• Senate
  • Leadership
  • Membership
  • Committees
  • Senate Rules
  • Joint Rules
  • Administration
  • Page Program
  • Audio/Video Streaming
• House
  • Leadership
  • Membership
  • Committees
  • House Rules
  • Joint Rules
  • Administration
  • Page Program
  • Audio/Video Streaming
• Who's My Legislator?
  • Interactive District Map
  • PDF District Map
  • Contact County Clerk
  • Search by Address
• Contacting Legislators
  • Capitol Contacts
  • Contact by Name
  • Contact by District
  • Contact by Committee
• Committees
  • Standing
    Committees
    • Senate Committees
    • House Committees
    • Joint Committees
  • 2011 Interim Committees
• Legislative Council
• Legislative Services
  • Organizational Chart
  • Administration
  • Budget and Policy Analysis
  • Information Technology
  • Legislative Audits
  • Research and Legislation
• Budget Information
  • JFAC
  • Budget Process
  • Budget Publications
  • Staff
  • Agency B4 Forms
  • EORAC
  • Federal Stimulus
• Legislative Audits
• Office of Performance Evaluations
• Redistricting Commission

EXCUSED:

During the 2003 legislative session, the committee conducted an in-depth study of the budget of the Department of Health and Welfare. He has asked the Department to present a one-day overview of the budget they prepared for the Governor's office for SFY2005.

Committee members should contact the chairman if they have a specific item of interest to be considered for an in-dept study during this session.

During the interim this year, several items of interest were considered and Chairman Brandt has been working with individual members and task force members. He listed several areas the committee has been involved with, such as, Senator Stegner has diligently worked for several years with mental health issues and, hopefully, has a consensus piece of legislation for this year. Suicide prevention is another issue and is also part of that. The Child Support Program is an issue that all members have had an opportunity to deal within one way or another.

This past year, a prescription drug task force has tried to get an enhanced authorization program organized. There is also a new Medicaid bill of legislation. How in-depth does the committee want to be involved with this issue?

The budget aspect, the committee will cover as much as members or JFAC (Joint Finance Appropriations Committee) members request or need.

EXCUSED:

16-0203-0401

First, they provide the requirements for instructors, education, certification, and agency licensure for a new level of EMS provider called the EMT-Intermediate which was created with legislation passed in a prior session of the Idaho Legislature. The EMT-Intermediate will allow more advanced skills and medications to be provided to patients, and is expected to primarily benefit rural areas that are unable to train or support paramedics.

The second issue addressed in this docket is the repeal of one of twelve (12) requirements for EMS agency licensure in Idaho. The section listing these requirements are on page 9. Subsection 10 on page 11 "local governmental authorization" was accomplished through the EMS agency documentation of compliance with local EMS ordinances and ambulance district rulings as part of their application.

While the EMT-Intermediate rule drafting was in progress last fall, a controversial application was received by the EEMS Bureau. We were confronted with conflicting endorsements of an application from an EMS agency based in a city in Idaho, while the county opposed the application.

The rule provided no guidance for this type of scenario or any other where city and county opinions or ordinances are in conflict. This rule was determined to be an inappropriate delegation of our authority and is beyond the scope of assessing the personnel, equipment, and other agency-specific functions to determine fitness for licensure.

16-0210-0401

The Division of Health is updating the Rules on Idaho Reportable Diseases to include SARS and West Nile virus infection on the list of Reportable Diseases and Conditions. We also added the control measures that will be taken if either of these diseases is reported. We added SARS to the list of daycare and school reportable and restrictable diseases.

These additions to the rules will enhance control and prevention of these
diseases in Idaho.

16-0214-0301

Because they are interconnected, she discussed both dockets at this time. She provided a fact sheet describing these dockets. (See attachment #1)

These rules do not propose new language. They simply consolidate all rules affecting swimming pools into one chapter, and repeal a chapter that no longer contains any significant language once the swimming pool language is moved.

Docket 16-0214-0301 - This docket consolidates existing language about the construction and operation of swimming pools into one chapter as a result of the repeal of chapter 16.05.05 (docket 16-0505-0301). The movement of language includes: provision of legal authority to establish fees for services; permit and plan review fee amounts; and provision for the waiver of fees. This docket will also allow for the elimination of the reference to chapter 16.05.05. No new language is being proposed.

Docket 16-0505-0301 - The purpose of this docket is to repeal the entire chapter. After the split of IDEQ (Idaho Department of Environmental Quality) from the Idaho Department of Health and Welfare in 2000, and the movement of sections of IDAPA 16 into IDEQ's code, chapter 16.05.05 was left with three substantive sections: 130 swimming pool permits, 202 clean indoor air act regulation waivers, and 900 waivers of fees. Section 202 is redundant with language contained in the rules governing indoor smoking. Only the swimming pool permit and waiver of fees language remains. Proposed changes in docket 16-0214-0301 will move language from this chapter, leaving no substantial language in IDAPA 16.05.05. Therefore, the chapter can be repealed.

16-0219-0301

We have significantly changed the appearance of the rules from previous iterations in that we have adopted the federal Food Code by reference in these rules and specified only the modifications we are making to that federal code. This approach has significantly reduced the volume of the rule and thus the associated cost of rule making.

There were three areas of concern that were expressed and all have been addressed:

• Concern that a person "in charge needed to be present during all hours of operation." That was resolved by adding Section 201 that states that a person in charge or their designee needs to be present during "hours of food preparation and service."

• A request from a chain grocery store that the rules allow self service to bulk frozen fish. No consensus was reached and in the absence of federal or other guidance on the matter, a conservative approach was taken and the rules continue to restrict that type of self service access.



• Finally, in the process we failed to involve one group of the regulated community. That group was the correctional facilities/jails. We learned Monday that the rules would cause considerable disruption to the variety of food preparation and service methods used in those facilities. We believe the most appropriate resolution to the concern is a statute that exempts those facilities from compliance with the Food Rules. That statute is being drafted and will be supported by both the Department of Health and Welfare and the District Health Departments.

16-0301-0201

The fiscal impact of the rule changes are $2,000 for automation (includes development of an ad hoc cost report and programming for rule change). Operational Costs: an annual program cost savings of $78,000 in State General Funds is projected.

Negotiated rule making was not conducted since all rule changes were made in order to assure consistent program operation following the State's legislative increase in the maximum TAFI grant payment.

16-0301-0301

MOTION:

A motion was made by Senator Darrington to approve Docket No. 16-0301-0301. The motion was seconded by Senator Sweet, and motion was carried by voice vote.

16-0301-0302

The Department of Health and Welfare requested the committee to reject Sections 346, 347, 348, and 349 of IDAPA 16-0302-0301. It was determined these sections will not do what the Department first anticipated.

16-0303-0301

The rule sets forth administrative procedures for the Department to access employment and health insurance information through the use of the National Medical Support Notice, in order to secure health insurance for children as a part of a child support order. It also sets forth either parent's ability to request an administrative review.

16-0304-0202

These rule promulgation removes the requirement that legal and qualified immigrants receiving disability benefits be legally present in the United States as of August 22, 1996, for food stamp eligibility; adds references to the disability criteria; deletes references to SSI being a means-tested program; updates total number of weekly hours for part-time employment, references to standard income deductions gross monthly income eligibility standards net monthly income eligibility standards and maximum food stamp benefit.

16-0304-0301

16-0305-0203

16-0305-0301

16-0305-0302

16-0308-0301

The rule amendments were made to clarify citizenship requirements and extend eligibility to TAFI for citizens and qualified non-citizens in compliance with federal regulations. The rules were also amended to clarify individuals not meeting the citizenship or qualified non-citizens when all other conditions are met, may be eligible for medical services.

16-0308-0302

Section 133 is being amended to clarify the Social Security Number (SSN) requirements to align with the federal requirements that the SSN must be verified before an applicant is eligible for RAFI benefits.

16-0320-0301

16-0414-0301

To avoid having to change this rule on an annual basis and to reduce procedural steps in the administrative rules performed by state employees, the benefit determination procedures and the percentages will be place in the Intake Manual used for LIHEAP. A summary for determining the annual benefit will replace the procedures, also, language has been clarified and some renumbering of the section.

16-0612-0301

During the 3.5 percent hold back imposed by the Office of the Governor, it is necessary to increase the percentage of the amount families are required to pay for their child care each month. In order to achieve $265,400 in savings by June 30, 2003, it is necessary to increase co-payment by six percent (6%) per child, per month. This will be accomplished in rule change by increasing the sliding fee schedule found in IDAPA, Section 06.12.307 by 6 percent (6%).

Senator Kennedy voted Nay Senator Bailey voted Aye

Senator Burkett voted Nay Senator Sweet voted Aye

Senator Ingram voted Nay Senator Darrington voted Aye

Senator Stegner - absent excused Senator Compton voted Aye

Senator Brandt voted Aye

The substitute motion was carried by a vote of 5 Ayes, 3 Nays, 1 absent.

nine (9) rule making dockets for the Division of Medicaid, as follows:

16-0309-0212

The purpose of this docket is to update the terminology used to describe the department's Traumatic Brain Injury Waiver program in order to improve understanding and clearly describe services. Medicaid staff worked with internal staff and external stakeholders to update these rules for this program that has been in effect since October 2002.

Two positive comments were received on this docket. Legislative Services found no issues with this docket.

The department requests you approve this docket as final.

16-0309-0215

Both Health & Welfare Germane Committees had some concerns about how the temporary rules affected access to case management services, particularly for those individuals with mental illnesses. The Germane Committees directed the department to amend the temporary rules.

The department met with legislators and provider representatives in order to address crisis coverage. As a result of these meetings, this docket was amended to:

• Allow up to four (4) hours per month of crisis case management without department authorization,
• Retain the four hours of ongoing crisis management, and
• Include another four (4) of crisis if more restrictive criteria have been met.

A key outcome of this work was the development of criteria that reflects a "crisis" and clarification of crisis case management services.

Crisis case management means "linking, coordinating, and advocacy" ­ it does not entail the provision of direct services such as crisis counseling, transportation, or skills building which are provided through other channels. Also, these rules require providers to document crisis services and submit written justification when crisis hours fall into the more restrictive category.

This amended docket also lengthens the interval for service plan reviews from 120 days to 180 days. The amended docket also allows licensed clinical professional counselors without private practice licensures and marriage and family therapists to provide case management services.

Rather than keep the temporary rule in place while the pending rule awaits legislative approval, the Department amended the temporary rules with the same revisions which have been made to the pending rule.

This concludes my overview of the amendments made to this pending rule docket 16-0309-0215. The department requests your approval that this docket be approved as final by this Committee.

An e-mail to the committee was submitted, for the record, from Steve Hansen of Idaho Falls, Idaho, dated January 14, 2004. His e-mail reported "Since these temporary rules are at least slightly better than the previous rules, I will not testify in opposition to them."

16-0309-0217

This rule docket updates terminology regarding the department's peer review organization and provides for the consistent application of penalties for late submission of a review docket. The clarification was made to ensure that all procedures are submitted in a timely manner for medical necessity review to protect the public health and safety.

This concludes my presentation on Docket 16-0309-0217. The department requests your approval that this docket be approved as final by this Committee.

16-0309-0218

This rule docket removes the Medicaid payment for the entry of laboratory results into the Clozapine National Registry for participants who require Clozapine to treat mental illness.

In October 2001, the department reduced its payment for this service from $29.07 to $5.00 to bring our payment into line with what other states were paying. After additional research we found that Utah, Wyoming, Montana, and Nevada were not paying for this service at all under their Medicaid programs. Last year, Idaho Medicaid followed suit and elected not to continue the $5.00 administrative processing payment. This is consistent with other reimbursement policies which do not establish an additional reimbursement rate for administrative activities.

The department requests your approval that this docket be approved as final by this Committee.

16-0309-0301

This rule docket describes the payment methodology used to reimburse out-of-state nursing homes for care provided to Medicaid eligible persons.

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

This concludes my presentation on Docket 16-0309-0301. The department requests your approval that this docket be approved as final by this Committee.

16-0309-0304

This rule docket restores routine and preventive coverage for adults effective July 1, 2003. Medicaid was able to restore these benefits as a result of a special appropriation at the conclusion of last year's legislative session.

This docket also includes technical changes that reflect new HIPAA (Health Insurance Portability and Accountability Act) coding requirements.

The department requests your approval that this docket be approved as final by this Committee.

16-0309-0306

This rule change reflects benefits added for mental health case management as a result of a special Medicaid budget appropriation for State Fiscal year 2004. You may recall that mental health case management benefits had been reduced as part of the 2003 Budget Holdback. The holdback designated a service cap of four hours of targeted case management per month. With this year's appropriation, Medicaid has been able to restore some of the ongoing case management services that had been reduced.

The department was allocated approximately $148,000 to provide additional mental health case management services. The department increased the number of ongoing case management hours ­ those that do not require meeting"crisis" criteria ­ from four hours per month to five hours.

The resulting benefit package currently allows for:

• Five hours of ongoing case management,
• Three hours of crisis case management that doesn't require prior authorization; and
• Four hours of crisis case management that requires justification and prior approval.

This concludes my presentation on Docket 16-0309-0306. The department requests your approval that this docket be approved as final by this Committee.

16-0309-0310

The purpose of these rule changes is to reduce the administrative barriers that have created reluctance among school districts to become Medicaid providers. Over the past year, department staff has been working in collaboration with the department of education and school representatives to streamline procedures that will improve access to care for Medicaid eligible children. By encouraging increased school participation in Medicaid, more children may be served in a familiar environment with services coordinated and managed under a single roof.

We have already seen the positive affect of this rule change. In January 2003, there were just 44 school districts enrolled as Medicaid providers. By June 2003, this number increased to 71 districts. The number of eligible children receiving services also jumped during this time frame, up from 3,300 to 6,400.

School district providers are unique in that they fund the Medicaid state match ­ there are no costs to the state Medicaid program when services are billed by a school-based provider. This is an attractive service arrangement that the department wants to further develop and support. The department has begun working with some private providers and school district representatives to develop protocols and templates for coordinating services. Private providers can play a key role by providing an additional resource during the school hours. Children can be better served by having most of their needed services provided during the day rather than after a long school day. Schools are encouraged to contract with providers and bill Medicaid for all services whether provided directly or through a contract. Many school districts have already established this arrangement in their communities.

The department will continue to work with schools and private providers to support this cost-effective collaborative effort to providing services to school aged children.

The department requests your approval that this docket be approved as final by this Committee.

Jana Jones, from the State Department of Education (SED), presented public appreciation to the Department of Health and Welfare for the excellent work and dedication the department provides to the SED.

16-0309-0311

From a procedural stand point, you are reviewing this docket in the middle of its development. These rules were published as temporary rules in the November Administrative Bulletin. Three public hearings were conducted, and public comments were accepted through November 26, 2003.

As a result of the hearings and comment, the Department has developed amendments to these temporary rules which are to be published in the March Bulletin. You have been provided with a copy of the amendments to this rule docket. The department has informed stakeholders that the amendments are intended to be retroactive to December 1, 2003 ­ the effective date of these rules.

The Department is asking this committee to extend these temporary rules on the condition that the Department precede with the amendments that have been provided to you. It should also be noted that once these amendments are published, there will be additional time for comment and hearing.

In addition, these rules will come before you in the 2005 session for final approval.

The main reasons for these rule changes are to clarify service provider roles in light of staffing reductions in the Department's Regional Mental Health Authority and to address health & safety issues.

The rule changes affect two distinct mental health benefits: 1) Psycho-Social Rehabilitation (PSR) and 2) Mental Health Clinic services.

The first part of the docket changes the PSR rules to reflect the reduction in Department Regional Mental Health staffing. As a result of the reductions, private PSR providers will now perform the assessment and service planning functions previously done by state staff.

Additionally, these rules incorporate service definitions, clarify provider qualifications, and spell out service expectations. Significant clarifications include the requirements that:

• PSR Agencies personnel coming into direct contact with participants must comply with existing statutes governing criminal history check requirements; and,



• PSR agencies must provide 24-hour crisis response services for their participants or make contractual arrangements for the provision of those services.

The changes to the mental health clinic rules and related partial care rules were made primarily due to safety issues. Over the past year, the department was alerted to situations where individuals appeared to be at risk when receiving care under this benefit.

Prior to these rules, "partial care" -- a Mental Health Clinic Service -- could be applied to a number of programs. Some of these programs consisted of supplying clients with cigarettes, coffee, and television for up to eight (8) hours per day. And because service expectations were not clearly articulated, many of the safety issues found over the past years have arisen in this service setting.

The rules before you tighten up the definition of partial care services to a structured program of therapeutic interventions. The intention of these rules is to remove any confusion about what services should be provided and to clearly define the expected service outcomes.

This rule docket does not introduce any new federal or state requirements for mental health clinics except for the inclusion of building standards, which were added as a direct result of documented cases of child endangerment due to substandard buildings that were being used as clinics. These temporary rules contain federal and state guidelines that have been in effect for many years. All changes are intended to result in a greater understanding in the provider community of the scope of mental health services as they are required to be.

Based on three public hearings scheduled in Boise, Pocatello and Coeur d'Alene during November, amendments were prepared that further clarify service expectations. The comments received came from the department's Family & Community Services Division, the department's Fraud & SURS (Surveillance and Utilization Review Section), private providers, and individuals and families receiving services under this rule docket.

An area of significant confusion has been the requirement for physician oversight ­ both in terms of expectations for clinic supervision and for individuals' care. The additional amendments the Department is proposing clarify the requirements as follows:

• Clinics must be under the direction of a physician and must spend as much time in the facility as is necessary to assure that participants are getting services in a safe and efficient manner in accordance with accepted standards of practice, (have used one hour per month).



• Each participant's care must be under the supervision of a physician directly affiliated with the clinic. The clinic may have as many affiliations as necessary to meet the needs of the participants served. The physician (can be the existing health care physician) who supervises the participant's care does not have to deliver this service on-site.

This concludes my presentation on Docket 16-0309-0311. The department requests this Committee to extend these temporary rules with the condition that the Department proceed with the proposed amendments.

These rules are necessary to accurately describe changes in provider roles and to ensure the safety of individuals receiving services under this benefit.

Representative Janice McGreachin had provided committee members with a letter regarding docket 16-0309-0311. She invited the committee to attend the House Health and Welfare Committee meeting on Thursday (01/22/04) in the afternoon as the House discusses docket 16-0309-0311. (See attachment #1)

The Mental Health Providers Association of Idaho President April Crandall, testified in opposition to Section 469 of docket 16-0309-0311.

Kelly Keele from the Mental Health Providers Association, testified in opposition to docket 16-0309-0311, and provided three handouts outlining his objections. (See attachment #2, #3 and #4)

Laura Seuri from the Mental Health Providers Association, testified in opposition to docket 16-0309-0311.

After a lengthy discussion and review of IDAPA 16-0309-0311, Chairman Compton determined to hold this rule and reschedule for an additional hearing later next week. The Chairman expressed the appreciation of the committee to the people who attended the meeting and those who presented testimonies.

IDAPA

16-0309-0213

This is a pending rule that the Division is asking this committee to approve. This same rule was presented last year as a temporary rule and the committee voted to extend it.

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 same 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 before you implements both the statutory amendment and court decision by:

• Removing state payment for abortions to save the health of the mother.



• Changing the two physician certification requirements to certification to one physician.

No comments were received opposing the rules, and no hearing was requested.

The department requests you vote to approve this rule.

EXCUSED:

Dr. Olsen of Mesa, Arizona, was elected to a six-year term on the AARP Board of Directors at the 2000 Biennial Convention. During the 2000-2002 biennium he served on the Board Governance Committee and the AARP Insurance Trust of the Health Care Options Program. He also continues to serve as chair of the Convention Program Committee.

Dr. Olsen retired in 1992 as President and CEO of Delta Dental Plan of California. Prior to that he was an executive director and managing editor of the Academy of General Dentistry and served in the United States Army.

Dr. Olsen has received numerous awards and recognitions including induction in the Delta Dental Association Hall of Fame, receipt of the first Hillenbrand Fellowship in Dental Administration and Volunteer of the Week from the Mesa Arizona Independent Newspapers.

Dr. Olsen stated, I'm pleased to have the opportunity to talk and brief you today about the new prescription drug benefit in Medicare. The historic passage of the Medicare prescription drug bill has created opportunities and challenges for MRP, its members and volunteers, but we also believe this has opened a new era of opportunity for Medicare beneficiaries throughout the country.

The law is 681 pages long-about the size of a big-city phone book--and that's what I'll be trying to summarize in the next few minutes. I'll do my best.

The benefit portion of the bill is worth about $400 billion over the 10-year period from 2006 to 2016. Four hundred billion is a very good down payment, it's a good start, and what we like about the legislation is that it puts this benefit into the structure of Medicare. Four hundred billion dollars, however, does not cover all of the need, and we'll be working in the years ahead to try to expand that commitment.

Given that, Congress had to make some choices about where the $400 billion was best spent, and they emphasized two areas, maybe three areas. The first was that they wanted to be sure that those with the greatest need, those at the lowest end of the income scale, were taken care of, and I'm going to talk about the low-income benefit.

Secondly, they wanted to be sure that people who had very high drug costs were taken care of. And third, we wanted to provide incentives to employers who provide retiree coverage to stay in the game, not to continue this trend that we're seeing in which employers drop coverage. So let me deal with those three areas and then I'll talk about the basic benefit itself that will apply to everyone.

With regard to low-income people who are at or below the federally defined poverty level, those folks have to pay no premium, they have no deductible, there is no gap in coverage. They get coverage from the first dollar up through whatever they have to spend, and all they face are co-payments of $1 for a generic drug or $3 for a brand-name drug. So for those at the very bottom of the scale, the coverage is actually excellent. It's virtually first-dollar coverage with the exception of very modest co-pays.

The next level is defined as 135 percent of poverty, and people between 100 percent of the poverty line and 135 percent of the poverty line have essentially the same deal that I've just described: No premium, no deductible, no coverage gap, no cap, and they have to pay co-payments of $2 for a generic drug or $5 for a brand-name drug.

For those between 135 percent of poverty and 150 percent of poverty as

federally defined, there is no premium. There is a $50 annual deductible. The co-payments are 15 percent of the cost of the drug, and there is no coverage gap.

All these co-pays are subject to asset tests. If a couple has assets of up to $9,000 they have the lowest co-pays. If their assets range from $9,000 to $20,000, they have higher co-pays. And couples with assets of more than $20,000 will pay the highest co-pays. This asset test will affect about 12 percent of the people in the low income categories.

So one thing we're pleased with is the low-income benefit, which is really quite generous and should allow people who are poor or near poor to get very good coverage of the drugs that they need.

I also said that the Congress made a very good-faith effort to try to take care of those who have very high prescription drug costs. And essentially above $3,600 in out-of-pocket costs, Medicare will pick up 95 percent of whatever remains. To give you a sense of what this means, one example would be that-let's take someone who has no drug coverage now and has $10,000 in prescription drug costs. If he has no coverage now, he is paying that full $10,000. Under this legislation he is paying about $4,000 and Medicare is picking up the other $6,000.

The subsidy that's provided in this legislation to employers to continue to provide good benefits is very important to us. Some of those employer plans offer a more generous benefit than is available in this package, and we want them to continue to do that. Right now employers are allowed to deduct the costs of those plans from their adjusted gross income, so they have a bit of a tax incentive to do it.

This bill, on top of that, adds a subsidy that pays 28 percent of the actuarial value of the drug benefit they provide, between $250 and $2,250. So that's pretty generous right there. It reduces their cost by about a third.

In addition, this bill makes that subsidy tax free, so that actually adds something. We are hopeful that this will keep those employers in the game in continuing to provide the kind of benefits that they provide now. And I should add, because there have been some expressions of concern, that that subsidy covers not just employers in the private sector but employers in the public sector as well.

So a state government employee or a teacher or anyone else who has retiree benefits through their public employment, those employers will receive the same incentive to continue to provide those benefits, as do private employers. And I think that's very important.

Now let me go to the shape of the benefit for people who are not in the lower-income categories that I described. Once again, this is not as generous a benefit as we would like. What we will see in this legislation, which takes effect in the year 2006, is a premium that will average $35. It may vary slightly depending upon the health costs in your particular region of the country but it should be $35 a month. In addition, they will have a $250 deductible. Once they have met that deductible of $250, from there up through $2,250, Medicare will pick up 75 percent of the costs of their prescription drugs. So it's pretty good coverage up too there: three out of four dollars will be reimbursed.

Most of this bill does not take effect until the year 2006, as I said. People don't have to make a decision until sometime in the fall, maybe November, of the year 2005. So they will have plenty of time to think about this and decide whether or not it makes sense for them. At AARP we're committed to continuing to provide additional information that people may want to take into account in making that decision.

And we actually have on our website now a quick benefit calculator that will let people interactively plug in the amount of what they expect their drug costs to be and then it will give them a sense of how much reimbursement from Medicare they will get under this legislation. And I'd urge folks to use that; it may save them a lot of pencil-and-paper work.

That calculator is very accurate. If you put in the amount that you expect to spend, it will tell you how much of that will be covered. Of course, the more difficult estimate is what you expect to spend. You've got to look at this a bit on the insurance principle. So people may want to feed in not the amount that they're spending now but the amount they want to protect themselves against with some coverage in the years ahead in making their decision.

There are a few provisions of this legislation that will actually go into effect this year. A drug discount card will be available. We haven't seen the final details on this. My guess is that that will give people about a 15 percent saving off retail price on the drugs they buy. That card should cost about $30. Once again, this decision is up to the individual.

Some people may be able to get drug discounts through other vendors outside of the Medicare approved ones that are just as good, and if so, they may want to take a pass on that. It's their decision. But I think for low-income residents, for low-income beneficiaries, there is an additional feature that makes this very good protection for them, and that is both for the 2004 and 2005, the low-income beneficiaries will receive a $600 credit on that card. It's like a debit card for those folks. They have $600 and can use that $600 to pay for their prescription drugs bit by bit until they exhaust the $600, and then they'll get the 15 percent discount.

On balance we think this benefit was well worth supporting. We think it is a good start to where we have to go. We think it will provide good immediate relief for low-income beneficiaries and for those with very high drug costs, and there will be some coverage for everyone else in the beneficiary population. If you spend, for example, in the course of the year, about $3,000 on prescription drugs, after 2006 you'll get about $1,500 of that covered, and that I think makes it worth doing at that level.

So, on balance, great start. We've been trying to get this for more than 10 years. Congress has rolled the boulder up the hill several times only to have it slip away, and I think we finally got it over the hump and it can only get better from here.

Our goal is to make prescription drugs more affordable and this is one major piece. It's a piece that we're going to try to improve over time, but the other thing is we're going to be working on a lot of other things to try to make prescription drugs more affordable for seniors, any number of things: free notification plans, bulk buying plans, trying to help reimportation workable.

So I want you to know we're going to continue this and we're going to continue trying to fight to make prescription drugs more affordable.

Dr. Olsen thanked the committee for allowing him the opportunity to meet with them today.

The purpose of this bill is to delete county jails and state correctional facilities from the requirements of the Idaho Food Code. This code, enforced by the Idaho Department of Health and Welfare, is designed to apply to restaurants and other private and public food service entities. State correctional facilities and county jails have their own rules and regulations pertaining to service of food within correctional facilities and jails that are better designed to meet their needs. Implementing Health and Welfare rules on food service would create a significant financial burden on the state and on county governments that would require additional funding from the state general fund and local property taxpayers. This bill will avoid that unnecessary burden.

This bill has no adverse impact on the general fund or on county budgets.

16-0309-0305

To promote and protect the health and safety of Idahoans the Department is committed to continually improving systems and process used to identify the right level of care and services required by Medicaid participants in Nursing Facilities.

The Uniform Assessment Instrument is the tool used by the Department to assess whether or not a participant requires Nursing Facility level of care. This tool is criteria based, objective instrument that reflects the participants' physical and mental functional capacity and limitations.

The scoring system for the Uniform Assessment Instrument was quantified for scoring levels of care for supervision. The rules are being amended to reflect current practice and to assure services on the Uniform Assessment Instrument are consistent. This change will promote consistency throughout the Department and help assure those participants are receiving the level of services they require.

This rule docket was published in the August Administrative Bulletin. Two positive written comments were received. Legislative Services had no technical, substantive, or procedural concerns with these pending rules.

This concludes my presentation on rule docket 16-0309-0305. I respectfully ask the committee to adopt this pending rule as final. I will be glad to answer any questions from the committee at this time.

16-0309-0309

The purpose of this docket is support the January 20, 2004 Department's commitment to providing both the right price for services and the right services for participants. Additionally, we want our rules that govern our services to be clear to all stakeholders. This docket includes two different Sections of the Medical Assistance rules, Section 121 and Section 146.

Idaho Medicaid has used the same reimbursement methodology as Medicare for Ambulatory Surgical Center. Medicare has recently changed their methodology for reimbursing these facilities and this change is not compatible with Idaho Medicaid's automated system. The Department will continue to use the historic reimbursement methodology instead of the new Medicare methodology. The reference in Section 121 of the rule to Medicare's methodology has been deleted.

The second section of rule being addressed in this docket deals with Personal Care Services. Section 146 of the Medical Assistance rules, was deleted completely and the entire section was reorganized and rewritten in plain language based on ongoing input of staff and provider. In response to public comment a new subsection was added to permit agencies to use a software system allowing personal assistants to register their start and stop times and maintain a list of services they provide by placing a telephone call to the agency system from the participant's home. This does not replace the documentation requirements of these rules.

This rule docket was published in the October Administrative Bulletin. Legislative Services had no technical, substantive, or procedural concerns with these pending rules.

This concludes my presentation on rule docket 16-0309-0309. I respectfully ask the committee to adopt this pending rule as final.

16-0309-0307

16-0313-0301

16-0323-0301

16-0411-0301

16-0417-0301

These dockets all relate to the new chapter of rules provides a coordinated and comprehensive process for Idaho Medicaid to prior authorize Developmental Disability (DD) program services for eligible adults.

• 16-0323-0301 - This rule change supports the implementation of the Department's new prior authorization process for Developmental Disability (DD) services. The rule change identifies the standard for the Department to assess individuals with a developmental disability for determination of eligibility and participant budget for services.



• 16-0411-0301 - These rule changes support the implementation of the Department's new prior authorization process for DD services. The rule changes establish the requirement for Developmental Disabilities Agencies (DDAs) to obtain prior authorization for DDA services for all adult participants. They also require DDAs to submit Provider Status reviews semiannually and annually.



• 16-0417-0301 - These rule changes support the implementation of the Department's new prior authorization process for DD services. The rule changes establish prior authorization for Residential Habilitation Agency services. They also require Residential Habilitation agencies to submit Provider Status reviews semiannually and annually. In response to comments received from the Board of Health and Welfare, testimony presented at public hearings, and written comments submitted by the public and Department staff, several clarifications and additions were made to the temporary rule. This is a companion docket to 16-0313-0301.

EXCUSED:

16-0309-0308

No public hearings were held. Two (2) positive written comments were received.

This docket of temporary and proposed rule deletes section 204 (pg.268) which describes the Surveillance and Utilization Review (SUR) Committee. This committee functioned to review instances of suspected fraud, abuse, and misconduct and make recommendations concerning corrective actions such as suspension of payments or provider agreements. We maintain that the deletion of this section in these rules removes "an important check and balance necessary for making critical judgments that may tremendously impact the very existence of provider entities that are the subject of such allegations, and the livelihood of the people they employ in reliance on their provider agreements.

Section 208 (pg. 269) Suspension of Payments Pending Investigation has been amended to state "The Department may suspend payments in whole or in part in a suspected case of fraud or abuse pending investigation and conclusion of legal proceedings related to the provider's alleged fraud or abuse."

"Suspect" is defined in Webster's dictionary as "To consider to be guilty without proof."

"Alleged" is defined as "To assert without proof."

Section 208.01 Basis of Suspension of Payment states in part "When the Department through reliable evidence suspects fraud or abuse . . . Medicaid payments may be withheld or suspended."

Since the determination of what constitutes "reliable evidence" at the

investigation stage is a subjective determination at best, and the Surveillance and Utilization Review (SUR) Committee in section 204 has been deleted in this set of rules, these judgments will be at the sole discretion of the investigators alone. It is entirely reasonable to expect that the investigation team be required to appeal to a higher objective authority in providing sanction for these very critical suspensions. This not only serves to protect the rights of those accused, but also serves to protect and ensure the impartiality, accountability and credibility of the investigation's unit.

These rules also delete section 210 (pg. 269) which provides a process for Appeal of Immediate Actions such as suspension of payments or provider agreements. This section stated "the Department shall provide for a hearing within thirty (30) days of receipt of a timely filed notice of appeal." Section 224 of these rules clarify that appeals will be governed under the "Rules of Contested Case Proceedings and Declaratory

Rulings" in IDAPA 16.05.03 . . . As far as I can tell, there is no requirement for the Department to provide a hearing within any specific period of time. We believe that access to timely appeal hearings are also an important check and balance to ensure appropriate protections against arbitrary, capricious and dictatorial enforcement actions. Many providers would be financially ruined and unable to recover from these administrative processes within a few weeks let alone a month or more.

The way in which these pending rules are structured allows for the possibility that a provider accused of committing fraud or abuse could be summarily put out of business based on an unsubstantiated charge with no real recourse or due process rights during the interim. We suspect that there are many more instances of unfounded charges of fraud than complaints that ultimately result in convictions.

In summary, we agree that suspensions are in order in cases where a provider refuses to provide investigators with relevant records necessary to conduct their investigation. We have been under the understanding that this was a fundamental requirement of a provider of Medicaid-funded services all along. This refusal is an overt act that is an incontrovertible fact, as opposed to an unsubstantiated allegation. We disagree with the removal of timely due process protocols described in sections 204 and 210. We respectfully request that this committee amend this rule to restore sections 204 and 210. We also request that sections 208 and 209 be amended to require the approval of the Surveillance and Utilization Committee in cases where suspension of payments or the provider agreement are determined necessary to avoid immediate danger to the public health and safety. This concludes my prepared presentation on this docket.

Discussion: The motion as presented does not kill Docket 16-0309-0308, and a further review will be conducted at a later time.

The motion was carried by a voice vote.

16-0310-0203

reimbursement. The department requests that you, adopt this pending rule as final. Your committee approved this docket last year as

temporary.

As a result of the Governor's 3.5% holdback, we are paying hospitals 3.5% less each month. The Department is requesting that the Committee approve this Pending rule as final.

16-0310-0204

approved this docket as temporary, last year and the department

would now like you to adopt this pending rule as final.

This rule changes how Medicaid pays for wheelchairs for residents of Intermediate Care Facilities for the Mentally Retarded, also known as ICFs. This rule was changed following negotiations between the Department and the ICF industry.

Medicaid -under these rules- directly pays Durable Medical Equipment Suppliers instead of paying the ICFs who previously purchased the wheelchairs. This change has three positive effects:

It eliminates the cash flow problem experienced by small ICFs when a resident requires a highly specialized and expensive wheelchair.

Since Medicaid purchases wheelchairs directly from the suppliers,

costs are reduced because Medicaid reimbursement is less than the retail prices that ICFs paid.

The participant is more readily accepted for admission into the small facilities and keeps the wheelchair, no matter if he moves between facilities or into a community placement.

The Department is requesting that the Committee to approve this

pending rule as final.

16-0310-0301

This rule explains that out-of-state nursing homes are reimbursed using the same rate they receive from the Medicaid program in their home state. Other minor clarifying language has been added to improve understanding of this reimbursement section.

In addition, this docket incorporates Title 42 of the Code of Federal Regulations, Part 447, entitled "Payment for Services," and the Medicare Provider Reimbursement Manual into these rules.

16-0310-0302

This docket changes how monthly Medicaid payments are paid to hospitals in order to lessen the effect of overpayments and under-payments. The change will improve the accuracy of payments during the course of the year rather than waiting until cost settlement which often occurs two-years after the interim payments are made. The change will improve cash flow for the Department.

The change only affects those hospitals where payments vary by more than $100,000 on their most recent cost report. The Department is requesting that the Committee approve this rule.

16-0310-0303

reimbursement methodology. The department requests that this committee adopt this pending rule as final.

This rule clarifies four sections in Chapter 16.03.10. The first section clarifies the occupancy adjustment factor. The clarification is to specify that the property rental rates are not included in the total property costs for the occupancy level calculation.

The second section clarifies the extension of the effective date for a special rate.

The third section clarifies that all financial reports are subject to audit.

The last section clarifies the process regarding amending Disproportionate Share Hospital surveys, otherwise know as DSH.

16-0317-0301

the Department is seeking your approval of docket 16-317-0301. This docket is being presented as a pending rule and applies to Medicaid policy for case management services referred to as service coordination.

This docket is a rewrite of the current four (4) sections of Medical Assistance rules pertaining to case management services for Individuals with Developmental Disabilities; individuals receiving Personal Care Services; Individuals with Mental Illness, and for children who meet certain medical criteria.

The rewrite of these rules combines all four (4) sets of rules into one section. The combination and standardization when possible of all rules governing case management services reimbursed by Medicaid is part of our effort to make our rules more consistent, understandable and accessible to providers.

The chapter defines the requirements for all common functions of case management as well as specific requirements for each type of eligible participant group. This includes eligibility requirements; case management functions; availability and access to services;

provider qualifications; agency responsibilities; required documentation and payment for service limitations.

This rule rewrite was developed during a negotiated process that involved:

1. Medicaid participants who receive each of the four types of case management services;

2. Case management and other interested provider associations;

3. Advocacy groups

4. Individual Service Coordinator's from Service Coordination agencies.

This concludes my presentation to the Committee on this docket. I respectfully ask the committee to adopt this pending rule as final.

EXCUSED:

16-0311-0101

I am before you today to review a temporary rule Docket Number 16-11-0101. The Department is asking to be extended for a year.

This temporary rule sets a cap on beds in community intermediate care facilities for persons with mental retardation at 486 beds. Of that 486, 12 are reserved for time-limited emergency use.

The Department is before you requesting extension of the ICF/MR 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. I am not aware of concerns from any other group.

16-0322-0301

We are requesting that the committee recommend adoption of these pending rules.

There are three changes to these rules:

Subsection 428.01 is being amended to cite to the Board of Nursing rules without referencing specific sections due to changes made to those rules.

Subsection 428.02 is being amended to delete a process which conflicts with the Board of Pharmacy rules.

During the 2003 Legislative session House Concurrent Resolution 17 asked that the Department and the Board of Pharmacy develop rules to allow the return of unused, unopened medications to the dispensing pharmacy for credit. Stakeholders (Trade Associations IDALA, IHCA,

and Pharmacy) and providers were involved in the development of the process and rules.

Subsection 428.04 is being amended to allow residential care and assisted living facilities to return unused or unopened medication to the dispensing pharmacy for credit.

The Residential Care Council for the Elderly and the Board and Care Council voted unanimously to support the rules during the October meeting.

The Board of Health and Welfare approved the rules in their November meeting.

There were two positive comments received. No negative comments and no request for hearing. We respectfully request that the committee recommend adoption of these pending rules.

Michelle Glasgow , executive director of the Idaho Assisted Living Association testified the Association does support the rules with some clarification. The Association has concerns with Section428.02, Medication Distribution System - Each facility shall use Medi-sets, or blister pack, or other system as approved by the department. The Medication System must be filled by a pharmacist and appropriately labeled in accordance with pharmacy standards. "A licensed nurse may fill Medi-sets which must be appropriately labeled with medication name, dosage, amount and time to be taken, and special instructions if appropriate."

Jim Alexander, a pharmacist from Mountain Home, testified in support of the deletion of that section of the rule. He explained the liability involved and the responsibility of a pharmacist in repackaging medications.

16-0309-0214

The purpose of these pending rules is to improve and protect the health status of our participants through the provision of quality care. These rules will allow Medicaid to provide our participants with the most effective drug at the right price through a variety of pharmacy management tools.

Idaho Medicaid, like many other state Medicaid and commercial pharmacy benefit programs, has implemented a variety of pharmacy management processes . . . tools. These common management

strategies include generic substitution requirements, prior authorization of drugs and coverage limitations like limits on quantities per prescription and early refills. This rule docket provides for the tools that support appropriate management of the Medicaid pharmacy program. These

pharmacy management strategies are already standard practice in commercial health insurance plans.

These rule changes also allow Medicaid to make decisions based on objective scientific information. This objective scientific information (commonly referred to as evidence-based reviews) will provide the clinical foundation and support for our pharmacy management processes. Medicaid will encourage the use of effective medications at the best price through these management tools. The purpose of this rule docket is appropriate access.

In December 2003, Medicaid processed nearly 217,000 prescriptions. Less than 1,400 required any type of prior authorization. Less than one-half of 1-percent of the prescriptions processed through Medicaid. Approximately 75 percent of those that needed prior authorization were

approved.

Idaho paid $128 million for Medicaid prescription drug benefits in fiscal year 2003. In fact, Prescription drugs were the second most expensive Medicaid benefit following hospital services and accounts for 15% of the Medicaid budget. However, the combined effect of these rule changes helped to avoid an estimated $20 million in pharmacy costs in state fiscal year 2003 and an overall cost avoidance of $32 million in pharmacy costs since 2002 when these rules were initiated.

Amendments to the temporary rule docket were made following legislative approval. The amendments are based on comments received in the public hearing, testimony presented before the Senate Health and Welfare Committee and negotiations during the 2003 Legislative session. For example, as requested the Department has included two new subsections that provide for a 72-hour supply of a covered drug in an emergency and states that the Department will respond within 24 hours to a request for prior authorization.

These rules provide important tools that allow us to continue the delivery of quality care to our Medicaid clients by providing the most effective drug at the right price. Overall these rules will help Medicaid improve the health of our participants by delivering quality care and managing costs.

The Department requests that the Committee approve the rules in Docket 16-0309-0214 as final.

Stan Gibson, a pharmacist in Nampa and past president of the Idaho Pharmacy Association, testified to support Docket 16-0309-0214.

Rick Sutton, a pharmacist for Shopko stores, testified to support Docket 16-0309-0214, and requested the committee to approve the rules.

Clyde Dailey, state director for AARP Idaho, testified and submitted the following written comments.

Jim Alexander, an independent pharmacist in Mountain Home, testified in support of Docket 16-0309-0214.

Clyde Dailey testified and explained that on behalf of AARP Idaho's 150,000 members I wish to thank you for this opportunity to testify before you today. AARP has long advocated for quality medical care. As the Committee is well aware, prescription drugs are an integral factor in the effective treatment and prevention of disease. As such, there is a wide range of drugs available which purport to treat the same condition.

After careful review of Idaho Department of Health and Welfare Medicaid rules that will permanently establish its Enhanced Prior Authorization Program, AARP Idaho supports this rule. This unbiased, scientific approach identifies the most effective drugs in today's health care market and protects the safety of the consumer.

Jim Baugh, executive director of CO-AD (Comprehensive Advocacy Group), testified about Docket 16-0309-0214 and Docket 16-0309-0303 at the same time. He did not ask the committee to reject the pharmacy rules, but did sound a cautionary note about this particular type of activity. He is concerned about the increased cost of drugs and prior authorization.

Dan Fuchs, submitted the following written comments to support the pharmacy rules: His written comments are:

I am a member of the Idaho Board of Health and Welfare, and I have been a licensed pharmacist in Idaho for 17 years.

My family owns and operates five (5) pharmacies in the Twin Falls area. Our five pharmacies serve thousands of Medicaid clients annually, and that number grows every year. I have watched Idaho Medicaid struggle to meet the rapidly increasing demand for prescription medications. And, I have watched the cost of those medications rise just as quickly.

Medicaid has correctly recognized, in my opinion, that only a carefully managed pharmacy program can effectively deal with this problem. Medicaid has taken steps that will give the state the opportunity to manage costs and still make sure Medicaid patients receive the important medicines they need.

I urge the committee to approve the rules that allow the Medicaid Pharmacy Unit to manage the prescription program.

One of the issues you are looking at is the rules' docket for operation of the prior authorization program. The prior authorization program creates a little more work for me, but the value I get from the program, as a taxpayer and a pharmacist, is far more important. The prior authorization helps Medicaid manage costs and still deliver needed medications for clients. I do not see it as a roadblock to good health care, but using the same practices as private health insurers.

The prior authorization process is fast and barely noticeable to my customers. Medicaid pharmacists are quick to respond if there are problems.

I understand that the program has saved the Department millions of dollars. I ask that you support this important program by approving the rules before you today.

Jeffrey K. Edwards, MD, St. Mary's Clinic in Cottonwood, submitted written comments to support of the pharmacy rules. His written comments follow:

As a licensed family practice physician here in Idaho, I strongly urge you to support the proposed pharmacy rules currently under review by the committee.

As a doctor in a small rural Idaho community, I want to talk to you briefly about the importance of a Medicaid pharmacy prior authorization program. You may know it as the Enhanced Prior Authorization Program, but whatever its title, it is extremely valuable to me as a physician and most importantly to my clients.

The pharmacy rules for the Enhanced Prior Authorization Program (EPAP) ensures the best health outcome for Medicaid clients by selecting the most effective drug at the right price.

The prior authorization program has three main components:

• Evidence-based clinical review process
• A pharmacy and therapeutics committee
• An automated system called SmartPA that reviews prior authorization requests in seconds, making the process quick and convenient to pharmacists and doctors; and transparent to the Medicaid client.

The prior authorization program is a tool, working in conjunction with the Pharmacy and Therapeutics Committee, prior authorization gives health care professionals, like me, the information we need to ensure that Medicaid clients receive quality care at the best price. It provides physicians with the latest research on the efficacy and safety of drugs. It promotes something we call best practice medicine . . . or the best use of pharmaceuticals in patient care. And, it still provides me with the flexibility to prescribe the medicine my patients need.

The Division of Medicaid has made successful efforts to streamline the prior authorization process. In fact, virtually all my prescriptions for Medicaid clients pass through the system without delay. If a prior authorization is needed, it only takes minutes to submit the necessary information for the request.

I strongly encourage you to support this program because it provides the basis for quality care at the right price for Idaho's Medicaid clients.

16-0309-0303

I am here today to present pending rules regarding the Medicaid

Pharmacy Program in Docket 16-0309-0303. The Department is requesting these pending rules be approved as final.

One of the Department of Health and Welfare's goals is to improve the health of Idahoans. Medicaid provides services to some of the most vulnerable Idaho populations--elderly, children, and people with disabilities. The goal of the Medicaid Pharmacy Program is to provide quality care to Medicaid participants with the most effective drug at the right price. This rule change promotes the health and safety of Medicaid participants by assuring that objective research plays a primary role in our prescription drug program.

The rule supports the use of the most current expert objective research. This objective research, also known as evidence-based reviews, compares the relative safety, effectiveness and clinical outcomes of medications within a group of similar medications or drug class.

Evidence-based information allows the Department to make prior authorization and other program related decisions based on good science. Idaho Medicaid has joined with other states and countries to obtain current evidence-based drug class reviews from the Center of

Evidence-based Policy at OHSU. Dr. John Santa will provide further information regarding the Drug Effectiveness Project in a moment. The main point is that the use of national credible evidence-based reviews allows the Department to "globalize the evidence and localize the decision."

To localize the decision, the Department builds on the knowledge and expertise of fellow Idaho medical practitioners. This rule describes the membership, appointment and responsibilities of the Medicaid Pharmacy and Therapeutics Committee. This Committee is made up of practicing Idaho physicians, pharmacists, and health care practitioners (such as

Nurse Practitioners or Physician Assistants) who currently prescribe medication for our Medicaid clients. One of the Committee's roles is to make recommendations to the Department regarding the Enhanced Prior Authorization Program. Specifically, this Committee recommends which medications will not require prior authorization within a group of equally effective medications; thus, localizing the decision of the most effective drug after a global evidence-based review.

Additionally, in an effort to obtain the right price for medications paid for by Idaho Medicaid, this rule adds guidelines for a supplemental rebate program. Supplemental rebates will enable the Department to purchase prescription drugs in a cost-effective manner. Supplemental rebates will be in addition to rebates Medicaid currently receives. Supplemental rebates allow for price competition to occur after a thorough scientific

( evidence-based) review.

This rule change is based on comments made during the Public Hearing, 2003 Legislative rules presentations and meetings with a Legislative Task Force regarding the previous Docket No.16-0309-0214, dealing with pharmacy management tools. This rule was amended in response to information received during the comment period and consultation between the Legislative Task Force and Department staff.

Above all, through the use of evidence-based practices, establishment of a Pharmacy and Therapeutics Committee, and a supplemental rebate program, we will assure that objective research plays a primary role in our prescription drug program. Our program provides Medicaid participants with the most effective drug at the right price. The Department requests that the Committee approve the rules in Docket 16-0309-0303 as final.

John Santa, MD, a specialist in Internal Medicine testified and presented a project overview of drug effectiveness, a project of the Center for Evidence-based Policy, Oregon Health and Science University.

Dr. Santa explained he spends most of his time on the project, the Drug Effectiveness Review Project that I would like to briefly familiarize you with.

This project provides Idaho and other participating organizations with the most current, comprehensive, rigorous review of evidence regarding the comparative effectiveness and safety of selected prescription drugs. It does so in a way that is independent, scientific, and objective enabling local decision makers to evaluate all of their decision options.

The project is a collaboration of private and public purchasers, like Idaho, who think it best to do this information gathering step together. Each Participant, including Idaho, has a vote in selecting the drugs to be reviewed and identifying the key questions regarding these drugs. The project will be guided throughout by local decision makers with input from stakeholders in their state or organization.

The Center for Evidence-based Policy provides support to the Project by facilitating the collaboration, including contracting with Evidence-based Practice Centers to review and report on the drugs and key questions identified. Evidence-based Practice Centers (EPC) are designated as such by the federal government (Agency for Healthcare Research and Quality) as centers of expertise in studying important and difficult health issues in an independent, scientific, objective way. The EPC searches and sifts the world's information bringing order to what otherwise can be a very chaotic and complex process.

Let me share an example of the sort of information dilemma facing all of us that this process better informs. See ACP Journal Club, January 2004, "Carvedilol was more effective than metoprolol tartrate for lowering mortality in chronic heart failure."

I have attached a more detailed paper summarizing the key elements of systematic reviews. Such a review would find as many studies as possible like the one I have just shown you, look at all the important details in each of those studies and synthesize them. The Project would also update the reports every six (6) months to keep the information current. The commitment to regularly update is unusual in American scientific efforts. Additional detail is also attached on the process for systematic reviews. (See Attachments #1, #2 and #3)

Clyde Dailey, state director of AARP, testified to support Docket 16-0309-0303.

Peter Kozisek, MD, medical director of the Family Practice Medical Center in Boise, testified to support Docket 16-0309-0303. He has been very impressed with the work Medicaid has done throughout the past several years on this program. He has found the Medicaid staff very helpful, very efficient, and very accessible to physicians. The department has a very efficient and cost-effective Medicaid unit.

Roseanne Hardin, J.D.,LSW, submitted the following written comments:

As the current chair of the Board of Directors of the National Alliance for the Mentally Ill-Boise Affiliate, NAMI-Boise, I am writing to recommend that your committee not approve the above identified temporary and proposed rule as proposed by the Department of Health and Welfare as written. Our organization, made up of consumers of mental health services and family members of persons with serious and persistent mental illness, has grave concerns that this move to a prior approval/formulary approach will place persons in danger, and in so doing, greatly increase the cost of medical services required by these persons.

As you know, nearly one in five Americans at some point in their lives will be personally impacted by mental illness and nearly all of us have a family member or close acquaintance who is negatively impacted by mental illness. We all know that mental illness is caused by a chemical imbalance in the brain. We no longer believe mental illness is caused by bad parenting or lack of will power or initiative. The additional good news is that treatment, including psychotropic medications, do work and recovery is possible.

Older psychotropic medications, which are less costly, even when seemingly chemically effective, do generally have significant side effects which impact the patients' ability to tolerate the drug. People cannot tolerate these side effects and stop taking these drugs. Newer generations of medications are often more tolerable to patients as they do not result in the patient being "spaced out," fidgety, without sexual drive, and lessen the very common weight gain which may be dangerous to physical health. No medication works if it is not taken by the patient.

We at NAMI-Boise request that the proposed rules be amended to create a "mental health carve out" that would allow for final determination in the prior approval process to be left with the prescribing medical care provider, the individual who actually knows and works with the patient. Absent this fundamental patient-care provider right, it is likely fewer persons with mental illness will take, tolerate, and thus benefit, from the medications covered by Medicaid for their mental illness.

Medications that are not taken are a waste of money. Psychiatric crises that may have been avoided with appropriate medications, and the ensuing cost to all community, county and state systems are also a waste of money, but more significantly, a waste of human dignity and spirit.

It is recommended that the sections of Medicaid rule addressing prior authorization of pharmaceuticals in IDAPA 16.03.09.810.e and 814 be amended to create a "mental health carve out" which would allow final determination of the appropriateness of Medicaid covering the cost of the prescription be retained by the care provider who prescribes the medication, not the P&T (Pharmacy and Therapeutics) committee or a physician employed by the state agency.

It is certainly recognized by NAMI-Boise, that the Legislature has a duty to be prudent in the approval of publicly funded medications for persons in our State. The Legislature also has the duty to be compassionate and wise; two values not conflict in this instance. To be effective, medications must be able to be tolerated. If you have a loved one with mental illness, the best medication is the one that is effective to control symptoms and not create side effects that can't be tolerated.

Please consider these issues in review of these rules.

16-0611-0301

This docket had no hearings and two positive comments. The intent of these rules will make them more consistent and understandable, in particular by adding clarification around the word parent and certified adoption professional.

We had made some changes to the word parent in a previous docket through an omnibus clerical correction. Upon further review we needed to add better language around the word parent and other grammatical changes were incorporated. The addition of the term certified adoption professional was added and clarifications of the sections related to that

term was edited. Again, I would ask that the committee consider adopting these pending rules as final.

16-0601-0401

chart on page 82, there is a modest increase in the rate foster parents are reimbursed for the care they provide to the state's most vulnerable children. Although financial incentives are not the most important factor in recruiting and keeping foster parents, and Idaho's rates are still below the national average, your efforts at increasing the reimbursement rates are appreciated by Idaho's foster parents.

I would again ask that the committee consider extending these temporary rules.

EXCUSED:

If adopted, the Senate and House of Representatives concurring therein, that IDAPA 16.03.01, Sections 346, 347, 348 and 349, rules of the Department of Health and Welfare relating to eligibility for Medicaid for families and children, adopted as pending rules under Docket Number 16-0301-0302, be, and the same are hereby rejected and declared null, void and of no force and effect. This concurrent resolution has no fiscal impact.

The purpose of this bill is to delete county jails and state correctional facilities from the requirements of the Idaho Food Code. This code, enforced by the Idaho Department of Health and Welfare, is designed to apply to restaurants and other private and public food service entities. State correctional facilities and county jails have their own rules and regulations pertaining to service of food within correctional facilities and jails that are better designed to meet their needs. Implementing Health and Welfare rules on food service would create a significant financial burden on the state and on county governments that would require additional funding from the state general fund and local property taxpayers. This bill will avoid that unnecessary burden.

This bill has no adverse impact on the general fund or on county budgets.

Richard Schultz, Administrator of the Division of Health for the Department of Health and Welfare testified and had no objection to SB1215.

16-0603-0301

He explained he is here to discuss Docket 16-0603-0301 with pending changes to the Rules and Minimum Standards Governing Alcohol/Drug Abuse Prevention and Treatment Programs. He explained, I am asking you to adopt these pending rules as final.

Our mission at Health and Welfare is to promote and protect the health and safety of Idahoans . . . in my part of the department we focus on substance abuse. A year ago, this committee approved temporary rules that standardized treatment for Drug Court participants. These rules are now accepted in courts and communities across the state.

We distributed the temporary rules to all approved alcohol/drug treatment providers, drug court coordinators and trial court administrators. We received two (2) comments throughout the year that did not necessitate additional changes to the rules.

We are excited about our partnership with the Idaho Supreme Court to continue the success of the Drug Court Program in Idaho. We again ask that you adopt these pending rules as final.

16-0613-0301

and

16-0613-0302

Community Services, Department of Health and Welfare.

She explained, I am here today to present rule changes to Docket Number 16-0613-0301, a pending rule for which I am seeking adoption of the repeal of the entire chapter. Docket 16-0613-0302 is the pending rule for which I am requesting adoption and final approval for Emergency Assistance for Families and Children. No hearings were held and no comments were received on these rule changes.

Part of our mission at Health and Welfare is to prevent child abuse, neglect and out-of-home placement of children. This non-substantive rule change helps us do that by standardizing the use of Emergency Assistance funds we use to help families address immediate crises that put children at risk.

First, the pending rules will allow direct service providers in all Department programs, not just licensed social workers in Children and Family Services, to authorize these one-time funds on behalf of families. This expedites the responsiveness of the Department to resolve the families, emergency conditions, precisely when timeliness is critical to child safety and well-being. This also increases our ability to intervene early and divert families from a longer term and more intrusive services such as Child Protection or Temporary Assistance.

Additionally, these rules specify the types of Emergency Assistance services that are to be available statewide. This clarification assures that children at risk and their families receive individualized services, based on their presenting needs and it assures that this array of emergency services is consistently available, regardless of where the family lives in the state.

The Department of Health and Welfare is charged with providing families in crisis with timely, appropriate and accessible services in order to preserve the safety and stability of vulnerable children. The rule changes and clarifications before you will help us in achieving this important

outcome.

16-0614-0201

16-0501-0301

and

16-0501-0302

This pending rule, Docket 16-0501-0301, pertains to the protection and disclosure of the Department's records. This docket repeals the current chapter of rules and is being rewritten in Docket 16-0501-0302, which will comply with HIPAA (Health Insurance Portability and Accountability Act) requirements.

Dr. Payne explained this Docket 16-0501-0302, is a pending rule and is adopting a new chapter of rules to govern the disclosure of Department records. The new rules specifically comply with HIPAA requirements. These rules have been extensively reviewed and in some cases amended after they were initially published in April as temporary rules. Access to documents is extensively regulated by state and federal law. These rules implement those laws.

EXCUSED:

Docket No.

16-0614-0201

This rule was presented to the Legislature during the previous session as temporary. I am here today to ask you to adopt the pending rule as final.

Three hearings were held on these rules. There is a typographical error on the summary page in you binders. All hearings were held in December 2002. No written or verbal comments were received.

The first change in the rules is to require permittees to pay outstanding fines prior to renewal of the annual permit. The state auditor recommended this change be made to improve the rate and timeliness of fine payments. The change will increase permittee awareness of the

law, and the need to comply with the law.

A technical change was also made changing the date used in the formula to determine the number of inspections.

I request that you adopt these pending rules as final to provide the Department clear authority to enforce tobacco inspections and collect fines from retailers who sell tobacco to our minors. It continues to be a vital building block in the efforts to keep Idaho minors safe and drug-free.

A brief discussion was held about the number of penalties and fines; the federal block grant; enforcement efforts to prevent young women and young men, under age 25-years, from using tobacco products; the removal of cigarette vending machines, working with Idaho's Indian Tribes and law enforcement authorities, and changing the word "shall" to "must."

27-0101-0205

Docket 27-0101-0205, relates to controlled substance prescription forms authorized by House Bill 331.

This rulemaking recognizes revised controlled substance prescription forms authorized by House Bill No. 331 in the 2001 legislative session, as well as Senate Bill No.1417 in the 2002 legislative session. The proposed rule changes outline the requirements for controlled substance prescription blank forms, as well as discipline to be assessed by the Board of Pharmacy in the event practitioners fail to follow the requirements of statute and rule with respect to controlled substance prescription blanks.

Robert Seehausen, Chief Executive Officer of the Idaho Medical Association (IMA), testified he has no problems with the rules.

Dr. James Scheel, from the IMA reported he has no objection to the rules.

27-0101-0302

The current rule treats "preparations containing ephedrine or salts ephedrine" as prescription drugs. The proposed rule sets out specific criteria for ephedrine products that can be sold without prescription. These criteria include maximum dosage requirements and label disclosure and warnings.

Fee Summary: Pursuant to Section 67-5226(2), Idaho Code, the Governor has found that the fee or charge being imposed is justified and necessary to avoid immediate danger. An immediate danger is inherent in ephedrine products if they are sold in dosage amounts in excess of the rule or containing synthetic rather naturally occurring ephedrine alkaloids. The fee charge under this rule is necessary to fund testing of these products to ensure compliance with the requirements of the rule.

Mr. Markusen asked that this rule be made final.

27-0101-0303

This rule change allows return and use of unopened and unused drugs. This change responds to House Concurrent Resolution (HCR) No.17 directing the Board of Pharmacy and the Department of Health and Welfare to develop necessary statutory and rul changes to allow the return and use of unopened and unused drugs.

Section 156.02 - Defines the annual report of the registered pharmacist-manager.

Section 156.03 - Defines the responsible pharmacist manager.

Section 156.04 - Defines the responsibility of the pharmacist manager.

Section 156.05 - Defines the return of drugs or other items. In the interest of public health, drugs, medicines, sickroom supplies, devices and items of personal hygiene shall not be accepted for return by any pharmacist or pharmacy after such drugs, medicines, sickroom supplies, devices and items of personal hygiene have been taken from the premises where sold, distributed or dispensed, except that unopened "Unit Dose" packaged medications for in-patient of residential or assisted living facilities, licensed skilled nursing care facilities, and hospitals may be returned to the dispensing pharmacy for credit provided the medications are liquid medication that have been supplied in manufacturer sealed containers and remain unopened, or the medications are in unopened "Unit Dose" packaging. In addition, the following conditions set forth in Subsection 156.05b.

HCR No.17 was passed during the 2003 legislative session, and this rule does comply with HCR17.

A discussion was held regarding these rules of the Board of Pharmacy and a possible conflict with the rules of the Department of Health and Welfare's Medicaid rules work together, long-term care facilities, the safety of drugs, and a pharmacist's option to refuse to accept the returned drugs.

27-0101-0304

This rule change expands the list of acceptable pharmacy references which are part of the required library in each pharmacy. This change is necessary to implement an expanded list of acceptable pharmacy references now recognized by the Board of Pharmacy.

Section 152.01 - Required Books - The latest edition and supplement(s) of the following: Idaho Pharmacy Law and Rules; A current pharmacy patient counseling reference; Facts and Comparisons; one (1) of the following current pharmacy references - Facts and Comparisons, Clinical Pharmacology, Micromedex: and one (1) other current pharmacy reference of your choice (book or computer diskette).

19-0101-0301

The Board of Dentistry's pending administrative rules are intended to accomplish the following matters:

• To incorporate the American Dental Association's Principles of Ethics, Code of Professional Conduct and Advisory Opinions ("Principles of Ethics") by reference into the Idaho Board of Dentistry's professional standards. A copy of the ADA's Principles of Ethics is included in these materials. The ADA's Principles of Ethics address such areas of dental practice as patient self-determination, patient confidentiality, standards of care and dentist veracity. The ADA's Principles of Ethics are currently applicable to all Idaho dentists who are members of the Idaho State Dental Association or the American Dental Association. A violation of the Idaho Board of Dentistry's professional standards can result in disciplinary action against a dental licensee. See Attachment #1)



• To specify those dental specialties which are recognized and licensed by the Idaho Board of Dentistry. The Idaho Board of Dentistry currently licenses six (6) dental specialties and the Board members determined that those specialties should be expressly identified in the administrative rules.



• To define advertising terms and delineate what conduct constitutes false, misleading or deceptive advertising. At present, the Idaho Dental Practice Act [Idaho Code § 54-924(4) and (9)] specifies that false, fraudulent, misleading and deceptive advertising is proscribed and may provide grounds for disciplinary action against a licensee. Enforcement of the advertising provisions in the Idaho Dental Practice Act requires the Idaho Board of Dentistry to specify those matters that constitute impermissible advertising conduct.

Jerry Davis, Director of the Idaho Dental Association, reported the vast majority of dentist support the rules.

15-0120-0301

The proposed rule changes eliminate many existing requirements regarding the day-to-day operation of Area Agencies on Aging (AAAs). This will allow more flexibility in the AAA's provision of services to the elderly through implementation of consumer choice programs. These AAAs are not state agencies but are subject to federal laws and rules.

EXCUSED:

Steve Allred, Director of Idaho Department of Environmental Quality, gave the introduction of Suzanne Budge Schaefer to the Committee members. He stated the Review Panel consists of ten members: three representatives from state agencies, four from the community, and three selected by the Governor. Suzanne has an undergraduate and Master of Science degree in Geology. Her experience includes working on the US geological survey. She has spent time in Houston and Oklahoma on an oil patch. And she worked briefly at INEEL. She has been in Boise for 15 years and has been working mainly on regulatory environmental issues.

Senator Stegner addressed Suzanne asking if her other positions would conflict with this appointment. Suzanne did not believe there ever would be, however, if a case should come up she would be sure to disclose that information to the Governor, and would be replaced at his wish.

Senator Darrington gave a history of the Hazardous Waste Management Act, and the creation of the Hazardous Waste Advisory Panel. The Hazardous Waste Plan says the State of Idaho will not be more stringent than the Environmental Protection Agency (EPA) in regard to RICRA, and the RICRA amendments.

The Committee will vote on the Gubernatorial Appointment of Suzanne Budge Schaefer at tomorrow's meeting.

Senator Compton commented on the value and institutional memory of senior Senators who provide valuable insight to those in the Legislature, especially freshman Senators. He stated that Senators Darrington and Ingram have such extensive knowledge and experience, they are an example of why term limits are not a good idea.

Orville Green, Administrator, Waste Management Remediation, DEQ, referenced DEQ Annual Report 2003, on page 5, a discussion of the Underground Storage Tank program summary: federal rules that owners/operators must abide by, and the leaking underground storage tank program. Since 2000 DEQ has seen the completion of 226 leaking underground storage tanks, however, during the same time frame, 105 new leaking tank sites were identified.

Chairman Brandt asked how many tanks out of the 105 are still in use? Mr. Green stated 197 leaking UST were on record through July 2003. Mr. Green stated that 226 tanks have been cleaned up since 2000. DEQ maintains a running tabulation of active/non-active sites.

Chairman Brandt stated that a rule addressing primacy and new regulations for existing tanks was rejected by the Senate Resources and Environment Committee last year. He asked whether the new leaking tanks were a result of not having adequate regulations. The rule last year would've required an extra piece of equipment put on the tanks. Would these 105 tanks been required to have this piece of equipment? Mr. Green stated these tanks would have required this equipment, under the federal rules, several tanks were cited for not having this equipment. 17% of the facilities inspected were cited for this reason. The purpose for the UST rules is preventative, not responsive.

Last fall EPA, Environmental Protection Agency, enacted an aggressive inspection of UST in Idaho. Erik Sirs, Project Grants Officer for UST and LUST Programs, Enforcement Compliance Officer, EPA informed the Committee of the results of the inspections. He gave background of the UST program in Idaho, results of Idaho Initiative, and Significant Operations Compliance, a national measure that states how Idaho is doing.

The UST program has two components. The first component is prevention, compliance and enforcement which is federally run. The second is LUST which is state run.

The Idaho Initiative was developed due to previous years field experience indicated there was a low compliance rate occurring in the state. It is EPA responsibility to administer the compliance program within Idaho. Mr. Sirs brought in other EPA inspectors from around the region to assist in the project.

Chairman Brandt asked Mr. Sirs how many inspectors there were to perform the inspections as he told the Senate Resources and Environment Committee last year. Mr. Sirs stated that Idaho has one federal inspector and two for the Region.

Mr. Sirs stated the regional area selected for the project included: Idaho Falls, Pocatello, Couer d'Alene, and Boise due to large population centers and gave a large snapshot of the state. He tried to choose sites that had not been inspected before. Letters were sent out two weeks in advance indicating what information the inspector wanted to see when they came on the site. 94 inspections were performed. 20 facilities passed, 33 written warnings were issued (may have involved field citations) and 47 field citations with monetary penalties resulted. A total of 146 violations were recorded for the 94 inspection sites.

Mr. Sirs referenced a graph depicting Enforcement Results in various categories of pie charts.

Violations

• Insurance Related 8.4%
• Upgrade Violations 27.4%
• Corrosion Protection 13.7%
• Release Detection 49.5%
• Temporarily Out of Service 1.1%

Chairman Brandt recollected that nowhere in a written rule is it required, even federally, that sensors be included, it is strictly interpretation. Mr. Sirs stated the rules require two things for line leak protection: monitoring for catastrophic (3 gallons/hr.), and/or annual tightness test, monthly monitoring (electronic sensor), visual inspection (logging number in a chart). Chairman Brandt restated that if a facility had other equipment installed, monitored it properly, they wouldn't need the sensor. Mr. Sirs stated this was correct.

Mr. Sirs stated UST compliance is an issue of significant importance, ground water resources are the primary source of drinking water and EPA is the agency currently responsible for UST compliance. EPA has requested additional resources to conduct other inspections to see if the trend holds true. On the national level, the Energy bill is still in question, and the enforcement section could assist the state with resources.

Senator Compton asked for clarification on 3400 tanks available for review in the state. He asked if the 94 inspected were primarily service stations. Mr. Sirs stated they were. Senator Compton asked how he came up with selecting this two-percent sampling. Mr. Sirs stated it was at random, based on area, he looked for a large amount of facilities within a large area for the purpose of ease of use in conducting the quantity of inspections.

Chairman Brandt asked Mr. Sirs if he found a visibly leaking UST during his inspections. Mr. Sirs reported not one leaking tank was found.

Chairman Brandt referenced an Idaho Statesman article entitled "EPA inspectors find evidence of leaking fuel tanks in Idaho", which gave numbers that didn't coincide with the chart before the Committee at present. Mr. Sirs stated the numbers in the article differ slightly because of some last minute data that was entered into the current chart.

Senator Bailey asked for clarification on the citations issued during the inspections. Mr. Sirs stated that the citations issued were for violations of regulations not for contaminating the water.

Senator Darrington stated that the UST are just one type of problem that could spoil the water quality. He also asked whether there has been any study on the correlation between those violations and underground leaks.

He stated the important thing is that the Committee is assured and the industry is assured that the things checked have validity and make a difference to the whole program.

Discussion among the Committee members included: the fact that Idaho has no program; the facilities haven't been inspected before; the results are alarming, and is there any chance that those inspected didn't have the adequate records on hand; and what the state of Idaho needs to do to prevent ground water contamination from UST.

Senator Bailey asked what is entailed in the clean up of a site. Mr. Allred stated that the tank is ceased use, repaired or removed; contaminated soil around the tank is removed, but the most costly is what is in the ground water and removing it. $2.6 million was spent cleaning up these sites, some of the money was state funds. He stated the problem is with the lack of personal responsibility and accountability. He reiterated there is a need for a program to make people personally accountable.

Chairman Brandt stated there is a need to protect the water. He is frustrated with regulations that change all the time, what is good today isn't necessarily good tomorrow. He thanked the EPA for validating the direction last year when the inspection question was brought to the Senate Resources and Environment Committee. However, when the rule was before the Committee they were told there was one inspector, yet there were twelve inspectors, plus the administrative staff to handle the inspections. He stated the Idaho Statesman article made it sound like Idaho had fourteen leaking tanks, when in fact there were no leaking fuel tanks found at all.

Senator Kennedy stated that he didn't want the EPA or DEQ to think that this legislative body does not feel it should accept the responsibility to do a fair share in prevention responsibilities of protecting the ground water. He stated it was necessary to revisit the matter, to see if there are reasonable regulations to allow our state to join the other states to adequately protect the ground water.

Suzanne Budge Schaefer, Idaho Petroleum Marketers and Convenience Store Organization, introduced Bob Franklin, Charlie Jones, and Dennis Baird (see sign in sheet). Suzanne distributed handouts to the Committee: "Idaho UST Enforcement Initiative, October 27-30, 2003, EPA Region 10, Submitted by Idaho Operations Office December 3, 2003" and "Overview of Underground Storage Tank Regulation in Idaho" and an EPA Memo (see attached). She stated that Idaho has been a success story with an 85% clean up rate, there are declining claims, and declining leaking sites. She stated that Idaho has 3548 active tanks, 9157 closed tanks which is 61% closure rate. She reported approximately 3000 tanks are insured. She said there is a case to be made that the federal regulations have been very effective in the state of Idaho, regardless of whether there is a state program. Currently they must comply with the federal rules, to get insurance, if they don't have insurance they do not operate. She stated that the rules haven't changed but the interpretation of the rule has changed which is what causes the frustration.

Senator Bailey stated that he would like to see meetings offered in North Idaho. Senator Ingram asked who conducts the tests and who collects the fees. Toni stated legislation is proposed to transfer the responsibility over to the Bureau of Occupational licensing.

Senator Darrington stated that as these changes take place, it is important to make sure these rules are maintained under the Health and Welfare Committee.

EXCUSED:

Reappointment:

Suzanne Budge Schaefer of Boise, was reappointed by Governor Dirk Kempthorne for a term commencing March 6, 2003 and expiring March 6, 2006. She is the manager of SBS Associates, LLC, in Boise.

Her educational background includes a Master of Science in Geology from Colorado, and a Bachelor of Science in Geology from Logan, Utah.

Mrs. Schaefer's previous work experiences include: The Galltin Group in Boise; Corporate Relations Vice President of AIA Universe Insurance Group in Boise; Executive Director of the Idaho Council on Industry and the Environment, Boise; Scientist, Geosciences Group, Idaho Falls; Geologist for Conoco, Inc. in Houston, Texas; Geological Intern for Sohio Petroleum in Denver, Colorado; Graduate Teaching Assistant for Colorado School of Mines in Golden, Colorado; Geological Field and Laboratory Assistant for the U.S. Geological Survey, Denver, Colorado; and, Consultant for the Colorado School of Mines Core Lab in Golden, Colorado. Her political affiliation is Republican.

Over the past several years, the Legislature has enacted a number of cost reduction initiatives intended to curb Medicaid costs. Attached is a list of some of the more recent examples. Despite these initiatives, anticipated savings have not been realized, and expenditures continue to rise, surpassing appropriations in fiscal years 2001, 2003 and 2004.

One weakness in the Medicaid program that has hindered the budgeting process is that the agency has not routinely provided the Legislature with information on the extent to which it has achieved the cost savings anticipated by cost reductions. Such reporting is necessary to keep the Legislature informed of the impact of its policy decisions and to assist the Joint Finance -Appropriations Committee in identifying budget needs. JFAC will be directing the Department of Health and Welfare this year to respond to those questions this year.

Another challenge to cost containment efforts by the Legislature are the sometimes inconsistent intentions which develop between three committees JFAC and the House and Senate germane committees. In some instances, there is not a consensus to support the necessary changes in rules and regulations that are required to implement cost reduction measures that were intended in the appropriation bill from the previous year, which essentially takes the department off the hook, or at a minimum places the Department of Health and Welfare in an awkward position.

We need your help this year in focusing on clear cost containment goals in the budget process. For the past twenty years the average increase in the General Fund Medicaid budget has been nearly 14%. We are no different than other states in seeing a disproportionate amount of our resources chasing significant caseload and health care cost increases year in and year out. We also know the choices are difficult.

As you know we set aside time at the close of the budget hearing process for the germane committee chairs to address JFAC. We would like to enlist the help of your committees in examining what cost control policies would be most appropriate for reigning in the spiraling costs of Medicaid. Specifically, we would appreciate an actual committee vote on potential cost control measures, then have you present those results during your JFAC presentation the second week of February. Some of the issues could include, among others:

1. Reducing or freezing provider rates

2. Reducing or restricting eligibility

3. Reducing or eliminating certain Medicaid benefits

4. Implementing a co-payment system

5. Identifying long-term care reduction strategies

6. Continue efforts to shift other relevant state programs to Medicaid

7. Implement some form of provider fees.

As always, we look forward to working closely with you in the coming session. Your input is crucial for finding common ground on how best to stabilize a program that continues to increase in funding requirements beyond our means.

Committee members reviewed and discussed the JFAC memorandum and the chart "Medical Assistance Program, Anticipated Savings from Medicaid Cost Reduction Initiatives." (See Attachment #1).

The committee suggested the chairman contact the Department of Health and Welfare and discuss the seven (7) items listed in the JFAC memorandum. What programs in Medicaid have federal mandates and cannot be changed, and does the Department believe the seven items are obtainable?

EXCUSED:

He explained, as in the past the Department has five appropriations. This year's request is a very plain and straightforward request. Simply put, it is maintenance of the current operations budget.

The Department's overall 2004 appropriation was $1.292 billion; this year's request is $1.453 billion or a 12.4% increase.

The 2004 appropriation required general funds of$375.8 million, while the 2005 request is $415.7 million, or a 10.6% increase.

The increases are primarily made up of Personnel Cost Rollups or benefit increases, medical inflation, increased Medicaid caseloads and the 2% change in employee compensation or CEC. We also have two new expansion decision units, as well as, the annualization of startup costs for the CHIP B and CHIP Access card programs.

The Division of Family and Community Services (FACS) has the most

changes. This year, we are transferring the Sheltered Workshops from

FACS to the Division of Vocational Rehabilitation. This transfer moves

almost $3.8 million from the FACS budget and out of the Department.

Within FACS, we also have two new expansion decision units. These

decision units are for funding in the Infant & Toddler program and the foster care program. The Infant & Toddler program provides early intervention services for children up to three years of age who have developmental disabilities. This funding will bring the department into federal compliance for meeting our timeliness in providing service access. The second decision unit, for foster care, is requesting a 5 percent (5%) increase in the amount paid to foster care parents. Currently, for a 10-year-old child, we pay $286 per month compared to an average of Idaho's neighboring states of$413, or 44% less. This increase will move the amount to $300 per month and will still keep us 37% less than our neighboring states. The general fund costs of these programs are $220,000 for the Infant & Toddler program and $161,500 for the foster care program.

Within the FACS appropriation, we also have an increase in employee

compensation of $1.1 million, and an increase in employee benefits cost of $1.4 million.

The general fund impact for this appropriation is a $1.1 million reduction.

Again, this is due to the transfer of the Sheltered Workshops to the Division of Vocational Rehabilitation.

The appropriations for Indirect Services, Welfare and Health have no

material increases outside of the change in employee compensation totaling $573,300. Personnel cost rollups of $763,000 and the annualization of the CHIP program in the Division of Welfare for $421,200. The overall increases for these three divisions total $1.5 million in general funds.

The final appropriation is Medicaid. Medicaid has an increase of$39.4

million in general funds.

Most of the increase is caused by three simple facts. The first being, more people will be enrolled in Medicaid next year, . . . which leads into the second, meaning we will pay for more services, and . . . the third, the cost for many services are also increasing.

More people . . . More services . . . and providers charging more for those services. That accounts for $35.3 million or 90% of the general fund increase in our Medicaid request.

The remaining $4.1 million is related indirectly to the CHIP expansion

approved by the Legislature last year .The cost for services in the new CHIP B and CHIP Access Card programs will be covered by a combination of funds from the state's premium tax fund and the federal government.

However, we anticipate that interest in the new CHIP programs will also

drive up enrollment in the current CHIP program and Medicaid's Pregnant Women and Children program. This is often referred to as the woodwork effect. The state share of increased costs for these two programs would be $3.4 million - which will come from the General Fund.

Finally, Medicaid has $130,000 for annualization of Chip program

supplemental request and $230,000 for the combined CEC and Personnel cost rollup.

Again, as a high level recap: the 2005 budget . . . is maintenance of current operations budget with an overall increase of$39.8 million in general funds primarily found in six (6) items that increase costs and one that reduces cost.

The additions are:

• $35.3 million for the "normal," annual increased cost of doing business in Medicaid;



• $550,000 for the annualization of Chip B & Access Card supplemental;



• $3.4 million for woodwork effect associated with the new Chip B & Access Card programs;



• $2.3 million for personnel cost rollups or increases in benefit costs;



• $1.8 million for CEC or Change in employee compensation; and, $381,500 for the two new expansion decision units I mentioned;



• Those increases are reduced by $3.8 million and the transfer of the Sheltered Workshop program and funding out of the Department to the Division of Vocational Rehabilitation.

The committee discussed "required vs. optional" Medicaid Services. In FY1993, expenditures for federally required services amounted to 75% of the overall Medicaid budget with the cost of optional services 25% of the total. The FY 1993 total was $300.3 million.

In FY2003, expenditures for federally required services dropped to 44% of the overall Medicaid budget with optional services expanding to 56%. The FY 2003 total was $869.6 million.

Required Services - Idaho must ensure that Medicaid clients receive the health care services required by federal guidelines. These mandatory services include physician visits, family planning, laboratory tests, health screening services for individuals under age 21, hospital inpatient and outpatient services, and prescription drugs for children and pregnant women.

Optional Services - Idaho also provides a number of optional services, such as prescription drugs for adults; expanded personal care services; full coverage of prosthetic devices for adults; dental, eye, and hearing services for adults; heart, liver and other organ transplants for adults; payment for services at long-term care facilities for the mentally retarded; adoption and expansion of a children's health insurance program; services for developmentally disabled adults; mental health services for adults; chiropractic and podiatry services; physical therapy; enhanced pregnancy services; and services from ambulatory surgical centers.

The committee reviewed a chart about the Department's 2005 appropriations: (See Attachment #1)

• Medicaid - 73.8%
• FACS - 10.1%
• Welfare - 8.4%
• Public Health - 4.7%
• Indirect Support - 2.7%
• Councils - 0.3%

A Medical Assistance Program, expenditure by service category, listing of what services are required (federal mandated/state services), and the actual and estimated percentages were also reviewed. (See Attachment #2)

It's important for people to know that the Department's investment benefits all Idaho residents. This is wise use of taxpayer dollars because the money spent in the community often stays in the community. Those dollars are spent again and again to help create jobs and create an infrastructure that provides healthy and safe communities.

A discussion was held pertaining to complaints Health and Welfare had received during the last year, such as:

• The number of complaints the Department had received from small providers about late or timely payments during the last year?

Mr. Butler stated, "we receive complaints on a periodic basis." He informed the committee that Senator Ingram brought one group of providers before us, pressing us about late payments. We did our research and found out that, on average, we paid that group every 22-days. Their claim was the payments were at 40-days. Mr. Butler reported, "yes," we are late on some payments, but any billion dollar industry will have a lag-time, but for the most part we are timely. The average payment rate is 22-days, some later and some shorter, but overall payments are made within 22-days.

• If a payment is late, does Health and Welfare pay interest on the late payment? Is there a statute in Idaho Code governing the Department paying interest on late payments?

Mr. Butler reported there is no obligation for the Department to pay interest unless it is stated in the contract.

• Senator Bailey referred Mr. Butler to Idaho Statutes, Title 67, State Government and State Affairs, Chapter 57, Department of Administration, 67-5735 - Processing ­ Reimbursement of Contractor: "Within ten (10) days after the property acquired is delivered as called for by the bid specifications, the acquiring agency shall complete all processing required of that agency to permit the contractor to be reimbursed according to the terms of the bid. Within ten (10) days of receipt of the documents necessary to permit reimbursement of the contractor according to the terms of the contract, the state controller shall cause a warrant to be issued in favor of the contractor and delivered. Contracts let or entered into by or through the division of purchasing are exempt from the provisions of Section 67-2302, Idaho Code; provided, however, that late contract payments may be assessed interest by the vendor at the rate set forth in Section 63-3045, Idaho Code, unless another rate is established by contract."



• Section 67-2302(3), Idaho Code, State Government and State Affairs, Chapter 23, Miscellaneous Provisions: "Unless specifically provided by the terms of a contract that details payment requirements, including penalties shall be due automatically when bills become overdue. It shall be up to each vendor to calculate and invoice interest at the time payment is due on the principal."



• Section 67-2302(17), Idaho Code, "Each state department, institution and agency head shall be responsible for prompt payments. In all instances where an interest payment has been made by a state agency because of a late payment, the responsible state agency head shall submit to the joint senate finance-house appropriations committee of the legislature at the time of that agency's budget request hearing an explanation of why the bill is paid late and what is being done to solve the late payment problem."

Kelly Buckland, Director of the Idaho Independent Living Council, explained that in 1996 Governor Batt started the Medicaid Reform Council, and they made recommendations about changes to Medicaid. The Medicaid BUY-IN program for Idahoans with disabilities was recommended by the Council. The Medicaid BUY-In is a program that helps people to work by permitting them to buy into Medicaid while working. For people currently on Medicaid, there is no incentive to work more than part-time because if they earn even one dollar too much, they will lose their Medicaid coverage. That coverage pays for the supports and services that people with disabilities need to go to work. With Medicaid BUY-IN, when the eligible person goes to work, they pay a premium, based on a sliding scale, which enables them to retain their coverage. The program encourages independence instead of trapping people in dependence and poverty.

Mr. Buckland requested the committee, when they meet with JFAC (Joint Finance Appropriations Committee), to support the Governor's request in his State-of-the-State address, "many Medicaid recipients are penalized if they have a job." I say we remove of the penalty, and to enable Medicaid recipients to work without losing health care benefits and services that help them remain independent. I urge your support of this common sense change."

Joyce McRoberts, Deputy Director for the Department of Health and Welfare, informed the committee members that today the Department started the "Any Door Initiative" project in Moscow, Region II.

EXCUSED:

16-0309-0311

She explained. Two weeks ago I presented this rule docket 16-0309-0311 regarding Medicaid's Mental Health rules.

When I first presented this rule docket, you heard testimonies from the Mental Health Provider's Association. You also heard that Medicaid was responding to some of these concerns through rule amendments that we had begun to draft. Additionally, Representative McGeachin testified about her concerns regarding the appropriate role for paraprofessional.

Your committee requested that ­ because of the issues expressed ­ that Medicaid staff and the providers who testified sit down and sort through these issues.

I'd like to briefly review with you, the twofold purpose of these rules:

• There was a need to reflect changes in provider and department responsibilities as a result of staff reductions in the Regional Mental Health Authority; and

• There was a need to clarify service expectations and provide service definitions in response to health & safety concerns, particularly for services provided in Partial Care settings.

The rule changes relate to two distinct mental health benefits: 1) Psycho-Social Rehabilitation (PSR) and 2) Mental Health Clinic services.

The first part of the docket identifies changes to the Pycho-Social Rehabilitation (known as PSR rules), reflecting the reduction in Regional Mental Health staffing and the resulting changes in the roles and responsibilities of private PSR providers. The functions of assessment and service planning have been transferred to the private PSR providers.

Additionally, these rules incorporate service definitions, clarify provider qualifications, and spell out service expectations. Significant clarifications include the requirements that:

• PSR Provider Agency personnel coming into direct contact with participants must comply with existing statutes governing criminal history check requirements; and,



• PSR agencies provide 24-hour crisis response services for their participants or make contractual arrangements for the provision of those services.

The changes to the mental health clinic rules and related partial care rules were made primarily due to safety issues. Over the past year, the Department was alerted to situations where individuals appeared to be at risk when receiving care under this benefit.

As I mentioned in my previous presentation, prior to these rules, "partial care" ­ a Mental Health Clinic Service ­ could be applied to a number of programs. Some ­ included what might be considered babysitting, others included a lot of television watching, and some including boot camp type services. And because service expectations were not clearly articulated, many of the safety issues found over the past years have arisen in this setting.

This rule docket does not introduce any new federal or state requirements for clinic except for the inclusion of building standards, which were added as a direct result of documented cases of child endangerment due to substandard buildings that were being used as clinics. These temporary rules contain federal and state guidelines that have been in effect for many years. All changes are intended to result in a greater understanding in the provider community of the scope of mental health services as they are required to be.

These temporary rules, effective December 1st were published in the November Administrative Bulletin. Three public hearings were conducted and public comments were accepted through November 26, 2003.

Last week, Department representatives met with representatives from the Mental Health Provider Association to discuss how to address concerns with the rules and related service issues. Our meeting was very productive. We found a great deal of agreement regarding the need to have our rules reflect the best possible outcomes for individuals receiving mental health services. We also agreed to commit to monthly meetings to jointly draft amendments to the temporary rules that are before you in order to address some inconsistencies and make changes.

The outcome of this meeting was an agreement to ask Legislators to extend these temporary rules with the understanding that the Department will work with stakeholders to amend these rules.

The Department is committed to continued negotiations with stakeholders in order to produce rules that reflect best practices with the primary goal of meeting the needs of individuals with mental illness with the best outcomes. The resulting rules will be in compliance with applicable state and federal laws, protect the health and safety of the recipients, are cost effective, and recognize resource limitations.

A work group is scheduled to meet on February 5, to begin reviewing amendments. Members of the work group include representatives from the Family and Community Services Division, Medicaid, Mental Health Providers Association, Fraud & SURS, Consumers and Advocates. The group will meet at least monthly until rule amendments accurately reflect the desired outcomes. The amendments will be published and hearings will be conducted. The amendments will not go into effect until they have received public review and providers have had time to make necessary changes in their business practices.

The Department presented this rule docket to the House Health & Welfare committee last week. At that meeting, the Department and representatives from the Mental Health Provider Association asked the committee to extend the rules. However, the House Committee decided to hold its decision until after the meeting on the 5th in order to see what progress is made. Two members of the committee (Representative Garrett and Representative Henbest) asked to join the work group. A mental health provider who represents Representative McGeachin's concerns will also join the work group.

Although we know that improvements can be made to this temporary rule docket, and we are committed to making those changes, we still believe that it is in the best interest of the individuals receiving these services for this committee to extend the temporary rules. Without these rules, we will lose ground on our ability to ensure safe care. Some services will continue to be provided by unqualified staff, and some qualified staff will be unable to provide services. I'd be glad to share additional impacts if this committee would like further information.

This concludes my presentation on Docket 16-0309-0311. The Department requests that the committee extends these temporary rules with the Department's assurance that it will continue to work with stakeholders on amendments that will address areas of concern.

I will be glad to answer any questions that the committee might have regarding this docket.

Written comments received by to the Senate Health and Welfare Committee to be included the minutes are:

My name is April Crandall and I am President of the Mental Health Provider's Association. Representatives from our association have met with Department of Health and Welfare staff regarding the PSR and Clinic rules for community mental health services Docket 16-0309-0311.

We met with the Department on January 22, and I would like to compliment the Department on the willingness to meet and to commit to continued meetings and negotiation.

• We agreed that there was much work to do together to mold community mental health services that are quality services for those with mental illness and services that are a good value for taxpayer dollars. We discussed our concerns with Partial Care (Day Treatment Definition), Physician Requirement, and unfunded mandates. We agreed to discuss these further.



• We agreed to ask the Health and Welfare Committees to extend these Temporary and Proposed rules with the commitment to work on amendments together.



• We agreed to schedule monthly meetings with other stakeholders at the table to produce amendments that reflect quality services that are reasonable in compliance with federal and state laws and that is within the capability of the private providers.



• We agreed to published rules with scheduled hearing and have effective dates that would give time to include changes as discussed with the stakeholders. The Department agreed to do a reimbursement analysis to possibly include a reimbursement increase in the July budget set for next year.



• We agreed to look at the future possibility of accreditation standards, using resources up front to ensure quality services and to poor quality or misuse of taxpayer dollars. We are going to look at better communication strategics and to decide when enforcement begins on the disputed areas in the temporary and proposed rules. The decision was that disputed areas would not be enforced until they were resolved.



• We ask you, as the Health and Welfare Committee, to extend the temporary and proposed rules with the idea of amendment negotiation.

I'm available for questions on community mental health services, differences between mentally ill individuals and mentally handicapped (developmentally delayed) individuals. Thank you.

16-0309-0308

for the Department of Health and Welfare, presented these pending rules, Docket 16-0309-0308, for adoption as final rules.

These rules govern the Department's activities relating to investigation of Medicaid fraud and abuse and have been amended to help the Department protect the program funds and clients from fraud and abuse.

These rules have been amended to cleanup language due to federal rule changes and restructure the rules and make them clearer. In the changes we have clarified the department's ability to access and copy records of services provided to Medicaid clients.

Changes have been made to clarify the Department's ability to deny

payments or exclude providers for failing to provide access to records. This language is consistent with federal regulations and is clarifying existing authority.

Changes have been made to clarify and standardize the appeal process for department actions. The Department is attempting to consolidate rules, and appeals are defined by the Rules Governing Contested Case Proceedings.

Clarifications have been made on the Department's actions to mirror the federal regulations when suspending payments to providers for fraud. This is not adding authority, but holding the department more accountable in these types of actions.

We did not receive any public comment or opposition to the pending rules.

I presented these rules to this committee last week and heard opposition or testimony from two groups. One did not oppose the rules, however, opposed the organizational structure of the fraud unit.

I have met with the second group, the Mental Health Providers Association. They represent a group of providers who are trying to provide needed services. They understand rules to address fraud and abuse within our vulnerable program are necessary to stop those providers who will drain program resources, and cast distrust on their profession and the services they perform. Their concerns were relating to the repeal of Section 204 which discussed the referrals to a Surveillance and Utilization Review Committee, and the repeal of Section 210 which provided for a hearing within 30-days for an immediate action when suspending payments or a provider agreement. The committee described in Section 204 is no longer in existence, and I have committed to the association to further define the process for decision making when suspending payments to providers. With this commitment, the Mental Health Providers Association has agreed to support these rules to allow the Department to stop unnecessary waste and abuse, provided Section 210 is restored.

The Department does not oppose restoring this section.

Mr. Chairman and members of the committee, when I presented these

amendments to you last week, I also heard discussion of due process,

concerns with suspending providers, HIPAA violations with access to

records, and nonspecific discussion regarding the department being "heavy handed" or retaliatory with providers. This greatly surprises and concerns me, and I would like to discuss with you the business of fraud investigations to hopefully address any concerns you may have.

First, due process is fundamental in our appeal processes. Our appeal rules provide due process, and appeals are heard by an independent contract hearing officer. Our independent hearing officer is required by contract to set a hearing date within 30-days of an appeal. To address the concerns of the association, I am recommending we restore Section 210 to ensure a hearing within 30-days. The Department will also look at amendments to the contested case rules, and I will commit to involving the association with those revisions.

I also serve as the Bureau Chief over the HIPAA (Health Insurance Portability and Accountability Act) Privacy Office for the department. The Department's ability to access records for the purpose of fraud investigations is in no way a violation of HIPAA regulations. HIPAA provides authority to access these records for the purpose of treatment, payment, and operations.

I also heard concerns about suspending provider payments and my staff being "heavy handed" with providers. I have seven (7) staff responsible for investigating fraud within a program which in one week, processes over 150,000 claims and pays out over 17 million dollars. In only one week!

Over 85% of these claims are received and paid electronically, which ensures fast payment and little or no human oversight or intervention. With over 15,000 providers to watch over, if a single provider wanted to submit fraudulent claims it would not be difficult to submit them electronically and fraudulently obtain a large volume of money. This was the case in the newspaper article on Sunday and provided in your handouts, where a social worker was able to steal more than $150,000 billing for clients she never saw. This type of example is not often encountered and is considered the "exception."

I am sorry to bring this news to you, but we do have white collar criminals within our vulnerable program. These are thieves masquerading as health care providers. They are, however, the exception to the 15,000 providers in the program. Unfortunately, they often turn out to be our trusted health care practitioner, members of your community, your constituents, or even members of your church. Not so long ago, one of these exceptions had been given the title by her community of the "Business Woman of the Year," and later was sentenced to over two years in prison for stealing from our program.

Many of the provisions in these fraud rules are written for these providers who are the "exception," and they are vital for us in order to protect program dollars and clients.

The Department has always had the ability to suspend provider payments. The revisions in front of you actually tighten this ability and raise the burden from merely "suspecting fraud and abuse" to now we must show "reliable evidence" of fraud and abuse. It also clarifies the notice requirements and how long a suspension may last which was not previously defined.

If you will refer to the chart, Provider Investigations, which I have provided to you, it shows the results of fraud cases opened in the last three years. (See Attachment #1).

There have been 659 fraud cases opened in the last three years. Of those cases,

• 199 cases or 30%, were closed and we were able to unfound the allegations made against a provider.



• 53 cases or 8%, resulted in provider education or clarification of processes.



• 223 cases or 33%, resulted in a recoupment action. Keep in mind often a case is not opened unless there is some likelihood a problem or overpayment exists. These cases recouped over 2.7 million dollars.



• Even with less restrictive payment suspension requirements, only four (4) of 659 cases resulted in a payment suspension action. This is a little over ½ of 1%. In those cases, three of them have already been prosecuted for healthcare fraud in federal court and the fourth has been referred to federal prosecutors for review. These four providers are considered the "exception" for which we need the ability to suspend a provider and stop fraudulent program dollars from going out the door.

In looking at these figures, I believe they clearly show the Department is

committed to pursuing fraud and abuse in the program, however, they show we do not use the "heavy hand" approach I have heard rumors about. We deal with those providers who are "exceptions" appropriately, in order to protect our program resources and vulnerable clients.

To further discuss the way my staff approach such actions against providers, my office was cited by the legislative auditor's office in a final audit finding, as being "slow to react to fraud and abuse" for not suspending payments to a provider they determined was submitting fraudulent claims. My office would not agree to issue such a suspension until we had gathered all of the facts, and were absolutely sure it was necessary to protect the program dollars or clients. Giving the provider the benefit of the doubt. In the end, a suspension of payments was not warranted and allegations against the provider were unfounded.

My office continually undergoes review and scrutiny regarding practices and effectiveness.

• Annual legislative audits review cases, resolutions, staffing qualifications, and our investigative approach.



• November 2000, the Office of Performance Evaluations (OPE) Review noted our efforts comparable or exceeding other states and, therefore, recommended we not establish a Medicaid Fraud Control Unit. This is raised because last week I heard concerns about the need for a certified unit in the Attorney General's Office. The OPE recommended against this approach, and recommended the fraud unit be transferred out of Medicaid and into the Division of Management Services. This division is the finance and accountability arm of the Department.



• There was a 2002 review by the Center for Medicare & Medicaid Services (CMS). The Medicaid Alliance for Program Safeguards team reviewed our compliance with federal regulations to include our ability to suspend payments to fraudulent providers. We were commended on our efforts.



• In August 1999, the Healthcare Financing Administration (HCFA) Program Integrity review commended my staff on their efforts preventing and detecting fraud and abuse in the Medicaid program.



• And finally, the most apparent scrutiny of all, the providers in this state. If due process was not upheld or providers were approached with a heavy hand, you and I would both have heard this quite clearly from providers with specific examples, not general comments. Comment was made by one member of the Senate Committee last week that he was surprised to hear of such concerns. I must say that not allowing due process, or unnecessary actions by my staff would not be tolerated by the provider community, nor myself. If raised, I would appreciate the opportunity to respond to specific concerns or examples.

As Senator Bailey pointed out last week, enforcement agencies are often looked upon negatively. I agree with him whole heartedly. Having

investigated 659 providers in the last three (3) years, I would anticipate my staff would not be popular with a few providers, but these would be the exceptions and not the typical providers investigated.

I am also the Bureau Chief over the Internal Audit section in the Department, responsible for reviewing internal controls and ensuring the department is accountable. This task along with fraud investigations are not popular functions, however, I can assure you that with this charge, we will do our best to protect our program resources and dollars.

The Department has received numerous letters from significant providers in our program, commending my staff on the professional approach used during the investigations, even when they were required to refund a large amount of dollars overpaid. I have attached some of those letters for your review. To quote one physician who repaid an excess of $10,000, and said he was pleasantly surprised and pleased with the Medicaid auditors and went on to say "You are to be commended on such personable staff in a department that is often derided by others as being distant or secretive to its contracted providers." These are examples of how the majority of our provider contacts are resolved.

Chairman and members of the Committee, I am proposing to you that these rule amendments provide us with the necessary tools to protect our valuable and limited program resources. They help bring us one step closer to addressing the unfortunate "exceptions" we encounter within our program, which can quickly drain our program resources. I am asking you for your confidence and support in these efforts and to adopt these rules as final rules to further help the Department protect our program funds and clients from fraud, with the exceptions of rejecting Section 210 which address the concerns of the provider association.

Thank you and I will stand for questions.

Greg Dickerson, a representative for the Mental Health Provider Association, testified to support and adopt these rules, with the exception of restoring Section 210, and the commitment made to revisit Section 204, and draft the due process the Department currently uses and replace it. He appreciated the efforts of the Department to work with providers.

Douglas K. Merkley, a private attorney from Pocatello, testified about his objections to Docket 16-0309-0308. He expressed grave concerns about the process of the Department's fraud investigations, especially the section of suspending payments to a provider. This can cause a business to shut down. Prior to due process of appeals. Mr. Merkley reported he represents several clients in his area who has had problems dealing with staff from the Department's fraud unit.

Committee members discussed the proposed pending rules governing fraud investigations and the suspension of payments during an investigation. The Department's actual proposed changes to Sections 204, 208, 209, and 210, Docket 16-0309-0308, are shown below:

Section 204: SURVEILLANCE AND UTILIZATION REVIEW (S/UR) COMMITTEE (Reserved). Instances of suspected fraud, abuse, or other misconduct may be referred to a review committee organized by the Department. The committee shall consist of health professionals and other staff appointed by the Director or his designee. The committee may also consult with other professionals as determined necessary by the committee. The function of the committee will be to review and make recommendations concerning corrective action.

Section 208: SUSPENSION OF PAYMENTS PENDING INVESTIGATION. "In the event that The Department identifies may suspend payments in whole or part in a suspected case of fraud or abuse and the Department has reason to believe that payments made during the investigation may be difficult or impractical to recover, the Department may suspend or withhold payments on any pending or subsequently submitted claims while the provider continues to participate in the program pending investigation and conclusion of legal proceedings related to the provider's alleged fraud or abuse."

Section 209: INTERIM PROVIDER AGREEMENT SUSPENSION. In the event that the Department identifies a suspected case of fraud or abuse, and it determines that it may summarily suspend the provider agreement when such action is necessary to prevent or avoid immediate danger to the public health or safety, the Department may summarily suspend a provider or employee of a provider. This provider agreement suspension temporarily bars the provider from participation in the Medicaid Program pending investigation and Department action. Such a finding will be incorporated in the order. The Department will notify the provider shall be given notice but the order of the suspension. The suspension is effective when issued immediately upon written, electronic, or oral notification.

Section 210: APPEAL OF IMMEDIATE ACTION (Reserved). When payments have been suspended or withheld or the provider's agreement is suspended pending investigation, the Department shall provide for a hearing within thirty (3) days of receipt of any timely filed notice of appeal.

Written comments received by the Department of Health and Welfare regarding fraud investigators were submitted into the record:

Bret Hamilton, administrator, Teton Family Services, Inc., in Pocatello, regarding the Fraud Unit. (See Attachment #2)

Carl E. Wood, Jr., Evergreen Pharmaceutical, Inc., in Kirkland, Washington. (See Attachment #3)

Stephen DeNagy, M.D., Family Care Center in Idaho Falls. (See Attachment #4)

Jeff Hough, lobbying director for the Cooperative Action, LLC, submitted written comments from Bill Southerland, president of the Idaho Assisted Living Association (IDALA). (See Attachment #5)

Mike Ponkow, administrative director of the Cooperative Action LLC in Chubbuck, Idaho also submitted written comments requesting the committee to reject this rule and ask the Department of Health and Welfare to formulate a new better defined rule that the providers can comply with. (See Attachment #6)

A Letter of Opinion from William A. von Tagen, Division Chief, Intergovernmental and Fiscal Law, Idaho Attorney General's Office, was introduced. The letter addressed the question "whether the placement of the Department's Bureau of Audits and Investigations within the Division of Management Services sufficiently insulates the Bureau from the influence of the Division of Medicaid." Based on the following analysis, I believe it does. (See Attachment #7)

Mr. Warren read Section 212 - Civil Monetary Penalties - "Pursuant to Under Section 56-209h, Idaho Code, the Department may assess civil monetary penalties against a provider, any officer, director, owner, and/or managing employee for conduct identified in Subsection 211.01 through 211.09 of these rules. The amount of penalties shall may be up to one thousand dollars ($1,000) for each item or service improperly claimed, except that in the case of multiple penalties the Department may reduce the penalties to not less than twenty-five (25%) if the amount of each item or service improperly claimed if an amount can be readily determined. Each line item of a claim, or cost on a cost report is considered a separate claim. These penalties are intended to be remedial, at a minimum recovering costs of investigation and administrative review, and placing the costs associated with non-compliance on the offending provider."

Discussion: Senator Burkett - thinks this rule making is completely confused. It gets back to the distinction between fraud, on the one hand, and then the rule also refers to misconduct, abuse - both financial abuse and potential client or patient abuse. He thinks we need something different for fraud. People suspected of fraud, it might be appropriate to suspend payments for 30-days, wait for a hearing, then after a hearing finding probably cause you move onto the next step.

Senator Compton asked Senator Burkett if he was rejecting the docket entirely? Senator Burkett responded, "yes," the changes. The motion was seconded by Senator Bailey.

DIscussion: Senator Burkett explained that Mond has told us it is working pretty well right now, and that he can operate under this rule. Senator Burkett believes the Department should come back next year with a rule that is drafted correctly. He also believes the Department should have two sets of rules. One set of rules for misconduct, abuse and bad practices, and a different set of rules governing Medicaid fraud.

Committee members express their difference of opinions relating to the proposed changes and the effects on the Department's fraud unit.

After a lengthy discussion, review, and consideration of the above listed pending sections in Docket 16-0309-0308 (Sections 204, 208, 209 and 210), Senator Bailey withdrew his second to this substitute motion.

The motion died for lack of a second.

Discussion: Senator Kennedy explained the motion is to reject the changes being made to rules 210 and 204, and to approve the other amendments being made by Docket 0308 (16-0309-0308).

The motion died for lack of a second.

The substitute motion was seconded by Senator Kennedy.

Discussion - The committee members held a general discussion relating to providers, suspended payments and suspension of contracts, immediate danger and safety of a client, and why do the rules need to be changed. If Section 209 is returned to the rules, how it was before these proposed changes were made, the Department could still suspend a provider's agreement. The changes proposed by the Department were intended to clarify the rules, to make it clearer on the grounds which they would suspend a license.

Senator Burkett restated his substitute motion - the motion was to reject Sections 209, 210, and 204, and approve the remainder of the changes to the temporary rules 0309-0308 (Docket 16-0309-0308).

Call for Vote: The substitute motion failed.

This motion was seconded by Senator Darrington.

A roll call vote was taken on the original motion:

Senator Kennedy voted Nay Senator Stegner was absent

Senator Burkett voted Nay Senator Ingram was absent

Senator Bailey voted Nay Senator Darrington voted Aye

Senator Sweet voted Nay Senator Compton voted Aye

Senator Brandt voted Aye

The original motion - 3 Ayes, 4 Nays, 2 absent and excused

The motion was seconded by Senator Brandt.

A roll call vote was taken:

Senator Kennedy voted Aye Senator Ingram was absent

Senator Burkett voted Nay Senator Darrington voted Nay

Senator Bailey voted Nay Senator Compton voted Aye

Senator Sweet voted Aye Senator Brandt voted Aye

Senator Stegner was absent

This substitute motion carried, 4 Ayes, 3 Nays, 2 absent and excused.

EXCUSED:

Kelly Pierce, Chairman, Commission for the Blind and Visually Impaired presented three appointees to the Committee. The Commission consists of five members. David Hand is a re appointee. Jim Solom, and Bruce Zimmerman are new appointees.

David Hand, of Boise, Idaho is up for reappointment to the Commission for the Blind and Visually Impaired to serve at term commencing July 1, 2003 and expiring July, 1, 2006. Mr. Hand has been with the Commission since 1998, when he filled an unexpired term. This will be his second three-year term. He has 27 years experience in the Idaho Lodging and Restaurant industry. Since 1964 he has worked on the "talking book," reading on a recorded device. He stated he wants to repay the Commission for the benefits he has received from the programs.

Senator Ingram asked Mr. Hand about funding of a program entitled "News Line Program." A program that records newspapers being read so the visually impaired can stay updated on the latest news. The program needs $26,000. Mr. Hand informed the Committee members that The National Federation of the Blind was introducing some legislation this session in regards to this issue, and that any involvement by the Commission in this regard would be improper. Mr. Hand stated he was working to disseminate information to the right people.

James Solom, of Lewiston, Idaho, is up for appointment to the Commission for the Blind and Visually Impaired to serve a term commencing on July 1, 2003 and expiring July 1, 2006. Mr. Solom has 22 years of Executive experience in Communications, having worked for and with several large communication companies. He also has 12 years teaching experience at the University level. He came from southern California to Idaho to work on building an IdaNet, which runs from Moscow, Idaho to the Canadian border. He also worked on running a DS3, high speed network, from Couer dAlene to Boise. It was while working on this project that Mr. Solom lost his site. He attended a school in Boise for four months to learn Braille, and to use Voice activated computers. He is now pursuing a doctorate degree in Education from the University of Idaho, and anticipates graduating in 2005. He stated the Commission for the Blind and Visually Impaired has provided him with invaluable resources and his wish is to provide assistance, and mentor to others with visual impairments.

Senator Stegner asked about options for tutoring for the blind at the University of Idaho campus, as well as the lack of a Braille printer for blind student use.

Bruce Zimmerman, of Hidden Springs, Idaho is up for appointment to the Commission for the Blind and Visually Impaired to serve a term commencing on July 1, 2003 and expiring July 1, 2006. Mr. Zimmerman has held many corporate positions, has taught at the university level, and is currently a consultant and professor at the University of Phoenix, Boise center. Mr. Zimmerman was accompanied by his three-year-old German Shepard guide dog. He anticipates assisting those who have lost their sight due to age, illness or physical trauma in the area of accessibility. He would like to improve the travel options for the visually impaired, as well as, make technology available for those who could benefit.

The Committee members were impressed with the character and experience of each Commission appointee.

There was no discussion on the rule.

There was discussion on the rule relating to the Allowable Cost Manual. The Committee would like to see the date and edition of the manual stated within the rule. The reasoning being the Commission could change the manual without approval of the Legislature. Mr. Stevenson, Department of Administrative Services, stated the Commission has statutory authority to change the rule as they see fit. He recommended the Commission issue a temporary rule with the change, to incorporate the date and edition of the Allowable Cost Manual, for the legislature to approve.

Due to public comment, changes were made to proposed text as follows: include definition for supportive counseling; revisions were made in practice of social work; the word endorsement was added to 350; and competent practice for social workers is defined.

Mr. Hales described the three levels of a social worker: Baccalaureate social worker, Master social worker, and Clinical social worker. In section 010 (03) Definitions, page 256, psychotherapy can only be practiced by Clinical social workers, or Master social workers under the supervision of a Clinical social worker. Another distinction was made regarding independent practice of social work and private practice of social work and the Clinical Practice Exemption, Section 201(04) Practice of Social Work, (04) page 257. The exemption allows a longer period of time to meet the requirements, and expands the number of supervised hours to receive training.

Senator Ingram asked Mr. Dickerson if he felt anyone had been excluded or alienated by the rule. Mr. Dickerson stated with the agency exemption clause, Master social workers can claim supervision by other Clinical professionals. This allows flexibility. He stated it was critical to revise the rule to clarify the definitions of social workers.

Chairman Brandt stated there was written testimony submitted to the Committee members from Larina Warnock, and Bob Willhite.

Senator Stegner brought to the attention of the Committee and Ms. Jacobsen, the lack of a date and edition inclusion into this rule, as well, as on page 272, in regards to documents/manual references.

EXCUSED:

Dr. MacMillan has performed extensive research on fish health and aquaculture issues and has published many scientific articles and papers. He has served on many task forces, committees and associations studying water quality, fish health and aquaculture issues.

Dr. MacMillan was originally appointed to the Board of Environmental Quality on July 1, 2000. He lives in Twin Falls, Idaho. Dr. Macmillian has been reappointed by Governor Dirk Kempthorn for a term to expire on July 1, 2007, and his political affiliation is with the Republican party.

Senator Darrington asked Dr. MacMillan about his work with toxic elements and fish. Senator Darrington reported his committee will soon be hearing proposed legislation relating to aquaculture terrorism and increasing the criminal penalties for those terrorist acts.

Mr. Purdy is a past director of the Idaho Cattleman's Association, served on the Board of Directors of the Idaho Nature Conservancy, and was awarded the National Environmental Stewardship Award, the Department of Interior Stewardship Award, and is in the Southern Idaho Livestock Hall of Fame.

He was originally appointed to the Board of Environmental Quality by Governor Dirk Kempthorn on July 1, 2000, and reappointed for a second term beginning July 1, 2003. His area of interest and expertise is water. He has been reappointed by Governor Dirk Kempthorn for a term to expire on July 1, 2007, and his political affiliation is with the Republican party.

Mr. VonLindern is a graduate from the University of Idaho in Civil Engineering, and is a licensed engineer. He has been Public Works Director for the City of Lewiston and Grangeville, Idaho. Formerly he worked for the Idaho Division of Environmental Quality as a water quality engineer and then Regional Administrator of Region II.

Currently he is the Environmental and Manufacturing Manager for Alliant Techsystems, a manufacturing operation in Lewiston. His primary responsibilities include managing the department to exceed environmental compliance requirements and setting future environmental direction for the location.

Mr. VonLinder is active in a number of environmental organizations and serves as Chairman of the Nez Perce Local Emergency Planning Commission, Vice Chairman of the Clearwater Basin Advisor Group, and has previously served on the Hazardous Waste Facility Siting Panel. His political affiliation is Republican.

Background:

• Two (2) separate loan funds -Water Pollution Control (Wastewater) Loan Fund & Drinking Water Loan Fund.



• Wastewater Loan Fund established in 1987 Amendments to Clean Water Act & Idaho Code, Title 39, Chapter 36, authorized federal funding through federal fiscal year 1994.



• Drinking Water Loan Fund established in 1996 Amendments to the Safe Drinking Water Act and Idaho Code, Title 39, Chapter 36, authorized federal funding through federal fiscal year 2003.



• Purpose of both funds is to provide perpetually a revolving source of low interest loan funds for design and construction of wastewater and drinking water projects (loan repayments go back into the fund to be re-lent to others).



• Each Fund receives:
• Annual Congressional Appropriation (approximately $6.5 and $8 million)
• Annual 20% State Match appropriated from Water Pollution Control Account ($1.3 and $1.6 million)
• Loan Repayments (Principal & Interest)
• Interest on Repayments (Cash in the Fund-invested by State Treasurer)



• Federal Funds are in form of a "Capitalization Grant" that comes from EPA.



• Capitalization Grants require:
• Annual Priority List of Projects Approved by DEQ Board
• Schedule by which federal funds are awarded



• Loan Terms - repaid within 20 years of project completion; interest rate must be below market (3.5% for FY04).

SRF Requirements:

Some Major Project Requirements

• Engineering report prepared by Licensed Professional Engineer
• Environmental information Document (EID)
• DEQ issues a finding - (Categorical Exclusion, Finding of No Significant Impact Environmental Impact Statement)
• Must be bid like any public work's project
• Loan closed at the end of construction (Revenue Bond, LID Bond or Promissory Note issued)

Loan Status:

Total Amount Loaned:

• Wastewater SRF - $176 million. Drinking Water SRF - $40 million (See Attachment #1)

Total Amount Capitalized Through State FY04:

• Wastewater SRF - federal ($102 million); state match ($20 million); Repayments *$71 million); interest on Fund ($10 million.
• Drinking Water SRF - federal ($45 million); state match ($12 million); repayments ($1 million); interest on Fund ($16 thousand).

Status of Federal Grants - received Federal FY03 funds; Federal FY04 funds not released; Federal FY05 in President Bush's budget 35 percent (35%) cut for wastewater SRF.

Projected Need for Loan Funds:

• Wastewater - 2000 Needs Survey $181 million; FY03 - $41 million; estimated FY04 - $12 million.

Current legislative forecast for Water Pollution Control Account. (See Attachment #2)

Path Forward:

Alternative means of Capitalization for loan funds.

• Leverage funds through Treasurer's Bond Bank
• Sell part or all of portfolio - bond bank or private sector.
• Request establishment of a group to investigate and consider alternative sources of capital.

Director Allred requested the committee to consider an interim legislative committee to meet with DEQ and others to study the Loan program. Senator Brandt agreed to send a letter to pertinent committees for their interest in forming an interim committee.

Currently, the programs are funded by 4 percent (4%) of the annual federal contributions (approximately $13.8 million per year). This level of federal contribution is expected to decrease and will not provide sufficient resources for DEQ to manage the programs as the total funds managed have increased to more than $150 million. This funding mechanism will allow the programs to be self supporting.

There is no fiscal impact to the general fund. A reduction in the SRF funds available for future loans would be in the amount of the funds used to administer the program. DEQ envisions no increase cost to borrows. The current "at or below" market interest rate will continue.

It sets forth the policy, title, required license and definitions. Additionally, it provides for a board, to be appointed by the Governor, with qualifications, number, terms of office, removal from office, procedures, powers and duties. It states finances, fees, providing for the issuance of licenses with an annual renewal. It provides for the revocation or suspension of licenses, violations and penalties. It establishes that an emergency exists and that this act shall be in full force and effect on and after its passage and approval. The IBOL will provide administrative, legal and financial services to the board.

There will be no fiscal impact to the General or Dedicated funds. This will be a self-supporting program funded by operator licensing fees.

EXCUSED:

Appointee Floor Sponsor__

Bruce Zimmerman, Hidden Springs Senator Kennedy

James Solem, Lewiston Senator Stegner

David Hand, Boise Senator Burkett

22-0103-0301

A) Docket 22-0103-0301 is a pending fee rule of the Idaho State Board of Medicine. The rule is adopted as a pending rule by the Board of Medicine and is presented for review by the 2004 Legislature.

b) Rules submitted for consideration by the 2003 Legislature and

due to some last minute concerns the rules were requested to be disapproved by both the House and Senate Health and Welfare Committees to allow the Board to make further revisions.

c) The rules were published in the Administrative Bulletin for the State of Idaho on October 1, 2003, as proposed fee rules and notification was provided to every licensee of the Board in the Board of Medicine newsletter in the summer of 2003.

d) Public hearing - held in November 2003 and changes were made the proposed rule as result of the public input.

II. OVERVIEW:

a) The rule revises and updates the scope of practice definitions and provides clear requirements for the delegation of patient services by the supervising physician, and provides method for requesting the approval of special procedures.

b) The rule provides for patient safety by limiting the numbers of physician extenders that a physician may safely supervise and provides for required review of education, training, and experience of each physician assistant assigned.

c) Provides that a copy of the delegation of services agreement be filed with the Board.

d) The rules also define committee membership requirements and clarifies the responsibilities per the 1993 resolution of the Board of Medicine.

e) No fees are increased nor is an increase anticipated, in fact the Board anticipates being able to reduce fees with on-line renewal.

f) Provides housekeeping and grammar changes.

III. SUMMARY OF CHANGES - PROPOSED:

Sections:

000 - Grammar changes and corrects omission of graduate PA

010.02 - Names of accrediting agencies listed

010.04 - Addition of education and training listing to each Delegation of service agreement.

011 - Adds the requirements for the committee membership and responsibilities.

021 &022 - Clarifies the application process and limits the application pending period.

028b - Scope of practice language changed to reflect agreed language.

Concerns expressed were " and other anesthesia services associated with the operating room." The interpretation was that PA's would be allowed to perform all forms anesthesia delivery.

028d - Supervising physician definition reiterated in scope of practice.

033 - Delegation of services agreement changed to include education and training of physician assistant, and clarification of process to approve specialized procedures and periodic review of the plan and services.

037 1-2 I Removes trainees from the discipline and adds failure to report

violations of the rules as grounds for discipline.

053 - Adds delegation of services agreement requirement for graduate

physician assistants.

Rules are listed as fee rule. No additional or increased fees are charged or anticipated. Language is changed to reflect range of fees.

PENDING RULES:

000 - Grammar changes.

010 - Corrects the accrediting agency name and requires review of Delegation of Services (DOS) agreement by the Board.

028 - Clarifies scope of practice and changes wording to agreed language. Clarifies the limitation of supervision to three (3) PA's with a waiver allowing up to six to be supervised.

030 - Adds listing of PA education and training on all DOS agreements, and provides requirements for special procedure approval.

036 - Grammar changes and clarification of graduate application.

037 - Removes redundant language, adds graduate PA"S to discipline

requirements.

22-0104-0301

a) Docket 22-0104-0301 is a pending fee rule of the Idaho State Board of Medicine. The rule is adopted as a pending rule by the Board of Medicine and is presented for review by the 2004 Legislature.

b) The rules were published in the Administrative Bulletin for the State of Idaho in October 1, 2003, as proposed fee rules and notification provided to every licensee of the Board in the Board of Medicine newsletter in the summer of 2003.

c) Negotiated rule process for the AT and PA highlight needed changes to these rules.

II. OVERVIEW:

a) The purpose of the rules is to update the rules for supervising physicians as required by changes to the PA rules and to add the requirements for directing physicians as required by the changes to athletic trainer's act and rules.

b) The rule provides for patient safety by limiting the numbers of physician extenders that a physician may safely supervise and provides for required review of education, training, and experience of each physician assistant assigned.

c) Defines fee range for the registration of directing physicians.

d) Clarifies the responsibility of supervising and directing physicians, directs complaints to the appropriate licensing board and limits scope of practice to that of the supervising physician or directing physician.

III. SUMMARY OF CHANGES:

a. Proposed Rules: Section:

000-007 - Changed to reflect current statutory guidelines for rule format.

010 - Definitions added to reflect addition of directing and alternate directing physician, clarifying existing definitions and adding correct statutory and rule references.

020-022 - Clarifies responsibilities of supervising and directing physicians related to professional group supervised, directs complaints to the appropriate licensing board.

030-40 - Defines registration requirements and sets fees for directing physician category.

SECTION - PENDING RULE:

010 - Corrects typographical error and removes limitation on numbers of professionals licensed.

019 - Clarifies definition of available supervision.

020 - Removes requirement for recording of review, clarifies limitation on number of licensees supervised.

040 - Clarifies fees as they apply to all supervising physicians.

Adds fee for directing physicians and clarifies fees as they apply to all supervising physicians(including interns and externs).

22-0110-0301

a) Docket 22-0110-0301is pending fee rule of the Idaho State Board of Medicine.

b) The pending rules before the house are the result of negotiated rule-making process with chiropractic physicians association, athletic trainers association, and physical therapist association representatives. Licensees of the board were notified of the rulemaking process in the summer 2003 newsletter.

c) The rules were published in administrative bulletin 03­10 and a public hearing was held in October 2003.

II. OVERVIEW:

a) The purpose of the rules is to update the rules for athletic trainers to reflect changes of House Bill 199.

b) The rule provides for a more formal defined relationship with the directing physician to be defined as the Athletics service plan or protocol.

c) Defines the duties and responsibilities of the directing physician, clarifies the licensing types, allows for two-year renewal, and clarifies the renewal process including continuing education requirements.

d) Clarifies appointment and responsibilities of the Board of athletic trainers, and designates that a contact person for the Board of Chiropractic Physician's be assigned.

e) Clarifies the complaint process has it relates to the directing physician and the athletic trainer.

f) Requires the scope of practice to be consistent with the practice of the directing physician.

g) No fees were increased nor is there increase anticipated.

III. SUMMARY OF CHANGES:

a. Proposed Rules: SECTION:

001-007 - Format and wording changes as per state requirements.

010 - Definitions clarified, addition of service plan and Chiropractic Physicians Boards.

011 - Rules added for removal of board member for cause and removal of references to registration.

012 - Scope of practice defined and limited to scope of directing physician.

013 - Defines the requirements for service plan. Written agreement/plan

between AT and physician on what services will be provided, addressing situations outside of scope of practice, and reviews.

014 - Defines responsibility of directing physicians.

015 - Registration requirements for directing physicians.

016 -030 - Clarifies requirements for licensure and application requirements.

040 - Clarifies the license renewal and expiration requirements and clarifies license types. Defines the requirement for continuing education.

050-051 - Defines inactive license status and the application of inactive fees to full licensure status. Changes fees to range of fees.

052 - Defines grounds to refuse licensure or take other licensure action.

061 - Changes fee to range. No additional or increases in fees are listed or anticipated.

b. PENDING RULES: SECTION:

012 - Addresses the issue concerning recreational athlete with agreed language.

013 - Clarifies the form and format for service plan.

014 - Defines methods of availability of direction, identification requirements and complaint procedures.

015 - Clarifies directing physician registration requirements and provides fee range for new category of "directing physician."

030 - Defines application process and removes reference to registration.

040 - Clarifies the license issue, renewal and expiration terms.

052 - Adds the practicing beyond the scope of the directing physician to grounds for licensure action.

Appendix A - Removes patient and returns wording to athlete.

22-0111-0301

a) Docket 22-0111-0301 pending fee rule of the Idaho State Board of Medicine. The purpose of the rules is to comply he statutory requirements of the new respiratory therapy act passed by the 2003 Legislature.

b) The pending rules are the result of negotiated rule-making process with the polysomnographer's association and respiratory therapist association representatives. Licensees of the board were notified of the rulemaking process in the summer 2003 newsletter.

c) The rules were published in administrative bulletin 03­10.

II. OVERVIEW:

a) The purpose of the rules is to update the rules for respiratory therapists to reflect changes of Senate Bill 1165.

b) The rule provides addition of Polysomnographer permit types and related terminology definitions.

c) Defines permit requirements and grounds for discipline for permitted polysomnographers.

d) Clarifies appointment and responsibilities of the Board of respiratory therapists and provides dual licensure permit requirements for polysomnography representative.

e) Provides for two-year licensure renewal process.

f) Provides an uniform grounds for refusal to issue or renew a license or permit and suspension and revocation of license or permit.

III. SUMMARY OF CHANGES:

a) Proposed Rules: SECTION:

00-07 - Grammar and format changes, addition of polysomnography to rule authority.

010 - Addition of polysomnography terms to definitions..

011 - Clarifying the RT Board membership, responsibilities, terms and

grounds for removal of board members.

031 - Adds the permit requirements for PSG and corrects terms used,

clarifies inactive RT licensure, defines application and continuing

education requirements for permitees.

033 - Defines exemptions as related to RT licensure.

034 - Clarifies language and removes annual licensure requirement.

035 - Includes PSG in definitions of grounds for licensure action, clarifies

and provides standard terms for grounds for license action.

046 - Provides range for fees charged, clarifies application of inactive

license fees to reinstatement cost.

046.02 - Provides fee range consistent with RT fees for PSG.

046.03 - Clarifies dual license status with no additional license fee

required.

b. PENDING RULES: SECTION:

011 - Correct grammar and typographical errors.

032 - Clarifies requirement for all applications.

035.05 - Corrects terminology, clarifies supervision requirements.

035 - Clarifies action as related to PSG respiratory care.

EXCUSED:

Dr. Kunze received his PhD in Physics (high energy experimental) from Carnegie Mellon University. He is a Licensed Professional Engineer and Mechanical Engineering in Idaho and Missouri. He was previously also licensed in Colorado, California, Nevada, Utah and Montana.

His work experience includes 20 years at the Idaho National Engineering Laboratory, 15 of those in nuclear engineering and five in geothermal and energy conservation engineering, most in project management positions. His geothermal work included environmental analysis and environmental report preparation. He directed the drilling of the first new geothermal wells in Boise, which launched the Boise downtown and state office building heating projects.

His political affiliation is Republican.

The purpose of this legislation is to help ensure that a woman receives information about fetal development, and the possible effects of an abortion on her health. To provide procedures when abortions may be performed and to provide for certain information to be made available to anyone seeking an abortion.

Fiscal impact - The Department of Health & Welfare is currently in the process of updating the printed information that is required by existing law. The only additional expense to this legislation is the cost to design a web site, which is estimated to be approximately $25,000.00. Also, there may be a copyright fee to publish certain photographs on the internet. This cost is estimated to be approximately $7000.00. There is a provision in the legislation that the Department of Health & Welfare may charge a reasonable fee to help offset these costs.

Senator Bailey voted Aye Senator Sweet voted Aye

Senator Stegner voted Aye Senator Ingram voted Aye

Senator Darrington voted Aye Senator Compton voted Aye

Senator Brandt voted Aye

The motion was carried by a vote of 8 Ayes and 1 Absent and excused.

The purpose of this bill is to revise the membership of the current regional mental health advisory boards and provide for additional powers and duties for the new boards which will increase their function beyond the advisory level.

The legislation will require the county commission chairs, and the Department of Health and Welfare program manager and the regional director in each region to appoint the members of the boards with

representation specified in the legislation. Once appointed, a list will be sent to the Department of Health and Welfare.

The legislation requires the collaboration, cooperation, and communication between the regional mental health boards, the regional substance abuse authorities and the regional children's mental health councils in order to increase efficiency and avoid duplication of efforts and services.

The new boards, once established, may develop a service plan component for their region that will address unmet needs within the region. Once developed, the service plan component will be submitted to the state mental health authority for their review and approval, and upon approval will be subject to appropriations made for that purpose.

Fiscal impact - There is no fiscal impact on the state general fund or any political subdivision, subject to future appropriations by the legislature or local governmental entities. This does not prevent each regional board from soliciting or acquiring funds from other sources for purposes that they may deem necessary or appropriate.

The purpose of this proposed legislation is to define the term "extended access oral health care program" and to create a new dental hygienist's license endorsement that would provide for a dental hygienist who satisfied the applicable qualifications to be issued an "extended access dental hygiene endorsement" which would authorize the holder of the endorsement to provide dental hygiene services under a dentist's general supervision through an extended access oral health care program. An extended access oral health care program would include dental hygiene services provided through local, state and federal programs, hospitals, schools, community health centers and through such other nonprofit or charitable dental hygiene programs which are annually approved by the Board of Dentistry and which provide free or low-cost dental hygiene services to persons who, due to age, infirmity, handicap, indigence or disability, are unable to receive regular dental hygiene care in a private dental office. The proposed legislation deletes the requirement that a dentist issue written orders to a dental hygienist working under general supervision. The dentist must now diagnose and determine the treatment to be provided by the dental hygienist or authorize the dental hygienist to perform prescribed treatment.

Fiscal impact - Additional Board of Dentistry staff time will be required to process applications for the new dental hygienist license endorsement. The Board of Dentistry has not, as yet, determined whether an additional endorsement fee will be imposed in connection with the new dental hygienist license endorsement. As such, there is a possible fiscal impact on licensees.

The purpose of this proposed legislation is to amend the Idaho Dental Practice Act (Chapter 9, Title 54, Idaho Code) by the addition of a new Section 54-935 that would provide for a retired dentist who satisfied the applicable licensure qualifications to be issued a "volunteer's license." A volunteer's license would authorize (and limit the holder to provide dental services on a volunteer basis (no expectation/receipt of remuneration above the amount of actual expenses incurred) while practicing under the auspices of specifically approved extended access oral health care programs. A holder of a volunteer's license could not practice outside the permissible scope of the license and could not convert the license to another status (i.e., active, inactive, provisional or special status). A licensee practicing within the permissible scope of a volunteer's license would be entitled to immunity from civil liability so long as not practicing negligently. The purpose of the proposed legislation is to increase access to dental care among underserved members of the public.

Fiscal impact - The proposed statute provides that there will be no fees imposed in connection with the volunteer dentist's license. As such, there will be no fiscal impact on licensees.

The purpose of this proposed legislation is to amend the Idaho Dental Practice Act (Chapter 9, Title 54, Idaho Code) by the deletion of the restriction in the existing definition of "dental assistant" found at Idaho Code 54-903(3) which only authorized dental assistants to practice under the direct supervision of a dentist and to include the term "dental assistant" in the definitions of the terms "general supervision" and "indirect supervision" presently found at Idaho Code 54-903(8) and (9). At present, the Dental Practice Act only authorizes a dental assistant to practice under the "direct supervision" of a dentist. Direct supervision requires that the dentist be personally present in the dental practice and that the dentist reviews the treatment provided by the dental assistant before the patient leaves the practice. Indirect supervision and general supervision require less stringent levels of supervision of an auxiliary's work by the dentist. The Board of Dentistry has determined that at some point in the near future it will be warranted and necessary to allow a dental assistant to indirect levels of supervision. The proposed revision will provide the necessary, statutory authority for the Board of Dentistry to promulgate administrative rules authorizing dental assistants to perform permissible functions under varying levels of supervision.

Fiscal impact - There is no fiscal impact on either dental assistants or the Board of Dentistry by reason of this proposed statutory amendment.

The Conrad or State J-l visa Waiver Program would authorize the State of Idaho Department of Health and Welfare to recommend up to 30 (thirty) foreign trained physicians per federal fiscal year to locate in communities that are federally designated as having a health workforce shortage. Final approval of J-l Visa Waiver requests are made by the U.S. Department of State and the Bureau of Citizenship and Immigration Services. Under this proposed program, rural and underserved communities in Idaho would be able to apply for the placement of a foreign trained physician after demonstrating that they are unable to recruit an American physician, and all other recruitment/placement possibilities have proven to be inaccessible.

Fiscal impact - The administration of a Conrad/J-l Visa Waiver Program in Idaho will be funded by receipts generated from levying a processing fee for each application received. The fee amount will be $1,000.00 per application, and may be revised at the beginning of each state fiscal year by the Director of the Department based on costs to administer the program. The number of applications processed cannot exceed 30. Fiscal Impact to communities seeking this resource is estimated at $2,000 for FY 2005. The processing fee will support the time of a Program Specialist, clerical support, and travel expenses associated with processing the application, providing technical assistance, monitoring and program evaluation. Other than the obligatory fee, there are no federal or state funds to support this program. There is no impact to the General Fund.

Ms. Rowan's explained, the program proposed by RS 13528C2 would give the Idaho Department of Health and Welfare the authority to administer a J-1 Visa Waiver Program for the State of Idaho.

This program would allow the Department to recommend the placement of foreign trained physicians in rural and underserved communities across the state.

• These are qualified physicians; the foreign trained physicians would have to successfully complete an American residency program, and achieve a license to practice in the State of Idaho.



• Our communities would initiate the request for these placements.



• This is an option of last resort for communities that face dire recruitment challenges; they must first show that every effort to hire an American physician was tried and exhausted.

The Department of Health and Welfare would make a recommendation from a qualifying applicant to the U.S. Department of State. The final approval comes from the U.S. Department of State and the Immigration Agency. In exchange for this placement, the physician is obligated to serve in areas that are federally designated as having a shortage of health professionals for a minimum of three years.

Under federal and state law, the state is authorized to set aside transfers of assets owned by recipients of Medicaid where the transfer is made without adequate consideration and those assets could have been used to pay for the medical assistance provided through Medicaid. In a recent decision, a state district court ruled that the state's action was barred by a four-year statute of limitations which ran from the date of the transfer even though the circumstances of the transfer were not reasonably discovered by the state until after the four years had elapsed. The proposed legislation adds language to Idaho Code Section 56-218 that would prevent the statute of limitations from running until such time as the state discovers, or reasonably could have discovered, that the asset transfer was without adequate consideration. "Discovers" or "reasonably could have discovered" as used in proposed subsection 56-218 (8) is intended to have the same meaning as "discovery," as interpreted by the courts, in subsection 5-218(4), Idaho Code.

The proposed legislation also makes a technical correction to Idaho Code 56-218 to clarify that the non-Medicaid spouse of a Medicaid recipient need not survive the Medicaid recipient in order for the department to file a claim against the community property of the non-Medicaid spouse's estate.

Fiscal impact - Additional Medicaid recovery is difficult to estimate because details of transfers have been concealed from the state. For purposes of this legislation, additional recovery is estimated as follows:

SFY 2005: $100,000

SFY 2006: $100,000

SFY 2007: $100,000

SFY 2008: $100,000

SFY 2009: $100,000

Ms. Allyn explained, under state and federal law, the state can recover the cost of Medicaid services from the estate of a deceased Medicaid client. This includes property essentially given away by Medicaid clients prior to death - but the state's right to recover transferred property is only for a limited period of time - four (4) years.

This bill amends existing law to specify when that time period to recover transferred property begins.

The bill results from a court decision that the 4-year period to reverse a property giveaway had begun at the date of the transfer, even though the transfer was concealed from the department. The department did not find out about the transfer until well after four (4) years after the fact.

What this bill says is that the f-year period for recovering the property starts only when the department discovers or reasonably could have discovered the transfer.

The bill also makes a technical correction to clarify that the department can file a claim against community property in the estate of a spouse of a Medicaid recipient, even though the spouse predeceases the Medicaid recipient.

There has been disagreement between the Department of Health and Welfare and some residential or assisted living facility and certified family home operators about how to interpret the statutory basis for revoking or denying a license found in Idaho Code Sections 39-3345, 39-3375, 39-3545, and 39-3565 or certificate and the related definition of "substantial compliance" found in Idaho Code Section 39-3302(33) and Section 39-3502(32). Arguably, the language of these statutory provisions, when read together, can give rise to more than one interpretation.

After careful consideration, the Department has adopted a more narrow

interpretation of the law to provide that the serious action of denying or

revoking a license or certificate can only be taken by the Department when there is evidence that the health or safety of a resident is in danger. However, the failure of a licensee or certificate holder or license or certificate applicant to cooperate with reasonable requests of the Department during, or in connection with, a facility or home inspection will constitute resident endangerment.

Specifically, the proposed legislation amends Idaho Code Section 39-3345 and Idaho Code Section 39-3545 to provide that a license or certificate can be revoked or denied if the Department is persuaded by a preponderance of the evidence that the health or safety of any resident is in danger. Language is added to specify that the failure of a licensee or certificate holder or license or certificate applicant to cooperate with reasonable requests of the Department during, or in connection with, a facility or home inspection is presumed to endanger the health or safety of any resident. The definition of "substantial compliance" in Idaho Code Section 39-3302(33) and Section 39-3502(32), which is no longer referenced or relevant, is deleted.

These amendments do not affect the corrective actions available to the Department, or the circumstances when they can be applied, provided in Idaho Code Sections 39-3357, 39-3358, 39-3557 and 39-3558.

Fiscal impact - This legislation is expected to avoid some litigation costs. Based on an average hearing cost of $1,600 per hearing, and assuming that the equivalent of five hearings are avoided each year because of the language clarification, the legislation is estimated to result in the following cost avoidance:

Year 1: $8,000; Year 2: $8,000; Year 3: $8,000; Year 4: $8,000; and, Year 5: $8,000.

Mr. Rogers explained that the Department of Health and Welfare has decided that this proposed legislation does not provide the level of clarity that is needed. The department and others will work on the issues during the summer; therefore, he respectfully requested RS13526C1 be held.

EXCUSED:

The purpose of this legislation is to clarify that the Medical Professional Training Defibrillator Operator is released from all liability due to providing the necessary training and prescription to the operator.

This legislation will give the Training Professional the same lawful protection now granted to the Operator.

There is no fiscal impact.

Fred Riggers, from Nez Perce, Idaho, testified to support RS13731C1. He reported he was one of the first people in Idaho to take the EMS (Emergency Medical Services) test, and being an EMS is very hard. He requested the committee support the legislation.

Over the past several years, the Legislature has enacted a number of cost reduction initiatives intended to curb Medicaid costs. Attached is a list of some of the more recent examples. Despite these initiatives, anticipated savings have not been realized, and expenditures continue to rise, surpassing appropriations in fiscal years 2001, 2003 and 2004.

One weakness in the Medicaid program that has hindered the budgeting process is that the agency has not routinely provided the Legislature with information on the extent to which it has achieved the cost savings anticipated by cost reductions. Such reporting is necessary to keep the Legislature informed of the impact of its policy decisions and to assist the Joint Finance -Appropriations Committee in identifying budget needs. JFAC will be directing the Department of Health and Welfare this year to respond to those questions this year.

Another challenge to cost containment efforts by the Legislature are the sometimes inconsistent intentions which develop between three committees JFAC and the House and Senate germane committees. In some instances, there is not a consensus to support the necessary changes in rules and regulations that are required to implement cost reduction measures that were intended in the appropriation bill from the previous year, which essentially takes the department off the hook, or at a minimum places the Department of Health and Welfare in an awkward position.

We need your help this year in focusing on clear cost containment goals in the budget process. For the past twenty years the average increase in the General Fund Medicaid budget has been nearly 14%. We are no different than other states in seeing a disproportionate amount of our resources chasing significant caseload and health care cost increases year in and year out. We also know the choices are difficult.

As you know we set aside time at the close of the budget hearing process for the germane committee chairs to address JFAC. We would like to enlist the help of your committees in examining what cost control policies would be most appropriate for reigning in the spiraling costs of Medicaid. Specifically, we would appreciate an actual committee vote on potential cost control measures, then have you present those results during your JFAC presentation the second week of February. Some of the issues could include, among others:

1. Reducing or freezing provider rates

2. Reducing or restricting eligibility

3. Reducing or eliminating certain Medicaid benefits

4. Implementing a co-payment system

5. Identifying long-term care reduction strategies

6. Continue efforts to shift other relevant state programs to Medicaid

7. Implement some form of provider fees.

Chairman Brandt explained that he must meet with JFAC on Wednesday, February 11, and the JFAC is seeking methods to control the increases in providing health care services. The committee reviewed and discussed JFAC's seven (7) issues as listed above.

The committee members did not believe they have enough detail information and knowledge about the Department's FY2005 budget request to make a determination of what items can or could be reduced.

The committee was informed on January 27, by the Department of Health and Welfare (DHW), that the DHW's FY2005 budget request is the same as what Governor Dirk Kempthorn requested in his State-of-the-State and Budget address to the Legislature.

The committee members had numerous questions about the DHW budget, such as:

• What cost savings the DHW had during the last budget year (FY04), from the changes implemented as recommended by the committee last session?
• What cuts were implemented?
• Is the DHW "heavy" in upper management and salaries?
• If reductions were implemented in the number of line-staff, were reductions also made in the number of managers to equal those cuts in staff?
• What would provider fee reductions entail?
• What would the impacts be if a scale-back on the number of people eligible for Medicaid services, or a reduction in provided services?
• What would be the impacts of reducing or deleting some program services?
• The impact of freezing salaries of upper management?
• If the committee does propose cuts to the Health and Welfare budget, should one of the seven cost savings methods (listed above) be recommended, or should they review the DHW budget and then determine where the recommended cuts be made?
• What DHW systems are being implemented to increase efficiency and improve services to provide quality health care?
• Should the committee look for specific reductions in specific programs or specific areas of eligibility requirements?
• Committee members agreed the Department of Health and Welfare has hard working, professional individuals, who do a good job.
• Is DHW providing the best service for the best use of dollars?
• Should DHW reduce administrative costs - not Medicaid services?
• Long-term care - does the DHW have a dedicated staff in charge of long-term health care planning?
• What is the DHW's long-term health care plan?

The committee members agreed that Idaho cannot afford to maintain the current services and eligibility for Medicaid services. Idaho simply does not have the funds to maintain this current status.

After discussion, and at this time, no recommendations were made to the JFAC seven reduction selections listed in the letter. The committee members requested the Department of Health and Welfare meet with them and present a detailed budget outline.

He explained, the Buy-in program is for Idahoans with disabilities wanting to work themselves off the system and are trapped by the all-or-nothing nature of the Medicaid program, i.e., if a person's income is below a certain level, he or she receives full Medicaid benefits; if a person makes one dollar more, he or she receives nothing.

People with disabilities have to make decisions based on financial reality. Should they consider returning to work, facing the risk of losing vital Medicaid benefits? As a result, they are compelled not to work and find themselves trapped into poverty. We should not be discouraging people with disabilities from working, earning a regular paycheck, paying taxes and moving off public assistance. A Medicaid buy-in program would enable Medicaid participants with disabilities to contribute to society.

In year 2003, the Blue Ribbon 2020 Task Force recommended that the state implement a Medicaid Buy-In Program so that individuals with disabilities could continue to receive Medicaid benefits and share in the cost of those benefits after obtaining employment.

Written comments were received from Steve Rodolets, Idaho Benefits Planning Assistance and Outreach Program. His comments, in summary, "The Medicaid Buy-In can simply remove the governmental order to not earn a living for ourselves and our families if people require medical attention to stay alive. Earned income can be achieved, even it won't cure what ails us. Then we might join you all in complaining about our taxes and the weather."

Mr. Buckland, again encouraged the committee to ask JAFC to finance this program.

EXCUSED:

This concurrent resolution would reject certain pending rules of the Department of Health and Welfare relating to the medical assistance program. The effect of this resolution, if adopted by both houses, would be to prevent the agency rules from going into effect.

On Friday, January 30, 2004, the committee held a second hearing concerning the Department of Health and Welfare's rules governing the Bureau of Fraud and Investigations. The committee rejected two sections of Docket 16-0309-0308, Sections 204 and 210.

Senators Kennedy, Sweet, Ingram and Compton voted Aye.

Senators Bailey and Darrington voted Nay.

Senators Burkett, Stegner, and Brandt were absent and excused.

The motion to send RS13985 to Print was carried by 4 Ayes, 2 Nays, and 3 absent and excused.

He explained the purpose of this bill is to close a loophole that exists in the law dealing with the 180-day delayed application process. The original intent of the 180-day delayed application was to encourage a provider or applicant to seek other resources that the individual may legitimately qualify for.

Generally, the process for applying to the county requires an application be submitted within 31-days after a person receives services. However, the provider may choose to file a delayed county assistance application, if it is determined that the applicant may qualify for one of the six (6) resources listed in the law. Because counties are the payers of last resort, that resource should be applied for before seeking property tax assistance. The other resources are limited to: medicaid, medicare, social security, crime victims, workers' comp, 3^rd party insurance.

After determining that an individual may legitimately qualify for one of these, the provider or applicant can then file a county indigent application up to 180-days after the service is rendered by the provider. During that time frame, hopefully, one of the resources would have paid or otherwise notified the applicant or provider they ha ve been denied, thereby enabling them to file with the county.

The problem that has occurred, primarily in the north with out-of-state providers, is that the law is vague and seems to enable a provider to file for the 180-day delay if they just missed the 31-day filing window, and the person cannot qualify for another resource.

The counties are bound to comply with the time-lines outlined in the

Idaho code. The changes made to the 180 days delayed process simply

clarify those time-lines and qualifications for filing a delayed application for those providers who ha ve misused the time-lines allowed by law.

The counties originally were going to seek repeal of the section, but after investigating it further determined that it would have caused a significant impact on some counties. Also, it does work as many of the providers work with the counties. The language changes clarify the intent of this section.

The other two (2) changes are only clarity. One says that Medicaid

co-payments and deductibles would not be considered as a necessary medical service, and the other deletes the uniform county guidelines on indigent eligibility.

He discussed, Section 3, that Section 31-A3504, Idaho Code, be, and the same is hereby amended to read as follows:

35-A3504. ADVISORY DECISIONS OF PANEL. The general responsibility of the advisory panel will be to consider the eligibility of applicants on claims referred to them and render written opinions regarding such eligibility of applicants as based upon review of analysis of the resources available to the applicant, as defined in the Uniform County Guidelines on Indigent Eligibility referred to in section 31-3503 section 31-3502(17), Idaho Code. Following proceedings on each claim, the advisory panel shall provide the affected parties with its comments and observations with respect to the claim. They shall indicated in such comments whether the applicant appears to have resources available to him or her sufficient to pay for necessary medical services; does not have adequate resources; or any comments or observations which may be relevant and appropriate. The findings of the advisory panel may be used by affected parties in resolving contested claims in a manner consistent with the findings presented. However, such findings will be advisory in nature only and not binding on any of the affected parties.

There is no fiscal impact on the State of Idaho or any political subdivision.

The program proposed by Senate Bill Number 1291 would give the Idaho

Department of Health and Welfare the authority to administer a J-1 Visa Waiver Program for the State of Idaho.

This program would be discretionary and voluntary on the part of the Department. It would allow the Department to recommend the placement of up to thirty foreign trained physicians in rural and underserved communities across the state per federal fiscal year.

• These are qualified physicians; the foreign trained physicians would have to successfully complete an American residency program, and achieve a license to practice in the State of Idaho.



• The application will require a signed employment contract between the community and the physician. The physicians must agree to provide direct patient care full time for a minimum of three years in family medicine, internal medicine, pediatrics, obstetrics and gynecology or psychiatry, and they must serve Medicaid and Medicare patients, and provide a sliding payment scale for those who are compromised in their ability to pay for care.



• Our communities would initiate the request for these placements; not the Department, and not the foreign physician. In addition to being in a workforce shortage area, facilities that provide primary medical or mental health services and are financially viable may apply.



• This is an option of last resort for communities that face dire recruitment challenges; they must first show that every effort to hire an American physician was tried and exhausted. Evidence of active recruitment over a minimum of six months has to be shown.



• The Department has monitoring and reporting obligations; if the terms and conditions for approval and placement are not met or cease to be fulfilled by the physician or the hiring facility, the physician may face deportation. The Department may deny future participation in the program if an applicant does not satisfy the reporting requirements, if the physician does not serve the community or population that he was committed to, the physician does not remain employed by the applicant for the full three years of employment, or if the applicant or physician is out of compliance with these or federal terms.

The Department will collect an administrative and processing fee of $1000 per application. The amount may be adjusted by the director to satisfy actual costs, should it be determined that it is in excess of $1000. There is broad community support for this fee.

The application process is as follows:

• A qualifying facility submits a complete application to the Department for consideration after recruiting, screening, and agreeing to hire a physician holding a J-1 Visa.



• If favorable and if all terms are met, the Department may then make a recommendation to the U.S. Department of State, that a waiver be granted to the J-1 physician.



• The U.S. Department of State reviews the application and recommendation received from the State of Idaho, and takes action along with the Immigration Agency. If a Waiver is awarded, the physician is notified directly. The physician then must seek and H1-B Visa - which is essentially a work permit for someone with non immigration status. Their work contract with the community becomes binding.

In the past, Idaho communities have had access to similar, federally administered programs. The criteria for the federally administered program have become so stringent that very few Idaho communities would have access to it, though their level of need remains the same. The handout that is offered with this presentation shows areas of the state that would be eligible to request a primary care physician under this proposed state-administered program (in yellow). The facilities on the map are the few entities which might be eligible to participate in the federally administered program. (See Attachments #1 and #2)

Dr. James Scheel, Idaho Medical Association, testified the IMA supports this legislation.

Leslie Phelps, chief executive officer, of the Glenns Ferry Health Center, an Idaho Community Health Center, testified on behalf of Idaho's eight corporate Community Health Centers and the Idaho Primary Care Association.

She shared the strengths and benefits on how the creation of an Idaho Conrad J-1 Visa Waiver Program would assist us in providing primary health care services throughout Idaho.

• This program would expand the physician recruitment options to recruiting highly qualified physicians into many rural areas.



• Idaho is the only state without a Conrad J-1 Visa Waiver Program to help in assisting health centers and others recruit physicians.



• This program will help address some of the difficulties we face in recruiting physicians into rural areas. Idaho has recently fallen to 50^th in the Nation in the number of health care practitioners to population adding to our dilemma and need of recruiting options.



• The Conrad Program would assist Idaho rural communities that have been unable to recruit an American physician for six months or more.



• In addition, it provides an opportunity to hire a highly qualified foreign physician who has received residency training by an accredited residency program in the United States.

As previously mentioned, the Conrad J-1 Visa Waiver Program requires the foreign physician to practice in a Health Professional Shortage Area (IPSA) or medically undeserved area for three years. As you can see, this would assure us not only that health care services are being delivered, but also provide continuity of care over a period of time. Generally, the physicians extend their contracts for longer than the three (3) year requirements.

Glenns Ferry Health Center over the last three (3) years lost the ability to recruit four highly qualified J-1 Waiver physicians adding to our cost of providing services because we were forced to contract with locum tenen physicians approximately every three to four months to maintain coverage. This was a tremendous challenge since many physicians lack the skills necessary to meet the needs of the health centers delivery model.

Located in a rural area we need family practice physicians who are highly trained, possess obstetrical/delivery, and C-section skills as well as the medical skills to meet the growing health care needs.

• The foreign physicians are the brightest, most highly skilled and knowledgeable physicians from their countries.



• The foreign physician has the skill level required to meet the many demands of the primary health services provided by health centers.

Recently, Glenns Ferry Health Center was able to hire a J-1 Waiver physician through the Health and Human Services J-1 Visa Waiver Program. A state Conrad J-1 Visa Waiver Program would add to our ability to recruit qualified physicians in a more timely, effective and efficient manner than other options.

The fiscal impact for the implementation of such a program to the Department of Health and Welfare will be minimal. An application fee amount, as stated in 39-6113, will be no less than $1,000 and may be revised at the beginning of each state fiscal year. Receipts generated from levying a processing fee for each application will fund the program.

The State J-I Visa Waiver requirements for a health center corporation or other entity and physician are many. The fact that the physician is required to be licensed by the Idaho State Board of Medicine prior to applying for the J-1 Visa Waiver Program assures that very strict standards are met.

In closing I would like to urge your support for a State J-1 Visa Waiver Program. It would provide a positive avenue to help address the physician recruitment needs to assure continued and improved quality health care access for all Idahoans.

Senator Bailey agreed to be the Floor sponsor for SB1291.

EXCUSED:

This legislation allows the Department of Environmental Quality to use a portion of the interest revenue from wastewater (CWSRF) and drinking water (DWSRF) loans for operating the programs.

Currently, the programs are funded for 4% of the annual federal contributions (approximately $13.8 million per year). This level of federal contribution is expected to decrease and will not provide sufficient resources for DEQ to manage the programs as the total funds managed have increased to more than $150 million. This funding mechanism will allow the programs to be self supporting.

There is no fiscal impact to the General Fund. A reduction in the SRF funds available for future loans would be in the amount of the funds used to administer the program. DEQ envisions no increased cost to borrowers. The current "at or below" market interest rates will continue.

Mr. Jerrel presented two handouts. Attachment #1 - Funding State Revolving Fund (SRF) administrative costs, and Attachment #2 - Operator Certification Improvements for Drinking Water and Wastewater Professionals. The federal EPA requires an annual audit be done on the programs.

Don Munkers, Idaho Rural Water Association, testified IRWA supports this legislation and requested the committee to send SB1278 to the floor with a do pass recommendation.

Protection of public health requires the use of licensed professionals for operating water and wastewater utilities, and testing backflow assemblies. This legislation provides for the transfer of licensure responsibilities for Drinking Water and Wastewater Professionals from the Department of Environmental Quality to the Bureau of Occupational Licenses (IBOL).

It set forth the policy, title, required license and definitions. Additionally, it provides for a board, to be appointed by the Governor, with qualifications, number, terms of office, removal from office, procedures, powers and duties. The Department of Environmental Quality will hold a position on this board.

The legislation states finances, fees, providing for the issuance of licenses with an annual renewal. It provides for the revocation or suspension of licenses, violations, and penalties. It establishes that an emergency exists and that this act shall be in full force and effect on and after its passage and approval. The IBOL will provide administrative, legal and financial services to the board.

After discussion, the Department of Environmental Quality Director Steve Allred, requested the committee to send SB1279 to the 14^th Order for amendment and clarification.

Discussion:

Dick Rush, Idaho Association of Commerce and Industry, testified that IACI strongly supports SB1279.

Molly Steckel, a representative for the Idaho Chapter of the American Council of Engineering Companies (ACEC), testified to support SB1279, but ACEC does have an issue with Page 2, Line 1, of SB1279, "Operating personnel shall include every person making system control or system integrity decisions about water quantity or water quality that may affect public health."

She testified, the issue is the phrase "system integrity decisions" could be construed as an engineering function that we perform. The members of the ACEC are responsible for the design of the public drinking water systems and public wastewater systems. The ACEC performs studies, design the systems, write the manual that governs the system and do the initial printing. The ACEC recognizes that the intent of SB1279 is not to preclude the ACEC from doing the engineering they are qualified to do, however, it could be interpreted that way. And, if that were the case, engineers would be prohibited from performing the functions they are required to perform, or they would need to go get the other license.

The ACEC has suggested different language for SB 1279, and requested time to meet with DEQ and draft amendment language that everyone would be comfortable with.

A call for the vote on the substitute motion to send SB1279 to the 14^th Order was made.

The substitute motion to send SB1279 to the 14^th Order was carried by a voice vote.

This legislation amends Section 54-2309, Idaho Code, to clarify conditions for non-issuance and revocation of licenses. It adds language making a violation of the Board rules and grounds for a disciplinary action against a licensee.

There is no fiscal impact on general or dedicated funds.

This proposal responds to requests from the public to broaden representation of the Board.

The impact on dedicated funds would be the travel expenses for three board meetings a year for one board member. This board does not receive honorariums.

EXCUSED:

This legislation removes language in Idaho Code that requires

patients admitted to an Idaho hospital on the recommendation of a

licensed podiatrist, to have their required history and physical performed by a physician licensed pursuant to Chapter 18, Title 54, Idaho Code. Podiatrists are trained, qualified and licensed under Idaho Code to perform this routine examination.

There is no fiscal impact.

This legislation would expand family planning services in Idaho to women of childbearing age with incomes up to 133% of the Federal Poverty Level. Family Planning services are limited to counseling and medical services prescribed or performed by an independent licensed physician or a qualified certified nurse practitioner or physician's assistant and includes diagnosis, treatment, contraceptive supplies, related counseling, and restricted sterilization. Contraceptive supplies include condoms, foams, creams, jellies, prescription diaphragms, intrauterine devices and oral contraceptives.

Effective family planning healthcare reduces the number of unintended pregnancies and therefore the number of abortions. Planned pregnancies also result in healthier women, healthier babies, and healthier families.

Fiscal impact - The preliminary estimates indicate that 39,195 women would be eligible. Research data suggest that 25% of these women would be likely to enroll, and use these family planning services. Without increased access to family planning services, the state could anticipate spending 1.5 million on pregnancy and child health care costs for this population. The cost to the state for these additional enrollees for family planning is estimated to be approximately $500,000. The cost avoidance realized by the state will be around $1.0 million. This family planning expansion is possible through a 1115 demonstration waiver in which the Federal Government funds 90% of the cost. The state of Idaho

funds 10% of the cost. In 2003 an independent study was funded

by the Center for Medicaid and Medicare, which found that the six (6)

states included in the study all achieved budget neutrality after operating under the waiver.

Representative Henbest is a member of the House Health and Welfare Committee. She was questioned about why this proposed legislation was presented to the Senate Health and Welfare Committee and not to the House Health and Welfare Committee and Chairman Sali. She answered "no" when questioned about Chairman Sali being aware of the legislation, and explained this was not intentional.

Whenever a proposed House legislation is placed on a Senate Committee agenda, that does not mean the Senate Committee supports

the proposed legislation.

Discussion: Protocol and curtsey; legislation belongs in the House Health and Welfare Committee and should go before the Chairman as that is the appropriate place for the legislation; neither sponsor from the Senate is present to speak for the bill; legislation sponsored by a Senator and going before a House Committee; the right of a House representative to bring forth legislation to a Senate committee, and the prerogative of the chairman to accept or deny proposed legislation; and committee shopping by members of both the Senate and the House.

Senator Sorenson and Senator Keogh are cosponsors of RS13992, but did not discuss the legislation with the committee chairman and did not attend today's hearing.

After the discussion, Senator Compton withdrew his original motion.

Senators Kennedy, Burkett, Darrington, and Compton voted Aye.

Senators Bailey, Sweet, and Brandt voted Nay.

Senators Steiner and Ingram were absent and excused.

The substitute motion to Print RS13992 carried with 4 ayes, 3 nays, 2 absent and excused.

The purpose of this legislation is to help ensure that a woman receives information about fetal development, and the possible effects of an abortion on her health. To provide procedures when abortions may be performed and to provide for certain information to be made available to anyone seeking an abortion.

Fiscal impact - The Department of Health & Welfare is currently in the process of updating the printed information that is required by existing law. The only additional expense to this legislation is the cost to design a web site, which is estimated to be approximately $25,000.00. Also, there may be a copyright fee to publish certain photographs on the internet. This cost is estimated to be approximately $7000.00.

Senator Brandt explained he is also a sponsor of RS141013, and that is why the legislation was before the Senate Committee and not the House Health and Welfare Committee. He could have presented RS141013, but requested Representative McGeachin to be the presenter. He also informed the committee members that SB1294 will remain in the committee as this proposed legislation replaces the bill.

This proposed legislation changes the previous SB1294, and changes are as follows:

• Page 1, line 24 - Retain "informed consent" basic definition from previous statute.



• Page 3, line 8 - Change "any pregnant patient or immediate family member" to "any person." This makes the language identical to the language in the "parental consent" statute.



• Page 3, line 11 - Addition of language making it clear that retention of the signed verification is primia facia evidence of the physician's compliance with the requirements of 18-609. This was added at the suggestion of Representative Ring who expressed concerns that the bill had taken out all reference to protection of the physician who was in compliance with the provisions of the law.

• Page 3, line 32 - Addition of language making it clear that the patient may secure the written materials from the abortion provider or his agent. In order to assure a broad availability of this vital information, however, the woman may also secure the materials from many other sources (including health clinics, Planned Parenthood office. . . .) But that at the very least these materials will be available from district health offices and regional offices of the Department of Health and Welfare.



• Page 5, line 20 - Clerical revision changing the language from "on or after" to "on and after" so as not to allow a delay in the requirement that the materials be provided.



• Page 5, line 22 - Remove the requirement that the department charge a fee for the materials. This will allow that the materials be available in a broad range of outlets allowing for a true flow of information. This section also adds language requiring that the materials be made available in "easily accessible locations." This will assure the most accessible dissemination of the information to assure availability.



• Page 6, line 31 - Changes the word "prepare" to "provide" making it clear that the director shall have available for use by abortion providers the forms required in order to comply with the provisions of this statute.

He explained, 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 to improve quality of care. Records used in peer review are confidential and privileged and generally are not subject to subpoena or discovery. This confidentiality allows open and honest communication which is critical for the peer review process to work.

Idaho's peer review statutes only apply to peer review of care provided in hospitals and other health care organizations. Emergency medical services (EMS) personnel provide care to patients before they arrive in the hospital setting. The quality of care EMS personnel provide is of critical importance to all Idahoans. Their current attempts at peer review are severely curtailed because they are not covered by these statutes.

This legislation would include EMS personnel within Idaho's peer

review statutes and thereby encourage their participation in this most important quality improvement tool.

Fiscal Impact - This bill will have no fiscal impact on state or local funds.

The purpose of this legislation is to amend Section 46-1007, Idaho Code, to clarify jurisdiction of licensed emergency medical service agencies; and amending Section 46-1009, Idaho Code, to provide an exception to jurisdiction of the sheriff.

The jurisdiction and authority of police and fire departments is protected in 46-1007(3) but not that of emergency medical services. Approximately 85% of the ambulance services in Idaho are not affiliated with a fire department or law enforcement agency. This change will provide the same clarity about chain of command for EMS agencies as for fire agencies. Sheriffs are generally not trained or equipped to command medical incidents, and some local EMS agencies are frequently not affiliated with a sheriff's department, though they may frequently work together and cooperate with law enforcement. This legislation is in the best interest of public safety in our communities.

Fiscal impact - There is no fiscal impact to the General Fund.

The Department has been known as Health and Welfare for many years and the name no longer makes sense. It does not reflect the widespread and critically important roles we play in local communities in every corner of the state. It is time to change the name. The old name suggests that "welfare" is half of what we do, and nothing could be further from the truth.

Very little of what is done today can be considered "welfare" as most people define it. Welfare goes back to the days when the Department gave out cash assistance without expecting anything in return. Today, that is no longer true.

I propose "social services" because that far more accurately explains the services the Department provides communities. By providing health and social services, we invest in people - some of them in need, some of them in crisis. By doing so, the Department also invests in local communities, local businesses, and local jobs.

That is not welfare. That is investment in our communities, and investment made through social services, not welfare.

Fiscal impact - $30,000 for replacement of signs at Department facilities and telephone book changes. Implementation is set for July 1, 2004.

EXCUSED:

This legislation updates the practice act for dental hygiene. It raises the fines for the unlawful practice of dental hygiene to a minimum of $500 to not more than $1,000. The bill also changes the number on the State Board of Dentistry by one with the addition of a dental hygiene member. Under this proposal the board would have five dentists, three dental hygienists and one consumer member. The additional hygiene member would be appointed on an at-large basis. The legislation will also allow for the selection of the licensing board chair to be either a dentist or dental hygienist and it would require that a quorum consist of at least one dental hygienist.

Fiscal Impact - The cost of the additional dental hygienist on the board is approximately $6,000. Presently the funds are available in the licensing board's account to pay for the cost of the new position. The board's funding domes from the licensure and renewal of licensure of dentists and dental hygienists. There is no impact to the General Fund.

Mike Sheeley, executive director of the Idaho Board of Dentistry, testified the board had not seen this proposed legislation. The board just met, and Mr. Hoaglun did not inform the board about this proposal. The Board of Dentistry is not scheduled to reconvene until April 2004. Mr. Sheeley could not support RS13849C1 at this time.

Jerry Davis, executive director of the Idaho State Dental Association, agreed with the statement of Mr. Sheeley. The Idaho Dental Association has not reviewed this legislation.

Discussion: The Chairman directed the parties involved to meet in good faith soon, and try to resolve the issues.

The legislation puts into statutes the requirement that any school, college or other program teaching dentistry or dental hygiene must be accredited by the American Dental Association's Commission on Dental Accreditation. Additional changes require accreditation for dental hygiene programs through regional accrediting agencies recognized by the U.S. Department of Education. It also requires that the program for dental hygiene be conducted for a minimum of two (2) academic years.

Fiscal Impact - There is no fiscal impact.

Senator Kennedy asked Mr. Hoaglun about any discussions, particularly the two-year educational requirements, with the Dental Association. Mr. Hoaglun reported there have been no formal discussions. Previously, there has been a discussion about the two-year educational requirements in rule vs. statute.

Idaho Code reads: 54-915(3) - Shall, for dental hygiene, have successfully completed the course of study in dental hygiene, and received a degree from a dental hygiene school accepted or college whose dental hygiene program is accredited by the American dental association's commission on dental accreditation or its successor specialty accrediting agency and is approved by the board. Such school or college must be accredited by a regional accrediting agency for colleges, universities, or institutions of higher education which is recognized by the United States department of and must conduct a curriculum consisting of not less that two (2) academic years for dental hygiene graduation with courses at the appropriate level to enable matriculation into a more advanced academic degree program;

Jennifer Kelly, president of the Idaho Dental Hygienists Association, explained that Idaho has two accreditation programs. She supports this legislation.

Mike Sheeley, explained that currently the Board of Dentistry does require graduation from a dental hygiene program accredited by the American Dental Association. That requirement is in currently in rule. He has not seen the proposed legislation and cannot support it as he has real concerns about the bill.

Jerry Davis reported he agrees with the statement of Mr. Sheeley.

Senator Stegner explained he had to leave, but encouraged committee members to seriously consider funding both of these programs, the ACT Team and Community Resource Development. Both are areas where we can make a significant impact on families and individuals in delivery of those services. He believes it is very appropriate for the committee to request the Joint Finance-Appropriations Committee to provide funds for these programs as they both are vital to Idahoans.

Mr. Deibert explained, during 1993 the Department of Health and Welfare began a study of a model community-based system started in the state of Wisconsin. We asked for and received funding from the Legislature to incorporate Assertive Community Treatment and Psychosocial Rehabilitation ACT Teams in Idaho. We made the commitment because of the positive clinical outcomes.

Act Teams work focuses on people with serious and persistent mental illness, such as schizophrenia. The purpose of the program is to minimize rehospitalization and enable consumers to live successful and productive lives in their communities. There were significant reductions in hospitalization or incarceration for individuals with serious and persistent mental illnesses, who were involved with the ACT team treatment service. There is a marked increase in cost to provide service to this population. ACT Teams provide services every 24-hours, 7-days per week.

In 1993, the Department received $890,000 to fund our initial network. Again in 1995, the Legislature approved and additional $600,000 for ACT Teams which allowed the Department to expand partial ACT Teams to all seven (7) regions in Idaho. There are two types of ACT Teams, Urban and Rural Teams.

The current general fund ACT Team appropriation is $1.8 million. Mr. Deibert distributed a chart outlining the current ACT costs, full-time employees (FTEs) and budgets per region. Current ACT Teams are not staffed to National standards. An additional 55.75 staff and additional psychiatric time are needed to meet the National Urban Maximum team size, or additional staff plus psychiatric time to meet the Minimum Urban team size. The chart outlines the cost for seven (7) full ACT Teams, total cost for one new ACT Team, and the total cost for seven (7) full ACT Teams. (See Attachment #1)

CRFF is an elementary aged program that serves children in grades K through 6 with overall program goals being; to strengthen families to prevent child abuse and neglect, increase school readiness of children and increase the self-reliance of families through utilization of community resources.

The Department provides local school districts with program coordination and funding to hire Community Resource Workers (CRW) to work with school staff to identify children who are underperforming in school due to unmet physical or emotional needs in their home environment. The CRW meets with the families, assesses their strengths and needs, and links them with existing community resources.

The CRFF Program provides two levels of services, Emergency Assistance Services (EA) and Assessment and Referral Services (A&R). Family participation is voluntary. All families who choose to participate in the program receive up to 30 days of home-based supportive services (A&R). Within this 30-day period, some families may require more comprehensive planning and services. These families may be eligible for emergency assistance services.

• The program began in 1994 in Boise as a partnership between the Boise School District and the Department of Health and Welfare.



• In 1996 the program was replicated in Region 1.



• CRFF expanded in 1997 with the replacement of Aid to Families with Dependent Children, (Title IV-A, AFDC) with Temporary Assistance to Needy Families (TANF). States were encouraged to use their welfare reform savings to maintain or expand child welfare and family self-reliance services. The Department, recognizing the success of the two established pilot sites, used welfare reform as an opportunity to expand the CRFF Program statewide, and enter into partnerships with 90 school districts throughout Idaho.



• Two levels of services were provided to families which included Assessment and Referral (A&R) services up to 30 days and Emergency Assistance (EA), 90 day intensive in-home family services.



• From 1999 to 2001, 11,546 families were referred to the program and of those 2,173 families received EA service, 7,103 received A&R. The remaining families either declined or were not eligible for services.



• In school year 2001-2002, with shrinking TANF dollars, the funding source for the program changed.



• The 2001 legislative session resulted in legislative intent language which directed $2,000,000 in TANF funds to be used to provide a 2-to-1 match between the school district and the Department. The school districts could use their discretionary dollars, and for every $2 contributed from the schools the Department provides $1.



• 2000-2001 School Year - 93 school districts participated with 110 CRW's.
• 2001-2002 School Year - 29 participating districts and 32 CRW's.
• 2002-2003 School Year - 22 participating districts and 30 CRW's.
• 2003-2004 School Year - 18 participating districts and 26 CRW's.

The Department has committed $2,000,000 for the 2003-2004 school year. The program continues the same as in the past year with the Department contributing $1 for every $2 spent by the school districts.

Three additional handouts relating to the Community Resource Program were distributed. (See Attachments #2 , #3 and #4)