accountability to the victim, and increasing the opportunity to successfully transition the juvenile back to the family and community.

Ms. Allyn reported currently the Medicaid program provides only emergency services to the adult population. The program also provides some limited coverage of other services dignity of the client. Both the House and Senate Health and Welfare Committees have expressed concern that the current program does not address the needs of the most vulnerable clients within the Medicaid population. At the request of the Senate and House Health and Welfare Committees, The Department of Health and Welfare examined some options that were proposed during the hearings on these rules.

The three (3) options for consideration are:

Option 1 - The Idaho State Dental Association, in a letter from Dr. Scott Kido, provided several suggestions to redesign the adult dental program. The proposal would result in reducing service options to include preventive and limited restorative services focused primarily on the most vulnerable clients. The proposal also includes an increase in dental fees to improve access to services. Implementation of the proposal will require restoration of the balance of the $7.1 million in SFY2003 and $8.4 million reduction in SFY2004.

Option 2 - This option would be budget neutral and provide the basic preventive and restorative services to the most vulnerable developmentally and physically disabled in the Medicaid program as well as continuing emergency services to all adults. Those emergency services would include care to adults with tooth and gum conditions at high risk for periodontal infection likely to lead to bacteremia or other serious health concerns, as requested by the House Health and Welfare Committee, provided these services are limited to the most serious conditions. Budget neutrality would be accomplished by a reduction in nonessential services in the children's dental program in the area of orthodonture. In consultation with the dental community, the requirements for orthodonture will be restructured which will allow approximately $600,000 to be shifted to coverage of the most vulnerable adults to provide the limited preventive and to coverage of the most vulnerable adults to provide the limited preventive and restorative program. This would allow preventive and restorative coverage to approximately 3,500 individuals.

Option 3 - The third option is to maintain the current adult emergency dental service program.

Dr. Kido explained the ISDA believes an adult Medicaid dental care benefit program should be restored, and the ISDA does not support reinstating the program as it was before it was eliminated. That program, while well intended and through no fault of the Department of Health and Welfare, was flawed, wasteful, caused significant economic and ethical challenges to the providing dentists, and did little to encourage personal responsibility for the recipient's own oral health.

At a subcommittee meeting last week, he reported he observed several very separate issues.

a) Provide preventive dental care to the physically and mentally handicapped. This issue is ISDA's highest priority. There are many handicapped citizens that simply are not capable of taking care of themselves. Unchecked and untreated dental disease can become a life threatening problem in these individuals. Treating these patients after their dental problems become so severe is practically inhumane. It also proves to be extremely expensive to the state. Expensive root canals, crowns, bridges, etc., should not be part of a preventive dental plan.

b) Allow individuals with high risk health problems, i.e., artificial heart valves, diabetes, medicated for seizure disorders, cancer patients that have received radiation treatment to the jaws, organ transplant recipients, etc. While this group suffers from serious medical problems, they probably are not in the same situation as the mentally and physically handicapped. Most of these individuals are capable of independent living and can assume sone responsibility for their own oral health. The fact that these people cannot afford their dental care seems to be the issue. People with these conditions need a consistent level of dental care to protect them from serious complications.

c) Reducing the use of hospital emergency rooms to treat dental problems. Often someone covered by Medicaid will seek hospital emergency room care for help with a dental problem. Typically it is a dental problem that has been neglected for a long time and now has developed into an emergency situation. The difficulty Medicaid patients have accessing not only private dental offices, but also community health center dental clinics are very well documented. Usually the emergency room does not actually fix the problem, but will treat the symptoms with pain medicine and antibiotics.

Unfortunately, helping the issues (a) and (b) will not affect issue (c). The mentally and physically handicapped and the seriously ill are not the ones predominately using the hospital emergency rooms to treat dental problems. . . not yet anyway. Unless a preventive dental program isn't made available to them soon, I'm afraid we will see a rise in their usage of hospital emergency rooms too.

To address the problem, we need to study the old Medicaid dental program. Instead of devoting resources to adequately fund programs focused on preventing dental disease before it starts, (dental disease is almost entirely preventable) the state had been attempting to pay to fix every cavity in every tooth in every Medicaid recipient in Idaho, with few limits to what that care was. All dental insurance companies in Idaho have a maximum annual benefit cap, except Medicaid. How could the state possible afford to pay for such a high level of dental care, for the segment of our population that has 80 percent of all the state's dental disease? Of course, it couldn't, and the results are what we are dealing with today.

What Idaho needs is a complete overhaul of the Medicaid system. Develop a system that promotes prevention and instills an attitude of personal responsibility for one's oral health, Utilize all of the highly trained dental professionals in the state. Limit the care provided to preventive and limited restorative procedures, and pay a higher fee for the limited procedures. If a patient wants a higher level of care than what the state can afford, let them pay for it themselves. Most dentists would be willing to offer significant discounts to these people (especially if they are fairly compensated for the other covered procedures), yet the patients would still have a personal investment in their own oral health. ISDA stands ready to advise and help implement such a program.

Until this happens, the cycle will continue where the poor have bad teeth and poor oral hygiene, where dentists are fed up with Medicaid and drop out. We think you can work with the Division of Medicaid to implement covering these people. Whether it takes modifying the legislative intent of the rule cutting adult Medicaid coverage, or expanding the term emergency dental services only.

Dr. Kido explained he wants to offer help at a common sense, practical approach to Medicaid dental coverage. We have lost the focus on fixing the immediate issue...which is, what to do now? Kathleen Allyn has worked very hard at coming up with a politically, realistic approach that will get us by until we have time to really fine tune reform.

Dental care for the disadvantaged is such an important issue to me, my passion sometimes leads me into conflicts with people I regard with deep respect. I understand the realities of this budget year that makes implementing a plan such as what I outlined quite difficult, if not impossible, in the short term. I cannot walk away from what I think is the right thing to do, and I cannot turn my back on a population that desperately needs dental care . . . but I believe it would be best in the long term if ISDA and the Medicaid department work together for a common goal.

If we simply restore the old program, it will be very difficult to cut it back later. It would be much better to add preventive and limited restorative to an emergency only program. So if we can't implement option 1 now, I would support finishing out the year with option 2 and then working out option 1 later. But option 1 won't happen later without clear directives from the legislators.

Option 2 has some weaknesses, but they can be worked out as long as we know the intent of the legislators. I'm assuming option 2 would include the preventive/limited restorative codes ISDA suggested in option 1, only that the coverage would be limited to the most helpless and needy.

Again, I offer my experience and knowledge of dental matters in anyway that will be of help to you and the State.

EXCUSED:

PRESENTATION

All of these CRPs were originally incorporated to provide employment services, including competitive placement in jobs in private industry, as well as work services (work in center-based sheltered environments). Over time, most members have added other services, which may include developmental therapies, residential care, case management or other programs. However, our primary focus remains work and employment. Our belief is that all people, regardless of disability, should be afforded the opportunity to work and become a contributing member of society. We view this as both a right and a responsibility.

In about 1996, the Department of Health and Welfare made major changes in the disability service system. Vocational contracts were eliminated and an hourly fee for service was instituted. The provider network was expanded from 13 providers to more than 30 providers, and the system was expanded to include for profit providers. The ideas behind these changes were to expand consumer choice of services and providers and to create competition, which would drive rates down. Choice was indeed expanded, but rates did not go down. Additionally, with few exceptions the "not for profit" providers stopped providing services above the amount the state had available to pay. Consequently, between the implementation of these changes and this fiscal year, before the holdbacks, the waiting list for vocational services grew to 190 individuals. The holdback has led to this list now exceeding 600 individuals. The list contains names of people who currently receive no vocational services as well as those who wish to have services increased or reinstated to the level they were before the holdback.

All individuals, even those who contact us directly, must be referred to the Idaho Division of Vocational Rehabilitation (IDVR). IDVR completes or orders a vocational assessment or evaluation, and based on that information as well as interviews with the consumer and those of importance in that consumer's life, determines the type and amount of service appropriate for the individual. When vocational rehabilitation maintains a case, services are funded through a combination of 80 percent federal and 20 percent state dollars. Although many states use Medicaid dollars to fund vocational services, Idaho does not. In Idaho the funding is 67 percent general fund and the remainder is Social Services Block Grant (SSBG) money and TANF (Temporary Assistance for Needy Families) dollars the state moved to the SSBG.

IACRP members work with businesses and industries throughout Idaho, and those businesses either employ people we train, or they contract with us for work. The work is provided by the individuals with disabilities we serve who all earn real wages. The wages our consumers earn offset the cost of state provided services and SSI (Social Security Insurance) payments.

Despite what we consider being the best possible return on tax payer dollars, when the Governor ordered a 3.5 percent reduction in general funds, the Department of Health and Welfare cut the general funds appropriated for vocational services by 27.5 percent. The huge cuts are also destabilizing the vocational system. Statewide there are staff layoffs.

We ask you to support us in our efforts to reduce the amount of our FY2003 budget cut and support intent on the FY2004 budget.

A fact sheet about the appropriations impacts on the Idaho Association of Community Rehabilitation Programs was reviewed. (Attachment #1)

The Department of Health and Welfare Deputy Director Joyce McRoberts testified and disagreed with the 27.5 percent budget cut to the vocational rehabilitation programs. She explained the Department reviewed the budget as a whole, and made the least budget cuts where it would affect services to clients.

The Committee agreed to request the Division of Family and Community Services Administrator Kenneth Deibert to meet with them and explain the process used in determining program cuts, and the fairness of those programs' reductions.

She discussed the testimony of February 14, 2003, presented by Scott Kido, president of the Idaho Dental Association. Dr. Kido's plan for co-pay and limitations (caps) are issues to consider later, but are not feasible at this time and not included in the current Medicaid appropriations.

A lengthy discussion about the 2002 JFAC legislative intent language was held.

[Option #2 - This option would be budget neutral and provide the basic preventive and restorative services to the most vulnerable developmentally and physically disabled in the Medicaid program as well as continuing emergency services to all adults. Those emergency services would include care to adults with tooth and gum conditions at high risk for periodontal infection likely to lead to bacteremia or other serious health concerns, as requested by the House Health and Welfare Committee, provided these services are limited to the most serious conditions. Budget neutrality would be accomplished by a reduction in nonessential services in the children's dental program in the area of orthodonture. In consultation with the dental community, the requirements for orthodonture will be restructured which will allow approximately $600,000 to be shifted to coverage of the most vulnerable adults to provide the limited preventive and restorative program. This would allow preventive and restorative coverage to approximately 3,500 individuals.]

EXCUSED:

Appointment

27.0101.0201

He explained a memorandum from Kent E. Nelson, deputy attorney general for the Contracts and Administrative Law Division, that the House Health and Welfare Committee raised issues regarding the registration fee under Docket No. 27.0101.0201. In light of the House committee's concerns, the Board of Pharmacy wishes to revise the rule to reduce the proposed registration fee to $100 and to clarify that the product may be registered either by the manufacturer or by a wholesaler or other entity in the sales chain. This change will allow wholesalers or other entities to have a product registered in Idaho even if the manufacturer is not particularly interested in doing so.

The mechanism for accomplishing this revision would be for the Legislature to reject Docket 27.0101.0201 with the understanding that the Board will enact the new rule as a temporary and proposed rule. The changes in the new rule are in Subsection xi. No further action is required by the Senate Health and Welfare Committee.

58.0101.0201

The Department of Environmental Quality Director C. Stephen Allred explained this pending rule, IDAPA 58.0101.0201, is needed to update the state implementation plan that the Environmental Protection Agency (EPA) must approve for Idaho to have a delegated program under the federal Clean Air Act. Without that update, the federally enforceable rules are inconsistent with Idaho current law, and could be enforced through the federal courts by third parties.

EXCUSED:

A proposed amendment to SB1067 is Section 2, page 2 of the printed bill, line 23, following "minor" insert: If it is otherwise lawful for the minor to be on the premises of the permittee." was reviewed.

The proposed changes consist of the addition of a "minor exempt" tobacco retail permit, and language to allow the conduct of tobacco permit inspections without the assistance of a minor for all businesses holding a "minor exempt" tobacco retail sales permit. Businesses self-identify for the "minor exempt" tobacco retail sales permit by certifying that at least 55 percent of their revenues come from the sale of alcohol for consumption on site, or adult oriented entertainment. Businesses provided a "minor exempt" tobacco retail sales permit are routinely inspected by an adult inspector for all random and unannounced inspections during the year, and are subject to the same level of investigation as all other permit holders for written complaints.

Any minor entering a tobacco specialty store is not subject to being cited for a violation of Idaho law, in the same way as when entering a bar. Idaho Code makes it clear that a minor entering a bar is subject to a misdemeanor. Idaho law does not make it a misdemeanor for a minor to enter a tobacco specialty shop. More correctly, it is a violation of Idaho Code 39-5706(4) as it relates to self-service displays for businesses to allow minors into the store.

Idaho Code 39-5706 requires vendor assisted sales, and makes sales from self-service displays illegal. Stores gain an "exemption" allowing the use of self-service displays if their total merchandise is comprised of at least 75 percent tobacco products, and minors are not allowed in the store. The store must post notice that minors are not allowed in the store on all entrance doors. Owners of businesses, with at least 75 percent of their merchandise in tobacco products, have an option to not allow minors into their businesses in exchange for having self-service displays in their stores. "Exempt" business owners that allow minors to enter or remain an "exempt" tobacco store violated Idaho Code 39-5706(4). The compliance inspection expectation is that the minor would be refused entrance at such locations.

Idaho Code, Section 5706 Vendor Assisted Sales (1):

1. It shall be unlawful to sell or distribute tobacco products by any means other than vendor assisted sales, where the customer has no access to the product except through the assistance of the seller.
2. On and after January 1, 2000, it shall be unlawful to sell or distribute tobacco products from a vending machine. From January 1, 1999, to December 31, 1999, vending machines shall be located in a place not accessible to persons under the age of nineteen (19) years.
3. It shall be unlawful to sell or distribute tobacco products from self-service displays.
4. Stores with tobacco products comprising at least 75 percent of total merchandise are exempt from requiring vendor assisted sales, if minors are not allowed in the store and such prohibition is posted clearly on all entrance doors.

1. Minors assisting with inspections do not violate Title 39 Chapter 57. This protection is found in Idaho Code 39-5703(2) and is applicable only when conducting compliance inspections.

Idaho Code, Section 5703 Possession, Distribution or Use by a Minor:

(1) It shall be unlawful for a minor to possess, receive, purchase, sell, distribute, use, or consume tobacco products or to attempt any of the foregoing.

(2) It shall be unlawful for a minor to provide false identification, or make any false statement regarding their age in an attempt to obtain tobacco products.

1. A minor who is assisting with a random unannounced inspection in accordance with this chapter, shall not be in violation of this chapter.



2. A minor may possess, but not sell or distribute tobacco products in the course of employment, for duties such as stocking shelves or carrying purchases to customers' vehicles.



3. Penalties for violations by a minor. A violation of this chapter by a minor shall constitute a misdemeanor and shall be punishable by imprisonment in any appropriate facility not exceeding six (6) months, a fine not exceeding $300, or both such fine and imprisonment. The court may, in addition to the penalties provided herein, require the minor and the minor's parents or legal guardian to attend tobacco awareness programs or to perform community service in programs related to tobacco awareness.

Marguerite McLaughlin was appointed to the Board of Environmental Quality July 1, 2002, by Governor Dirk Kempthorn. The Governor has reappointed her for a term commencing July 1, 2002 and expiring July 1, 2006. She served nine (9) terms as an Idaho State Senator for District 7. She also served two (2) terms as an Idaho State Representative for District 7.

Other civic experiences include serving as the Democratic caucus chair, assistant Democratic Leader and Democratic Leader; co-chair for the Joint Legislative Oversight Committee, served on the Finance, Transportation, Commerce and Human Resources, Resources and Environment, Local Government and Taxation, Education, and State Affairs committees. She has served on many interim committees, councils, and task forces including the Western States Legislative Forestry Task Force, Legislative Council, Legislative Council on River Governance, Change in Employee Compensation, Electric Utility Restructure, Health Insurance Premium Task Force, Idaho Housing Board, Endowment Fund and Restructure Task Force, and Health Insurance Premium Task Force. She was appointed by Governor Phil Batt to serve on the Workforce Training Council, Medicaid Reform Task Force, and the State Insurance Fund Commission.

She was recently appointed by Governor Kempthorne to serve on the reorganization of the Department of Lands. She also serves on the Clearwater Valley Hospital Board; Board of Trustees; Joint School District 171; past president of the Orofino Celebrations; Orofino Chamber of Commerce; past president, VFW Auxiliary to Post 3296; president, North Idaho Deanery; Council of Catholic Women, and PEO Sisterhood, an educational and charitable organization. Her political affiliation is Democrat.

Donald J. Chisholm was appointed to the Board of Environmental Quality July 1, 2000, by Governor Dirk Kempthorn. The Governor has reappointed him for a four (4) year term commencing July 1, 2002 and expiring July 1, 2006.

He is an attorney, in private practice since 1967, a general practitioner in solo law practice. Practice includes representation of small businesses, real estate, estate planning and probate, municipal law, civil litigation (including domestic relations) and occasional representations of criminal defendants. His bar admissions include the Idaho Supreme Court and United States District Court, United States Court of Appeals (9^th Circuit), United States Supreme Court, and the United States Tax Court.

Other professional activities include former president, Fifth District Bar Association; a former member of the Appellate Rules Committee of the Idaho Supreme Court; a former member of the Idaho State Bar Disciplinary Committee; former panelist, Idaho State Bar Association Bar Exam Preparation Committee, and former member of American Arbitration Association Panel of arbitrators for the Northwest Region.

Other community and public service include: member and former president of the Rupert Rotary Club; former director and past president of Rupert Country Club; former director and past president of Magic Valley Regional Rehabilitation Services; former legal counsel to Magic Valley Rehabilitation Services; former board member and past president of the school board of St. Nicholas School; board member and president of St. Nicholas School Endowment Foundation; helped establish public mental health services in Minidoka County; published articles advocating consolidation of county and municipal entities and utilities in Mini-Cassia area; co-plaintiff and plaintiff's counsel in successful litigation to sever unlawful financial relationship between Cassia County and Intermountain Health Care; appointed to the Idaho Board of Health and Welfare by Governor Dirk Kempthorne, July 1999, for a term ending January 2001; and appointed to the Idaho Board of Environmental Quality by Governor Kempthorne in June 2000 and served as Chairman of the DEQ board, July 2000 to July 2002. His political affiliation is Republican.

1. Communications and process for DEQ rules;
2. Common Sense Committee;
3. Intervene between Idaho and Environmental Protection Agency;
4. Compliance and enforcement, reasonable approach;
5. Lack of representation from North Idaho.

Greg Nelson, a representative for the Idaho Farm Bureau Federation, testified he does not disagree with the negotiation rule making process, it is a good process. He discussed several issues he has with the Department of Environmental Quality (DEQ). One such issues is pertained to a 8-9,000 head dairy. When a siting committee has a DEQ representative with them, and the siting committee signs-off, then the DEQ staff goes before the county commission and spends-off a bunch of considerations they say the siting committee did not take care of, and then the dairy does not get approved, and a whole bunch of new science get woven into the issue. In this case the issue was ammonia, yet DEQ had sign-off on the Garnet Energy Plant being built, that the ammonia they would create would be no problem to the air, yet the dairy was going to cause considerable ammonia emissions.

Senator Ingram asked about vehicle emission testing in Kuna. Mr. Gannon believes vehicle emission testing for air quality should remain a volunteer program. He also expressed his concerns with tort reforms ; pressurized water system requirements, Indian Creek, pollution of air quality requirements, and problems with implementation and working with some DEQ rules. He wants DEQ to use a "common sense" approach to individual case.

Dick Rush, Vice President of the Idaho Association of Commerce and Industry (IACA), testified he believes this type of general discussion, at a legislative level, is very important. IACA represents most of the manufacturing industry in Idaho. He believes Idaho does need an effective inspection agency. IACA did not oppose the DEQ regulations proposed this year, and believes very strongly in the negotiated rule process. Some concerns of IACA include non municipal solid waste and the areas not strongly regulated; streamlining the permit process; air quality regulations; water quality regulations, and primacy rules. He stated IACA did not oppose any of the DEQ rules this year. He explained House Bill 150, called the Good Science bill, is important to good science peer review data.

EXCUSED:

I would like to present briefly the Department's perspective on this subject. I want you to know that none of the recommendations for budget hold backs made, in FY 02 or FY03, have been easy decisions on the part of the Department. These have been very difficult decisions because we recognize that each one of the reductions had impacts on individual lives, whether they were employees of the State or consumers of our services. We did not make cuts to programs because we do not value the service, or lack compassion for the people served. We reached our decisions after careful consideration of many factors.

Let me state briefly, some of the priorities upon which the Department based its decision-making. First and foremost, we wanted to avoid reductions in programs that the Department has statutory responsibility to provide. We focused our reductions in staffing and services to areas where impact on community, staff, and client safety would be avoided. Our reduction plan took into careful consideration the need to achieve required levels for general fund maintenance of effort for our mental health, substance abuse, and infant and toddler programs to avoid reduction in federal dollars. We are seriously close in all of these programs to having state general funding levels that are below the target maintenance of effort levels required by the Federal Government for continuation of funding through Block Grant appropriations.

Lastly, if our budget reduction strategies would impact consumers, we wanted to make sure there were service options available either through the Department, or other community or private sector service delivery systems. I believe that our hold back strategy, as it relates to the reductions in sheltered workshops funding, meets the priorities that were established in our budgeting process.

I would like to discuss with you a handout that you have before you that lists the general fund reductions the Division of Family and Community Services has had to make during FY02 and FY03. I believe it is extremely important that as we consider any of the budget reductions for any programs that they are made in the context of the overall reductions the Division has had to incur over the last two fiscal years.

As you can see from a review of the data for FY2002 and 2003, the funding reductions for workshops are certainly not disproportionate to other programs within the Division, as has been suggested by the Association. Certainly, a state general fund reduction of 41 percent in child protection and children's mental health, in my view, is substantially greater than the reductions for the workshops.

One last point about our budget reduction strategy that I would like to point out to you is our effort to leverage, as much as possible, Federal dollars. Of the $11million dollars that the Division has lost in funding, just more than $800,000 was lost in Federal dollars. We have made every effort in our strategies to maximize the level of federal funding, to offset the total impact of budget reductions on the consumers that we serve within the Division. I believe we have been quite successful in achieving that outcome.

In the materials presented to you by the Association, it was suggested that $657,264 should be returned to the sheltered workshops appropriation, and that the Division should take an equal amount of reductions in general fund support for other services that are the responsibility of the Division. Before considering that option, I feel it is my responsibility to inform you of some of the potential consequences of that action.

It is extremely important for you to understand that at this point, most of the remaining state general funds that we have appropriated to this Division are heavily leveraged against federal dollars. Depending upon the program, our match rate ranges from a high of 80 percent to a low of 50 percent. If we were required to make these reductions, The Department would be forced to look at elimination of between 29 and 47 positions in our children's mental health, adult mental health, or child protective services, in order to generate $657,264 in general fund savings. These positions fill critical roles providing services to the chronically mentally ill, who lack resources to purchase services from private providers, or through Medicaid-funded programs. If we look at just mental health services, each clinician carries a caseload of approximately 40 individuals on an ongoing basis. If we were to lose that number of positions, between 1,200 and 1,900 individuals would be left without a therapist to provide them with the necessary treatment and care to address their serious mental conditions. It would potentially place us in further jeopardy in our efforts to comply with the federal Jeff D. lawsuit and it would most likely place an additional burden on our local communities and counties to provide care to these individuals.

If we were required to make this level of reduction, we would not be able to hold harmless the staffing levels in our child protective program, as we have been able to achieve throughout past reductions. Any reduction in this program which continues to see dramatic increases in the number of reports of abuse, neglect and mistreatment and a 53 percent increase in substantiated cases of abuse, neglect, and mistreatment, between FY2002 and 2003 would have, in my view, unacceptable consequences for the safety and well being of our children.

I fully recognize that the reductions the workshops are being asked to make have impacted the consumers they serve, and have reduced the funds that are available for them to conduct their business operations. I believe when you look at the overall perspective of the impact of the alternatives that we faced when developing our plan, you can see there were no good options, but only options that provided varying degrees of disadvantage.

Committee members also asked questions about, but not limited to, the following issues:

1. What programs were not required to have a budget reduction?
2. Base appropriations;
3. Federal requirements and program mandates;
4. Substance abuse program reduction;
5. Total amounts of funds available to workshops, other funding resources, what other options available for workshops;
6. Evaluations, referrals, and backlog for clients to get into a workshop;
7. Limited employment for workshop clients;
8. Plans for an additional hold back in FY2004;
9. Services provided, transportation and rate of payment, duplication in service areas;
10. FTE (full-time employees) FTP (full-time positions), and number of staff reductions in each program, how many staff reductions were administrative management staff, and how many management positions were eliminated the past year;
11. Available funding through federal grants;
12. Reduction of mental health therapists;
13. Consolidate administrative manager positions such as combine mental health and developmental disabilities program mangers;
14. Fairness in reductions in workshops and programs;

1. Idaho Code 39-4601requirements, and
2. Cost savings.

Jeff Crumrine, from the Magic Valley Rehabilitation Service, and M.C. Niland, a representative of the Workshop Association, testified and requested the Department of Health and Welfare restore the $657,000 budget cut to the shelter workshops.

EXCUSED:

Health care organizations maintain a formal peer review process in order to reduce the occurrence of illness and death and to enforce and improve standards of medical practice. This process enables research, discipline, and medical study. Records used in peer review are confidential and privileged and are not subject to subpoena or discovery proceedings, as set forth in Idaho Code 39-1392.

This legislation serves to clearly define key terminology, to include: "peer review," "peer review records," and "patient care records." It also delineates the circumstances upon which records lawfully may be released by the health care organization that owns them. It clarifies immunity from civil liability. Further, a new section fully delineates the health care organizations' reporting obligations to the state board of medicine and details the sanctions and content of mandatory reports. In addition, the measure clarifies that no physician or surgeon shall be required to report information known, learned or discovered as a result of access to peer review records or participate in peer review.

This legislation will have no fiscal impact of the state general fund.

An amendment to SB1102 was discussed pertaining to Section 6 "On page 6 of the printed bill, in line 10, delete "may" and insert: "shall"; and delete lines 21 and 22 and insert: "or authorized by it."

A detailed review was made to SB1102 and some specific areas discussed, but not limited to, are:

1. Definition of a "peer review" (Page 2, line 20 of SB1102);
2. Internal reviews controlled by the hospital, and external reviews by independent parties;
3. Quality assurance of peer review;
4. Records confidential and privileged, protection of records;
5. What triggers a peer review;
6. Discoverable data in records;
7. Reportable issues about quality of patient care;
8. What actions required to be reported to the Board of Medicine;
9. Voluntary or involuntary revocation - who would make that determination;
10. Patient quality care and safety;
11. If the Board of Medicine takes an action, when is that information made public? If no action is taken then no public notice is made.

The Board of Medicine Executive Director Nancy Kerr testified to support of SB1102. The Idaho Medical Association CEO Robert Seehusen testified to support of SB1102.

EXCUSED:

Ms. Cassel explained she will leave a video titled Vaccines: What CDC Documents And Science Reveals by Sherri J. Tenpenny, D.O., and a packet of information about Vaccination Liberation, will be left in the Committee's office for review by committee members during this legislative session. Some items for review, but not limited to the following:

1. Vaccination Liberation - Idaho Chapter - The right to know, the freedom to abstain;
2. A list of books, videos and audiotapes available through Vaccination Liberation; Vaccination Liberation's lending library;
3. Basic facts to know about vaccinations;
4. Facts about Hepatitis B - the disease and the vaccine;
5. Measles, mumps and rubella - the disease and vaccine;
6. Facts about influenza;
7. Want a smallpox shot? It could KILL you;
8. Smallpox pandemic planned-are you ready;
9. Vaccination exemption pursuant to Idaho Code 39-4804;
10. Vaccination workshop, February 23, 2002;
11. Vaccination - dispelling the myths;
12. Vaccines - new plague for a new era;
13. Antibody theory;
14. How do the vaccines work;
15. Shaken baby syndrome - the vaccination link, and shaken baby impact syndrome, flawed concepts and misdiagnoses based on a review of 28 cases;
16. Disease - scary-go-round;
17. Why the compulsory vaccination laws must be repealed;
18. Neurosurgical focus by Joseph H. Piatt, Jr., M.D.
19. Hydrocephalus in infants and children;
20. Recombivax HB - Hepatitis B vaccine;
21. Retrospective review - case of Damian Kershner, following jury trial of Michael Shutz;
22. Pertussis - North Idaho outbreak 1997, an epidemiological report and case study;
23. What is coming through that needle - the problem of pathogenic vaccine contamination, and
24. Testimony by Jerri Johnson, Health and Human Services Policy Committee.

Angie Vasques, director of the South Idaho Chapter of Vaccination Information and Liberation, Burley, Idaho, testified that Idaho's vaccination law needs to be revised. As with any law, there should be penalties for breaking the law. If I leave this hearing today and get caught speeding or running a red light, I am fined and I pay the ticket. There is no physical evidence that I was caught speeding other than the officer witnesses me do the crime. There is no other evidence except for his word against mine, but I still have to pay the price for the crime I did of breaking the law.

We have testimonies of healthcare workers and other breaking the law by not following Idaho Code 39-4804. When they do not tell parents that vaccines are voluntary in this state, and even more, not telling parents what adverse reactions can occur after their child receives a vaccine before vaccinating them, then they should pay a fine.

In summary, Ms. Vasquez, testified I was once a parent who believed in vaccines completely. I was never told of the dangers of vaccines. From the beginning of my school years, I read in books, was told by doctors, even watched in cartoons how important getting shots were to be healthy and protect us from dangerous diseases. Never once was I told there might be a possible negative side effect. As I grew up and had my own children, I never thought twice whether or not to vaccinate my children. There was never a discussion about the issue. Whenever I got the reminder in the mail, "It's time for your child's shots" I immediately scheduled an appointment to have them vaccinated, believing it was important to keep them healthy.

Today, my daughter is just a statistic for having a vaccine reaction. She is dead because I was never told there was even a possibility of an adverse reaction to her shots. Doctors only tole me of the "benefits" but never the dangers.

When registering your child for school, you are not told of exemptions to required vaccines. One family in Benewah County is home schooling their child as they did not want to risk an adverse vaccine reaction. They wanted their child to attend public school and were astounded when they learned a year later that other children attended school without having vaccines.

People who enjoy working with food, taking care of the elderly or sick patients, and make that their careers in life are denied employment or terminated from their jobs for refusing a Hepatitis A or B shot.

Idaho Code Chapter 39 Section 4804 needs to be clarified. Informed consent is not really happening before a shot is administered in this state. The medical procedure known as vaccination is not emergency medicine and carries the risk of permanent disability or death. It is imperative that before parents submit themselves or their children to such a procedure, they are told it is voluntary in Idaho as well as the very real dangers involved. There also needs to be a penalty for those who violate the law. Everyone who requests vaccination records for school or daycare entry, or for government programs such as WIC or Medicaid, needs to follow the law and tell their clients that vaccines are voluntary in Idaho. Also, employers should not be imposing a risky, unnecessary medical procedure on their employees as a requirement for employment.

Christy Shult testified briefly and provided written testimony on behalf of her son Michael Shutz as well as Joshua King, Ricky McCusker, and all other who have been falsely accused and convicted of violent child abuse, with the most common offense defined as Shaken Baby Syndrome. She explained she is personally familiar with the details. The discovery of these cases holds compelling evidence supporting the innocence of each. Yet all three (3) are imprisoned with sentences ranging from four (4) years fixed, with six (6) years indeterminate, fifteen (15) years fixed, with life indeterminate, and three (3) years fixed, with six (6) years indeterminate, (the consolation for taking the plea bargain), respectively. This is unconscionable injustice, and must be viewed as such by all who become aware.

The inconsideration of the accused begins in the hospitals, where it has become obvious that the allegation of child abuse is taking precedence and substitution of screening tests to determine the possibility of a chronic condition or other malady. Such as the child my son was accused of harming. One doctor, of the many attending, discovered the child had Hydrocephalus that had gone undiagnosed despite accelerated head growth that had been taking place since birth. A chronic condition, with suspicions of the Hep.B vaccination the child received within a day of birth having caused. However, regardless of the cause, the diagnosis remained as Shaken Baby Syndrome, and the significance of the Hydrocephalus was negated at the trial, as was a massive recurrent hemorrhage following the four (4) month immunizations of the child.

There are tactics used by Health and Welfare workers and others threatening the mothers' of the alleged victims with loss of custody to the State if they do not cooperate with the implication of their boyfriend or husband as the perpetrator. Subtle hints of this were brought out during testimony at my son's trials, as well as references in the discovery.

I do not discount that child abuse exists. However, there are highly credentialed, experienced experts who believe the Shaken Baby Syndrome diagnosis to be seriously flawed. And that innocent people are being accused and convicted is a criminal act in itself. If we do not make a move in an honest and positive directions, we are failing the very innocents we claim to protect.

Section 54-504. The barber board will expand exemption to include all licensed nurses, persons practicing in their own homes on family members without compensation, and to allow services for those unable by ill health, medical confinement or involuntary incarceration to go to the barber shop.

This legislation would require barber schools or colleges approved by the board to deliver to the board a $20,000 bond.

Section 54-513 deals with location and performance of services, changing the term registered to license, and adding the term barber-stylist.

Section 54-518 strikes language dealing with temporary permit fees. There will be no impact on General or Dedicated funds.

Section 54-804 allows to strike language designating levels of nursing experience, adding barber-styling as a designation and allow cosmetologists to provide services for those unable to go to a cosmetological establishment. There will be no impact on General or Dedicated funds.

There is an anticipated income to the dedicated fund for the Bureau of Occupational Licenses of approximately $550 per year.

Section 54-1609. Endorsement of Licenses: The board, in its discretion, and otherwise subject to the provisions of this act, and the rules of the board promulgated thereunder prescribing the qualifications for a nursing home administrator license, may endorse a nursing home administrator license issued by the proper authorities of any other state upon payment of a fee and upon submission of evidence satisfactory to the board that the applicant meets those qualifications established by the rules of the board.

Robert Vande Merwe, executive director of the Idaho Health Care Association, testified to support HB25.

EXCUSED:

This legislation amends existing law relating to the Board of Psychologist Examiners to clarify the requirements for fee payments. This bill also clarifies the manner of payment, which is directly to the National Examination Entity, as fees are now submitted directly to this entity and not the Bureau of Occupational Licenses. Additionally, the language in this legislation clarifies a processing fee of $25 that is charged by the Bureau of Occupational Licenses. This is not a new fee, and has been approved by the legislative body in law and rule.

This bill, HB 20, strikes outdated language from the Health and Welfare statute, Chapter 20 Title 39, dealing with the inspection of Barber Shops, and Cosmetology establishments. This legislation is presented to strike language that should have been changed in 1974.

SB 1120 will strike the remainder of the outdated language from this chapter. There is no impact on the General or dedicated funds.

There will be no impact on General funds. There will be no fiscal impact on Dedicated funds until rules are promulgated. The additional amount that would be realized at that time, if the entire fee cap was requested, would be an approximate increase of $1200 per year. This fee will allow the Board to recover development costs, and cover administrative costs.

The Committee will try to clarify some of the JFAC issues, and try to make suggestions as to where budget cuts could be made. The committee is not interested in trying to micro manage the Department of Health and Welfare, but try to be of assistance to both the JFAC and the department.

The Committee discussed obtaining a copy of the Department of Administration's annual Vacant Position Report for state agencies, to see if the report would provide additional information that would be helpful to the Joint Finance-Appropriations Committee.

Other items briefly discussed included the cost-savings bonus program, zero-based balancing, travel budget savings, accounting validation, enhancements, and performance levels set for departmental programs.

EXCUSED:

The department has planned an extensive educational briefing about issues that have come before the Senate Health and Welfare Committee. The meeting will also be heard during the week of March 4 - 7, 2003. Items planned for discussion today include the FTP (full-time position) authority for Fiscal Year 2002, and FTPs eliminated due to the 2002-2003 budget holdbacks, and net loss of personnel funding.

Two (2) charts were distributed giving a precise listing of positions eliminated, both for administrative and direct service positions. The FTP changes are listed by appropriation authorization, the staff positions for Indirect Support Services such as the Division of Family and Community Services, Management Services, Human Resources, Information Technology, and the director's office. The Division of Medicaid, Health, and Welfare were also discussed. A detailed review of the charts was held. (See attachments #1 and #2)

Numerous areas were reviewed and discussed, pertinent to the concerns about, but not limited to, the following:

1. Service delivery that will affect clients;
2. Additional staff layoffs and the impacts on programs;
3. Staff layoffs with bumping privileges and retention points;
4. The importance of the employees' three-step recognition awards program;
5. The risk of losing federal program funding;
6. Child protection workers (the department has not, at this time, reduced the number of assigned staff for child protection, but with additional budget reductions child protection workers will need to be considered;
7. Monitoring 149 federal grants within the department;
8. Communications - keeping communications opened as community liaisons and with line-staff;
9. Impact on direct support services and providers;
10. Possible consolidation of some staff positions and program impacts;
11. Allowing flexibility of certain program staff within the seven (7) department's regions;
12. Substance abuse, mental health, developmental disabilities programs;
13. Timeliness of payments for expenditures, and quality of payments, Self-reliance Program and Welfare-to-Work Program.

The Department receives five (5) appropriations bills, each with a dedicated number of authorized full-time staff positions.

EXCUSED:

This legislation relates to the qualifications of a designated examiner for purposes of adult and children's mental health services, amends Section 16-2403, Idaho Code, to further define terms of becoming a designated examiner, adding language to strengthen the qualifications to become an examiner making it consistent with the designated examiner definition in Section 66-317, Idaho Code. SB1128 further amends Section 66-317, Idaho Code, to define terms making it consistence with the designated examiner's definition found in the children's mental health services, Section 16-2403, Idaho Code.

This legislation will enable the director of the Department of Health and Welfare to promulgate rules to appoint other mental health professionals for adults, as current Idaho Code allows for children.

This bill, making the definitions for who can qualify as a designated examiner for adult and children's cases to include "other mental health professionals" will provide the Department of Health and Welfare additional qualified professionals to conduct designated examinations. This is particularly important in rural areas of the state, where access to mental health professionals is limited. There is no fiscal impact to these changes.

The Senate Health and Welfare Committee previously reviewed legislation, SB1076, and made recommendations for changes to the bill. SB1128 is a new legislation and incorporates the committee's suggested changes to SB1076.

Discussion:

1. Previous hearing of SB1076 was reviewed;
2. A review of Section 66-329(d), page 4, lines 46-51;
3. The qualifications of a social worker;
4. The need to have a medical examination by a person with the proper qualifications.

The motion made beforehand by Senator Compton, and seconded by Senator Sweet, was approved by a voice vote. Senator Bailey voted No. Senator Compton was assigned as sponsor of SB1128.

Gary Broker presented three (3) charts pertinent to the briefing today. The charts outlined programs' FY2003 FTP (full-time positions) authority for the Divisions of Health and Medicaid. (Attachment #1)

The second chart was previously presented with a typographical error, and now has the correct date of 03/03/2003. (Attachment #2)

The third chart is a summary of position changes due to the 2002-2003 budget holdbacks for the Department of Health and Welfare. Mr. Broker explained the full-time position authority for fiscal year 2002, original appropriation, was 3,092.01 positions. The current full-time position authority is 2,021.91, a reduction in full-time position authority of 170.10 positions. This chart also provides a summary of holdback position changes, by appropriation, for indirect support. (Attachment #3)

The Division of Medicaid Acting Administrator Randy May explained that Medicaid is, in essence, a health plan. In fact, it is the largest health plan in Idaho. This year, Medicaid will serve approximately 152,000 clients, and pay out about $850 million, in benefits, to more than 15,000 Medicaid providers throughout the state.

Medicaid's overhead operating and personnel costs are the smallest of all other health plans in Idaho. Medicaid's operating cost is 2.9 percent and personnel cost is 1.4 percent, a total of 4.3 percent. The national trend is between 12 and 15 percent. He stated that Medicaid is a very large, very complex, health plan.

Mr. May discussed efforts to try and control the growth of Medicaid costs. He outlined three (3) approaches that can affect Medicaid costs.

1. Reduce the number of people served, by tightening eligibility requirements and removing services to people.
2. Reduce the amount or scope of services.
3. Reduce the reimbursement rates. The Medicaid dental reimbursement rate is currently so low, that dentists do not want to treat Medicaid clients.

He outlined Utilization Management - a tool used for encouraging and getting people to use the appropriate type and the appropriate amount of services. Case in point, utilization of emergency rooms (ER) - last year Medicaid spent about $6.6 million on emergency room treatments, at an average cost of $106 per ER visit, not including doctor and laboratory fees. The top five (5) reasons people visited an emergency room was for earache, upper respiratory problems, unspecified stomach complaints, fever, or sore throat.

Several other Medicaid areas were discussed, such as:

1. Utilization Management Program (UMP) - This program has been very successful, and is important to reducing the cost of Medicaid.
2. Co-pay, even a $3 to $5 co-pay on emergency room treatments, and certain areas where a co-pay cannot be required.
3. Federal mandated limits on co-pay requirements.
4. Requesting a waiver to some of the federal mandates.
5. Developing standards for visits to emergency rooms, and reducing the number of ER visits.
6. Employees - location of employees statewide, and the addition of 24 FTP to Medicaid.
7. Economy - lower economy drives up the demand for Medicaid services, increases growth and effects on Medicaid's costs.
8. Private employers providing health care insurance plans.
9. Upcoming long-term health care needs and growth in service demands.
10. Medicare does not pay for prescriptions, and Medicaid does.
11. Poverty levels - 133 percent base.

He reported that 95 staffs are involved in direct services. The vast majority of those staffs are involved in the process of vital statistics, such as providing services to people wanting their birth certificates or a death certificate, etc.

The Emergency Medical Services (EMS), employs about 20 staffs. They support a statewide communication center, provide technical assistance, monitor grants to community EMS units, and evaluate EMS system performance. Emergency Medical Services supports a statewide system that responds to critical illness and injury situations. Those services include ambulance licensing, and certifying EMS personnel. About 60 percent of the EMS ambulances are operated by volunteers.

Mr. Schultz outlined the responsibilities and functions of the 153 staffs assigned within the division, such as:

1. The state's vaccine program for children.
2. The newborn screening and clinic services.
3. The workers' health and work site safety unit.
4. Health Promotions - preventive health programs and services to local Health Departments, schools, businesses, hospitals, and community-based organizations.
5. Management of grants.
6. Laboratories and services provided.
7. There are 35 different programs in the division, and three (3) are federally funded.

He encouraged committee members to visit the EMS communication center located in Meridian, and also to tour the local state laboratory.

Senator Darrington recommended having the Bureau of Emergency Services Bureau Chief Dia Ganor come and explained the EMS services. He also encouraged members, as time allows, to visit the communication center. Mr. Schultz reported he is willing to arrange a field trip at the convenience of the committee members.

EXCUSED:

A motion was made by Senator Sweet to approve the committee's minutes of Tuesday, February 25, 2003. Motion was seconded by Senator Bailey, and motion was carried by a voice vote.

The Division of Welfare Administrator Scott Cunningham presented an educational program update regarding the position changes in the statewide Self Reliance programs, due to the 2002-2003 holdbacks. He explained the programs that are administered and the services that are delivered through the Self Reliance program. He also explained the Welfare-to-Work Program.

We provide for the following benefit programs: Temporary Assistance for Families in Idaho (TAFI), Aid to the Aged, Blind and Disabled (AABD), Food Stamps and the Idaho Child Care Program (ICCP).

In addition to the benefit services I described, we also provide the full range of child support services, including: collections, paternity establishment and support order establishment.

Finally, the statewide Self Reliance program administers a series of community service programs, including: Community Service Block Grant (CSBG), Community Food and Nutrition Program, Low Income Energy Assistance, Telephone Assistance Program and Weatherization Assistance.

I would direct you to the section of your handout entitled "Division of Welfare Positions." I would like you to keep in mind that at the same time we were making decisions about how to address the budget holdbacks, we were also engaged in a realignment whereby the direct administration of the programs was being transferred from the regions to the divisions. So, while we were addressing the holdbacks, we were also guided by our transition plan which required us to develop consistent program services statewide and look for program efficiencies throughout all our programs.

The first position action taken was to reduce the number of fraud and collection positions by four (4) full-time Positions (FTP). The program had seven (7) positions, but we felt that with new technology, and streamlined fraud referral procedures, we could handle the work with three (3) investigators; one located in North Idaho, one in the Treasure Valley and one in Eastern Idaho that could also serve the Twin Falls area.

The second position action we took was to eliminate 3.8 Community Resource Development positions, and assigned those duties to the regional Self Support Managers.

The third action we took was to reduce the number of statewide trainers by nine (9) positions. Prior to this reduction, there were 25 trainers statewide.

The fourth action we took was to complete the transfer of all employment-related services to existing TAFI employment services contractors for a reduction of 13.8 FTP. The contractors utilized are both government and non-government organizations. This action created no new expense to the State.

The fifth and sixth actions we took involved streamlining the central office administration by: regionalizing the Food Stamp Quality Control (FSQC) which eliminated 11.5 central office positions. In the old system, the central office staff provided all quality control checks which involved traveling statewide in order to ensure compliance with the United States Department of Agriculture, Food and Nutrition Service agency. I also eliminated two (2) positions in my office, and have spread that work out to remaining staff.

When the second 3.5 percent holdback was announced, we were still in the process of transitioning the administration of the Self Reliance programs to the Division, and we were still committed to finding efficiencies and promoting consistency. The first thing we did was to eliminate 12 vacant, but funded positions.

Next, we analyzed where we might be able to improve processes or serve outlying offices and achieve savings. We decided to move staff out of four (4) field offices, eliminate the positions and have other field offices provide services to those affected individuals and families. We have the technology and capacity to serve people via the telephone, voice response units and to a limited degree -- e-mail.

Montpelier and Malad are now being served out of the Preston office, Bellevue is now being served out of the Jerome office, and Homedale is now being served out of our Nampa and Caldwell offices.

Finally, and probably the most difficult decision to make was to eliminate seven (7) regional self reliance manager positions, and their support staff. Prior to making this decision, we had an opportunity to run a pilot project in Region 7 with an existing child support supervisor and an existing benefit supervisor, that proved to be highly successful. Our current structure has each region following this successful pilot with each acting area supervisor reporting directly to either the benefits or child support bureau chief.

I would now direct your attention to the chart entitled "DHW Central Office Positions" and the column entitled Division of Welfare. I must tell you that the majority of our staff in the central office have multiple duties so some of these FTP numbers are expressed as the equivalent of an FTP, but it may be four (4) staffs who perform the work at a .25 FTP level.

The first group of staff consists of 8 FTP - bureau chiefs and supervisors who respond to new state and federal laws and regulations, and develop policy to support the numerous changes that govern our work.

As you can see, the bulk of the staff, 28 FTP, in the division performs policy implementation work. This includes: rule writing, policy development for field staff, help desks, liaison with federal and other state agencies, and automation/business requirements.

We have two (2) staff who direct the statewide quality control and audit activities for all of our programs (Medicaid and Food Stamps have a very specific federal requirement about quality control and audit functions).

As you can well imagine, with the span of programs in the Division of Welfare, we have some very heavy federal reporting requirements on program outputs and persons served. That requires the equivalent of four (4) FTP's worth of time. In the same vein, virtually every program we administer has a federal requirement to maintain and submit an annual State plan. This requires the equivalent of four (4) FTP on an annual basis.

We have three (3) staff who are engaged in business improvement projects. Those projects are: simplified notices, child care, and performance management/ balanced score card. We also have one (1) staff person who is working on developing a new system called A-Med.

The FTP listed as executive administration is my position. I am ultimately responsible to the director for all aspects of the Self Reliance Program: audits, budget management, program performance, personnel and member of Executive Leadership Team.

The last FTP is a legal support position for the deputy attorney general's staff who is housed in our child support unit.

Mr. Cunningham's handout, referred to previously, about the enhanced work services contracts - Welfare-to-Work - Self Reliance Program included the following information.

Philosophy:

• Work Services is the heart of Idaho Welfare Reform
• At-risk citizens are moved from Welfare dependent programs toward economic independence through employment
• The "Work First" process has revitalized human service efforts to move participants from welfare, from poverty, from dependence and onto a path toward self sufficiency
• Work First Model -
• Get a job, any job
• Keep a job
• Get a better job

History:

• From Family Support Act of 1980s ~JOBS/JSAP (Job Search Assistance Program), programs to current Welfare Reform TANF program since 1997.
• Current program has fewer exemptions from work requirements. In addition to job-ready individuals, EWS (enhanced work services) serves those TAFI individuals with physical and mental disabilities, limited education/literacy, transportation issues, Substance Abuse, etc. (Limited exemptions from participation are for rare childcare issues).

• Target Populations:



• TAFI and Food Stamp recipients who the Department has a rule obligation to provide work services for.
• Are required to perform significant work activities in order to receive benefits from the department.

• TAFl participants are required to participate 30 hr/week (42 USC 607)
• Federal FS participation requirements are much lower than TAFI requirements (7CFR 273.7) however contractors make every effort to engage these participants at 30 hrs/week as well.

• The federal government has placed hard to meet specific countable* activities on this population that Idaho must meet. (TAFI: 50 percent of population must meet a countable activity requirement of 30 hrs/wk, 90 percent of 2-parent TAFI families must pass this requirement).



• These mandatory participation and activity rates have been met statewide over the past several years, in a large part by contracting these services out to competitive bidders who have performed or been replaced since 1997.

• Since 1997, Idaho has achieved incentive payments from the Feds for excellent job placement and retention results.

*Countable activities have been defined by the Federal Government and exclude many of the activities our hard-to-serve participants need to engage in order to later successfully gain employment. For example, Drug and Alcohol or Mental Health counseling is not considered a "countable activity." Contractors have successfully juggled to Federal requirements with the needs of the participants to create win-win situations.

Current Efforts:

• New work services contracts were awarded commencing April 1, 2002 from a competitive RFP (request for proposal) process.



• Seven (7) contracts throughout state with four (4) different contractors: two (2) for-profit companies, one (1) nonprofit company, and one (1) state agency.



• Current contractors:



• Provide consistent services to participants statewide
• Have achieved cost savings to the Department through competitive bid process and successful negotiations
• Include formal performance requirements, with financial consequences for poor performance
• Successfully put this T and B money into the business community.

Services Provided:

• Assessment of current situation
• Job Readiness Services
• Case Management
• Post Employment/Transitional services
• Supportive Services such as transportation dollars, tools, clothing for employment or other goods and services needed to secure or maintain employment.

Services are Based on Work First Model: Put participant into a job first with their existing assets and skills, and then work on keeping that job. Finally, efforts into enhancing employment status are offered to participants previously placed in employment.

Funding:

• T&B (trustee and benefit) dollars used. TANF Funding is 100 percent federal funds, JSAP (Job Search Assistance Program) funding is an average of 50 percent federal funds and 50 percent general funds.

_____________________________________________________________________

	Contracted Services	Supportive Services For participants	Total
TANF	$5,387,000	$953,000	$6,340,000
JSAP	$ 445,200	$116,100	561,300
TOTAL	$5,832,000	$1,069,100	$6,901,300

_______________________________________________________________________

• Of this nearly $7 million budget, only $338,700 comes from the state General Fund.



• With reduced DHW staffing, the work services workload was moved to contractors to provide work services.

Results:

• April I - December 31, 2002:



• 6582 non-duplicated participants served
• Of these, 1469 have been placed in jobs
• Average job placement: 32 hours/week, $7.15/hr
• These results have been achieved at an average cost of $443.07 per participant for Contracted Services and $81.33 for supportive services per participant.

Savings:

• Total spent July - December 2002 = $3,277,069, reflects an estimated savings of $400,000 due to performance based service delivery.



• Additionally, these savings have enabled the Department to offer contracted enhanced work services for non-custodial parents. Goal - obtain employment and pay child support. The model is based upon earlier Idaho NCP (non custodial parent) projects in northern and south eastern Idaho which demonstrated a 75 percent increase in Child Support payments after 90 days post-service, and 34 percent increase in the amount of payment after mediation services. These services are expected to commence by April 1, 2003 (therefore no outcome data is currently available).

Monitoring:

• All seven contracts have been closely monitored.
• July - December 2002 Results:
• 991 formal case reviews completed statewide
• Requirement = 90 percent or better standard for accuracy and timeliness in service delivery.
• Cumulative average for ALL contractors during this time period is 94.46 percent.

This chart outlines the Medical Assistance Program expenditures by service category, in millions of dollars. The chart was previously review on January 28, 2003, and is included as a part of those minutes on the Internet. The chart lists services required by the federal government, by state government, and services required by rule.

The committee members discussed Idaho's Medicaid mandates as shown in the Department of Health and Welfare's Facts/Figures/Trends 2002-2003 publication, page 16. Idaho's Medicaid program provides coverage of health care services which are required by the federal government, Idaho Code or Idaho Rules. The list of SFY2002 mandated expenditures by federal, state, and rules cost a total of $776.6 million, as listed below:

MEDICAID MANDATES - FEDERAL (in millions):

1. Hospital Related Services $149.2 Includes services for Inpatient/Outpatient Hospital - $139.1

Hospital DSH (Disproportionate Share Hospital) - $10.1

2. Nursing Home Care $117.2

Includes services for Nursing Facility

3. Physician and Clinic Services $56.5

Includes services for:

Rural Health Clinic - $4.2

Federally Qualified Health Center - $1.7

Indian Health Services $1.6

Physician Services - $1.6

4. Medical Transportation $11.7

Includes services for Medical Transportation

5. Lab and X-ray Services $7.7

Includes services for Laboratory/Radiology Services

6. EPSDT Services $3.8

Includes services for Early Periodic Screening and

Diagnostic Testing

7. Family Planning $1.7

Includes services for Family Planning

8. Hospice Benefits $0.6

Includes services for Hospice Benefits

MEDICAID MANDATES - IDAHO CODE (in millions)

1. Prescribed Drugs $114.2

Includes services for Prescribed Drugs

2. Waivers and Personal Care Services $92.7

Includes services for:

Aged/Disabled - Waiver - $46.3

Personal Care Service Plan - $14.9

Idaho State School & Hospital /State Hospital South and

Developmentally Disabled Waiver - $30.8

Traumatic Brain Injury Waiver - $0.7

3. DD/MH Care $34.6

Includes services for:

Targeted Case Management - $13.5

Development Disability Center - $31.8

Inpatient Mental Health - $9.1

4. ICF/MR Care $34.6

Includes services for Intermediate Care Facility for

the Mentally Retarded

5. Dental $20.4

Includes services for Dental Services

6. DME/Medical Supplies $8.7

Includes services for:

Durable Medical Equipment - $8.5

Medical Supplies - $0.2

7. Other Practitioners $8.7

Includes services for Other Practitioners

8. School District Services $2.3

Includes services for School District Services

9. Outpatient Rehab $1.1

Includes services for Outpatient Rehabilitation

10. District Health $0.1

Includes services for District Health

11. Nurse's Aide Training $0.1

Includes services for Nurse's Aide Training

MEDICAID MANDATES - IDAHO RULES (in millions):

1. Mental Health $36.7

Includes services for Mental Health

2. Child Health Program (Title XXI) $16.7

Includes services for Child Health Program (Title XXI)

3. Medicare Parts A & B $14.6

Includes services for Medicare Part A & B

4. Home Health Services $6.9

Includes services for Home Health Services

5 Ambulatory Surgical Centers $4.8

Includes services for Ambulatory Surgical Centers

6. Physical Therapy $4.0

Includes services for Physical Therapy

7. Institutional MH Diseases/SHS $3.0

Includes services for Institutional Mental Disease/SHS

8. Healthy Connections $2.0

Includes services for Healthy Connections

9. Group Health Plan Payments $1.6

Includes services for Group Health Plan Payments

10. Breast and Cervical Cancer $0.5

Includes services for BCC

11. DUR/Other $0.2

Includes services for Drug Utilization Review

Total expenditures for programs - $776.6

Other Medicaid issues reviewed and discussed included the following:

1. Medicare Part A and B payments, and why beneficial to Medicaid clients to receive Medicare insurance;
2. W-2 expenditure category when discontinued;
3. Disposing of assets to "spend-down" to become Medicaid eligible, and the process to recoup those costs;
4. Physicians and dentist discontinuing treatments for Medicaid clients due to low reimbursement rates;
5. Idaho ranks #49 of the states in number of Medicaid programs offered;
6. Match funds - Federal 70 percent and state 30 percent;
7. Cost of nursing home beds;
8. Most expensive Medicaid services are hospital related services, nursing home care, and prescription drugs.

1. Eliminating any one of these programs presents specific problems. Eliminating them all would not meet the savings target for the current fiscal year. Eliminating them all also falls short of all 2003 and 2004 targets. Mr. Broker explained staff bumping privileges. (Attachment #2)



2. Attachment #3 - is a list of Medicaid programs - If the Legislature cut 360 staff, eliminated all general fund-only programs and eliminated the operating expenses identified, legislators would remain well short of all four savings targets. To reach the savings targets, they would be forced to eliminate a significant number of Medicaid optional services.

3. What program, if eliminated, would not impact federal funds? (See attachments #2 and #3)

The committee members held a lengthy review of the charts presented, and discussed reductions of staff and effects on programs, increased co-pay for child care, closure of some state institutions and where patients could be placed, eliminating the Katie Becket services, and increasing eligibility requirements.

EXCUSED:

Representative Gagner's intent language is as follows:

Section 3. The Legislature has concerns relative to the degree of reductions to specific program budgets in the recent 3.5 percent holdback, and as a result, the House Medicaid Task Force met with providers of services and the Department of Health and Welfare personnel and identified short-term savings of $1,123,700 annualized.

It is the intent of the Legislature that a pro-rated amount equal to $230,900 be restored to three budgets; $71,600 to Targeted Case Management and Services Coordination; $48,500 to Residential Habilitation Services; and $110,800 to Sheltered Workshops.

It was recommended that Representative Gagner be invited to meet with the committee and discuss his legislative intent language.

The Department of Health and Welfare's legislative intent report is as follows:

There is hereby reappropriated to the Department of Health and Welfare any unexpended and unencumbered balances of the Cooperative Welfare Fund for fiscal year 2003, to be used for nonrecurring expenditures only for the period July 1, 2003 through June 30, 2004. The reapporpriation shall be computed by the Department of Health and Welfare from available moneys.

This section allows the Department to efficiently spend out appropriation balances, without requiring processing of encumbrance transactions. This also provides incentive for the Department to operate economically at year end to preserve funds for spending the next year. Historically, the Department does not receive any appropriation for capital outlay or minor (under $30,000) facility maintenance projects, and must use carryover funds for these items. If reappropriation authority is not provided for, the Department would be required to encumber fund balances to preserve spending authority. This would require additional staff to account for these encumbrances.

Notwithstanding the provisions of Section 67-3516(2), Idaho Code, the Department of Health and Welfare is hereby authorized to expend all receipts collected as noncognizable funds for the period July 1, 2003 through June 30, 2004.

This section allows the Department to maximize funding available from receipts collected, without requesting supplemental spending authority. Many times the Department is able to collect additional funds to support programs that are not anticipated at the time the budget is requested. For example, the Department was able to pay an additional $10 million dollars to inpatient hospital facilities which utilized match from these facilities and federal funds (no state funds were needed). Any receipt collected from federally funded programs must be spent on that program, or the federal share must be returned to the grantor agency.

It is legislative intent that the appropriation of moneys from the Cancer Control Fund specifically supersedes the provisions of Section 57-1702, Idaho Code.

This section allows the Department to spend appropriated personnel funds from the Cancer Control Funds. Idaho Code 57-1702 does not provide for using these funds for personnel. The Department is able to more economically provide services using state staff than under contract.

The Department spends $50,000 for personnel costs to coordinate contracts, and provide technical assistance to health districts on the programs. There is $237,500 used for contracts in tobacco risk awareness contracts with health districts, tribes, and physician groups. This is used as match for federal grants in this area. There is an additional $85,800 used for contracts with the health districts in the breast and cervical cancer program. Total in governor's recommendation is $401,700, however, historically the account has not generated over $375,000 in income. Any unencumbered balance at year end reverts to the General Fund.

As appropriated, the state controller shall make transfers of the General Fund to the Cooperative Welfare Fund, periodically, as requested by the director of the Department of Health and Welfare, and approved by the Board of Examiners.

This section allows the Department to operate more efficiently, and reduces the number of transactions required to conduct business. Since most of the Department's programs involve the use of federal funds, either directly or indirectly, most payments are funded from federal and state dollars. If the cooperative welfare fund and the related general fund transfer were not available, each payment would have to be split between federal and state funds. Since the exact federal/state share is not known until after cost allocation is run on a monthly basis, an adjustment would be required to change the federal/state share to the actual amounts. This would require additional staff and computer resources to maintain.

The Department must have adequate cash on deposit in the state controller's and state treasurer's accounts before warrants are written. However, federal funds cannot be requested from the federal treasury until they are actually used to cover redemption of warrants. Because of this, the Department must have access to state funds to cover the delay from the time warrants are issued, until they are redeemed and the federal funds can be deposited. For example, on a weekly Medicaid payroll the 70 percent federal share must be drawn as follows:

Business days after warrant is issued until federal funds are drawn	% available to draw
Day of issue 1 day after issue 2 days after issue 3 days after issue 4 days after issue 5 days after issue 6 days after issue 7 days after issue 8 days after issue 9 days after issue 10 days after issue	0 0 52.3% 2.1% 9.3% 14.8% 10.9% 4.4% 2.3% 1.1% 2.8%

1. Responsibilities of germane committees;
2. JFAC (Joint Finance-Appropriations Committee) responsibilities;
3. Request JFAC to let a germane committee know in advance of any proposed legislative intent pertaining to appropriations;
4. Have authors, or others, meet with germane committees to discuss legislative intent language;
5. Germane committee take an active role in preparing intent language for allocations of funds;
6. Impacts of legislative intent language on agencies;
7. Working in cooperation with JFAC and ensuring legislative intent language incorporates the germane committees' policies to agencies.

EXCUSED: